What Does a Structural Heart Program Do in the Hospital?
A structural heart program provides minimally invasive, catheter-based treatments for valvular and congenital heart diseases through a mandatory multidisciplinary team of interventional cardiologists and cardiac surgeons working together to deliver procedures like transcatheter valve replacements, valve repairs, and closure of cardiac defects. 1, 2
Core Functions and Services
Primary Procedures Performed
Structural heart programs deliver transcatheter interventions for conditions previously requiring open-heart surgery or deemed inoperable:
- Valve interventions: Transcatheter aortic valve replacement (TAVR), mitral valve repair (MitraClip), mitral and tricuspid valve replacements, balloon valvuloplasty 2, 3
- Defect closures: Patent foramen ovale (PFO), atrial septal defects (ASD), ventricular septal defects, paravalvular leak repairs 4, 5
- Left atrial appendage occlusion for stroke prevention in atrial fibrillation 5
- Hypertrophic cardiomyopathy treatment: Alcohol septal ablation 4
- Adult congenital heart disease (ACHD) interventions: Pulmonary valve replacements, complex shunt procedures 3
The Multidisciplinary Team Structure
The defining principle is that structural heart programs require joint cardiology-surgery collaboration—programs using only one specialty are fundamentally deficient. 1, 2 The team must include:
Core members 6:
- Interventional cardiologist (medical co-director)
- Cardiac surgeon (surgical co-director)
- General cardiologist with valve disease expertise
- Heart failure specialist
- Echocardiographer with advanced 3D transesophageal echo (TEE) training
- Cardiac CT specialist
- Cardiac anesthesiologist
- Advanced practitioners (nurse practitioners/physician assistants)
- Patient navigator/program coordinator
- Data manager
- Hospital administrator
Additional specialists as needed:
- Electrophysiologist
- Stroke neurologist
- Vascular surgeon
- Cardiac intensivist
- Perfusionists
- Social work and palliative care
Institutional Requirements
Facility Infrastructure
Programs require specialized equipment and spaces 2, 7:
- Hybrid catheterization laboratory or operating room with high-resolution fluoroscopy and hemodynamic monitoring capabilities
- Advanced imaging: 3D echocardiography (transthoracic and TEE), cardiac CT, cardiac MRI when available 1, 6
- Intensive care units with personnel experienced in post-valve procedure management 7
- On-site cardiac surgery program with immediate availability of surgeons and perfusionists 5
- Comprehensive inventory of specialized devices: large-bore vascular access equipment, closure devices, various stents, retrieval devices, and procedure-specific implants 7
Volume and Quality Standards
Institutions must demonstrate established surgical and interventional programs with outcomes meeting or exceeding national benchmarks 6:
- Active surgical valve program participating in STS Adult Cardiac Surgical Database
- Established interventional cardiology program with proven experience in PCI, balloon valvuloplasty, and related procedures
- For LAA occlusion specifically: minimum 50 structural or left-sided ablation procedures annually, with at least 25 involving transseptal puncture 5
Patient Care Pathway
Pre-Procedure Phase
The program provides comprehensive evaluation through:
- Multidisciplinary team conferences for case selection and treatment planning 6
- Advanced imaging interpretation (echo, CT, MRI) to determine procedural eligibility 1
- Shared decision-making between heart team, patient, and family regarding intervention versus surgery versus medical management 3
- Assessment of surgical risk, anatomic suitability, and alternative treatment options 2
Procedural Phase
Procedures combine interventional and surgical expertise:
- Real-time intraprocedural TEE guidance (critical for procedural success) 1
- Hemodynamic assessment and catheter-based valve crossing techniques 3
- Large-bore vascular access with ultrasound guidance and closure techniques 3
- Transseptal puncture skills for left-sided procedures 5
- Immediate management of complications including pericardiocentesis and device retrieval 5
Post-Procedure Care
Intensive follow-up includes:
- Specialized nursing and technical staff trained in transcatheter interventions 6
- Intensive care monitoring for high-risk patients 7
- Long-term outcome tracking through mandatory registry participation 7, 5
- Outpatient clinic follow-up with dedicated office space and ancillary testing facilities 6
Critical Distinctions from Traditional Cardiology
These programs differ fundamentally from standard interventional cardiology because they require:
- Dual specialty leadership: No single specialty possesses all necessary skills 1, 2
- Complex anatomic knowledge: Detailed understanding of valvular anatomy, left atrial appendage morphology, and congenital defects 5
- Advanced imaging integration: Ability to interpret and utilize 3D echo, CT, and MRI for procedural planning 1, 3
- Surgical backup: Immediate availability of cardiac surgery for complications 5
- Resource intensity: Labor-intensive pre- and post-procedure care requiring institutional financial commitment beyond standard reimbursement 7, 6
Quality and Data Management
Programs must maintain rigorous quality standards:
- Mandatory national registry participation with timely case submission and follow-up reporting 5
- Institutional multistakeholder process for evaluating patient selection, outcomes, and quality metrics 5
- Long-term outcome tracking including survival, complications (stroke, vascular, renal), valve function, and need for reintervention 7
Common pitfall: Programs attempting to establish structural heart services without adequate surgical partnership or institutional commitment inevitably fail to provide optimal patient-centered care and should not proceed 1, 2.
The complexity and resource requirements of structural heart programs are comparable to heart transplant and ventricular assist device programs, requiring similar institutional infrastructure, dedicated personnel, and regulatory oversight 7.