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Flying The Nest: Interventional Cardiology Fellowships in the Contemporary Resident Training Model
Asad Shabbir, ST7 Cardiology Registrar, John Radcliffe Hospital, Thames Valley Deanery
Interventional cardiology is a technically demanding subspecialty within cardiovascular medicine. With the widespread need for complex percutaneous coronary intervention (PCI) and structural heart intervention operators, procedural complexity has substantially increased over previous decades. Thus, all interventional cardiologists, regardless of whether their core skills lie in coronary or structural intervention, must have a comprehensive understanding of how to manage complex and calcified lesions, large bore arterial access, and the principals of valve interventions.
UK interventional cardiology trainees face critical decisions regarding further sub-specialisation after core cardiology training, particularly concerning whether to pursue an interventional cardiology fellowship, either domestically or abroad. Herein, I discuss the educational value, clinical impact, and career implications of interventional cardiology fellowships in the UK and overseas. I also share some of my experiences from when I completed my Interventional Cardiology fellowship in Madrid, Spain from 2022-2024, and how I navigated a European coronary fellowship in the post-Brexit era.
There are several key considerations that one must consider prior to embarking on an interventional cardiology fellowship. Primarily, the trainee should bear thought to the question of whether such a fellowship is required or not. Whilst certainly not mandatory, there are several key advantages to undertaking a period of intensive training at a high-volume procedural centre. This will, however, require a period of self-reflection to ascertain whether you may need additional time out of training to meet specific goals. From the perspective of recruitment to a consultant position, as well as the training aspects, fellowships demonstrate commitment, tenacity, and a clear professional trajectory. They can foster international collaborations, academic publications and research productivity, all of which might enhance your profile. Some fellowships also allow for time towards research projects and perhaps even higher research degrees, which will be of interest to those who wish to pursue academic careers, whilst also maintaining clinical skills in the cardiac catheterisation laboratory.
The NHS is experiencing increasing demand for interventional cardiology services, driven by an ageing population, rising rates of cardiovascular disease, and the expansion of catheter-based therapies into structural and congenital domains. Transcatheter aortic valve implantation (TAVI), for instance, has moved beyond high-risk patients to include intermediate- and low-risk populations, leading to a sharp increase in procedural volume. There is, therefore, a system-level need for a greater number of highly trained interventional cardiologists who can deliver these complex procedures safely and efficiently. Fellowships can help fill this gap by producing operators who are ready to take on full consultant-level responsibilities from day one, reducing the learning curve and enhancing service readiness.
One of the initial steps I took prior to planning my fellowship was finding time to meet with my training programme director (TPD) to identify where my specific training needs are and whether these can be met within the deanery. Generally, this applies to both coronary and structural training, as very few centres offer pre-CCT structural training or advanced coronary training in chronic total occlusions (CTO), complex high-risk indicated PCI (CHIP), and mechanical circulatory support (MCS). As such, it is recommended that this should be discussed in detail with your TPD as early into your subspecialty training time (ST6-ST7) as possible. Although I could have been exposed to most, if not all of these, I agreed with my TDP for 2 years of out-of-programme experience (OOPE) time to focus specifically on complex coronary intervention. Hence, I started searching for an appropriate centre that met my requirements.
Regional differences in exposure to UK-based trainees in structural and advanced coronary training should be considered. Without the opportunity to train in advanced skills through fellowships, there is a risk that training can vary significantly between deaneries and institutions. This inconsistency may lead to significant differences in regional competency, which must be avoided. It is highly likely that if your deanery cannot offer structural or advanced coronary training prior to your CCT, you will be supported to undertake this training as part of a fellowship.
The principal utility of an interventional cardiology fellowship lies in the acquisition of procedural volume and complexity that may not be attainable during standard training time. Many trainees report limited exposure to structural heart disease interventions such as TAVI, mitral interventions, and left atrial appendage occlusion procedures. Interventional fellowships, particularly those in high-volume centres, can provide concentrated training in these procedures in a relatively short period of time.
Furthermore, fellowships allow for a structured curriculum focused specifically on interventional skills that you may be lacking or would like more exposure to, including but not limited to; 1) intravascular imaging modalities; e.g., optical coherence tomography (OCT) and intravascular ultrasound (IVUS), 2) advanced coronary interventional techniques; e.g. intravascular lithotripsy (IVL), rotational atherectomy, orbital atherectomy and laser, 3) complex decision-making in the cardiac catheterisation laboratory, 4) gaining skills in delivering catheterisation laboratory-based education; i.e. learn how to be a future educationalist, 5) all aspects of structural intervention training.
These are all areas where cumulative experience and mentorship play vital roles, and where additional training time can meaningfully enhance competence and confidence. From a procedural standpoint, the British Cardiovascular Intervention Society (BCIS) recommends that operators should perform a minimum of 75–100 PCIs annually to maintain proficiency. A fellowship in a high-volume centre ensures a breadth of case exposure and helps gain the necessary foundation of skills required for lifelong learning as an interventional cardiologist.
There are also benefits to fellowships, beyond just adding more cases to your logbook. There is an advantage to be gained from working within different healthcare models. Undertaking procedures alongside different operators will expose you to unique operating styles, some of which you might employ in your own practice. Working in other clinical environments may highlight potential areas for improvement when you return to your home system, but may also allow you to see the good parts and particular systems which work well in your home institution. Invariably there will be differences between how local governance is implemented in different healthcare settings and you might be able to spot particular areas that might benefit from quality improvement when you return after your fellowship; such as cath lab turnover or consenting etc.
Finally, overseas fellowships sometimes allow for you to learn another language if you so wish, and also undergo a degree of cultural immersion, both of which could be once in a lifetime opportunities; this was certainly my experience from my interventional cardiology fellowship in Spain.
A key consideration for UK trainees is whether domestic training is sufficient to meet the thresholds for what is required to function as a contemporary interventional cardiologist, or whether international experience is necessary. While some UK centres of excellence, particularly tertiary referral hospitals, do offer robust interventional fellowships, not all trainees have access to such centres. This has led to a significant number of interventional trainees seeking overseas fellowships. However, in recent years, the numbers of UK-based centres offering competitively appointed high volume fellowships has dramatically increased.
UK-based fellowships offer some clear benefits. Firstly, geography is an important consideration to almost all trainees, most of whom would have settled in the UK to complete their national training number, and some of whom will have families and other attachments to the UK which preludes spending a significant period of time abroad. Secondly, it is often simpler to ascertain the training experience in UK centres, as it will invariably be easier to gain the feedback of previous fellows, and thus form an opinion on whether the site will be a good fit to meet your individual needs. Thirdly, by remaining in the UK you will essentially bypass all language, medical licence regulation and visa restrictions, making for a simpler training experience. Finally, UK fellowships offer very high-quality training, as reflected by the fact that many UK centres now host overseas trainees on a regular basis. To a significant number of trainees it is therefore completely understandable why there is a preference to remain in the UK, and many interventional trainees who have completed UK-based fellowships have subsequently gone on to gain substantive Consultant appointments in exceptional centres.
Contrary to most UK fellowships overseas fellowships are generally more experienced at hosting fellows from different backgrounds and countries. In Europe, it is considered common to complete a multi-year interventional fellowship after core cardiology training, as such most institutions have a track record of compressing an interventional training program into 1-2 years. There are far more hosting centres overseas than in the UK, and consequently there has been a greater choice of centres available overseas.
Overseas fellowships can be associated with logistical and regulatory challenges. Perhaps the greatest hurdle in organising overseas fellowships has been the effect of the UK leaving the European Union, i.e. through Brexit. This has multiple implications on professional validation, some of which must be navigated months/years in advance of the fellowship start date, and this was certainly my case when navigating the Spanish Healthcare system. In some countries, like in Spain, UK medical degrees now require homologation. Depending on the country, this can take over a year, and often requires several documents, including degree certificates and transcripts to be sent to the host country government institution for consideration. It is suggested that this is addressed as early as possible. I approached my host centre approximately 18-months in advance, and they were extremely experienced at hosting international doctors for fellowships, and were adept at helping me navigate the healthcare homologation system. I strongly advise you to select a host centre which has this experience and has a track record of having fellows from all across the globe, as they will often have a department to help with the organisational and administrative aspects of coming to the host country in a timely manner that fits with your OOPE timeline.
In some counties such as the USA, post-graduate examinations are a requirement of entry as a healthcare worker. It is advisable that if you are considering a fellowship or a career in such a country, the entrance examinations should be completed as early as possible.
Some non-English speaking countries require a minimum standard of language skills in order to work in healthcare institutions. They may also require translations of all the documents that are sent for the medical degree validation and may also require legal stamping. Importantly, you will have to communicate with patients and with colleagues effectively, and as such a day-to-day minimum standard of language proficiency is required to consent patients and also interact on the ward/clinic if that is also part of the training fellowship.
It is possible that a visa will be required to enter the country for an extended period of time. Depending on whether the fellowship is classed as post-graduate medical training as part of an affiliated university or as a practicing clinician in an independent hospital, different visas may be required. Part of the visa requirement is often a minimum ongoing salary or a grant and also private health insurance. The financial implications of this should be carefully considered.
Finally, overseas fellowships will invariably incur a financial burden. Moving to the country, navigating the rental market, day to day living with general consumables can be costly, and a spreadsheet of predicted costings should be made. As well as the British Cardiovascular Intervention Society (BCIS), several other training bodies such as the European Association of Percutaneous Coronary Interventions (EAPCI), The Royal Society of Medicine (RSM), and The Royal College of Physicians (RCP), offer grants and established funded fellowships. These should be explored in detail as they are often competitive appointments.
Nonetheless, international fellowships often provide access to cutting-edge research, exposure to clinical trials, and early experience with emerging technologies, thereby enhancing the trainee’s academic and professional development.
Recognising the limitations of formal fellowships, some UK trainees seek alternative pathways to enhance their skills. This is also a robust method for enhancing interventional skills. Some alternatives to formal fellowships include modular training during ST6–ST7 years in tertiary centres whereby trainees visit high volume centres for a short period of time to focus on specific skills, visiting observerships which may be particularly useful for structural interventions where you can observe expert operators, BCIS-approved short courses and simulation-based learning, and online platforms and case-based learning modules. These alternatives may be particularly suitable for those with family or financial constraints, or for those who seek targeted skill acquisition rather than broad procedural immersion.
Interventional cardiology fellowships offer substantial educational and professional value for UK-based cardiology trainees, particularly those with aspirations to lead in complex coronary or structural heart interventions. They enhance procedural competence, academic output, and job market competitiveness, and they help meet the NHS’s growing demand for skilled interventionalists.
However, fellowships are not universally necessary or suitable. Their utility depends on the quality of prior training, individual career goals, financial and personal circumstances, and the intended scope of clinical practice. Trainees should weigh the benefits of a fellowship against the opportunity costs, and ideally seek mentorship from established interventional cardiologists to guide their decision-making.
In an era of rapid cardiovascular innovation, lifelong learning and procedural excellence will remain essential. For many UK trainees, an interventional fellowship, whether at home or abroad, can be a transformative step toward fulfilling those aims.