This survey aimed at investigating the educational offerings in cardiac imaging in Italian University hospitals, as well as exploring the vision of the residents regarding both the present and the future of this subspecialty. Collected data provided an updated snapshot of cardiac imaging practice and education in Italy, which is likely applicable also to similar European countries.
Technological profile in Italian academic centers and training possibilities
National measures to contain health care costs in Italy brought to a progressive obsolescence of CT/MR equipment in recent years, enhanced by the fact that the country is the second in Europe in terms of CT and MR scanners installed [14, 15]. Nevertheless, the results of our survey showed that the minimum standard requirements to perform CCTA and CMR were fulfilled (i.e., 64-slice scanner CT and ≥ 1.5 T magnets equipped with chest multielement radiofrequency coils and an ECG monitoring system) in all Italian academic centers with residency programs accreditation. This is the natural evolution of data from two previous surveys of the Italian Cardiac Radiology Society, which reported that more than 96% of CCTAs were performed with at least a 64-slices scanner CT  and nearly 100% of CMRs were performed with at least a 1.5 T scanner .
However, cardiac imaging education is limited to basic applications in about the half of the sites. On this regard, the paradigm of CMR is particularly significant. In 45% of the centers involved in the study, advanced CMR imaging techniques are not routinely performed: 4D-flow is used in only 12% of the centers, but also a state-of-the-art technique, which should enter in daily routine, like myocardial mapping, is performed in only 43% of the centers. This can likely reflect the average obsolescence of MR scanners in the national territory (i.e., more than 5 years) which reaches up to 51% .
Number of examinations performed and skills
The Cardiovascular Radiology Residency Training Program in Italy spans a period of 6 months to be covered within 4 academic years. The goal would be, for each resident, to achieve independent competency and to continue self-education, as well as life-long learning techniques.
On this regard, we found significant differences in training opportunities in Italy between CCTA and CMR. The amount of CCTA scans performed per week was highly variable, ranging from 1 to 10 (in 50% of the centers) to more than 20 (in approximately 25% of the centers). CMR practice resulted in an average number of 5 performed exams per week, corresponding to an average of approximately 100–150 observed cases per resident during the training period. Considering the average number of weekly examinations performed in the evaluated centers for both CCTA and CMR, it is possible to learn about the total amount of examinations developed throughout the entire period of the residency course, which proves useful to sit to the EBCR Diploma examination .
In the majority of centers, radiologists administered drugs independently, which confirms the evidence that a radiologist could handle cardiac imaging procedures from acquisition to reporting.
Furthermore, the data make it easy to affirm that most radiologists involved in cardiac imaging perform CCTA, if compared to CMR (Fig. 2); CMR education represents a more challenging field and it will, therefore, be essential to improve primarily the skills of CMR during the future trainings.
Educational program aspects and future perspectives
Italian educational system is not structured in level 1–3 courses, as residency program is the “entry level” to start cardiac imaging practice, without a formal accreditation exam. This is eventually followed by a research postdoc or PhD.
Subspecialty competence in cardiac imaging must be provided to radiology residents as stated by the Ministry of Education, University and Research’s guidelines. This is in contradiction with our observed data, showing that 25% of Residency Programs lack the presence of a complete theoretical and practical educational training. However, probably at least a part of the residents of these schools have the opportunity to complete their training attending different schools and hospitals during the residency program, using the way of the external training, included in the Residency Training Program in Italy.
Most participants (74%) considered cardiac radiology relevant in their future careers but, at the same time, 28–30% of them reported the perception of an inadequate training.
Looking at our survey’s data, one may speculate that inefficient training is mostly center based (i.e., attributable to the suboptimal educational offer) rather than an organizational failure of the training programs.
Where cardiac imaging rotation is nonexistent, radiologists should be offered the opportunity of completing their cardiac rotation in referral cardiac centers.
Another important educational opportunity offered to the Italian radiology residents is the wide offer of the Italian College of Cardiac Radiology by SIRM in terms of basic and advanced theoretical and practical courses (e.g., “ABCardio” and “focus on” courses). This Italian educational offer is further integrated by the international initiatives of the ESCR (ESCR educational webinars: “basic,” “advance” and “case based”) and the European School of Radiology (ESOR) (i.e., ESOR Foundation Courses and ESOR Galen Courses).
Furthermore, in response to the COVID-19 pandemic, webinar educational activity was further expanded with monthly meetings (called “For beginners, Technical updates, Clinical-radiological correlation and Live Cases”). These always-available online resources seem to be an excellent tool for integrating and enhancing educational activities, and their availability and implementation will have to continue even when face-to-face meetings can be resumed.
Overall, our results are comparable to a similar survey focusing on cardiac imaging training from the USA . In the US survey, 71% of the residents had at least one dedicated cardiac imaging rotation of 3.37 weeks, building an overall experience in cardiac imaging of approximately 50–60 examinations during the entire period.
It is clear that the current programs not always combine cardiac examinations together with lectures, and alternative pathways should be sought by academic centers in order to provide a more complete cardiac educational route. Furthermore, a recent survey , looking at the barriers to academic activities that cardiovascular radiology trainees face worldwide, underlined the need for an update of the training programs and underlined the relevant role of academic activities in the cardiovascular department.
63% of radiologist residents imagine believe in a strong collaboration between radiologists and cardiologists in the field of cardiac imaging. These results are of utmost importance and highlights the fact that the future generations recognize the importance of a multidisciplinary approach to medicine, have a willingness to cooperate and an already well-established propensity to work in multidisciplinary clinical teams.
The UEMS recently approved the new ‘European training requirements in cardiology’ , where cardiologists are required to achieve a level of independence of 3 (i.e., trainee is able to perform the activity under indirect supervision) in cardiac imaging. This boosts an urgent adjustment of training process in cardiac imaging, in order not to transform the radiologist into a supporting figure to the imaging workflow.
However, it is nonetheless important to underline that in Italy, according to our data, only in 10% of CCTA and in 18% of CMR, there is a radiology-cardiology combined readout and these rather low percentages recognize some answers and open-up possible scenarios:
Impact on cost-effectiveness of two professional figures on a single imaging modality remains questionable, also in the light of the advance cardiac imaging reimbursement issues all over the world;
Regardless of a radiology-cardiology combined readout, a cardiologist at the occurrence can be involved according to a local expertise and to an organization collaborating with the radiologist in a patient-centered approach;
Similar data are confirmed by the ESCR, the MR/CT registry  which is the largest of ongoing data collections with over 340.000 cases included at the time of writing the manuscript, where a consensus reading of 18% for CCTA and 27% for CMR is reported.
Considering the “cardiac-imaging tsunami” that is approaching, the presence of a “clinical” radiologist, well trained in the field of cardiac imaging, will be fundamental. In patients with coronary artery disease, the radiologist can evaluate the heart and thorax beyond the coronary arteries and suggest an ischemia test (Stress CMR or CT perfusion) or, in patients with structural heart disease, he might evaluate the aortic, mitral valves, as well as the vascular accesses. In CMR, he would be able to optimize the acquisition protocol and provide imaging findings that are useful for the clinical management of patients.
This research has some limitations though. Firstly, while all Italian Universities responded to the first part of the survey, we only obtained replies from a moderate percentage of the Italian residents regarding the second part. This was probably due to the fact that the latter was not addressed directly to each resident but shared via social media; hence, the answers may not represent the global sample, being potentially biased by the selection of physicians who are likely to be interested in cardiac imaging. Secondly, the survey was focused on radiology activity, only offering a partial perspective of cardiac imaging training in Italy, with an obvious underestimation on the number and percentage of examinations performed by the cardiologists. Thirdly, the manuscript mainly focused on the training of radiologists, with no mention of the training of cardiologists; further studies could be needed to compare the training in advanced imaging of both categories. Finally, the survey does not assess several training opportunities offered to radiology residents outside from the specific site of each school. Hence, this survey may partially underestimate the true educational offer in cardiac imaging provided to the radiology residents.
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