Author + information
- Published online December 3, 2018.
- Dee Dee Wang, MD∗ (, )
- Jeffrey Geske, MD,
- Andrew D. Choi, MD,
- Omar Khalique, MD,
- James Lee, MD,
- Kimberly Atianzar, MD,
- Isaac Wu, MD,
- Philipp Blanke, MD,
- Sameer Gafoor, MD and
- João L. Cavalcante, MD
- ↵∗Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Clara Ford Pavilion, 432, Detroit, Michigan 48202
The rise of transcatheter structural heart interventions has increased the demand for physicians with specific, procedural-based, advanced cardiac imaging training. Structural heart disease (SHD) interventional imagers are an integral part of the heart team by ensuring high-risk procedures are appropriate, feasible, and safely executed. Recognition of SHD interventional imaging as a subspecialty of cardiac imaging is necessary and should be accompanied by formalized training programs. However, the relative novelty of this subspecialty and the poorly defined training requisites and skillsets are important barriers to this goal. Furthermore, there is a significant mismatch between the amount of time needed to plan and guide complex SHD procedures and current reimbursement attributed to the SHD imager. This perspective piece is put forth based on the experience of a group of early career physicians who have effectively created and run academic Structural Heart Imaging programs. To succeed in this career path, we describe the many pathways SHD imagers can advocate for themselves and the recognition of the unique requirements needed to thrive in this emerging subspecialty within the field of cardiology and cardiac imaging.
The number of devices and types of SHD interventions continues to expand. Procedures such as transcatheter mitral or tricuspid repairs, or paravalvular leak closures, are imaging intensive. In pre-procedural planning, SHD imagers serve as adjudicators (1). They must synthesize and review serial imaging studies from each potential patient before initial clinical presentation to ensure the necessary imaging evaluation has been completed, and to accurately account and justify the need for transcatheter intervention for patient’s clinical symptoms, and presence or absence of progressive changes in cardiac function, chamber size, and valvular pathology. Procedural success requires SHD imagers to be affable, agile, and able to rapidly integrate clinical information with imaging findings (fluoroscopy and transesophageal echocardiography). Unlike traditional open-heart surgery, in which imaging is often only called on to judge the efficacy of a procedure after surgical implantation has been completed, transcatheter therapies require the SHD imager to be an integral part of the interventions. Excellent knowledge of and ability to dynamically integrate multiple imaging modalities (i.e., in-depth spatial-understanding of 2-dimensional echocardiography, 3-dimensional transesophageal echocardiography, 4-dimensional computed tomography, and fluoroscopic overlay projections of cardiac anatomy in multiple angle projections) with hemodynamic interpretation to the imaging findings for the implanting team is critical to procedural success and forms the base of this subspecialty field of SHD imaging. Communication of imaging results during a procedure is critical and SHD imagers must be timely, succinct, and clear in their communication to all members of the team, including interventional cardiologists, cardiac surgeons, electrophysiologists, anesthesiologists, or industry clinical field specialists. Establishing common terminology for imaging landmarks with the entire team is critical before the procedure to facilitate communication and prevent unnecessary case delays or intraprocedural confusion. Post-procedurally, SHD imagers must be able to correlate imaging findings with intraprocedural results and evaluate for potential device complications. Exposure and familiarity to a variety of SHD interventions is required to generate sufficient imaging experience, and to avoid or anticipate complications and to facilitate procedural safety during high-risk transcatheter interventions. An SHD imager who has developed these unique skillsets (Table 1) is fully embedded in the SHD team (1).
SHD imagers must continue to advocate for recognition of the unique requirements needed to thrive in this emerging subspecialty. Sustainability within an SHD imaging career track is directly dependent on fair productivity metrics. Advocacy for SHD imaging reimbursement is in its infancy. In the United States, the Centers for Medicare and Medicaid Services hospital reimbursement has focused on payment for device cost and cost of device implantation (2). In this model, relative value units, a measure of value in the U.S. Medicare reimbursement formula for physician services, neither reflects the time or skillset required to successfully plan and guide complex SHD interventions, nor accounts for the health hazards and adverse effects on the SHD imager (i.e., radiation exposure) (3). A salary-based model is more likely to facilitate a successful SHD imaging career, as opposed to a relative value units productivity model. Until societal guidelines are established for this emerging field, differential procedural codes will likely continue to fall short of appropriate physician time allocation and reimbursement for the SHD imager.
The presence of a skilled SHD imager is critical to the growth and success of any high-volume SHD program. Time dedicated to appropriate synthesis of serial imaging studies, performance of high-risk intraprocedural imaging guidance to fit the needs of the operators, and correlation of post-procedural imaging with clinical factors leads to better patient outcomes. Integrated patient-centric teamwork and improved outcomes directly contribute to the “halo effect” of medicine, generating increased SHD program visibility and referrals to institutions with safer outcomes and more experienced operators. Next to every successful SHD interventional cardiologist there is a skilled interventional SHD imager, equally dedicated to exceptional patient care and experience.
Please note: Dr. Wang is a consultant to Edwards Lifesciences, Boston Scientific, and Materialise. Dr. Geske is a consultant to MyoKardia, Inc. Dr. Khalique is on the Speakers Bureau for Edwards Lifesciences. Dr. Blanke is a consultant to Edwards Lifesciences, Tendyne, Neovasc, and Circle Cardiovascular Imaging. Dr. Gafoor is a consultant to Medtronic, Boston Scientific, Abbott, Philips, and Siemens. Dr. Cavalcante has research grant support from Medtronic and consultant for Medtronic and Mitralign. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- ↵Little S. Putting together a structural heart program from the imagers perspective. 2018. Available at: http://asecho.org/wordpress/wp-content/uploads/2018/01/Little-Putting-Together-a-Structural-Heart-Program-from-the-Imagers-Perspective.pdf. Accessed May 2018.
- ↵2017 MITRACLIP Physician Coding and Payment Guide. Physician Coding and Payment Guide 2017. Available at: https://www.vascular.abbott/content/dam/bss/divisionalsites/av/docs/reimbursement/AP2940721-US-Mitraclip-Physician-Coding-Payment-Guide.pdf. Accessed June 2018.
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