First performed in the United States in the early 2000s, transcatheter aortic valve replacement (TAVR) represents a relatively new procedure within the field of interventional cardiology. However, over the past decade, the Yale Structural Heart Disease Program, spearheaded by John Forrest, MD, FACC, FSCAI, associate professor of medicine (cardiovascular medicine), has quickly developed tremendous expertise in this novel therapy, with more than 2,500 procedures performed to date.
This shift in clinical care was accompanied by a transformation in the educational approach at Yale through increased efforts to train cardiology fellows in these advanced techniques.
"During my cardiology fellowship, there was a shift in focus for interventional cardiologists,” Forrest said. “It wasn't just about coronary stents anymore. We started exploring avenues including transcatheter valve replacement, and in this the new frontier of structural heart interventions was born.”
As a junior faculty member, Forrest proposed starting a structural cardiology fellowship, one of the first accredited programs of its kind. In its initial years, the fellowship supported a single fellow and focused on an intensive final year of advanced training in this new specialty within cardiology and cardiac surgery. To be eligible for the program, fellows needed to have completed an internal medicine residency, general cardiology fellowship, and advanced fellowship in interventional cardiology – amounting to at least seven years of clinical training after medical school.
Today, the structural cardiology fellowship is a one-year program that supports two fellows and delves deeper into specialized procedures like TAVR, transcatheter mitral valve repairs, left atrial appendage occlusion, and atrial septal defect closures.
"Our program started small but was always about quality,” Forrest said. “After a few years of training one fellow annually, we expanded the program to two fellows and now welcome candidates from both interventional cardiology and cardiothoracic surgery backgrounds.”
The program employs a patient-centric approach, emphasizing clinical reasoning on top of performing complex procedures.
"Technical skills are paramount, but not sufficient. Our fellows also need to understand how to evaluate and explain risks and benefits to patients and their families. The patients we treat are often older and have multiple medical co-morbidities,” said Forrest. “It's not just about performing a complex procedure. It's about evaluating whether undertaking the procedure is the right choice to improve the patient's quality of life. In that regard, there is an increased emphasis on a patient-centered shared decision-making approach.”
"It's not just about performing a complex procedure. It's about evaluating whether undertaking the procedure is the right choice to improve the patient's quality of life. In that regard, there is an increased emphasis on a patient-centered shared decision-making approach.”
John K. Forrest, MD
Yale’s program has made an impact on the national stage and in the global medical community.
“Our fellows have gone on to lead departments worldwide, from prominent centers across the U.S to some of the largest hospitals in other countries around the world,” Forrest said. “We have also participated in efforts to standardize structural training at the national level, enhancing both the educational experience and patient outcomes.”
Looking forward, Forrest is excited about expanding patient care through new structural interventions. "The biggest volume we handle in terms of procedures is TAVR," Forrest said. "But in the mitral valve space and beyond, there's so much more we can do, and in many ways the field of structural heart disease is just at the beginning.”
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