Transradial versus transfemoral access for cardiac catheterization: a nationwide pilot study of training preferences and expertise in The United States.

BACKGROUND: The objective was to assess current training preferences, expertise, and comfort with transfemoral access (TFA) and transradial access (TRA) amongst cardiovascular training fellows and teaching faculty in the United States. As TRA continues to dominate the field of interventional cardiology, there is a concern that trainees may become less proficient with the femoral approach. METHODS: A detailed questionnaire was sent out to academic General Cardiovascular and Interventional Cardiology training programs in the United States. Responses were sought from fellows-in-training and faculty regarding preferences and practice of TFA and TRA. Answers were analyzed for significant differences between trainees and trainers. RESULTS: A total of 125 respondents (75 fellows-in-training and 50 faculty) completed and returned the survey. The average grade of comfort for TFA, on a scale of 0 to 10 (10 being most comfortable), was reported to be 6 by fellows-in-training and 10 by teaching faculty (p < 0.001). TRA was the first preference in 95% of the fellows-in-training compared to 69% of teaching faculty (p 0.001). While 62% of fellows believed that they would receive the same level of training as their trainers by the time they graduate, only 35% of their trainers believed so (p 0.004). CONCLUSION: The shift from TFA to radial first has resulted in significant concern among cardiovascular fellows-in training and the faculty regarding training in TFA. Cardiovascular training programs must be cognizant of this issue and should devise methods to assure optimal training of fellows in gaining TFA and managing femoral access-related complications.

Impact of the COVID-19 pandemic on interventional cardiology fellowship training in the New York metropolitan area: A perspective from the United States epicenter.

BACKGROUND: The healthcare burden posed by the coronavirus disease 2019 (COVID-19) pandemic in the New York Metropolitan area has necessitated the postponement of elective procedures resulting in a marked reduction in cardiac catheterization laboratory (CCL) volumes with a potential to impact interventional cardiology (IC) fellowship training. METHODS: We conducted a web-based survey sent electronically to 21 Accreditation Council for Graduate Medical Education accredited IC fellowship program directors (PDs) and their respective fellows. RESULTS: Fourteen programs (67%) responded to the survey and all acknowledged a significant decrease in CCL procedural volumes. More than half of the PDs reported part of their CCL being converted to inpatient units and IC fellows being redeployed to COVID-19 related duties. More than two-thirds of PDs believed that the COVID-19 pandemic would have a moderate (57%) or severe (14%) adverse impact on IC fellowship training, and 21% of the PDs expected their current fellows' average percutaneous coronary intervention (PCI) volume to be below 250. Of 25 IC fellow respondents, 95% expressed concern that the pandemic would have a moderate (72%) or severe (24%) adverse impact on their fellowship training, and nearly one-fourth of fellows reported performing fewer than 250 PCIs as of March 1st. Finally, roughly one-third of PDs and IC fellows felt that there should be consideration of an extension of fellowship training or a period of early career mentorship after fellowship. CONCLUSIONS: The COVID-19 pandemic has caused a significant reduction in CCL procedural volumes that is impacting IC fellowship training in the NY metropolitan area. These results should inform professional societies and accreditation bodies to offer tailored opportunities for remediation of affected trainees.

Impact of the COVID-19 pandemic on interventional cardiology training in the United States.

OBJECTIVES: We sought to determine the effect of COVID-19 related reduction in elective cardiac procedures and acute coronary syndrome presentations on interventional cardiology (IC) training. BACKGROUND: The COVID-19 pandemic has significantly disrupted healthcare in the United States, including cardiovascular services. The impact of COVID-19 on IC fellow training in the United States has not been assessed. METHODS: The Society for Cardiovascular Angiography and Interventions (SCAI) surveyed IC fellows training in both accredited and advanced non-accredited programs, as well as their program directors (PD). RESULTS: Responses were received from 135 IC fellows and 152 PD. All respondents noted reductions in procedural volumes beginning in March 2020. At that time, only 43% of IC fellows had performed >250 PCI. If restrictions were lifted by May 15, 2020 78% of IC fellows believed they would perform >250 PCI, but fell to only 70% if restrictions persisted until the end of the academic year. 49% of IC fellows felt that their procedural competency was impaired by COVID-19, while 97% of PD believed that IC fellows would be procedurally competent at the end of their training. Most IC fellows (65%) noted increased stress at work and at home, and many felt that job searches and/or existing offers were adversely affected by the pandemic. CONCLUSION: The COVID-19 pandemic has substantially affected IC training in the United States, with many fellows at risk of not satisfying current program procedural requirements. These observations support a move to review current IC program requirements and develop mitigation strategies to supplement gaps in education related to reduced procedural volume.

Impact of trainee involvement on patient radiation exposure and contrast volumes during invasive cardiac procedures.

PURPOSE: The impact of cardiology fellows (CFs) and interventional cardiology fellows (ICFs) on patient radiation and contrast exposure during diagnostic coronary angiography and percutaneous coronary intervention is unknown. METHODS: Between 2011 and 2014, 16,175 cases were retrospectively assessed involving 27 CFs, 22 ICFs and 24 staff as primary operators. RESULTS: During diagnostic coronary angiography, ICFs administered the lowest radiation dose (5,648±5,523 cGy*cm2; 1.30 ± 1.27 mSv)-achieving 22% less radiation than the staff (6,889±4,294 cGy*cm2; 1.58 ± 0.99 mSv) and 36% less than CFs (7,700±6,751 cGy*cm2; 1.77 ± 1.55 mSv) (p<0.01). When adjusted for access site, CFs administered more radiation than either the ICFs or staff. However, differences between ICFs and staff were exclusively observed during transradial procedures (p<0.01). With regards to contrast administration, ICFs administered less contrast (126.3 ± 57.6 mL) than either CFs (130±52.4 mL) or staff (132.7±47.6 mL) (p<0.01)-again, a finding isolated to the transradial cohort. Of the 6,751 percutaneous coronary intervention cases, no significant differences existed between the ICFs or staff cardiologists in patient radiation exposure-but a CF as the primary operator resulted in an 18% increase in radiation exposure. Notably, contrast use was not different amongst the types of operators (p<0.05). CONCLUSION: In conclusion, having a cardiology fellow as primary operator during invasive cardiac procedures increases patient radiation exposure and minimally increases contrast administration. Strategies to minimize patient radiation exposure while maintaining trainee involvement should be evaluated.

Qualitative and Quantitative Assessment of Technical Skills in Percutaneous Coronary Intervention: In Vivo Porcine Studies.

OBJECTIVE: Technical skill assessment plays an important role in the professional development of an interventionalist in percutaneous coronary intervention (PCI). However, most of the traditional assessment methods are time consuming and subjective. This paper aims to develop objective assessment techniques. METHODS: In this study, a natural-behavior-based assessment framework is proposed to qualitatively and quantitatively assess technical skills in PCI. In vivo porcine studies were conducted to deliver a medical guidewire to two target coronaries of left circumflex arteries by six novice and four expert interventionalists. Simultaneously, four types of natural behaviors (i.e., hand motion, proximal force, muscle activity, and finger motion) were acquired from the subjects' dominant hand and arm. The features extracted from the behaviors of different skill-level groups were compared using the Mann-Whitney U-test for effective behavior selection. The effective ones were further applied in the Gaussian-mixture-model-based qualitative assessment and Mahalanobis-distance-based quantitative assessment. RESULTS: The qualitative assessment achieves an accuracy of 92% to distinguish the novice and expert attempts, which is significantly higher than that of using single guidewire motions. Furthermore, the quantitative assessment can assign objective and effective scores for all attempts, indicating high correlation ( R = 0.9225) to those obtained by traditional methods. CONCLUSION: The objective, effective, and comprehensive assessment of technical skills can be provided by qualitatively and quantitatively analyzing interventionalists' natural behaviors in PCI. SIGNIFICANCE: This paper suggests a novel approach for the technical skill assessment and the promising results demonstrate the great importance and effectiveness of the proposed method for promoting the development of objective assessment techniques.

Audiovisual telesupport system for cardiovascular catheter interventions: A preliminary report on the clinical implications.

OBJECTIVES: This study aimed to validate the clinical implications of audiovisual telesupport system use. BACKGROUND: An audiovisual telesupport system with supervisors has been effective in guiding procedures when surgeons have limited experience with the technique. However, cardiovascular catheter interventions using an audiovisual telesupport system has not been previously reported. METHODS: Starting in September 2017, two cardiologists in Kamisu Saiseikai Hospital (Kamisu, Japan, with limited cardiologists) began performing cardiovascular catheter interventions using an audiovisual telesupport system. This system enabled them to perform catheter interventions with the support of advisors in the University of Tsukuba (Tsukuba, Japan). We retrospectively assessed procedure time and complications of percutaneous coronary intervention (PCI) and catheter ablation (CA). RESULTS: In the first 10 months, 21 patients with coronary artery disease underwent PCI using this system. The mean procedure duration of PCI was 42 ± 10 min. Nine patients with tachyarrhythmia including supraventricular tachycardia (SVT), ventricular premature contraction (VPC), common atrial flutter, and paroxysmal atrial fibrillation (AF) underwent CA using this system. The mean CA procedure time was 134 ± 31 min for SVT, 100 ± 14 min for VPC, and 200 min for AF. All PCI and CA procedures were successfully performed without any complications. CONCLUSIONS: The audiovisual telesupport system enabled cardiologists with limited human resources to provide safe and high-quality catheter interventions.

A CHIP fellow's transition into practice: Building a complex coronary therapeutics program.

BACKGROUND: Both the prevalence and complexity of coronary artery disease are on the rise in the United States, leading to a resurgence in novel techniques and equipment utilized to treat complex coronary disease. However, declining percutaneous coronary intervention (PCI) volumes and lack of formal post-graduate education opportunities have created a gap in treatment delivery for this patient population. Several complex, high-risk, and indicated PCI (CHIP) fellowships have been developed in an attempt to bridge this disparity. We present data from the first year of practice from a former CHIP fellow during development of a formal complex coronary therapeutics program. METHODS: Data was prospectively collected for PCIs performed during the first 12 months of practice for the lead author and compared to procedures performed in the 12 months prior to the study period. RESULTS: Out of 371 PCIs performed during the study period, 53.4% (198/371) were considered complex, including 126 chronic total occlusion (CTO) procedures. Compared to the previous 12 months, there was a significant increase in the number and complexity (median J-CTO score 2.1 vs. 1.3, p .04) of CTOs performed during the study period. CTO procedural characteristics and complication rates were similar to those previously published in large U.S. registries, with technical success in 93.4% (118/126) and procedural success in 85.7% (108/126). CONCLUSION: Following dedicated CHIP fellowship training and establishment of a formal CHIP program, procedural success and complication rates were achieved similar to those published in prior studies evaluating CTO PCI at high volume centers.

Improvement of clinical outcome in patients with ST-elevation myocardial infarction between 1999 and 2016 in China: The Prospective, Multicentre Registry MOODY study.

BACKGROUND: Reports showed no change of 7-day mortality after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) between 2001 and 2011 in China. National rolling one-year interventional standardized training programme began in September 2009. However, the improvement in clinical outcome following STEMI PCI after 2011 remains unclear. METHODS AND RESULTS: This multicentre MOODY registry study aimed to analyse the clinical improvement after STEMI PCI. Of a total of 9265 acute MI patients registered from 24 centres, 3142 STEMIs having a first medical contact time ≤12 hours and undergoing primary PCI were assigned to the Pre Group (n = 1014, between March 1999 and October 2010) or the Post Group (n = 2128, between 2010 November and 2016 October). The primary endpoint was in-hospital cardiac death. Study endpoints were also compared between trained and untrained operators and between experienced (≥50 primary PCIs/year) and inexperienced personnel. In-hospital death after PCI was 3.0% in the Pre Group, significantly higher than 1.6% in the Post Group (P = .035). The improvements in clinical outcome after PCI between the 2016 and Pre Groups were stably sustained through one-year follow-up. The significant reduction for in-hospital death was noted when primary PCI was performed by trained (1.4% vs 5.4%, P < .001) or experienced (2.7% vs 4.8%, P = .001) operators, compared to untrained or inexperienced operators, respectively. Inclusion of the untrained operator into the conventional risk model strongly enhanced the prediction for endpoints. Age, Killip Class 3, diabetes, trans-radial approach and system delay were five predictors of in-hospital death after primary PCI. CONCLUSION: PCI for STEMI by a trained and experienced operator was associated with significant reduction of in-hospital death. Our results strongly warrant the need for promoting the current system response and patient education.

Effect of a nurse-led individualized self-management program for Chinese patients with acute myocardial infarction undergoing percutaneous coronary intervention.

BACKGROUND: The study of the development and evaluation of self-management intervention among patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) is lacking, especially in China. AIM: To examine the effects of a nurse-led individualized self-management program (NISMP) on health behaviors, control of cardiac risk factors, and health-related quality of life (HRQoL) among patients with AMI undergoing PCI. METHODS: The quasi-experimental design included a convenience sample of 112 participants recruited from a tertiary hospital in China. The participants were assigned to the control group (n = 56) or the intervention group (n = 56). The intervention group underwent the NISMP, which includes six group-based education sessions, a face-to-face individual consultation, and 12-month telephone follow-ups. Data were collected at baseline and at the end of the 12-month program using the Health Promotion Lifestyle Profile, the Risk Factors Assessment Form, and the Short Form 36-item Health Survey. RESULTS: The baseline sociodemographic and clinical characteristics of the two groups were comparable (p > 0.05). After the 12-month intervention, the health behaviors and HRQoL of the participants in the intervention group had significantly improved (p < 0.05 for both) compared to those of the control group. Compared to the control group, the participants in the intervention group also reported significantly better control of cardiac risk factors including smoking (χ2 = 4.709, p = 0.030), low-density lipoprotein (χ2 = 4.160, p = 0.041), body mass index (χ2 = 3.886, p = 0.049) and exercise (χ2 = 10.096, p = 0.001). CONCLUSION: The NISMP demonstrated positive effects on health behaviors, control of cardiac risk factors, and HRQoL among Chinese patients with AMI undergoing PCI.

The Impact of Formal Training and Certification on the Relationship Between Volume and Outcomes in Percutaneous Coronary Interventions.

BACKGROUND: Little data are available on the impact of formal training and certification on the relationship between volumes and outcome in percutaneous coronary interventions (PCIs).The objective of this report is to study the relationship between PCI volume and outcome for a formally trained interventional cardiologist who is certified by the American Board on Internal Medicine - Interventional Cardiology subspecialty board. METHODS: The operator witnessed 3 different PCI volumes/yr over a 15-year practice period (2000-2014): <50 PCI/yr (years 2000-2006; n = 179), 50-100 PCI/yr (years 2007-2010; n = 256), and >100 PCI/yr (years 2011-2014; n = 427). Angiographic and procedural success rates were compared between the 3 volume groups, as well as in-hospital cardiovascular events (death, recurrent myocardial infarction, repeat PCI, stroke, or coronary artery bypass surgery). RESULTS: The in-hospital mortality rate throughout the study period was 0.8% and was not statistically significant among the 3 volume groups. There was also no significant difference among the 3 groups with respect to recurrent myocardial infarction or repeat PCI. There was a slightly higher rate of same-stay elective coronary artery bypass grafting in the early low-volume period compared with the other 2 groups (2.2% vs. 0.8% vs. 0.2%; P = 0.04). The overall angiographic and procedural success rates were 97.3% and 96.5%, and they were not significantly different among the 3 groups. CONCLUSIONS: Our study shows that the angiographic and procedural success rates of PCI, as well as the in-hospital mortality, do not seem to be dependent on the annual volume for formally trained and certified interventional cardiologists.

Should Technical and Anatomical Difficulties Discourage Operators From Embarking on Transradial Access for Percutaneous Coronary Intervention?

BACKGROUND: Use of the radial approach for PCI procedures is increasing due to lower rates of access-site complications/bleeding, and patient preference. However, femoral operators switching may be discouraged by the learning curve and by anatomical issues that may complicate the procedure. We aimed to define the frequency of anatomic variants and success rates during transradial access for PCI. METHODS: We retrospectively analyzed 2588 cases of PCI attempted by the radial route; radial/brachial and subclavian angiography was performed when obstructions were encountered. Presence of anatomical variants, spasm, and ability to complete the procedure were noted. RESULTS: Radial procedures were successfully completed in 2741/2588 cases (98.2%); in the remainder, switching to femoral approach was necessary. Local arteriography was performed in 221/2588 cases (8.5%) due to difficulties encountered; of these, 131/221 difficulties (59%) were due to problems at the radial arterial level, 58/221 (26%) were due to problems at the subclavian level, and 32/221 (15%) were due to problems at brachial arterial sites. Extreme radial tortuosity (18%) and radial loop (20%) had relatively lower rates of success followed by subclavian tortuosity (73%). Females had significantly higher incidences of radial spasm (6% vs 1.9% in men; P<.001), radial tortuosity (3.4% vs 1.7% in men; P=.01), and subclavian tortuosity (3.8% vs 1.8% in men; P<.01). CONCLUSION: Inability to successfully complete invasive procedures via the radial approach is uncommon. Even when encountered, most difficulties can be overcome with the use of vasodilators and hydrophilic wires. These data provide reassurance for would-be radial converts that the learning curve may not be as steep as envisaged.

Novel proctorship effectively teaches interventionists coronary artery chronic total occlusion lesions.

BACKGROUND: Interventionists' experience and skills are essential factors for successful chronic total occlusion-percutaneous coronary intervention (CTO-PCI). However, the construction of theoretical strategy independent from interventionists' procedure may also improve it. We sought to assess the feasibility of CTO-PCI using an educational system supported by a single expert proctor. METHODS: A total of 160 patients underwent CTO-PCI between 2009 and 2016 at 92 Japanese centers in the Hands-on proctorship project. The CTO-PCI strategy was discussed with all participants and their specialists, before and during the procedure. We divided patients into 2 groups based on the CTO-PCI experience of their interventionist: (1) the less experienced group (CTO-PCI ≤50 cases, n=65) and (2) the more experienced group (CTO-PCI >50 cases, n=95). Baseline characteristics, procedural complications, and clinical outcomes were compared between groups. RESULTS: No significant differences in patient age, sex, prevalence for coronary risk factors, and lesion complexity was observed between groups. The retrograde approach was used equivalently between groups (55.4% vs. 60.0%, p=0.56), and procedural success rates were similar (96.9% vs. 90.5%, p=0.12). The rate of proctor's bailout for recanalization were not frequent between groups (4.6% vs. 5.3%, p=0.85). No procedure-related mortality was noted in either group. In addition, no significant differences in procedural cardiac complications, including coronary dissection, perforation, or tamponade, were observed between groups (10.8% vs. 14.7%, p=0.47). CONCLUSIONS: The expert-supported CTO-PCI maintained high success rates regardless of interventionists' experience. This highlights the importance of theoretical strategy for the management patients undergoing CTO-PCI.

Building Blocks of Structural Intervention: A Novel Modular Paradigm for Procedural Training.

Structural heart disease is a rapidly evolving field, and approaches to procedural training are not standardized. We describe a novel modular approach to procedural training that considers each procedure as a series of building blocks that may be taught and assessed separately. Ten key structural heart disease building blocks can be identified, which, when combined with the cognitive skills of structural intervention and device-specific training, allow appropriate planning and implementation of structural procedures. Structural procedures require careful navigation of the aorta, left atrium, and right heart, including detailed understanding of relational anatomy. Component blocks include large bore vascular access, navigation within the left atrium, occlusion, snaring, and 3-dimensional relational anatomy. These building blocks also provide the foundation for new procedures through innovative use of the skill sets and devices to approach new clinical problems. The addition of device-specific training may be provided via proctoring and industry support. Using this approach, competency in less common procedures may be achieved and maintained. We discuss each building block in detail, approaches specific to the structural heart disease patient, the need for cross-discipline training, and empirical recommendations for training using this approach. We postulate that this new paradigm may be the preferred approach for training and assessment of structural heart disease interventional skills.