Structural Heart Disease Fellowship

What Is a Structural Heart Disease Fellowship?

Structural heart disease (SHD) fellowship is an advanced, post-interventional cardiology training year focused on catheter-based therapies for cardiac anatomy rather than coronary artery disease. The core procedural curriculum includes transcatheter aortic valve replacement (TAVR), transcatheter edge-to-edge mitral repair (TEER/MitraClip), left atrial appendage occlusion (LAAO), transcatheter mitral valve replacement (TMVR), and closure of structural shunts including atrial septal defects (ASD) and patent foramen ovale (PFO). Programs at higher-volume centers add tricuspid valve interventions, balloon mitral commissurotomy, paravalvular leak closure, and participation in early feasibility or IDE trials for emerging devices.

The distinction from general interventional cardiology (IC) training matters for application planning. Standard ACGME-accredited IC fellowship covers coronary intervention as its core; structural cases are supplementary and highly variable in volume across IC programs. A fellow completing IC at a community-affiliated program may log substantially fewer TAVR or TEER cases than a fellow at a high-volume academic center. SHD fellowship exists precisely to standardize and deepen that structural exposure before independent practice.

The field is expanding rapidly. Tricuspid technologies, TMVR systems, and transcatheter repair devices are moving from trials into clinical practice on a compressed timeline, which means a trainee finishing an SHD fellowship in the next few years will enter a procedural landscape meaningfully different from one even a few years older. That trajectory makes fellowship program selection consequential: case mix, trial participation, and imaging infrastructure today predict what an operator will be equipped to do in five years.

Accreditation Status

State this plainly: there is no ACGME accreditation for structural heart disease fellowships as of the current publication date. ACGME accredits internal medicine, cardiovascular disease, and interventional cardiology fellowships, but SHD training exists outside that framework. This has several downstream consequences that applicants should understand before they treat any program's self-description uncritically.

The Society for Cardiovascular Angiography and Interventions (SCAI) has published Structural Heart Disease Training Standards that function as the field's de facto accreditation benchmark. SCAI's standards address curriculum, case volume minimums by procedure category, supervision requirements, and documentation expectations. Programs that align their training to SCAI standards can describe themselves as SCAI-aligned or compliant with SCAI training guidelines, but this is not a third-party certification in the ACGME sense — there is no site visit, no independent verification of case log accuracy, and no annual reporting requirement enforced by an external body. SCAI has taken steps toward a more structured recognition pathway, but the architecture remains institution-dependent.

What "accredited" means in practice varies by program. Some programs use the term loosely to mean they follow SCAI guidelines internally. Others participate in SCAI's formal training program listing, which carries more weight but still does not constitute ACGME oversight. When evaluating any program's accreditation claims, ask specifically: Are you listed on the SCAI training program registry? Do you submit case log data to an external body? What documentation does the fellow receive at completion that a future credentialing committee can verify?

The absence of ACGME accreditation has a direct effect on hospital credentialing after training. Credentialing committees reviewing a new hire's application for TAVR or TEER privileges will look at case numbers, supervision documentation, and operator designation — not an ACGME certificate of completion. Programs that maintain rigorous logs and provide granular case documentation actually serve their graduates better in credentialing than programs that claim accreditation without the paperwork infrastructure to back it.

Training Pathway Prerequisites

SHD fellowship sits at the end of a long sequential pathway. The typical route for a US-trained physician:

• Internal medicine residency (3 years, ACGME-accredited, PGY 1–3)
• Cardiovascular disease fellowship (3 years, ACGME-accredited, PGY 4–6; includes core echo, cath lab exposure, and general cardiology training)
• Interventional cardiology fellowship (1 year, ACGME-accredited, PGY 7; coronary and peripheral intervention, hemodynamic support, structural cases dependent on program volume)
• Structural heart disease fellowship (1 year, not ACGME-accredited, PGY 8 or later)

That places most SHD fellows at PGY 8 at minimum, and PGY 9–10 is common when additional research years, preliminary programs, or prior subspecialty training are factored in. For IMGs, this calculation also includes time spent in prerequisite programs and, in some cases, research or observership years that extended the pathway.

The interventional cardiology year is a hard prerequisite at the overwhelming majority of SHD programs. There is no established route to a structural fellowship without completing ACGME-accredited IC training first. Some programs informally state they would consider an exceptionally strong candidate with advanced cardiac imaging training (e.g., advanced echocardiography plus IC), but this is rare enough that it should not factor into planning unless a specific program has told you directly that they have done it.

For international graduates who completed interventional training outside the US, the pathway is more complex. Most US SHD programs require or strongly prefer US ACGME-accredited IC fellowship completion. A foreign-trained interventionalist who has completed IC training abroad and wants a US SHD fellowship will typically need to either complete a US IC fellowship first or identify one of the rare programs that explicitly accepts foreign-trained IC graduates. Verify current requirements directly with ECFMG/Intealth and official sources for your application year.

Program Requirements and Case Volume Standards

SCAI's published training standards set minimum case volume benchmarks by procedure type. These numbers evolve as the field matures and as SCAI updates its guidelines; the figures below reflect general thresholds discussed in published SCAI documents — confirm against the current SCAI publication for your application year, as these are periodically revised.

In general terms, SCAI training standards describe minimum numbers in the range of:

• TAVR: A minimum number of cases as primary operator, with additional cases as first assistant; programs differ on whether fluoroscopy-only TAVR or echo-guided access counts toward operator minimums
• Transcatheter edge-to-edge mitral repair (TEER): Minimum cases with documented procedural roles; TEER has a steeper learning curve than TAVR and programs vary significantly in how many cases a fellow can realistically lead
• Left atrial appendage occlusion (LAAO): Minimum implant numbers; access and transseptal competency is usually bundled into this requirement
• ASD/PFO closure: Typically described as a minimum number across combined structural shunt closure procedures
• Transseptal puncture: A standalone technical competency with its own minimum case threshold, given that it underlies TEER, LAAO, and TMVR access

Beyond raw case numbers, SCAI standards address operator designation levels. SCAI's operator competency framework distinguishes between different levels of independent operator status, with specific case thresholds required to achieve each level. Fellows completing SHD training should exit with documentation supporting at least an entry-level independent operator designation for TAVR and, ideally, TEER. Programs that cannot get a fellow to that threshold — because of insufficient program volume, insufficient fellow autonomy, or both — are producing graduates who will face credentialing challenges.

Proctoring requirements after fellowship also factor into program choice. Many hospital systems require new structural operators to complete a proctored case series before granting independent privileges, regardless of fellowship training. Programs with strong alumni networks and faculty willing to travel for proctoring reduce the friction of the post-fellowship credentialing period substantially.

How Programs Differ: SCAI-Aligned vs. Informal Training

The practical consequence of this divide is most visible at the credentialing stage. A hospital's peer review committee examining a new SHD hire will scrutinize case logs, operator role documentation, and training program legitimacy. A fellow from an informal program who cannot produce granular case-level documentation with operator roles specified may face a longer or more difficult credentialing process, regardless of actual technical skill. This is not a hypothetical risk — it is a documented friction point in early structural heart careers.

Application Process and Timeline

SHD fellowship recruitment operates almost entirely outside ERAS and the NRMP Match. There is no centralized application system, no match scramble, and no standardized timeline enforced by any governing body. What exists instead is a relationship-driven, informally coordinated recruitment process that heavily rewards early networking.

Most programs post openings or begin informal recruitment 18 to 24 months before the fellowship start date. A fellow finishing IC training in June of a given year should expect meaningful outreach and application activity to begin during the first half of their IC fellowship year — meaning the process starts before the IC year is even complete. Programs that receive strong interest fill their one or two slots quickly and may not post a formal opening at all.

The practical recruitment sequence typically looks like this:

• During cardiovascular fellowship (PGY 4–6): Identify structural heart as a career interest; develop relationships with structural faculty at your institution and at conferences (TCT, ACC, PCR); begin establishing a publication and presentation record.
• IC fellowship application (PGY 6–7 transition): When choosing an IC program, structural heart volume and faculty relationships at that program should be weighted heavily. An IC fellowship at a center with high TAVR and TEER volume and active SCAI-aligned structural faculty dramatically improves both training and application competitiveness.
• Early IC fellowship year: Contact SHD program directors by email or at conferences; express interest directly. Many programs make informal commitments to candidates they know well before a formal application ever exists. Cold applications submitted through a website without prior relationship have lower conversion rates than outreach through a faculty connection.
• Mid IC fellowship: Formal applications submitted, interviews conducted. Interviews typically include a site visit, a procedural observation day, and conversations with current or recent fellows.
• Late IC fellowship: Offers made and accepted; some programs use informal oral offers without written contracts until closer to start date, which is an area where fellows should seek clarity.

For applicants at IC programs with low structural volume, the timeline pressure is higher, not lower. If your IC program cannot give you competitive TAVR or TEER numbers, you need faculty advocacy and external networking to compensate, and that requires starting earlier. Low IC structural volume is a solvable problem with planning; it becomes a harder problem if addressed six months before fellowship applications are due.

Program Directory and How to Evaluate Programs

There is no single authoritative directory equivalent to ACGME's accredited program database. The most useful starting points:

• SCAI's training program listing: SCAI maintains a list of SHD training programs on its website. This list is the closest thing to a verified program registry that exists. It is not exhaustive — some legitimate high-volume programs may not be listed, and some listed programs may have changed substantially since listing — but it is a defensible starting point.
• STS and TVT Registry data: The Society of Thoracic Surgeons and the Transcatheter Valve Therapy (TVT) Registry collect institutional TAVR and TEER volume data. Some of this data is publicly reported in aggregate and in peer-reviewed publications. Institutional volume is a more objective metric than program self-report; a program claiming to offer comprehensive structural training at a center doing a handful of TAVRs annually warrants skepticism.
• Published outcomes data: Centers with high structural volume often publish outcomes, participate in trial data, and have faculty on SCAI or ACC writing committees. A literature search on structural heart outcomes at a target program's institution is a reasonable due diligence step.

Questions worth asking explicitly during a site visit or informational call:

• How many TAVR cases does the program do annually, and how many does the fellow participate in as primary operator versus assistant?
• What is the TEER volume, and at what point in the year does the fellow typically begin leading cases?
• Is there an active TMVR or tricuspid trial? What is the fellow's role in that trial?
• What case log documentation system is used, and in what format is the completion letter provided?
• Where did the last two or three fellows take jobs? Are they credentialed independently at their new institutions?
• Is there a dedicated structural imaging faculty member (advanced echo or cardiac CT) involved in the fellow's training?
• What is the call structure, and does the fellow have protected time for research and imaging training?

The answer to "where did recent fellows go" is one of the most information-dense questions you can ask. A program whose graduates consistently land at high-volume academic or hybrid lab positions, obtain independent credentialing without difficulty, and remain professionally active in the field is demonstrating real outcomes. A program that cannot name recent graduates or whose graduates are not performing structural procedures independently is telling you something important.

Imaging and Hybrid Skills Required

Structural heart procedures are imaging-defined in a way that coronary intervention is not. The catheter and the valve are both invisible without imaging; case outcomes depend as much on the imager's read as on the operator's hands. Programs that train fellows primarily in fluoroscopy without substantive multimodality imaging exposure are producing structurally incomplete operators.

The imaging competencies expected of a well-trained SHD fellow include:

• 3D transesophageal echocardiography (3D TEE): Real-time guidance of TEER, LAAO, and TMVR; annular sizing for TAVR and TMVR; post-deployment assessment. The SHD fellow does not need to be an independent imager, but must be able to communicate in real time with the imager and understand what the images show procedurally.
• Cardiac CT planning: CT-based annular sizing for TAVR is standard of care; CT access planning for transfemoral, transaortic, and transcaval approaches; CT-guided LAAO sizing. Some programs have fellows perform their own CT analyses using planning software (3mensio, Materialise, or vendor-specific tools); others teach interpretation rather than acquisition. Both are acceptable, but the fellow who can run their own CT planning workflow has a meaningful skill advantage.
• Intracardiac echocardiography (ICE): Increasingly used for LAAO, ASD/PFO closure, and some TEER cases where TEE is avoided. ICE proficiency is becoming a differentiating skill as programs reduce anesthesia requirements for structural cases.
• Fluoroscopy and cine interpretation: Foundational; expected from IC training but deepened in the structural context.

Hybrid OR exposure is separately important. TAVR and TMVR in high-risk patients often occurs in a hybrid suite that functions as both a cath lab and an operating room, with cardiac surgery available or scrubbed. Understanding sterile field conventions, working with surgical colleagues, and managing the hybrid team are skills developed only in that environment. Programs that do all structural cases in a conventional cath lab without hybrid OR exposure leave a gap that becomes visible in the first year of independent practice.

When evaluating programs, ask whether fellows have dedicated imaging rotations, access to CT planning software with instruction, and regular case planning conferences where imaging data drives procedural strategy. Programs where imaging is handled entirely by a separate echo lab with no fellow involvement in planning are providing less complete training.

Board Certification and Credentialing After Training

There is currently no standalone ABIM board examination in structural heart disease. Completion of SHD fellowship does not confer a new ABIM certification. The operator's highest ABIM certification at that point remains interventional cardiology (if they sat that exam) or cardiovascular disease.

Hospital credentialing for structural procedures operates through a different mechanism. Credentialing committees — typically staffed by department chiefs, peer review chairs, and in large systems by a designated structural heart credentialing subcommittee — evaluate:

• Case volume logs with operator role specified (primary operator vs. first assist)
• Completion letter from the training program director specifying procedures performed and competency achieved
• SCAI operator designation level documentation, if the program uses that framework
• Peer review of outcomes during training, particularly for TEER given the learning curve
• Proctored case requirements post-hire, which vary by institution and device

SCAI's operator designation framework divides structural operators into levels based on cumulative case experience, with specific thresholds for TAVR and TEER. These designation levels are increasingly referenced in hospital credentialing policies, particularly at institutions that have adopted ACC/SCAI clinical guidance on structural heart program development. Understanding which SCAI level your case documentation supports — and whether your fellowship program has tracked that data — is a practical task to complete before your first credentialing application.

Emerging certification pathways: SCAI has discussed mechanisms for formal competency recognition in SHD, and the field is watching whether ABIM will eventually create an SHD certification pathway. Nothing has been finalized as of this writing. Candidates should monitor SCAI and ABIM communications directly; do not rely on secondhand accounts of what certification requirements will look like in the future.

Salary, Compensation, and Academic vs. Private Practice

For specific compensation figures, see the PGY Zero compensation data page, which is updated for the current year. General structural considerations follow.

SHD fellowship stipends are typically set at the PGY 8 or higher level at the training institution, using the same pay scale as other advanced subspecialty fellows. Because SHD is not ACGME-accredited, there is no ACGME-enforced minimum, and stipend amounts are institutional decisions. The range across programs is meaningful. When comparing programs, ask specifically about stipend, benefits, conference travel support, and whether the institution covers SCAI membership and meeting fees — these are not trivial on a fellow's budget at this stage.

Post-training compensation in structural heart is among the higher tiers in interventional cardiology, reflecting procedural demand, technical complexity, and the limited supply of trained operators. Academic structural positions carry lower base salaries than private or hybrid lab roles but typically include research infrastructure, trial involvement, and the case volume that comes with being a quaternary referral center. High-volume community and private practice structural programs offer substantially higher compensation, and many have invested heavily in hybrid lab infrastructure precisely to attract trained structural operators.

The choice between academic and private practice for a structural heart cardiologist has programmatic implications: academic positions generally sustain higher procedural complexity, maintain access to next-generation devices through trials, and offer protected time for the publications and conference presence that drive career-long influence. Private and hybrid lab positions offer volume, autonomy, and compensation that can meaningfully accelerate financial recovery from the long training pathway. Neither is categorically superior; they serve different professional priorities.

Research and Innovation Expectations

SHD is an active trial field. Most high-volume centers are enrolling in at least one device IDE trial, registry study, or post-market surveillance protocol at any given time. A fellow at such a center will have direct exposure to trial coordination, patient enrollment, informed consent, data collection, and — at some programs — a co-investigator role on a manuscript or abstract.

Typical research outputs during a well-structured SHD fellowship year:

• Participation in institutional TVT or STS registry data submission and quality review
• One or two abstract submissions to TCT, ACC, or SCAI annual meeting
• A case series, outcomes analysis, or registry sub-study manuscript in preparation or submitted by fellowship end
• Familiarity with device trial regulatory framework (IDE, HDE, IND) sufficient to participate meaningfully in enrollment

Programs with active IDE trial involvement are producing fellows who understand device development from the inside — an increasingly valuable competency as the field continues to generate new technologies. Fellows who participate in early feasibility trials during training have publications and relationships that translate directly into independent investigator status post-fellowship. When evaluating programs, ask specifically which trials are currently enrolling and what role, if any, the fellow plays beyond clinical care of enrolled patients.

For candidates with a strong research interest, identifying programs where the structural faculty are principal investigators on ongoing trials — rather than sub-site investigators — provides the deepest research exposure. PI-level involvement means the fellow sees study design decisions, sponsor interaction, and data analysis rather than only enrollment logistics.

Competitiveness and How to Stand Out

SHD fellowship is a small-volume recruitment market. Most programs accept one or two fellows per year. The applicant pool at top programs is composed of IC fellows from high-volume academic centers with publications, strong structural faculty endorsement, and established relationships with the SHD program. Building a competitive profile requires deliberate action starting earlier than most IC fellows anticipate.

Concrete steps that demonstrably improve competitiveness:

• Maximize structural volume during IC fellowship: This requires active effort, not passive presence. Ask to scrub structural cases beyond your core IC requirements. If your program has a structural fellow, build that relationship. If your IC program has low structural volume, discuss with your program director whether elective rotations at higher-volume centers are possible.
• Publications and presentations with structural focus: A first-authored case series on TEER outcomes, a registry analysis of TAVR complications, or a CT planning methodology paper signals both interest and capability. Abstract presentations at TCT or the ACC Scientific Sessions are visible to structural faculty who attend those meetings and serve as networking vehicles.
• Direct relationships with structural heart faculty at target programs: These relationships typically develop at conferences, through shared research collaborators, or through a faculty mentor who can make an introduction. An email from a respected structural cardiologist to a program director carries significantly more weight than a cold application.
• SCAI membership and engagement: SCAI membership as a trainee is inexpensive relative to the access it provides. The SCAI annual meeting and its trainee programming create direct exposure to program directors and senior structural faculty in an environment where informal conversations about fellowship are expected.
• Imaging competency demonstrated, not just stated: Fellows who can show they read their own CT planning studies, present image-guided procedural strategies at case conferences, and understand 3D echo findings in structural context are demonstrably better prepared than those who list echo as a skill on a CV without evidence.

For IC fellows at programs with genuinely low structural volume, honest self-assessment is required. If your IC program cannot provide the case exposure to make you competitive, this is a planning problem that should be addressed during the IC fellowship year, not at application time. Faculty advocacy, elective rotations, and proactive relationship-building can partially compensate; they cannot fully substitute for case volume, but they can shift a borderline application into a competitive one if the other elements are strong.

Frequently Asked Questions

Can I pursue a structural heart fellowship without completing a full IC fellowship?

For practical purposes, no. The overwhelming majority of SHD programs in the US require completion of ACGME-accredited interventional cardiology fellowship as a prerequisite. A handful of programs have made exceptions for candidates with extraordinary imaging backgrounds or foreign-trained interventionalists with equivalent documented experience, but these are rare enough that they should not form the basis of a training plan. If you are aware of a specific program that has communicated flexibility on this requirement, confirm it in writing before adjusting your pathway.

What if my IC program has low structural volume?

This is a real problem but not a fatal one if addressed early. Options include: negotiating elective rotations at higher-volume centers during IC fellowship (some programs allow one to two months at an affiliate); pursuing additional structural exposure through the SHD fellowship application process at programs that explicitly value other strengths; and compensating with imaging competency, research output, and strong faculty advocacy. What does not work: waiting until the end of IC fellowship and then explaining the volume deficit in a personal statement without a demonstrated mitigation strategy.

Is SCAI membership necessary?

Not technically required, but practically valuable. SCAI is the field's primary professional home for structural interventionalists. Membership as a trainee provides access to the training program registry, meeting discounts, networking events specifically designed for fellows, and visibility to program directors. The cost-to-benefit ratio at the trainee membership level is strongly favorable for anyone seriously pursuing an SHD career.

How long is the job search after SHD fellowship, and when should I start?

The structural heart job market moves faster than the general academic cardiology market. High-volume programs are actively recruiting trained operators, and informal conversations about post-fellowship positions sometimes begin during the SHD fellowship year itself. Active job searching typically begins six to twelve months before the expected start date. Academic positions may have longer lead times due to faculty governance processes; private practice or employed group positions may move faster. Starting outreach during the SHD year rather than at its end provides more optionality and avoids the pressure of accepting the first offer because the timeline is compressed.

What happens if I complete an informal SHD training experience rather than a SCAI-aligned program?

The outcome depends heavily on the quality of documentation your informal training produces and the institutional credentialing environment at your target employer. If your training program provides granular case logs with operator roles, a detailed completion letter, and structured imaging documentation, a credentialing committee at a reasonable institution can work with that. If your documentation is a single-paragraph letter confirming you "participated in structural cases," you will face friction. Before committing to any informal training arrangement, negotiate explicitly for case log systems, completion documentation format, and what operator designation level your case volume will support under SCAI criteria. Get those commitments in writing before you start.

Is there a path to structural heart for international medical graduates?

IMGs who complete US ACGME-accredited IM, cardiovascular disease, and IC fellowships are on the same footing as US medical graduates for SHD fellowship applications. The challenge is that the full pathway from IM entry to SHD fellowship start takes a minimum of seven years, and many IMGs have longer timelines due to preliminary years, research years, or repeat fellowship matches. IMGs with non-US IC training who want a US SHD fellowship will typically need to complete a US IC fellowship first. Verify current requirements directly with ECFMG/Intealth and official sources for your application year.