Curriculum interventional cardiology—Austria

The field of interventional cardiology is rapidly evolving and requires an advanced set of knowledge and skills. The present Austrian core curriculum of interventional cardiology provides standards for training in interventional cardiology. It is based on the core curriculum for percutaneous cardiovascular interventions of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) [1] and adapted to fit local requirements of the Austrian healthcare system. Other documents relevant for this curriculum include the European Society of Cardiology (ESC) core curriculum for the general cardiologist [2] and a statement endorsed by the American College of Cardiology and the American Heart Association on advanced training in interventional cardiology [3]. Also, the curricula for interventional training in cardiology by the German Society of Cardiology [4] and by the Swiss Society of Cardiology [5] were taken into account.

Physicians licensed by the Austrian Medical Chamber are eligible to undergo training. The trainee must have the necessary level of linguistic skills in German to enable communication with patients and colleagues. Trainees should be exposed to various aspects of interventional cardiology, including inpatient/outpatient and emergency/elective care. These are listed in Table 1.

The training program should be clearly defined for each trainee, with regular review of their individual progress.

Learning objectives represent specific aims the trainee has to reach by the end of the curriculum. These objectives are divided into three groups: 1) knowledge, 2) skills and 3) behaviors and attitudes.

Knowledge describes the requirements for trainees. The present curriculum defines the respective chapters for the intended learning goals. This knowledge includes disease pathobiology and concepts for treatment. It is important to highlight the need for long-term learning because even basic concepts of our understanding of a disease are subject to change based on emerging new evidence.

Skills represent the practical application of knowledge and are acquired from experience and training. These include the solution of practical challenges, clinical decision making, and performing specific procedures.

Behaviors and attitudes represent a commitment to perform excellent clinical care for the patient, taking ethical considerations and patient preferences into account.

It is important to highlight that first-hand exposure and practical experience are essential in learning special techniques. The number of cases performed by a trainee is certainly of importance but is not an exclusive measure of performance. Rather than a specific case volume needed to reach a certain competence level, such competence levels are defined for the individual progress of the trainee:

The anatomy and physiology of the cardiovascular system includes the structure and function of the heart, arteries, veins, microcirculation, valves and further, the pathophysiology of cardiovascular diseases such as atherosclerosis, hypertension, valvular dysfunction and heart failure. The ESC provides a wide range of information represented in the EECC curriculum. This knowledge can be obtained in different national courses.

Various diagnostic modalities are used in interventional cardiology, including electrocardiography (ECG), echocardiography, cardiac catheterization, angiography, intravascular ultrasound (IVUS), optical coherence tomography (OCT) and invasive physiological assessments (e.g., fractional flow reserve, FFR). Several national and ESC-organized courses impart this knowledge.

Appropriate medication is indispensable for interventional cardiology. The safe use of antiplatelet agents, anticoagulants, vasodilators and vasoconstrictors is necessary and their potential complications must be known as well accurately managed, for example, bleeding and contrast-induced nephropathy.

The diagnosis and management of coronary artery disease (CAD), including chronic coronary syndrome (CCS), acute coronary syndromes (ACS), and chronic total occlusions (CTOs) are cornerstones of interventional cardiology. This field contains the various treatment options for CAD, including percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and optimal medical therapy.

The diagnosis and management of structural heart disease, including valvular heart disease, congenital heart disease and left atrial appendage occlusion (LAAO), are of growing interest and new technologies are regularly implemented. For example, transcatheter aortic valve replacement (TAVR), mitral and tricuspid valve repair and replacement as well as closure of septal defects, have expanded the scope of interventional cardiologists.

Also, part of the EAPCI curriculum is the diagnosis and management of peripheral arterial disease (PAD), including atherosclerosis, acute limb ischemia and chronic limb ischemia, including various treatment options for PAD, such as angioplasty, stenting and atherectomy.

For a proper management of different complications of percutaneous cardiovascular interventions clinical knowledge and skills are needed. Additionally, a thorough reflection on any complications within the interventional team is crucial for effective management. Typical complications include bleeding, vascular access site complications, contrast-induced nephropathy and injury of coronary arteries.

In addition to striving for maximum patient safety, due to the nature of working in a radiation area, personal safety is also extremely important. Therefore, the principles of radiation safety in interventional cardiology, including the risks associated with ionizing radiation, radiation protection measures and dose reduction techniques must be trained.

The field of interventional cardiology is constantly evolving and to keep up with these changes it is necessary to rely on research, registries and clinical trials to evaluate the safety and efficacy of new techniques and devices.

Diagnostic coronary angiography is the first clinical and practical milestone on the way to becoming an independent interventional cardiologist. Prerequisites for starting training in cardiac catheterization comprise profound knowledge and understanding of the human vasculature (in particular coronary anatomy), indications, contraindications, potential complications and pitfalls of the procedure. Moreover, the trainee should already be able to analyze and interpret angiograms of normal and anomalous coronary arteries as well as those of coronary artery bypass grafts. Fortunately, the complication rates of diagnostic coronary angiography are low; however, severe acute complications, such as anaphylaxis, vasospasm, embolization, hemodynamic compromise, arrhythmia and vessel damage can still occur. As hemodynamic measurements, which require wiring of a coronary artery, are nowadays an important and increasingly applied part of many diagnostic procedures, even coronary artery dissection and perforation can very rarely occur during noninterventional cardiac catheterization. Finally, while severe bleeding complications are almost nonexistent in cases of radial artery access, they can become a major issue when femoral artery access is needed, specifically in older and frail patients. Therefore, an operator who is only cleared for diagnostic coronary angiography always requires a readily available back-up by a senior cardiologist who is proficient in interventional cardiology and able to manage complex complications as well as iatrogenic consequences of cardiac catheterization.

Institutions with a 24‑h service for primary percutaneous coronary intervention (PPCI) require on-call staff who are proficient in invasive management of acute coronary syndromes including all severity grades, such as cardiogenic shock and cardiorespiratory arrest. Physicians who cover the on-call service need to be independent operators with extensive experience in PPCI and be able to tackle possible complications of myocardial infarction as well as iatrogenic consequences of cardiac interventions. Based on the EAPCI document [1] at the end of training the trainee should be able to interpret clinical information, make treatment decisions and perform the technique or procedure and manage related complications as the first operator, without direct supervision of a senior interventional cardiologist (competence level IV). The competence level IV listed in Table 2 according to the current recommendations of EAPCI should also be met when performing on-call services without the back-up of senior operators.

In particular, the independent on-call operator should be ready to tackle the following challenges: acquiring peripheral arterial access from the radial or femoral artery can be challenging in patients who are restless or in shock. Intubation of the left or right coronary artery during cardiopulmonary resuscitation may require unusual C‑arm positions or projection angles. Acutely occluded coronary arteries in patients with ST-segment elevation myocardial infarction are mostly based on ruptured previously nonstenotic soft plaques and are usually easier to cross than severely calcified complex lesions in non-ST-segment elevation myocardial infarction or chronic total occlusions; however, bifurcation lesions and complex coronary anatomies including coronary artery by-pass graft interventions may be needed in acute settings. Hemodynamic compromise and arrhythmia can occur during PPCI and require a prompt response. Placement of a temporary pacing wire in the right ventricle from a femoral or jugular approach is an obligatory skill for on-call operators as well as subxyphoidal pericardiocentesis in cases of pericardial effusion or tamponade. The transition of an interventional cardiologist in training to an independent on-call operator may require a phase in which a senior interventional colleague is available as a secondary back-up if the primary physician encounters an overwhelming situation. If a situation cannot be handled by PPCI in a center without on-site cardiac surgery a formal cooperation with a tertiary center is mandatory.

Competence level V includes the ability to teach and supervise the technique or procedure to junior colleagues. While a structured academic program may not be feasible in all centers, teaching of junior colleagues including an adequate teaching environment is important for all centers involved in training of interventional cardiologists and is explained in more detail in “Chap. 7”.

In centers where hemodynamically unstable patients are treated or which serve as back-up for other centers, operators should be additionally able to perform more advanced procedures (competence level III for training according to current EAPCI recommendations) as listed in Table 3.

Supplemental table 1 lists extended skills (competence levels I and II) for procedures not performed in all centers. To obtain these skills, centers are encouraged to provide structured training opportunities, such as clinical rotation to other centers or training courses.

Quality management is crucial for an interventional training program. Monthly case discussions including morbidity and mortality conferences provide a structured feedback on the quality of interventions. Furthermore, a radiation safety program is required. Regular and standardized electronic data acquisition with an annual measure of procedural volume and performance measures is an additional important tool for the transparent monitoring of quality. These data should be the basis of an ongoing research program including participation in randomized controlled trials. Journal clubs should form a structured opportunity to critically appraise new evidence and current guidelines. Compliance with further local standards including minimum procedural volumes is a further prerequisite for a training center.

Up to date equipment is required to ensure the interventional safety and to perform state of the art interventions including calcium-modifying methods, intravascular imaging and invasive physiological assessment. Further equipment including percutaneous mechanical circulatory support devices is encouraged for advanced centers [1]. These should also provide the infrastructure for structural procedures.

The basis for a high-quality training in interventional cardiology is supervision and mentoring. The number of (full-time equivalent) trainees should not exceed the number of trainers. Every training center should have at least 2 experienced trainers with an experience of more than 5 years exclusively dedicated to interventional cardiology with proficiency in interventional skills mentioned in “Part 1”. There should be one dedicated educational mentor for each trainee being responsible for the implementation of the structured training for each individual trainee. This may include the keeping of a logbook, coordination of external rotations, attendance at courses and congresses and organizing structured learning. All interventional cardiologists at the center should support the interventional training as clinical trainers. Educational mentors should be supervised by the catheter laboratory director who is responsible for the achievement of learning objectives of each trainee. When the catheter laboratory director is the mentor another trainer should be involved in the training of the respective trainee.