title: Training the next generation of invasive cardiologists: Feasibility of implementing a trans-radial access program at an academic hospital.
abstract: BACKGROUND
  Slow adoption of trans-radial access (TRA) for left heart catheterization (LHC) in the U.S. may be related to concerns about procedural complexity and a steep learning curve. However, TRA acceptance among novice operators remains poorly characterized.
  
  
  METHODS
  We initiated a 1-year TRA learning period among lower-risk outpatients, followed by a "radial-first" policy for all LHC patients beginning year 2. By year 3, all fellows prospectively collected diagnostic LHC data as part of a quality improvement study. TRA procedural characteristics were compared with patients undergoing trans-femoral access for the 3months prior to the TRA program, and trends over time were evaluated.
  
  
  RESULTS
  Between 7/2009 and 6/2012, we identified 960 patients undergoing LHC via TRA by 23 rotating cardiology fellows supervised by 5 interventional cardiologists. When evaluated against the 160 trans-femoral comparator patients, TRA patients had lower procedural success through the initial access site (88% vs. 99%, p<0.001) and longer fluoroscopy times (9.5 [5.8-15.9] vs. 6.5 [3.1-12.7] min, p<0.001), with similar contrast volumes and fewer catheters used. Despite tackling more complex patients during years 2-3, there were improvements in fluoroscopy times, catheter utilization, contrast volumes, and procedural success rates over time (all p<0.001).
  
  
  CONCLUSIONS
  The dedicated adoption of TRA by an academic catheterization laboratory demonstrated improvements in efficiency and resource utilization over a relatively short period of time. Additional exposure to TRA during training may help facilitate acceptance of this approach among the next generation of invasive cardiologists.
  When initiating a trans-radial access program for cardiac catheterization at an academic training hospital, procedural success rates were lower and fluoroscopy times were higher than traditional trans-femoral access. Nonetheless, other procedural variables were similar between the 2 approaches, and improvements over time were consistent with the learning curves reported among experienced cardiologists in prior studies. Exposure to trans-radial access during training may help facilitate acceptance of this approach among the next generation of invasive cardiologists.
authors.affiliation: Mercy Heart and Vascular, Washington and Saint Louis, MO, United States; Saint Louis University, Saint Louis, MO, United States. Electronic address: jstolker@yahoo.com.
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Stolker
authors.affiliation: Saint Louis University, Saint Louis, MO, United States. Electronic address: mhhadid@gmail.com.
authors.forename: Mazen
authors.initials: M
authors.lastname: Hadid
authors.affiliation: Saint Louis University, Saint Louis, MO, United States. Electronic address: zainalmoiz@hotmail.com.
authors.forename: Zainal M
authors.initials: ZM
authors.lastname: Hussain
authors.affiliation: Saint Louis University, Saint Louis, MO, United States. Electronic address: srough@hotmail.com.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Rough
authors.affiliation: Saint Louis University, Saint Louis, MO, United States. Electronic address: Ibrahim_majd@yahoo.com.
authors.forename: Majd
authors.initials: M
authors.lastname: Ibrahim
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, MO, United States. Electronic address: kfkennedy@saint-lukes.org.
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Kennedy
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, MO, United States. Electronic address: dsafley@saint-lukes.org.
authors.forename: David M
authors.initials: DM
authors.lastname: Safley
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, MO, United States. Electronic address: dbaklanov@saint-lukes.org.
authors.forename: Dmitri V
authors.initials: DV
authors.lastname: Baklanov
authors.affiliation: Mercy Heart and Vascular, Washington and Saint Louis, MO, United States; Saint Louis University, Saint Louis, MO, United States. Electronic address: robneumayr@gmail.com.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Neumayr
mesh_terms: D000368:Aged; D006328:Cardiac Catheterization; D002309:Cardiology / Q000193:education*; D002406:Catheterization, Peripheral / Q000379:methods*; D002983:Clinical Competence; D003479:Curriculum; D004503:Education, Medical, Graduate / Q000379:methods*; D004521:Educational Measurement; D005240:Feasibility Studies; D005257:Fellowships and Scholarships; D005260:Female; D005263:Femoral Artery; D006785:Hospitals, University; D006801:Humans; D007396:Internship and Residency; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D015397:Program Evaluation; D017534:Radial Artery; D013997:Time Factors
keywords: Cardiac catheterization; Fellowship training; Trans-radial access