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Interventional Heart Failure: Current State of the Field

Miguel Alvarez Villela , Spencer Liu , Michael Yin ,

Michele L Esposito , Nima Aghili , Muhammad H Mustehsan ,
Ian Larson , Nikolaos A Diakos , Navin K Kapur

PII: S1071-9164(23)00374-3
DOI: https://doi.org/10.1016/j.cardfail.2023.09.014
Reference: YJCAF 5347

To appear in: Journal of Cardiac Failure

Received date: 24 September 2023

Accepted date: 25 September 2023

Please cite this article as: Miguel Alvarez Villela , Spencer Liu , Michael Yin , Michele L Esposito ,
Nima Aghili , Muhammad H Mustehsan , Ian Larson , Nikolaos A Diakos , Navin K Kapur , Inter-
ventional Heart Failure: Current State of the Field, Journal of Cardiac Failure (2023), doi:
https://doi.org/10.1016/j.cardfail.2023.09.014

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© 2023 The Author(s). Published by Elsevier Inc.

This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
Title: Interventional Heart Failure: Current State of the Field
Authors:
Miguel Alvarez Villela1,2
Spencer Liu3
Michael Yin3
Michele L Esposito4
Nima Aghili5
Muhammad H Mustehsan2
Ian Larson2
Nikolaos A Diakos6
Navin K Kapur3

1
Lenox Hill Hospital, Department of Cardiology, New York, NY
2
Montefiore Medical Center – Albert Einstein College of Medicine, Bronx, NY
3
The Cardiovascular Center, Tufts Medical Center, Boston, MA
4
Medical University of South Carolina, Charleston, SC
5
Colorado Heart and Vascular, St. Anthony Hospital, Lakewood, CO
6
Texas Heart Institute, Houston, TX

Corresponding Author:
Navin K Kapur
Email: nkapur@tuftsmedicalcenter.org
Mailing address: The Cardiovascular Center, Tufts Medical Center, 800 Washington St, Box 80,
Boston, MA 02111
Phone: 617-636-8252
Fax: 617-636-5913
Funding:
None
Disclosures:
None
Key Words: interventional heart failure, interventional cardiology, advanced heart failure,

hybrid training pathways

Abbreviations:
ACGME: American College of Graduate Medical Education
AHFTC: Advances Heart Failure and Transplant Cardiology
AMG: American Medical Graduate
A-IMG: American who is an International Medical Graduate
CCU: Coronary Care Unit
FTE: Full-Time Equivalent
HF: Heart failure
IMG: International Medical Graduate
IABP: Intra-aortic balloon pump
IC: Interventional Cardiology
IHF: Interventional Heart Failure
LVAD: Left ventricular assist device
MCS: Mechanical Circulatory Support
PGY: Postgraduate Year
STEMI: ST-segment elevation myocardial infarction
VA-ECMO: Veno-arterial extracorporal membrane oxygenation

INTRODUCTION

Despite important advancements in medical therapy, significant limitations persist in the

treatment of heart failure (HF) with incomplete response to medical therapy, preserved

ejection fraction and chronic kidney disease.1,2 Effective therapies in acute heart failure
are even more limited, especially impacting patients with diuretic resistance and

cardiogenic shock.1

Facing these challenges, rapid innovations are occurring in the heart failure space,

including the creation of multi-disciplinary cardiogenic shock teams,1 along with a

growing number of novel HF-specific therapeutic devices.2,3

This changing landscape calls for the advent of a new type of specialist in cardiology,

capable of bridging the gap between procedural skills in the cardiac catheterization

laboratory (CCL) and clinical skills for the treatment of complex HF patients.

Interventional heart failure (IHF) has emerged as a hybrid subspecialty addressing this

gap.4, 5

IHF combines training in interventional cardiology (IC) and advanced heart failure

transplant cardiology (AHFTC), both recognized subspecialties by the Accreditation

Council for Graduate Medical Education (ACGME) in the United States (US). However,

the concept of the IHF specialist remains foreign to most individuals and institutions. We

conducted a survey to delineate the scope of the specialty based on the experience of

currently practicing physicians.

METHODS

An anonymous, online, 37-question survey was created using the Qualtrics web-based

survey platform and distributed through the Society for Cardiovascular Angiography and

Interventions (SCAI ®) newsletter and publicized via Twitter using the first and senior

authors handles. To confirm the eligible profile of respondents, they were asked to report
the name of their AHFTC and IC training centers. The study was approved by the IRB of

the Albert Einstein College of Medicine.

RESULTS

Demographics

A total of 54 IHF cardiologist from 45 medical centers responded to the survey. A

minority were women (7%) and the majority were >35 y. of age (81%). Foreign

physicians practicing outside of the US were 22% (n=12) while US based physicians

were predominantly IMGs (60%) Figure 1.

Training Pathways

All IHF cardiologists achieved post-graduate year 7 (PGY-7), 54% achieved PGY-8 and

29% PGY>8. The majority (70%) completed training after 2013, when AHFTC gained

ACGME accreditation (Figure 1). ACGME accredited AHFTC fellowships in the US

were completed by 58% of AMGs, 68% of IMGs and 100% A-IMGs (American

graduates of international medical schools).

AHFTC training program center was reported by 77% (n=41), most were in the US

(83%) concentrated in the northeast (34%) and southern (25%) regions. Of the 12

respondents who did not disclose their AHFTC training program, seven (66%) reached a

PGY level ≥8 and did not report other alternative fellowship training, indicating this extra

year of training was indeed dedicated to AHFTC.

IC training program center was reported by all respondents (n=52). In the US, they were

concentrated in the northeast (31%), south (23%) and midwest (15%) regions while 21%

were outside the US.

Order and type of fellowship training was disclosed by a total of 48 respondents: Among

these, three distinct training pathways emerged (Figure 2):

A. IC fellowship first, followed by an ACGME accredited AHFTC fellowship: Most

trained after 2013 (87%).

B. ACGME accredited AHFTC fellowship first followed by IC fellowship: Nearly all

training after 2013 (97%).

C. Non-ACGME AHFTC performed before (30%) or after (70%) IC fellowship: Only

43% in this pathway trained after 2013, indicating that this is a less contemporary

training approach.

Only 20% (n=10) completed additional training beyond IHF. Of these, two trained in

critical care medicine, two in structural heart interventions, one in CHIP interventions,

one in clinical research and 3 in cardiac imaging. One did not specify his additional

training.

Current Practice Location and Setting

Most respondents are based within the US (78%). Practice setting was mostly hospital-

based academic (61%), followed by hospital-based non-academic settings (30%) and

non-hospital based private practice (9%).

Time in AHFTC in academic settings was: 37% <0.2 FTE, 37% 0.2-0.5 FTE, 22%

>0.5FTE (overall 74% ≤0.5 FTE) and in non-academic settings, 29% <0.2 FTE, 53% 0.2-

0.5 FTE, 18% >0.5 FTE. (overall 82% ≤0.5 FTE).

Among hospitals hosting IHF specialists, 59% had a heart transplantation program, 69%

had a durable-left ventricular assist devices (LVAD) program and 89% had an

extracorporeal membranous oxygenation (ECMO) program.

The areas of primary clinical focus for IHF cardiologists were coronary artery disease

(42%), cardiogenic shock (42%), structural heart interventions (11%) and heart

transplantation (5%).

IHF specialists regularly participate in the implantation of all temporary mechanical

circulatory support (MCS) modalities: Femoral IABP (95%), Impella (83%) and Veno-

arterial ECMO (69%), Right-sided Impella (50%), Axillary IABP (47%), TandemHeart

(36%).

Meanwhile 48% reported performing structural heart procedures: TAVR (36%) ASD

closure (27%) and MitraClip (20%).

Virtually all IHF physicians performed rounds in the cardiac intensive care unit (95%)

and participated in STEMI call (84%). Meanwhile 53% and 48% regularly cared for post-

transplant and post-LVAD patients and 21% participate in donor call.

Time dedicated to research was low with 81% dedicating <25% of their time to research,

and only 5% dedicating >50% of their time.

Opinions About the Field of IHF

A total of 65% of IHF cardiologists did not consider their training time excessive, 82%

would repeat the combined pathway again if given the choice and 86% would

recommend it to current trainees. Most (59%) advocate for heart failure fellowship

completion before interventional cardiology. Furthermore, 84% would advocate for the

creation of an integrated 2-year “Interventional Heart Failure” fellowship.

DISCUSSION

This is the first survey to systemically report on the IHF specialty. The IHF workforce is

growing in numbers and concentrating in the NE and south of the US, where early

training programs for IHF were developed, at centers housing heart transplant and

advanced MCS programs.

IHF specialists are focused mainly on coronary disease and cardiogenic shock. CICU

coverage is the most consistent clinical assignment held outside of the CCL and 70%

participate in the deployment and management of ECMO. Most (80%) devote ≤0.5FTE

to AHFTC outside of the CCL, and close to half routinely care for post-transplant and

post-LVAD patients.

These findings indicate that IHF is a unique specialty with advanced procedural skills

complemented by broad clinical abilities. IHF involvement with transplant and LVAD

patients as well as all portions of advanced MCS therapy is a particularity not shared by

other hybrid specialties in cardiology such as the IC and critical care combination.

Moreover, the strong CICU presence of IHF specialists can contribute to care
standardization between this unit, the transplant and LVAD program, and the CCL.

Hospitals at all levels of cardiovascular care could benefit from this figure to enhance

multidisciplinary care and articulate high acuity services in the current environment of

growing patient complexity (Figure 3).

Recognition of the IHF specialist as a unique figure holding a defined interdisciplinary

role is needed, however, to enhance their full potential. Challenges include the well-

drawn boundaries between sections in most cardiology divisions and the risk of over-

burdening the IHF physician with the call responsibilities of each role.

Hospital systems wishing to incorporate IHF specialists, need to also devise an

appropriate employment model that does not negatively impact the budget of the IC or

AHFTC sections who will unequally share the services of the IHF physician, as well as a

system of robust cross-talk between the different roles to fulfill.

Sustainable training pathways for IHF specialists are also needed. Current training

structure is evolving with AGME accredited AHFTC programs becoming predominant.

While no clear trend is seen in the order of training (figure 2), more than half of

respondents in this survey recommended completing IC fellowship last, likely to allow

more proximity between the acquisition of procedural skills and professional practice.

Moreover, most respondents, support the creation of integrated 2-year training programs.

Sadly, women are a small minority among IHF specialists (7%). The reasons for this are

complex and were not addressed by our survey. However, previous reports indicate that

women are less likely to pursue a career in IC, driven by the perceived negative attributes

of the specialty such as job inflexibility, sex discrimination and physical demands of the
 job.6 Some of these perceptions also apply to AHFTC,7 making this combination perhaps

particularly difficult to access for women.

Integrated training pathways would allow trainees to concentrate their time at a single

institution with suitable local mentors, and eventually allow for the creation of shortened,

integrated training tracks that can improve feasibility of IHF for all trainees. Training

programs in turn should view this as an opportunity for growth, given that interest in IHF

is on the rise at a time when only 38.4% of programs and 55.9% of positions filled for

AHFTC in the latest match 8.

CONCLUSION

The IHF specialty is growing, concentrating in the NE and South of the US and focusing

on the treatment of CAD and CS. Their presence across different key cardiac services

gives IHF specialists a potential strong role in the transformation of multidisciplinary

care.

Acknowledgements: We thank all the IHF specialists who generously responded to our survey.
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Figure Legends

Figure 1.
Characteristics and Distribution of Interventional Heart Failure Specialists

Figure 2. Training Pathways Among IHF Specialists Surveyed. Varying representation of

IMG, AMG and Foreign Physicians is seen across pathways. The year 2013 is
represented as an important cut-point when the AHFTC fellowship gained ACGME
accreditation in the US.

Figure 3.
Panel A. Central Role of the IHF Specialist in Multidisciplinary Cardiac Care
Panel B. IHF Involvement in Key Cardiac Services
Abbreviations: ACGME: American Council of Graduate Medical Education, AHFTC:
Advanced Heart Failure and Transplant Cardiology, CAD: Coronary Artery Disease,
FTE: Full-time equivalent, IHF: Interventional Heart Failure, IMG: International Medical
Graduate, PGY: Post-graduate year, U.S.: United States of America