Core Curriculum and Standardization of Training for the Catheterization Laboratory Specialist

The author has no conflicts to declare, and no grants were received for the preparation of this manuscript. In 1977, amidst immense skepticism, Professor Andreas Gruentzig performed the world’s first angioplasty in Zurich, Switzerland. Using a balloon catheter he and his wife fashioned in their kitchen, he dilated an 80% stenosis in the patient’s left anterior descending artery and thus ushered in the modern era of interventional cardiology.1-2 The ensuing years have witnessed tremendous expansions in developments and indications for these procedures, extending well beyond the cardiac arena. The second milestone in this field occurred with the advent of stents (bare metal), which improved not only the durability but, perhaps more importantly, the safety of coronary interventions. Accordingly, stent implantation, often in conjunction with other devices, has become the standard technique for most percutaneous coronary interventions (PCIs). Subsequently, the seminal RAVEL*3, SIRIUS†4, and TAXUS IV‡5 trials, which reported dramatically superior clinical restenosis rates of drug-eluting stents (DES) over bare-metal controls, heralded the new DES era in interventional cardiology. Our patients now enjoy a less invasive and lower risk alternative to surgical revascularization in many cases. These accomplishments have made interventional cardiology arguably the most rapidly growing of the cardiac disciplines. To ensure quality of patient care in the face of constant technical and procedural innovations, the American Board of Internal Medicine (ABIM) has instituted a standardized sub-specialty certification board examination for physicians practicing interventional cardiology, renewable every 10 years. Recognizing that no written examination can truly and fully assess a practitioner’s procedural expertise, the Board has nonetheless compiled what it believes to be the comprehensive core fund of knowledge within this discipline. However, the success and effectiveness of any such procedure is also largely dependent upon the efficiency and skills of the interventionalist’s other colleagues in the catheterization laboratory. The technologists and nurses play an integral role in equipment set-up, medication administration, hemodynamic monitoring and clinical patient assessment. Accordingly, in parallel with the ABIM’s physician certification, Mr. Charles “Chuck” Williams, BS, RPA, RT(R)(CV)(CI), RCIS, FSICP has spearheaded our initiative to standardize the education and training for all catheterization laboratory staff. Our document, “A Proposal for the Core Curriculum for Training of ‘Advanced Level Cardiology Specialist Assistants’ for the Performance of Percutaneous Coronary Interventions (PCIs) and Non-Coronary Interventions: Part II, Report of the International Society of Advanced Level Medical Imaging Physician Specialists (ALMIPS) and the Committee on Training and Competency Standards©” is published in the current issue of Cath Lab Digest. The document emphasizes the importance of understanding the indications and risks of the planned procedure in light of the patient’s history and physical examination. Device selection for specific anatomies, including various guiding catheter and guidewire properties, as well as indications for non-balloon/stent equipment such as atherectomy and distal protective devices are discussed. Moreover, today’s catheterization laboratory staff should be well-versed in non-coronary cardiac and non-cardiac interventions. Inherent in mastery of these skills is a thorough understanding of anatomy and physiology, including the pathology and pathophysiology of congenital anomalies. Additionally, the specialist should be familiar with pharmacologic and radiation safety issues encountered in the laboratory. Equally important as intra-procedural patient care is post-procedural management as well as recognition of potential complications. We are hopeful that this program will allow catheterization laboratories to identify those applicants who have satisfied and excelled in core curricular education, as well as to allow existing staff to further supplement their training. While the authors recognize that not all included topics will be incorporated into every catheterization laboratory practice, we feel that we have compiled the essential fund of knowledge for the specialist to not only offer a participatory, but potentially a leadership, role in any laboratory. We welcome any comments and suggestions from the readership and hope that this initiative will be embraced not only domestically, but internationally as well. The authors are indebted to Mr. Chuck Williams for his wholehearted dedication to this project. Please address all correspondences to Mr. Williams at iraa.rpa@gmail.com. * RAVEL: a randomized study with the sirolimus-coated Bx velocity balloon-expandable stent (Cordis Corporation, Miami, FL). † SIRIUS: 1,058-patient U.S. clinical trial evaluating the safety and efficacy of the Cypher sirolimus-eluting stent (Cordis Corporation, Miami, FL). ‡ TAXUS IV: a randomized, double-blind clinical trial looking at the Taxus paclitaxel-eluting stent (Boston Scientific Corp., Natick, MA) versus a bare-metal stent in 1,326 patients with single de novo lesions between 10 and 28 mm undergoing elective stenting.

1. Chen JP, Crisco LVT, Jabara R, King SB III. Late Angiographic Stent Thrombosis: the LAST straw for drug-eluting stents? Angiology April 2, 2008 (electronically published ahead of print). Available by subscription online at http://ang.sagepub.com/cgi/ rapidpdf/0003319707310279v1.

2. Chen JP. Late Angiographic Stent Thrombosis (LAST): the cloud behind the drug-eluting stent silver lining? J Invas Cardiol 2007; 19(9): 395-400.

3. Morice MC, Serruys PW, Sousa JE, et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 2002;346:1773-1780.

4. Moses JW, Leon MB, Popma JJ, et al. SIRIUS Investigators. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003;349:1315-1323.

5. Stone GW, Ellis SG, Cox DA, et al. TAXUS-IV Investigators. A polymer-based paclitaxel-eluting stent in patients with coronary artery disease. N Engl J Med 2004;350:221-231.