Background Right atrial appendage (RAA) thrombosis is exceedingly rare, is usually found incidentally on imaging, and carries a high thromboembolic risk. Case Summary An 83-year-old man with chronic atrial fibrillation complicated by previous bleeding episodes on anticoagulation and managed most recently with a WATCHMAN device presented after a mechanical fall. Imaging work-up revealed a new incidental finding of RAA thrombosis. Discussion This case highlights an uncommon thrombotic finding and that atrial fibrillation is a biatrial disease. Occlusion of the left atrial appendage does not eliminate the risk of right-sided thrombosis. Take-Home Messages Thromboembolic prevention in patients with chronic atrial fibrillation is challenging. Left atrial appendage occlusion devices, although effective, do not eliminate the risk of RAA thrombosis, as atrial fibrillation is a biatrial disease.

This paper describes the role of cardiovascular magnetic resonance (CMR) imaging in assessing patients with mitral valve disease. Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases. It often progresses without significant symptoms, leading to left ventricular overload, dysfunction, frequent decompensated heart failure episodes, and excess mortality. Cardiovascular magnetic resonance assessment is recommended for MR when routine ultrasound imaging information is insufficient or discordant. A well-planned CMR can provide an in-depth assessment of the mitral valve apparatus, leaflet morphology, and papillary muscles. In addition, it can precisely inform the impact of MR on left atrial and ventricular remodelling. The review aims to highlight established and emerging techniques for morphological assessment, flow assessment (including regurgitation and stenosis), myocardial assessment, and haemodynamic assessment of mitral valve disease by CMR. It also proposes a simplified clinical flow chart for CMR assessment of the mitral valve.

AIMS:Studies suggest that females have worse post-surgical left ventricular (LV) reverse remodelling and clinical outcomes than males in primary mitral regurgitation (MR). These studies were retrospective, used linear dimensions of the LV, and did not account for MR severity. This study is to determine if there are sex differences with respect to pre- and post-surgical LV remodelling and clinical outcomes. METHODS AND RESULTS:There were 143 prospectively enrolled patients (60 ± 12 years, males 70%) with primary MR who underwent pre- and post-surgical CMR evaluation. Clinical outcomes were ascertained by patient interview and chart review. Adverse outcomes were a composite of heart failure hospitalisations, need for reoperation, and death. MR volume (MRV) and MR fraction (MRF) were independent predictors of pre-surgical LV end-diastolic volume (LVEDV) and post-surgical change in LVEDV and sex was not an independent predictor. For each 1 mL increase in MRV there was an increase in pre-surgical LVEDV of 0.93 mL for males and 1.0 mL for females and a post-surgical decrease in LVEDV of 1.1 mL for males and 1.0 mL for females. Over a mean follow-up period of 3.3 ± 2.6 years there were 10 (7%) patients with adverse events and no significant difference in the event rate between males and females (6% vs. 11%, P = 0.5). CONCLUSION:In primary MR there were no sex differences in the degree of pre-surgical LV dilatation or post-surgical LV reverse remodelling. There were no sex differences in adverse clinical events. These findings highlight that males and females benefit similarly from mitral valve surgery and females should be referred for mitral valve surgery when appropriate.(Clinical Trials: NCT04038879, NCT03012178, and NCT04051411).

Cardiac magnetic resonance (CMR) quantifies aortic regurgitation (AR) and left ventricular (LV) remodeling. We aimed to evaluate the association of baseline CMR findings with reverse remodeling after aortic valve surgery and likelihood of normalization of LV volume/function is not clear. In a multicenter observational study of AR patients undergoing pre- and post-operative CMR, we evaluated AR severity and LV volumes on baseline CMR with reverse remodeling evaluated by LV volumes and function after surgery. We identified chronic AR patients enrolled in institutional databases at 3 centers between 2011 and 2022 with pre- and post-operative CMR. We also prospectively enrolled patients with AR and preop CMR to undergo a research CMR post-operatively at Houston Methodist Hospital during the year 2021. We studied 55 patients in total (17 enrolled prospectively), median age 57.0 (45.4–64.2) years, 87

In the ACC/AHA guidelines, the presence of symptoms plays a central role in determining timing surgery in primary mitral regurgitation (MR). Studies have shown a disconnect between the severity of MR and symptoms. The purpose of this study is to assess risk factors for symptoms in patients with chronic primary MR. There were 430 patients with degenerative MR and preserved left ventricular function who underwent cardiovascular magnetic resonance (CMR). MR volume (MRV) and MR fraction (MRF) were categorized as per the ACC/AHA guidelines. Patients were divided into three groups based on category of MRV and MRF: (1) MRV category > MRF category (V > F), (2) MRV = MRF category (V = F), and (3) MRV < MRF category (V < F). Symptoms were defined as shortness of breath, fatigue, and decreased exercise capacity and extracted from chart review. There were 134 (38%) patients who reported symptoms. Based on MRV, 236 (55%), 125 (29%), and 69 (16%) patients had mild moderate, and severe MR respectively. Based on MRF, 257 (60%), 130 (30%), and 43 (10%) patients had mild moderate, and severe MR respectively. There was no increase in the prevalence of symptoms with worsening MRV severity (39%, 40% and 30% for mild, moderate and severe MRV respectively, p = 0.4). There was a trend for increase in the prevalence of symptoms in patients with severe MRF (35%, 40% and 54% for mild, moderate and severe MRF respectively, p = 0.054). There was a significant increase in the prevalence of symptoms when comparing V > F, V = F, and V < F (20%, 40%, and 72% respectively, p < 0.0001). On multivariable analysis, risk factors for symptoms were age, female sex, MRF, and having a V < F. In patients undergoing CMR with degenerative MR the prevalence of symptoms do not increase with worsening MRV. MRV and MRF were not risk factors for symptoms but having V < F was a risk factors for the presence of symptoms. These findings suggest that symptomatic patients with MR may have other pathology which may be responsible for their symptoms. Further studies are needed to better characterize the relationship between MR severity and symptoms.

HomeCirculation: Cardiovascular InterventionsVol. 16, No. 42023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUB2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions): A Report of the ACC Competency Management Committee Theodore A. Bass, J. Dawn Abbott, Ehtisham Mahmud, Sahil A. Parikh, Jamil Aboulhosn, Mahi L. Ashwath, Bryan Baranowski, Lisa Bergersen, Hannah I. Chaudry, Megan Coylewright, Ali E. Denktas, Kamal Gupta, J. Antonio Gutierrez, Jonathan Haft, Beau M. Hawkins, Howard C. Herrmann, Navin K. Kapur, Sena Kilic, John Lesser, Lin C. Huie, Rodrigo Mendirichaga, Vuyisile T. Nkomo, Linda G. Park, Dawn R. Phoubandith, Nishath Quader, Michael W. Rich, Kenneth Rosenfield, Saher S. Sabri, Murray L. Shames, Stanton K. Shernan, Kimberly A. Skelding, Jacqueline Tamis-Holland, Vinod H. Thourani, Jennifer A. Tremmel, Seth Uretsky, Jessica Wageman, Frederick Welt, Brian K. Whisenant, Christopher J. White and Celina M. Yong Theodore A. BassTheodore A. Bass Search for more papers by this author , J. Dawn AbbottJ. Dawn Abbott Search for more papers by this author , Ehtisham MahmudEhtisham Mahmud Search for more papers by this author , Sahil A. ParikhSahil A. Parikh Search for more papers by this author , Jamil AboulhosnJamil Aboulhosn *Society for Cardiovascular Angiography and Interventions representative. Search for more papers by this author , Mahi L. AshwathMahi L. Ashwath Search for more papers by this author , Bryan BaranowskiBryan Baranowski †Heart Rhythm Society representative. Search for more papers by this author , Lisa BergersenLisa Bergersen ‡American Heart Association representative. Search for more papers by this author , Hannah I. ChaudryHannah I. Chaudry Search for more papers by this author , Megan CoylewrightMegan Coylewright Search for more papers by this author , Ali E. DenktasAli E. Denktas Search for more papers by this author , Kamal GuptaKamal Gupta §Society for Vascular Medicine representative. Search for more papers by this author , J. Antonio GutierrezJ. Antonio Gutierrez Search for more papers by this author , Jonathan HaftJonathan Haft Search for more papers by this author , Beau M. HawkinsBeau M. Hawkins *Society for Cardiovascular Angiography and Interventions representative. Search for more papers by this author , Howard C. HerrmannHoward C. Herrmann *Society for Cardiovascular Angiography and Interventions representative. Search for more papers by this author , Navin K. KapurNavin K. Kapur ¶Heart Failure Society of America representative. Search for more papers by this author , Sena KilicSena Kilic Search for more papers by this author , John LesserJohn Lesser #Society of Cardiovascular Computed Tomography representative. Search for more papers by this author , Lin C. HuieLin C. Huie Search for more papers by this author , Rodrigo MendirichagaRodrigo Mendirichaga Search for more papers by this author , Vuyisile T. NkomoVuyisile T. Nkomo Search for more papers by this author , Linda G. ParkLinda G. Park ‡American Heart Association representative. Search for more papers by this author , Dawn R. PhoubandithDawn R. Phoubandith Search for more papers by this author , Nishath QuaderNishath Quader **American Society of Echocardiography representative. Search for more papers by this author , Michael W. RichMichael W. Rich Search for more papers by this author , Kenneth RosenfieldKenneth Rosenfield Search for more papers by this author , Saher S. SabriSaher S. Sabri ††Society of Interventional Radiology representative. Search for more papers by this author , Murray L. ShamesMurray L. Shames ‡‡Society for Vascular Surgery representative. Search for more papers by this author , Stanton K. ShernanStanton K. Shernan §§Society of Cardiovascular Anesthesiologists representative. Search for more papers by this author , Kimberly A. SkeldingKimberly A. Skelding ‡American Heart Association representative. Search for more papers by this author , Jacqueline Tamis-HollandJacqueline Tamis-Holland Search for more papers by this author , Vinod H. ThouraniVinod H. Thourani ∥∥Society of Thoracic Surgeons representative. Search for more papers by this author , Jennifer A. TremmelJennifer A. Tremmel *Society for Cardiovascular Angiography and Interventions representative. Search for more papers by this author , Seth UretskySeth Uretsky ¶¶Society for Cardiovascular Magnetic Resonance representative. Search for more papers by this author , Jessica WagemanJessica Wageman Search for more papers by this author , Frederick WeltFrederick Welt Search for more papers by this author , Brian K. WhisenantBrian K. Whisenant Search for more papers by this author , Christopher J. WhiteChristopher J. White Search for more papers by this author and Celina M. YongCelina M. Yong ‡American Heart Association representative. Search for more papers by this author Originally published16 Feb 2023https://doi.org/10.1161/HCV.0000000000000088Circulation: Cardiovascular Interventions. 2023;16Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 16, 2023: Ahead of Print Table of ContentsPreamble1. Introduction...2051.1. Document Development Process...2051.1.1. Writing Committee Organization...2051.1.2. Document Development and Approval...2051.2. Background and Scope...2061.2.1. Evolution of Interventional Cardiology...2061.2.2. Levels of Training...2061.2.3. Methods for Determining Procedural Numbers...2072. General Standards...2072.1. Coronary Interventions...2072.1.1. Faculty...2072.1.2. Facilities...2072.1.3. Equipment...2082.1.4. Additional Resources...2082.2. Peripheral Vascular Interventions...2082.2.1. Faculty...2082.2.2. Facilities...2082.2.3. Equipment...2092.2.4. Additional Resources...2092.3. Structural Heart Interventions...2092.3.1. Faculty...2092.3.2. Facilities...2092.3.3. Equipment...2102.3.4. Additional Resources...2103. Training Components...2103.1. Coronary Interventions...2103.1.1. Didactic Program...2103.1.2. Clinical Experience...2103.1.3. Hands-On Procedural Experience...2113.1.4. Diagnosis and Management of Emergencies and Complications...2113.1.5. Diagnosis and Management of Less Common Clinical Conditions and Syndromes...2123.2. Peripheral Vascular Interventions...2133.2.1. Didactic Program...2133.2.2. Clinical Experience...2133.2.3. Hands-On Procedural Experience...2143.2.4. Diagnosis and Management of Emergencies and Complications...2143.2.5. Diagnosis and Management of Less Common Clinical Conditions and Syndromes...2153.3. Structural Heart Interventions...2153.3.1. Didactic Program...2153.3.2. Clinical Experience...2163.3.3. Hands-On Procedural Experience...2163.3.4. Diagnosis and Management of Emergencies and Complications...2173.3.5. Diagnosis and Management of Less Common Clinical Conditions and Syndromes...2183.4. Research and Scholarly Activity...2184. Training Requirements...2184.1. Competency Development and Evaluation...218Table 1. Components and Curricular Milestones for Level III Training in Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions)...219Table 2. Common Professional Behavior Competencies Relevant to All Clinical Cardiovascular Disease Specialists...2264.2. Procedural and Technical Experience...2254.2.1. Training Pathway and Procedural Number Guidance...225Figure 1. Interventional Cardiology Training Pathway...228Figure 2. Building Blocks of the Profession...229Table 3. Minimum Procedural Volume Typically Necessary for the Development and Demonstration of Interventional Cardiology Competencies...230Table 4. Minimum Procedural Volume Typically Necessary for the Development and Demonstration of Interventional Cardiology Competencies for Additional, Optional Adult Congenital Heart Interventions...2314.2.2. Coronary Interventions...2274.2.2.1. Anatomy and Pathophysiology of Coronary Ischemia and Interventions...2274.2.2.2. Periprocedural Assessment and Diagnostic Testing...2284.2.2.3. Consultation and Management...2314.2.2.4. Invasive Diagnostic Testing...2314.2.2.5. Clinical Syndromes...2314.2.2.6. Devices...2324.2.2.7. Procedural Techniques...2324.2.3. Peripheral Vascular Interventions...2334.2.3.1. Lower Extremity PAD...2334.2.3.2. Chronic and Acute Limb-Threatening Ischemia...2334.2.3.3. Renal and Mesenteric Artery Disease...2344.2.3.4. Subclavian, Vertebral, and Carotid Artery Disease; Acute Stroke...2344.2.3.5. Venous Disease...2344.2.3.6. Aortic and Peripheral Artery Aneurysm Disease...2354.2.3.7. Nonatherosclerotic Vascular Disease...2354.2.4. Structural Heart Interventions...2354.2.4.1. Aortic Valve Interventions...2354.2.4.2. Mitral Valve Interventions...2364.2.4.3. Pulmonic Valve Interventions...2364.2.4.4. Tricuspid Valve Interventions...2374.2.4.5. Nonvalvular Structural Heart Interventions...2374.2.4.6. Select Adult Congenital Heart Interventions...2375. Leadership and Administrative Skills...2386. Evaluation of Proficiency...238References...240Appendix 1. Author Relationships With Industry and Other Entities (Relevant)...243Appendix 2. Peer Reviewer Information...247Appendix 3. Abbreviations...249PreambleSince publication of its first Core Cardiovascular Training Statement (COCATS) in 1995,1 the American College of Cardiology (ACC) has defined the knowledge, experiences, skills, and behaviors expected of clinical cardiologists. Subsequent revisions have moved toward competency-based training based on the 6-domain competency structure promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties and endorsed by the American Board of Internal Medicine (ABIM).2,3 The ACC has taken a similar approach to describe the aligned general cardiology lifelong learning competencies that practicing cardiologists are expected to maintain. Many hospital systems now use the 6-domain structure as part of medical staff privileging, peer review, and professional competence assessments.Whereas COCATS and the associated Lifelong Learning Competencies for General Cardiologists4 focus on general clinical cardiology, ACC Advanced Training Statements and associated Lifelong Learning Statements define selected competencies beyond those expected of all cardiologists and that typically require training beyond a standard cardiovascular disease fellowship curriculum. This includes, but is not limited to, those disciplines for which there is an ABIM subspecialty certification. The Advanced Training Statements describe key experiences and outcomes necessary to acquire competency in a defined subspecialty area of cardiology in a structured training program. These are supplemented by Lifelong Learning Statements that address the commitment to sustaining and enriching competency over the span of a career.The ACC Competency Management Committee oversees the development and periodic revision of the cardiovascular training and competency statements. A key feature of competency-based training and performance is an outcome-based evaluation system. Although specific areas of training may require a minimum number of procedures or duration of training to ensure adequate exposure to the range of clinical disorders, the objective assessment of proficiency and outcomes demonstrates the achievement of competency. Evaluation tools include examinations, direct observation, procedure case logs, simulation, conference presentations, and multisource (360°) evaluations. For practicing physicians, these tools also include professional society registry or hospital quality data, peer-review processes, and patient satisfaction surveys. A second feature of competency-based training is recognition that learners gain competency at different rates. For multiyear training programs, assessment of representative curricular milestones during training can identify learners or areas that require additional focused attention.The recommendations in ACC Cardiovascular Training and Lifelong Learning Statements are based on available evidence and, where evidence is lacking, reflect consensus expert opinion. The writing committees are broad-based and typically include early-, mid-, and later-career specialists; general cardiology and subspecialty training directors; practicing cardiologists; people working in institutions of various sizes and in diverse practice settings across the United States; and nonphysician members of the cardiovascular care team. All documents undergo a rigorous process of peer review and public comment. Recommendations are intended to guide the assessment of competence of cardiovascular care providers beginning independent practice as well as those undergoing periodic reviews to ensure that competence is maintained.This Advanced Training Statement addresses the core competencies required of interventional cardiologists, including competencies related to coronary, peripheral vascular, and structural heart interventions. The competencies for coronary interventions in adults serve as the foundation for cardiologists who wish to pursue training in peripheral vascular or structural heart interventions. Furthermore, this statement identifies select competencies for interventional cardiologists who choose to focus their careers on peripheral vascular or structural heart interventions that may be acquired by some advanced trainees either during formal fellowship training or through subsequent training experiences. This document provides examples of appropriate measures for assessing competence in the context of training.The work of the writing committee was supported exclusively by the ACC without commercial support. Writing committee members volunteered their time to this effort. Conference calls of the writing committee were confidential and attended only by committee members. To avoid actual, potential, or perceived conflicts of interest resulting from relationships with industry or other entities (RWI) held by writing committee members or peer reviewers of the document, individuals were required to disclose all current health care–related relationships, including those existing 12 months before initiation of the writing effort. The ACC Competency Management Committee reviewed these disclosures to identify products (currently marketed or under development) pertinent to the document topic. Based on this information, the writing committee was selected to ensure that the majority of members, including the chair, had no relevant RWI. RWI was reviewed at the start of all meetings and conference calls and was updated as changes occurred. Relevant RWI for authors is disclosed in Appendix 1. To ensure transparency, comprehensive RWI for authors, including RWI not pertinent to this document, is available in a Supplemental Appendix. Employment information and affiliations of the peer reviewers are shown in Appendix 2. There are no RWI restrictions for participation in peer review, in the interest of encouraging comments from a variety of constituencies to ensure that a broad range of viewpoints inform final document content. Reviewers are required, however, to disclose all health care–related RWI and other entities, and their disclosure information is posted online. Disclosure information for the ACC Competency Management Committee is available online at https://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documents-task-forces, and the ACC disclosure policy for document development is posted at https://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy.Lisa A. Mendes, MD, FACCChair, ACC Competency Management Committee1. Introduction1.1. Document Development Process1.1.1. Writing Committee OrganizationThe writing committee consisted of a broad range of members representing the ACC, American Heart Association (AHA), Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery, American Society of Echocardiography, Heart Failure Society of America, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Society of Interventional Radiology, Society of Thoracic Surgeons and Society for Vascular Medicine. Each writing committee member performs at least 1 of the following roles: (1) early-, mid-, and later-career interventional cardiologists specializing in coronary, peripheral vascular, structural heart, and adult congenital interventions who work in institutions and catheterization laboratories of various sizes, representing both academic and community-based practice settings; (2) cardiovascular disease and interventional cardiology training program directors, including those who direct structural heart disease (SHD) and peripheral vascular intervention (PVI) programs; (3) specialists representing cardiac anesthesiology, cardiothoracic and vascular surgery, cardiovascular computed tomography (CCT), cardiovascular magnetic resonance (CMR), echocardiography, electrophysiology, general cardiology, geriatric cardiology, heart failure, interventional radiology, pediatric interventions, valvular heart disease, and vascular medicine, as well as those with expertise in quality assurance and systems of care; (4) nurse practitioners, physician associates, and interventional cardiology fellows-in-training; and (5) diversity in geographic region, gender, ethnicity, and race. The writing committee also included physicians experienced in defining and applying training standards according to the 6 general competency domains promulgated by the ACGME and the American Board of Medical Specialties and endorsed by the ABIM. This writing committee met the ACC’s disclosure requirements for relationships with industry, as described in the Preamble.1.1.2. Document Development and ApprovalThe writing committee convened by conference call and email to finalize the document outline, develop the initial draft, revise the draft based on committee feedback, and ultimately approve the document for external peer review. In addition, the committee conducted a survey of interventional cardiology training program directors to obtain additional insight into procedural numbers to consider in writing committee deliberations.The document was reviewed by 24 official representatives from the ACC, AHA, SCAI, American Association for Thoracic Surgery, American Society of Echocardiography, Heart Failure Society of America, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine, and the Society for Vascular Surgery, as well as by 39 additional content reviewers (see Appendix 2). The document was simultaneously posted for public comment from November 5, 2021, to November 29, 2021. A total of 748 comments were submitted on the document, which were reviewed and addressed by the writing committee. A member of the ACC Competency Management Committee served as lead reviewer to ensure a fair and balanced peer review resolution process. Both the writing committee and the ACC Competency Management Committee approved the final document to be sent for organizational approval. The ACC, AHA, and SCAI approved the document for publication with endorsement from the American Association for Thoracic Surgery, American Society of Echocardiography, Heart Failure Society of America, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Society of Thoracic Surgeons, and Society for Vascular Medicine. This document is considered current until the ACC Competency Management Committee revises or withdraws it from publication.1.2. Background and ScopeThe original 1995 ACC recommendations for training in adult cardiology evolved from a Core Cardiology Training Symposium.1 After several iterations, COCATS 4 focuses on trainee outcomes that require delineation of specific components of competency within the subspecialty, definition of the tools necessary to assess training, and establishment of milestones documenting the trainee’s progression toward independent competency.5 Ultimately, the goal is for the trainee to develop the professional skill set to be able to evaluate, diagnose, and treat patients with acute and chronic cardiovascular diseases.Each COCATS 4 document included individual task force reports that address subspecialty areas in cardiology, each of which is an important component in training a fellow in cardiovascular disease. Task Force 10 of that document addressed training in cardiac catheterization and updated previous standards for general cardiovascular training for fellows enrolled in cardiovascular fellowship programs.6 It addressed faculty, facilities, equipment, and additional support. It also addressed training components, including didactic, clinical, and hands-on experience, and the number of procedures and duration of training. Importantly, the COCATS 4 Task Force 10 report did not provide detailed guidelines for advanced training in cardiovascular interventions.This document focuses on training requirements for advanced training in interventional cardiology for adult patients, including coronary, peripheral vascular, and structural heart interventions. For training standards related to pediatric cardiac catheterization (diagnostic and interventional), readers should refer to the SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs “Task Force 3: Pediatric Cardiology Fellowship Training in Cardiac Catheterization” 7 and to the “SCAI Expert Consensus Statement for Advanced Training Programs in Pediatric and Congenital Interventional Cardiac Catheterization.” 81.2.1. Evolution of Interventional CardiologySince the first percutaneous coronary balloon angioplasty was performed in 1977, the evolution of endovascular technologies and procedures has allowed interventional cardiologists to treat an expanding population of patients with cardiovascular disease. This population now includes patients presenting with more complex coronary artery disease (CAD), advanced age, heart failure, peripheral vascular disease, and valvular disease, as well as other forms of SHD. Expanding cognitive and procedural competencies are required for practitioners to safely and effectively treat this increasingly diverse and complex patient population. A focus on cardiovascular health equity through understanding differences in care and outcomes related to patients’ sex, gender, race, ethnicity, and age, as well as social determinants of health are also integral to training a competent interventional cardiologist.9,10 Reevaluation of the current interventional cardiology training curriculum is necessary to adequately address the changing clinical challenges that present in practice.The ABIM requires 3 years of general cardiovascular fellowship in an ACGME-approved program to be eligible to take the certification examination in cardiovascular disease. Successful completion of this fellowship is a requirement for trainees to enter the 1-year interventional cardiology fellowship required for certification in this subspecialty. The competencies developed during general fellowship serve as a strong platform to support the additional knowledge and procedural skills acquired through interventional cardiology training. One year of advanced fellowship training focused predominantly on coronary interventions will not likely provide adequate clinical exposure and procedural experience to achieve competency in all other areas of interventional cardiology. Additional fellowship or postfellowship training will be needed to gain the experience necessary to become a competent, independent expert in most aspects of peripheral vascular or structural heart interventions, depending on the trainee’s career focus. This document provides the framework for training across the expanse of interventional procedures (see Section 4.2.1. Training Pathway and Procedural Number Guidance).1.2.2. Levels of TrainingCOCATS 4 updated standards for training fellows in cardiovascular medicine and established consistent training criteria across all aspects of cardiovascular diseases, including cardiac catheterization.6 For the cardiovascular fellowship, the following 3 levels of training have been delineated for training in cardiac catheterization.Level I training, the basic training required of trainees to become competent consultant cardiologists, is required of all cardiovascular fellows and can be accomplished as part of a standard 3-year training program in cardiology. In the case of cardiac catheterization, Level I represents training for those who will practice noninvasive cardiology and whose invasive activities will be confined to critical care unit procedures.6 This level will also provide training in the indications for the procedure and in the accurate interpretation of data obtained in the catheterization laboratory.Level II training, also described in COCATS 4, refers to additional training in 1 or more areas that enables some cardiologists to perform or interpret specific procedures or render more specialized care for patients with certain conditions. Level II training in selected areas may be achieved by some trainees during the standard 3-year cardiovascular fellowship, depending on their career goals and use of elective rotations. In the case of cardiac catheterization and peripheral angiography, Level II is defined as training for those who will either practice diagnostic cardiovascular catheterization or pursue further training in interventional cardiology.6 Notably, no certification examination currently exists to assess Level II competency in this field.Level III training, the primary focus of this document, requires additional training and experience beyond the cardiovascular fellowship for the acquisition of specialized knowledge and experience in performing, interpreting, and training others to perform specific procedures or render advanced, specialized care for specific procedures at a high level of skill. In the case of interventional cardiology, Level III training is for those who will practice diagnostic and interventional cardiac catheterization. In addition to coronary angiography and interventions, certain aspects of peripheral vascular and structural heart interventions can generally be addressed during an ACGME-dedicated interventional cardiovascular training year. Further training may frequently be required should fellows choose to pursue a career focus in peripheral vascular or structural heart interventions. Level II training in vascular medicine (see COCATS 4 Task Force 9 report11) is also recommended before or in conjunction with Level III training in catheter-based PVI.1.2.3. Methods for Determining Procedural NumbersThe recommended number of procedures performed and interpreted by trainees under faculty supervision has been developed based on published studies and guidelines, competency statements, and the experience and opinions of the members of the writing group. In addition, the writing committee surveyed interventional cardiology training program directors to gain additional insight into procedural volumes. Of 169 directors of ABIM-recognized interventional cardiology training programs, 54 responded. The procedural volumes suggested in this document were determined to be the minimum numbers sufficient to provide trainees with exposure to a variety and spectrum of complexity of clinical case material and to give supervising faculty sufficient opportunity to evaluate the competency developed by each trainee. The numbers of procedures that should be performed to achieve competence (see Section 4.2) are intended as general guidance. Notably, in assessing these volume numbers, the fundamental nature of educational milestones is proficiency and outcomes rather than length of exposure or the exact number of procedures performed. Flexibility is inherent to this concept, and the ACGME mandates that all programs establish milestones for the acquisition of various competencies by trainees during the course of fellowship training.2. General Standards2.1. Coronary Interventions2.1.1. FacultyDedicated faculty who are committed to teaching trainees are the most important resource for a high-quality interventional cardiology training program. Faculty serve as role models for professionalism and promote a positive learning environment to foster the education of fellows in clinical, procedural, and scholarly activities. Faculty must include specialists from diverse backgrounds with a broad range of expertise in knowledge base areas of interventional cardiology and related fields; noninvasive and invasive diagnostic testing; and therapeutic options, including medical management and percutaneous and surgical revascularization. The 2020 “ACGME Program Requirements for Graduate Medical Education in Interventional Cardiology” require a single designated program director and at least 1 additional ABIM

Mitral regurgitation is a common valvular heart disease with increasing prevalence due to the aging population. In degenerative (primary) mitral regurgitation, medical therapies are limited and the mainstay of treatment is mitral valve surgery . Patients are referred for mitral valve surgery based on the American College of Cardiology/American Heart Association guidelines, which recommend surgery in patients with severe mitral regurgitation. Echocardiography uses multiple parameters that lack reproducibility and accuracy. Studies comparing cardiovascular magnetic resonance (CMR) and echocardiography have shown that CMR is a better predictor of clinical outcome and postsurgical left ventricular remodeling than echocardiography.

Cardiac stress tests have been widely utilized since the 1960s for the diagnostic and prognostic assessment of patients with suspected coronary artery disease (CAD). Clinical risk is primarily based on assessing the presence and magnitude of inducible myocardial ischemia. However, the primary factors driving mortality risk have changed over recent decades. Factors such as typical angina and inducible ischemia have decreased, whereas the percentage of patients with diabetes, obesity and hypertension have increased. There has also been a marked temporal increase in the percentage of patients who require pharmacologic testing due to inability to perform treadmill exercise at the time of cardiac stress testing and this need has emerged as the most potent predictor of mortality risk in contemporary stress test populations. However, the long-term clinical risk posed by the inability to perform exercise and concomitant CAD risk factors are rarely reflected in the assessment of patients' prognostic risk in cardiac stress test reports. In this review, we suggest that the clinical utility of present-day cardiac stress testing can be improved by developing a more comprehensive assessment that integrates and reports all factors which modulate patients' long-term clinical risk following stress and testing. This should include assessment of patients' CAD risk factors, physical activity habits and mobility risks, and identification of the reasons why patients could not exercise at the time of cardiac stress testing. In addition, the assessment of four core non-aerobic functional parameters should be considered among patients who cannot exercise: assessment of gait speed, handgrip strength, lower extremity strength, and standing balance.

Mitral regurgitation is a common valvular heart disease with increasing prevalence due to the aging population. In degenerative (primary) mitral regurgitation, medical therapies are limited and the mainstay of treatment is mitral valve surgery. Patients are referred for mitral valve surgery based on the American College of Cardiology/American Heart Association guidelines, which recommend surgery in patients with severe mitral regurgitation. Echocardiography uses multiple parameters that lack reproducibility and accuracy. Studies comparing cardiovascular magnetic resonance (CMR) and echocardiography have shown that CMR is a better predictor of clinical outcome and postsurgical left ventricular remodeling than echocardiography.