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Career Paths in Cardiology: Interventional Echocardiography
Cardiology is a field with a wide range of subspecialty choices. Most FITs decide on a subspecialty in their first two years of fellowship; however, it is never too late to develop your niche. Exploring your options with an open mind will help you find the best fit within Cardiology. In this regular featured series, we highlight experts in Missouri that are engaged in sub-specialty fields.
Nishath Quader, MD, FACC, FASE, is a Professor of Medicine at Washington University School of Medicine in St. Louis, where she specializes in cardiovascular imaging with a focus on structural heart disease. As the Director of Interventional Echocardiography and Medical Director of Echo Lab Operations at Barnes Jewish Hospital, Dr. Quader has played a key role in advancing imaging for structural heart disease while also optimizing workflow and increasing efficiency of the echo lab operations.
She serves as the Program Director for the Cardiac Imaging Fellowship at Washington University, where she has mentored and trained numerous fellows. Her commitment to echocardiography is reflected in her leadership roles within national organizations, including the American Society of Echocardiography (ASE), where she is Chair of the Interventional Echocardiography Council, and a member of the ASE Board of Directors. As an editorial board member and reviewer for several high-impact journals, she also serves as the case imaging editor for Circulation: Cardiovascular Imaging.
In addition to her academic and clinical roles, Dr. Quader is a sought-after speaker, presenting at major cardiovascular conferences. She has been a co-author of several guidelines related to competency in Interventional Echo, preprocedural image screening, the ACC advanced training statement for structural heart disease, and currently serves as the co-chair of the ASE mitral TEER guideline. Her research interests focus on optimizing imaging techniques to improve outcomes for patients undergoing transcatheter procedures. Her dedication to both innovation in echocardiography and the mentorship of future cardiologists continues to shape the evolving landscape of cardiovascular medicine.
Tell us more about the field of Structural and Interventional Echo
Over the past decade, the field of structural heart disease (SHD) interventions has expanded dramatically. What began with TAVR, PVL closure, and ASD/VSD closure has grown to include mitral and tricuspid transcatheter edge-to-edge repair (M-TEER, T-TEER), transcatheter mitral and tricuspid valve replacement (TMVR, TTVR), left atrial appendage occlusion (LAAO), and other complex procedures.
This rapid growth has been possible in large part due to the skilled image guidance provided by interventional echocardiographers (IEs). Just like interventionalists, IEs have had to continuously adapt, mastering advanced imaging techniques and deepening their understanding of cardiac anatomy to support increasingly complex cases. It is a dynamic and intellectually stimulating field, but one that faces significant challenges—requiring coordinated, multi-society advocacy to ensure a well-trained workforce is available to meet the growing demand.
Can you tell us about your journey and interest in Structural and Interventional Echo
During my general and advanced imaging fellowships, I was drawn to intraoperative TEE, 3D echocardiography, and valvular heart disease. At that time, interventional echo was an emerging subspecialty. I recall performing TEEs for early TAVR cases, using 3D imaging for aortic annulus sizing, and providing procedural guidance for a patients enrolled in the COAPT trial.
After joining Washington University-St. Louis, I became one of the only imaging cardiologists in the Valvular and Structural Heart Disease Clinic. It quickly became clear to my colleagues that imaging was integral to procedural success. My expertise has evolved alongside the field and my implanting team—moving from aortic to mitral to tricuspid interventions and into every major structural procedure now available. This growth demanded that I stayed at the forefront of TEE and 3D TEE advances.
Nationally, efforts were also underway to formalize and elevate the role of the IE. The American Society of Echocardiography (ASE) transformed its structural heart disease task force into the Interventional Echo Council, advocating for guidelines, education, and recognition of the subspecialty. I have been fortunate to contribute to these initiatives, author guidelines, and lead advocacy efforts—and I now serve as Chair of the ASE Interventional Echo Council.
Are their formal training pathways in this specialty?
The concept of Level III training in SHD interventions was first introduced in 2019, recognizing that procedural imaging for SHD is distinct from advanced echocardiography training (1).
In 2023, ASE formalized this with guidelines on Special Competency in Echocardiographic Guidance of SHD Interventions. These guidelines outline pathways for both cardiologists and cardiac anesthesiologists—applicable to fellows in training and practicing physicians. They specify competencies, training duration, and procedural skills, recommending an additional 9–12 months of dedicated IE training beyond Level II or III echocardiography certification. Procedural minimums are defined but with the recognition that complex and novel devices require higher volumes to achieve proficiency (2).
What are the greatest challenges facing the field?
There are several challenges facing the field of IE. The main ones are:
- Workforce Shortage – The rapid increase in SHD volume has created a demand for more IEs, yet compensation inequities discourage trainees from pursuing this path. Many centers rely on rotating general imagers with limited exposure, which affects quality, growth potential, and leads to burnout among dedicated IEs.
- Compensation Disparities – CPT code 93355 (structural TEE) provides only 4.66 wRVUs for cases lasting 2–4 hours, compared to >30 wRVUs for the implanting physician during M-TEER. This imbalance impacts recruitment and retention.
- Radiation Exposure – IEs are exposed to significantly higher radiation doses than many implanting physicians. Awareness of and adherence to radiation safety protocols remains inconsistent (3).
- Lack of Awareness – Interventional echocardiography is often mistakenly equated with general echocardiography. It requires specialized training, advanced technical skill, and real-time procedural decision-making.
- Limited Training Programs – Few formal IE fellowships exist, largely due to lack of ACGME accreditation and funding constraints.
- Inadequate Institutional Support – In some centers, IEs are expected to complete their full clinical workload in addition to long procedural days, creating inequitable workloads and fueling burnout.
- Low Procedural Volume – Adequate case volume is critical for maintaining proficiency for both the implanter and IE; low volume settings risk poorer outcomes and procedural inefficiency.
What advice would you like to share with FITs that may be interested in considering a career in this specialty.
- Seek Dedicated Training – “On-the-job” exposure is rarely sufficient. Pursue formal IE training to ensure technical proficiency and patient safety.
- Evaluate Procedural Volume – When selecting a practice, assess the institution’s SHD case volume to maintain skills.
- Negotiate Fair Compensation – Understand alternative models (proxy wRVU, time-based, equal sharing, fixed salary) and advocate for equitable pay structures.
- Prioritize Radiation Safety – Go beyond lead aprons—ensure proper shielding, dosimetry, team education, and monitoring (4).
- Commit to Lifelong Learning – The field is evolving rapidly; staying current with device technology and imaging innovations is essential.
Mobile shielding options imperative to radiation protection intra-procedurally:
References:
- Hahn RT, Mahmood F, Kodali S et al. Core Competencies in Echocardiography for Imaging Structural Heart Disease Interventions: An Expert Consensus Statement. JACC Cardiovasc Imaging 2019;12:2560-2570.
- Little SH, Rigolin VH, Garcia-Sayan E, Quader N. Recommendations for Special Competency in Echocardiographic Guidance of Structural Heart Disease Interventions: From the American Society of Echocardiography. J Am Soc Echocardiogr 2023;36:350-365.
- Crowhurst JA, Scalia GM, Whitby M et al. Radiation Exposure of Operators Performing Transesophageal Echocardiography During Percutaneous Structural Cardiac Interventions. J Am Coll Cardiol 2018;71:1246-1254.
- Garcia-Sayan E, Jain R, Wessly P, Mackensen GB, Johnson B, Quader N. Radiation Exposure to the Interventional Echocardiographers and Sonographers: A Call to Action. J Am Soc Echocardiogr 2024;37:698-705.
