Interventional cardiology training

Summary

Interventional cardiology training programs are conducted within or after the general cardiology training in most European countries but, unlike in the United States, they do not attract a legal recognition approved in the EU. To stimulate the development of official homogeneous subspecialty training programs across Europe, in 2007 the European Association of Percutaneous Cardiovascular Interventions (EAPCI) developed a Curriculum and Syllabus, updated in 2020, and launched a web based educational platform. The two year program recommended level IV competency for most coronary interventions with the exception of rotational atherectomy and CTO recanalization, but accepts a level II for structural interventions. The absence of binding specifications for interventional training is mirrored by the absence of a revalidation program with no specific indications for continuous medical education in interventional cardiology. In practice, however, subspecialty training in interventional cardiology is provided at high level in most European countries, adopting or modifying the EAPCI Curriculum and running the training during and around the last years of official Fellowship. EAPCI is a large provider of interventional cardiology training, offering specific fellows’ courses, and education platforms. Its annual congress EuroPCR is the largest interventional course in the world.

History and current status of interventional training

FROM GRUENTZIG TO EuroPCR

In the past, a diploma for attendance at the Gruentzig courses in Zurich was a prerequisite for purchasing angioplasty balloons and guiding catheters from Schneider, the only company manufacturing this material in the 1970’s. Many things have changed since the time of those early pioneers, but Europe has maintained its worldwide lead in the organisation of educational courses. The mythical live demonstrations of Gruentzig in Zurich which created a core group of early adopters have been followed by other successful events such as the Meier course in Geneva, the Reifart course in Frankfurt, the Colombo/Grube course in Rome and Milan, the Serruys course in Rotterdam and the Marco course in Toulouse and Paris. From these last two events stemmed the EuroPCR course which became, in 2007, the official annual congress of the EAPCI, the largest educational event in interventional cardiology worldwide.

In 2005 EAPCI established a 2-day fellows course initially held in London and Krakow. This example was followed, with appropriate modifications and in the local language, in many European countries under the auspices of the national interventional societies. Since 2014 and under the direct supervision of the EAPCI Young group the course has moved to the Heart House in Sophia Antipolis. From 2017 the EAPCI Fellows Course has been linked to the EuroPCR congress in Paris, which is EAPCI´s main congress. Training fellowships for young interventionists to travel abroad are offered yearly by EAPCI, allowing candidates the opportunity to move to different centres and countries, thus promoting a more homogeneous training process throughout Europe.

INTERVENTIONAL CARDIOLOGY TRAINING IN EUROPE

The impetus behind many of these initiatives is the need to fill the gap caused by the lack of a formal programme of interventional cardiology training delivered by universities and teaching hospitals. In most European countries, the cardiology training Fellowship, now shortened to 4-5 years throughout Europe, consists of a period of training in internal medicine followed by specific training in cardiology, covering the different invasive and non-invasive fields. A formal programme of interventional training is in place in very few countries and is hardly ever enforced by appropriate legislation. The practical consequence of this absence of a formal training programme for interventional cardiologists is that all cardiologists as well as many other medical specialists such as radiologists, cardiac surgeons and vascular surgeons are legally entitled to perform percutaneous interventional procedures without any specific knowledge and experience in the interventional field. Radiologists, vascular surgeons can make the opposite claim when cardiologists embark in the interpretation of non-invasive diagnostic tests, such as MSCT, or perform peripheral interventions. A particularly difficult situation has been created by the rapid growth of transcatheter valve procedures, often claimed to be in the surgical domain but typically requiring catheter skills, including possible coronary cannulation and treatment. Although the training of specialists in interventional cardiology is often not formally regulated, the appointment of cardiologists who are expected to carry out angioplasties and other interventional procedures is, in practice, requested by the selection process with specific requirements confirmed in the final interview. France was the first European country to move to a structured programme with formal courses and a final exam, swiftly followed by the Netherlands, Denmark, Poland and others.

INTERVENTIONAL CARDIOLOGY TRAINING IN THE US, LATIN AMERICA AND ASIA

In the US the core training programme in cardiology consists of 3 years of internal medicine training followed by 3 years of cardiology training. Until 2000 training was expected to cover all aspects of non-invasive and invasive cardiology. The consequence was a rapid growth in the number of interventional specialists with a dangerous trend towards the creation of a vast number of low volume operators with inadequate training. Several publications showed a clear relationship between low operator volumes and poor outcome ^,.

In 1999 The Society for Cardiovascular Angiography and Interventions and The American College of Cardiology promoted, with the support and agreement of the American Board of Internal Medicine (ABIM), the American Board of Medical Specialties (ABMS), and the Accreditation Council for Graduate Medical Education (ACGME), a new dedicated subspecialty programme for interventional cardiology.

To be eligible, a candidate had to hold a valid existing board certification in internal medicine and cardiovascular diseases. The candidate then applied through either the practice pathway (“grandfathers” with no formal interventional fellowship) or the training pathway (with formal interventional fellowship) meeting specified procedural requirements. The practice pathway ended with the 2003 examination. Thereafter, all applicants had to qualify via the training pathway with graduation from an ACGME approved interventional fellowship experience after having passed a specific examination. Dedicated programs for coronary and peripheral training and, more recently, structural training have further improved the quality of the training programmes.

In Latin America, SOLACI has promoted a one year common pattern of training with similarities to the US training programme but lacking the legal certification in most individual countries.

In most Asian countries also, subspecialty training is not legally recognised but the pyramidal model applied in most hospitals is expected to ensure appropriate supervision and continuous growth in interventional skills. In Europe we often idealise the “Japanese” model of training. Junior doctors slowly progress from vascular access to diagnostic procedures and preparation of the lesion for final completion, with complex interventions such as CTOs assigned only to senior dedicated operators. In reality, this model focused on minute technical details such as wire shaping, material selection and handling is based on routine general practice rather than firm rules.

INITIATIVES OF THE EUROPEAN SOCIETY OF CARDIOLOGY AND ITS ASSOCIATIONS ON SUBSPECIALTY TRAINING

The most recent Core Curriculum in Cardiology was published by the Education Committee of the European Society of Cardiology in 2020 and contains an ideal pattern of training for the general cardiologist approved by all the national society members of the ESC. Also this document follows the recommendations of a task force appointed by the European Society of Cardiology and the European Union of Medical Specialists (UEMS) to identify the areas in need of specific additional training at the end of, or integrated into, cardiology training. That committee has endorsed the concept that the practice of activities such as interventional cardiology, electrophysiology and pacing, cardiovascular imaging and heart failure treatment may require a specific and additional training and they have set the general rules for regulating its organisation that requires devolving to each individual professional association the development of the specific educational content of the programmes . The Core Curriculum followed this advice and implicitly recognises that percutaneous interventions are part of a different subspecialty training. For instance, when managing a patient with chronic coronary syndrome the trainee at the end of his fellowship should be able to give an indication for coronary angiography and/or revascularization strategy but should not perform interventional or surgical therapy. Also the level of competence for diagnostic catheterisation and coronary angiography is a modest Level II and is limited to Level I for PCI and structural interventions
(Table 1).

Table 1. Description of competence levels

Technique	Description of competence
Level I*	No performance, even with direct supervision. Observation is recommended
Level II*	Performance as second operator and/or with direct, proactive supervision
Level III	Performance as first operator with reactive supervision, i.e., on request and quickly available
Level IV	Performance as first operator without supervision. Possibility of post hoc supervision
Level V**	Performance as first operator without supervision and ability to teach/supervise more junior colleagues

The European curriculum and syllabus of interventional cardiology training

The first Curriculum, published in EuroIntervention in 2006 , was an initiative of the ESC Working Group (WG) of Interventional Cardiology and the chairmen of the national interventional societies. They appointed a committee to provide a template for a homogeneous educational process for specialists in interventional cardiology in Europe. The curriculum recommended a two year programme divided into four semesters, with a stepwise approach to the direct engagement of the trainee who was expected to start dealing with the preparation of the patient for the intervention, including diagnostic angiography, and then assist (as second operator) the supervisor or other experienced interventionists performing the angioplasty procedure. It was recommended that the trainee started working as a primary operator for simple angioplasties under close supervision and assists in the most complex angioplasty procedures (bifurcations, thrombus containing lesions, chronic occlusions, diffuse disease, severe calcifications, etc.) until he/she reached a level of confidence allowing him/her to work as a primary and independent operator in both simple and complex coronary interventional procedures. Apprenticeship learning was defined as the mainstay of the training process in interventional cardiology. Candidates were required to be involved in procedure planning, assessment of indications and contraindications, specific establishment of the individual patient risks based on clinical and angiographic characteristics. A parallel formal learning programme was also required ensuring that the candidate achieves sufficient knowledge of all of the subjects included in the syllabus. Trainees were required to attend at least 30 full days (240 hours) in 2 years of specific interventional training sessions locally (study days and post graduate courses), nationally or internationally. In the curriculum it was indicated that all trainees had to be exposed throughout the training programme to a basic knowledge of the methods of research and interpretation of trial results in interventional cardiology.

Although the visionary document developed in 2006 inspired many of the national programs, its main drawback was the difficulty to move to a EU based regular update of the medical training across Europe, with no structured permanent regulating authority at the European level since all these activities are devolved to the individual member states. The Authors of the updated 2020 Curriculum accepted to lower their reach and decided not to provide specific minimum numbers for the training centers or the trainees. They maintained the principle of a two year specific training and spelled out the different characteristics of the training centers that they divided between Standard and Advanced (Table 2).

Table 2. Characteristics and requirements of Interventional training centres.

Basic characteristics (mandatory)	Number of trainees should not exceed number of trainers Catheterisation laboratory conferences, at least monthly Regular electronic database, audited by the national interventional association/working group Research programme Performance measures at least annually Quality programme Radiation safety programme Compliance with local standards according to national regulation bodies, including minimal procedural volumes
Standard centre	PCI including complex procedures (mandatory) Intracoronary imaging (IVUS and/or OCT, others) and invasive physiological assessment (FFR, iFR, RFR and others) (mandatory) CTO programme (recommended) Rotational atherectomy (recommended) Percutaneous mechanical circulatory support devices (encouraged) TAVI (encouraged)
Advanced centre	PCI including complex procedures (mandatory) Intracoronary imaging (IVUS and/or OCT, others) and invasive physiological assessment (FFR, iFR, RFR and others) (mandatory) CTO programme (mandatory) Rotational atherectomy and lithotripsy (mandatory) Percutaneous mechanical circulatory support device programme (recommended) TAVI (mandatory) Transseptal procedures (mandatory) Other structural procedures (recommended)

For the trainee, it was added a regular attendance and/or coordination of Heart Team meetings to the participation in the on call rota for STEMI and OHCA and the clinical management of the patient in the Cath Lab and in the ward. The Committee made an outstanding work in spelling ut all the novel procedures in coronary, peripheral and structural interventions attributing to each of the them the minimum level of competency required at the end of the training period. For coronary interventions, they required full competency (level IV) also for treatment of multivessel disease, left main disease and bifurcations, including the use of IVUS/OCT and of invasive physiological indices. PCI with the use of Rotablator or in CTO (both level II) or percutaneous mechanical hemodynamic support (Class III) were still requiring a direct proactive supervision or a proctorship on site. Also for TAVI, LAA closure, ASD/PFO closure a type II level of training (only closely supervised interventions or second operator) or (Mitral repair) type I level of training (observership recommended) were requested at the completion of the two years of training. This recommendation acknowledges the greater complexity of a rapidly moving field such as structural interventional cardiology, requiring a dedicated training via Master programs, and the need to have fully independent operators for the majority of the coronary procedures, especially urgent interventions such as primary PCI while more complex elective coronary procedures still remain under proctorship. Also for coronary interventions, the absence of a class V competence should represent a stimulus for further growth accepting the supervision of senior colleagues in the most complex procedures.

From principle to practice: The European web platform for interventional cardiology training

It is a formidable challenge to promote a homogeneous high standard of training in the absence of a formal legal recognition. The solution adopted by the ESC and its sister subspecialty organisations EIA, EHRA, ACCA and EAPCI is the development of web-based platforms dedicated to subspecialty training, with the scientific and educational content determined by the individual associations within a general scheme valid for all the subspecialties. The three cornerstones of the training process are knowledge, professional skills and professionalism. The most knowledgeable cardiologist with a complete background spanning from pathophysiology of coronary artery disease to the results of the most recent trials will be unable to work safely if he/she has not achieved sufficient practical experience in a variety of procedures, assisted and coached by qualified supervisors. Similarly, a physician combining good theoretical knowledge and hands-on experience can still be inefficient and dangerous if he/she does not show respect and human compassion towards patients in his/her practice and does not have the ability to select and motivate his/her team. Training in interventional cardiology must address these three complementary, essential aspects of the education process and must develop reliable methods of assessment to certify the progress made so as to indicate the additional steps required to become an independent professional.

The platform had its first release in 2016, offering the trainee the possibility to document attendance at accredited formal training courses and to record their catheter lab based procedures . The website asks for mandatory reports of directly observed procedures, periodical appraisals from the programme director and a 360 degree assessment, involving not only medical colleagues but also nurses, radiographers, technicians and patients. The final judgement should report on the trainee’s ability to interact with cath lab staff and colleagues, his/her attention to minimising patient risk by maintaining a good balance between a disposition to discuss complex procedures with more expert colleagues and the ability to make independent appropriate choices and cope with emergency situations. A final comprehensive examination is required at the end of the training with multiple choice questionnaire.

Continuous medical education: Specificity of interventional cardiology training

In a dynamic subspecialty such as interventional cardiology, with new material and techniques continuously being introduced, CME appears indispensable to maintain acceptable quality standards. Many European countries have established quality standards for revalidation
(Table 3) in the various specialties, with the need to enter all the accredited courses followed and ensure they fit into the CME requirements of the specialist involved. Obviously, since interventional cardiology is not officially considered a subspecialty, no specific CME requirements have been indicated in this field. A minimal number of 75 PCI procedures per operator per annum is recommended by the national societies in most European countries and this can be often tracked in dedicated databases open to the public reporting individual results. In the USA, however, besides evidence that this minimum number of procedures has been effectively performed, a formal revalidation process is required every ten years with interventionists required to sit a similar ABIM MCQ-based test to the test designed for new fellows. This additional burden on the shoulders of busy interventionalists, coming at a cost, has raised criticism. The ability of such tests to screen the presence of the minimal requirements for a safe practice has also been questioned (8). This healthy scepticism has to be considered to avoid the development of needless layers of bureaucracy when the capacity of the interventionalist should already be continuously monitored during the yearly appraisal process.

Table 3. Essential terminology pertinent to medical training and revalidation

Appraisal	Periodical discussion between supervisor and trainee to review the status of training and ensure the milestones indicated in the curriculum are reached. Action points are indicated and achievement of the indicated goals is checked in the following appraisal
Directly observed procedure	Supervisors are require to document the ability observed of the trainee to pose correct indications, adequately prepare the patient, obtain a valid informed consent, develop a treatment strategy for the angioplasty including planning of bail-out procedures, correctly execute the intervention and document result
360 degree assessment	The trainee and the appraiser will identify colleagues, nurses and other non-medical cathlab staff, patients, administrative staff relevant to evaluate the trainee’s ability to work effectively in a team. Written feedback is required and results are discussed between supervisor and trainee, establishing an action plan to improve interaction, when needed
Certification	Confirmation of the successful completion of the training process, normally issued by the professor responsible for the specialisation/fellowship programme appointed by the university according to programmes recognised by the Ministry for Universities or Higher Education
Accreditation	Acknowledgment from a hospital that the doctor has completed an officially approved training programme
Revalidation	Periodic review of the ability of the specialist to continue his work safely based on certified formal training and appraisal of the results of his/her recent activity and 360 degree assessment

Simulators for interventional cardiology training

Medical errors have been the fundamental reason for the creation of virtual reality training instruments for medical interventions. Error reduction in healthcare is a major task and has high priority for patient safety and to reduce the increasing costs of litigation. For centuries the traditional training model in medicine has been the direct exposure to procedures conducted on patients under appropriate monitoring by the trainee’s mentor. All interventional procedures are associated with a learning curve for the operator. During this learning curve it is generally accepted that there is a higher number of complications and a lower quality of performance than in procedures performed by experts. It is no longer acceptable to teach future operators using this apprenticeship model and the principle of competency-based training must prevail over volume-based training. Simulators have been a part of the aviation training curriculum for decades and this methodology has now been accepted in medical education to reduce errors, costs and to increase safety for the patient and protect the trainee and his mentor. Advanced simulators for different surgical procedures have been on the market for more than two decades and the training effect has been demonstrated in RCTs . Simulators for cardiac interventional procedures have been on the market for few decades but the improvement obtained training on a simulator has not been clearly demonstrated by head-to-head comparisons with the traditional apprenticeship model. Their use is frequently limited to newly introduced devices and techniques, with training supported by the Companies manufacturing these devices. Many attempts to validate the training effect in different angiographic simulators have been performed and some studies suggested a shorter and more consistent path to training completion .Only a few attempts have been made to demonstrate the transfer effect in peripheral interventions but no consistent attempts in coronary interventions. The high cost of simulators and the lack of compelling proofs of improvement may explain the slow pace of adoption of these expensive tools, belittled by conservative trainers as expensive video games. A wider adoption has followed the increased popularity of structural interventions. Modern simulators are suitable to run modules to teach not only coronary angiography and simple PCI but also modules to train CRT implantation, trans-septal puncture, pulmonary venous isolation, bifurcation stenting, CTO, LAA appendage closure and TAVI procedures. ESC and several national cardiology societies recognise the potential of this training method and now recommend the use of simulators to optimise and assess the training and define strict entry levels of adequate proficiency level before allowing the trainee to perform the intervention on a patient.

Training in peripheral interventions, treatment of structural heart diseases, non-invasive angiography with multidetector computed tomography and other invasive imaging techniques (intravascular ultrasound, optical coherence tomography)

The European Curriculum does not include any of the above topics as mandatory components of its training.

TRANSCATHETER PERIPHERAL INTERVENTIONS

The main challenge facing interventional cardiology is the definition for each individual procedure (carotid, renal, lower limb stenting, abdominal aneurysm exclusion) of a consistent pattern of training accepted by the other specialists potentially involved in these procedures. Some successful examples from the US of agreement among neuroradiologists, vascular surgeons and interventional cardiologists are certainly a positive stimulus for similar achievements in Europe . Obviously the technical aspects cannot cancel the need of a sufficient background clinical knowledge to pose correct indications, interpret the non invasive imaging tests, maintain an appropriate follow-up.

STRUCTURAL HEART DISEASE

TAVI and new mitral interventions (edge-to-edge leaflet clipping, direct or indirect annuloplasty, etc) are the main focus of attention but also novel tricuspid interventions, PFO and ASD closure, LAA appendage closure etc require a consistent pattern of training. To some extent and especially for the newest interventions, operator training is as important as appropriate indications and planning in delivering optimal results. Training is a challenge also for experienced interventionalists because it requires advanced knowledge of valve pathology, the biological surgical prostheses (valve-in-valve is probably the indication with greatest consensus), non-invasive imaging with special focus on MSCT and transthoracic and transesophageal echocardiography. Functional mitral regurgitation or LAA closure also require advanced knowledge of heart failure and rhythm disorders. In most cases training is directly provided by the companies selling the specific devices involved. In principle this method is not desirable because it creates insurmountable bias in the proctors who are unlikely to provide balanced information on indications, advantages and risks of the device in question. While many companies must be congratulated on the quality of the didactic courses they organise, the completeness and scientific reliability of these courses is not subject to an independent review. Patient safety when a proctor is called to operate in an unfamiliar environment with limited previous interaction with the local team may also represent an issue. Despite these theoretical pitfalls, results of proctored TAVI cases have been shown to come close to the best results of experienced centres, possibly because the most straightforward indications are selected. The involvement of interventional societies and a more independent and better regulated training process, especially for the most complex procedures, should be addressed rapidly when future procedures develop.

The challenge is much greater, since we must train new “hybrid” specialists with mixed surgical and interventional skills who will be ideally placed to perform and develop the growing number of mini-invasive procedures due to replace more invasive conventional surgical approaches. This requires an enormous change in mentality from both cardiologists and cardiac surgeons resulting in innovative curricula for future specialists. Interventionists, already a new breed with a mixed background, are in an ideal position to lead this change .
In order to help to structure the training in that field, a new Core Curriculum in Structural Heart Disease Interventions is currently under preparation under the umbrella of the EAPCI and should be published soon. The writing task force included three coordinating authors (Rui Campante Teles, Eric Van Belle and Radoslaw Parma) and a Task Force of 47 authors. All members have substantial expertise in different aspects of SHD percutaneous interventions. The writing task force was divided into 13 groups consisting of 3 to 4 members each, which developed, circulated, and revised the document.

RADIATION PROTECTION

Knowledge of the basic principles of radiation physics and radioprotection is an essential prerequisite for the use of ionising radiation in all European countries. The training and revalidation courses, however, should go beyond the basic principles, which are common to other medical operators from dentists to orthopedic surgeons. Practical tips and tricks to avoid or reduce the radiation burden to the patient and the operator must be taught in order to ensure they make use of the best x-ray systems/settings and the most advanced shielding modalities to reduce radiation exposure to patients and cathlab staff alike.

MULTIDETECTOR COMPUTED TOMOGRAPHY

In the United States, the Society of Coronary Angiography and Interventions in conjunction with the American College of Cardiology Foundation and the American Heart Association, the American Society of Nuclear Cardiology, the American College of Radiologists, the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography have promoted the preparation of a consensus document to define standards for training, accepting the principle that no medical professionals may have all the background needed for the interpretation. Cardiology fellows are expected to have comprehensive exposure to both acquisition and interpretation of cardiac MSCT throughout their training, and should master the relationship between the results of the MSCT examination and findings of other cardiovascular tests, such as catheter based selective angiography, nuclear cardiology, cardiovascular magnetic resonance imaging and echocardiography (when appropriate). To go one step further and be able to interpret and reconstruct coronary and cardiovascular investigations, the minimum number of cases to be performed and interpreted under supervision and the duration of training have already been indicated. Three different levels of expertise are defined and it is suggested that all cardiology fellows, most practicing cardiologists and especially interventional cardiologists should attain at least the first level of training. Although this level does not qualify a doctor to perform and interpret cardiac MSCT independently, it entails understanding the basic principles, indications, applications and technical limitations of MSCT and the interrelation with other diagnostic tests, which are essential for the appropriate use of cardiovascular MSCT in clinical practice. Professionals however, may receive training in their practice settings. Indeed there are a number of ways in which physicians can validate expertise and competence in MSCT.

CBCCT (cardiac computed tomography certificate of advanced proficiency) candidates are given multiple-choice electronic tests to be completed on a PC covering clinical indications and limitations of MSCT, scan technique and post-processing, principles of x-ray radiation physics and radiation protection. Although comprehensive in terms of background knowledge, these tests do not evaluate some practical abilities involved in cardiovascular MSCT such as patient preparation and instruction, choice of the most appropriate scan technique, optimisation of contrast injection protocol and scan parameters, manipulation of the three-dimensional MSCT dataset on a workstation to judge the reliability of the data, and importantly the reporting of the study. For these reasons, when possible, workplace-based assessment may reflect better the trainees’ acquired competence.

The European Society of Cardiology WG on Nuclear Cardiology and CT encourages the accreditation with the CBCCT. This reflects the relative paucity of training schemes across Europe offering comprehensive multimodality training in cardiac imaging (including cardiac MSCT). Trainees therefore, have to look for training at different facilities when the primary programme cannot fully accommodate their needs. The European Society of Radiology has identified cardiovascular multimodality cross-sectional imaging as a subspecialty and has made available a number of training and exchange fellowships to overcome the existing limitations and disparities in the availability of multimodality cardiovascular imaging facilities across Europe. Some national societies, for instance the British Society of Cardiovascular Imaging which has members with different backgrounds (but mainly in radiology and cardiology), have endorsed training guidelines similar to those published in the United States and also offers opportunities for curriculum-based accreditation. In Great Britain, applicants for level 2 accreditation in cardiac CT must have attended a dedicated level 2 course for a minimum of 5 days supplemented by onsite training at a hospital where one had reported at least 150 contrast cardiac CT examinations under the supervision of a grade 3 certified trainer. The case mix must include at least 50 cases of coronary analysis with the presence of significant stenoses, 25 cases of non-coronary pathology, 25 cases of patients who have undergone CABG, and at least 10 cases of patients with coronary stents.

INVASIVE INTRACORONARY IMAGING AND NON-IMAGING TECHNIQUES

Fractional flow reserve is the accepted standard proposed in the new ESC Revascularisation Guidelines, in the absence of non-invasive evidence of ischaemia, for the evaluation of stenoses of angiographically “intermediate” severity. The simplicity of the technique is one of the key elements of its success but nevertheless pitfalls must be addressed in specific seminars and learned from practice. There is consensus among experienced interventionists that a background experience of IVUS is an eye opener in terms of confidence in the application of appropriate balloon diameter and pressure and selection of techniques of lesion preparation. OCT has the advantage of a crisp delineation of the lumen-wall interface which allows reliable automated measurements of lumen area. For both techniques, specific training is required in order to consistently acquire and properly interpret the images and extract the relevant clinical information in the midst of a complex angioplasty procedure . Training programs must include all the techniques included in the Recommendations because it is very difficult to recreate the breadth and intensity of a training fellowship once a physician has assumed full-time clinical responsibilities.

CHRONIC TOTAL OCCLUSIONS

The EuroCTO Club has developed a model of training for defining lesions of low complexity, accessible with conventional PCI material and small changes in the conventional technique (i.e., bilateral injection, tapered soft polymer coated wires) and progressively more complex lesions that should not be approached without adequate training and/or the presence of a proctor.

Conclusion

Interventional cardiovascular practice remains a dynamic, rapidly evolving sub-specialty of cardiology which requires an optimal system for structured training. Appropriate legislation should be issued reflecting the growth of cardiology subspecialties and the need of certified training, following the US model. Despite the absence of a recognized training pattern, Europe remains an acknowledged leader in education and training in interventional cardiology thanks to the success of European courses and educational activities. Multiple ongoing initiatives have been promoted by EAPCI and the National Interventional Societies to fill the gap created by the lack of a formal homogeneous training and certification process and provide the conditions for a successful expansion of interventional cardiology in peripheral and structural interventions.

Personal perspective

Carlo Di Mario

The official approval of a new specialty called Interventional Cardiology requires a direct decision by National Governments since this legislation is demanded by the European Union to individual countries. A change in this is very unlikely in the near future. However, the European Union is expected to check compatibility with the essential principle of free movement of workers, including professionals, within the member states. If key country members follow the EAPCI proposal by developing national subspecialty programmes modelled on the EAPCI curriculum, the EU might be induced to promote initiatives to grant legal recognition for this educational model. Whilst waiting for this long-term goal, the European interventional community should continue to deliver “unofficial” but well regulated and high quality programmes of interventional training and ensure that the appointment/accreditation of interventional specialists is limited to fellows who have undertaken an adequate training programme. A high quality offer of educational programmes in the main European congresses and the development of European fellows courses and initiatives for exchange of fellows can greatly facilitate this programme of integration and ensure the achievement of higher common standards of training.