European Association of
Percutaneous Cardiovascular Interventions
a Registered Branch of the European Society of Cardiology
APPLICATION FORM:
APPLICATION FOR TRAINING CENTRES
TRAINING AND RESEARCH FELLOWSHIP PROGRAMME FOR
INTERVENTIONAL CARDIOLOGY
THE EUROPEAN ASSOCIATION OF PERCUTANEOUS
CARDIOVASCULAR INTERVENTIONAS
A Registered Branch of the ESC
TRAINING FELLOWSHIP PROGRAMME
To reduce the burden of cardiovascular disease in Europe through Percutaneous Cardiovascular Interventions.
The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France
Website: www.escardio.org/EAPCI - Email contacts: EAPCI@escardio.org
European Association of
Percutaneous Cardiovascular Interventions
a Registered Branch of the European Society of Cardiology
APPLICATION FOR THE EAPCI TRAINING AND RESEARCH FELLOWSHIP
Thanks to the financial support from industries sponsors, the European ASSOCIATION OF
CARDIOVASCULAR INTERVENTIONS (EAPCI), a registered branch of the European Society of Cardiology
(ESC), is offering a Training and Research Fellowship Programme available to qualified Medical Doctors
and Cardiologists working in the field of Interventional Cardiology. We invite separate applications from
both individuals and centres to be matched exclusively by the EAPCI Fellowship Committee. The starting
period for applications is 12th October 2015.
The deadline for applications is 15 January 2016, with a start date between 1 June and 31 December
2016.
Prior to completing this form, please carefully read the Rules and Regulations for the EAPCI Training
and Research Fellowship Programme for interventional cardiology.
Rules are available on the EAPCI website:
http://www.escardio.org/communities/EAPCI/Pages/welcome.aspx
Section: Education – Training and Research Grants
All parts of the application form must be returned by
15st January 2016
Any application received by fax and/or post only or received after the
mentioned deadline will not be acceptable.
To reduce the burden of cardiovascular disease in Europe through Percutaneous Cardiovascular Interventions.
The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France
Website: www.escardio.org/EAPCI - Email contacts: EAPCI@escardio.org
European Association of
Percutaneous Cardiovascular Interventions
a Registered Branch of the European Society of Cardiology
APPLICATION FOR THE EAPCI INTERVENTIONAL CARDIOLOGY TRAINING AND
RESEARCH GRANT
Name Centre
City
Country
Phone number*
Fax Number*
e-mail
*: These fields are not mandatory
Address of Centre
To reduce the burden of cardiovascular disease in Europe through Percutaneous Cardiovascular Interventions.
The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France
Website: www.escardio.org/EAPCI - Email contacts: EAPCI@escardio.org
European Association of
Percutaneous Cardiovascular Interventions
a Registered Branch of the European Society of Cardiology
HEAD OF THE DEPARTMENT APPLYING FOR THE EAPCI TRAINING AND
RESEARCH FELLOWSHIP PROGRAMME
1. Name and title:
2. Name and address of Department:
Phone number *
Fax number *
Email
*These fields are not mandatory
3. Name and position of proposed Fellowship Supervisor:
Phone number *
Fax number *
Email
*These fields are not mandatory
4.
Name and title of Administrator for the Fellowship Programme:
Phone number *
Fax number *
Email
*These fields are not mandatory
5. Please state in a few words:
a. Why the centre is appropriate for this training and how it will ensure that candidates meet
their objectives :
b. How many fellows and from which countries, did you train for at least 6 months, over the last
5 years?
Training fellows
Total
1 year
fellows
Past (last 5 years)
Present
Expected during the grant period
To reduce the burden of cardiovascular disease in Europe through Percutaneous Cardiovascular Interventions.
The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France
Website: www.escardio.org/EAPCI - Email contacts: EAPCI@escardio.org
European Association of
Percutaneous Cardiovascular Interventions
a Registered Branch of the European Society of Cardiology
6. Could you please give a starting date (between 1 June and 31 December 2016) to welcome the
fellow?
a. Could you specify if their activities were orientated more on Basic Science, Clinical
research or both?
b. Could you specify which of the metallic and/or bioabsorbable drug-eluting coronary stents
are used in your lab?
c. Other?
7. Could you specify which of the transcatheter aortic valve system is used in your lab?
a. Other?
b. We do not perform aortic valve interventions.
8. Could you specify which of the TRANSCATHETER MITRAL VALVE SYSTEM is used in your lab?
a. Other?
b. We do not perform mitral valve interventions.
9. Could you specify which of the following structural heart disease interventions is performed in
your lab? Please specify devices:
a)
b)
c)
d)
e)
f)
laa closure
pfo closure
asd closure
vsd closure
paravalvular leak closure
we do not perform structural heart
yes
yes
yes
yes
yes
interventions
no
no
no
no
no
devices:
devices:
devices:
devices:
devices:
10. Could you specify which of the intracoronary imaging system (IVUS/OCT/NIRS) is used in your
lab?
a)
b)
c)
d)
e) Other?
11. Could you specify which of the physiological lesion assessment system is used in your lab?
a)
b)
c) Other?
Fluoroscopy / angiographic system:
Siemens

Phillips

GE

Other: _______
To reduce the burden of cardiovascular disease in Europe through Percutaneous Cardiovascular Interventions.
The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France
Website: www.escardio.org/EAPCI - Email contacts: EAPCI@escardio.org
European Association of
Percutaneous Cardiovascular Interventions
a Registered Branch of the European Society of Cardiology
Do you have a hybrid room?
do you have cardiac surgery on-site?
yes
yes
no
no
12. Short description of the training you provide to training fellows?
13. How many fully recognised interventional cardiologists are working in your centre?
a)
b)
c)
d)
e)
f)
g)
Number
Number
Number
Number
Number
Number
Number
of
of
of
of
of
of
of
PCI per year:
TAVI per year:
mitral valve interventions per year:
structural heart disease interventions per year:
IVUS per year:
OCT per year:
FFR per year:
14. Could you please indicate if you have a fellow to suggest?
15. Can you certify that all the educational activities will be delivered in English?
yes / no
16. Do you have restrictions to welcome foreigners?
17. What are the requirements in your country and/or your centre?

Working permit?
yes / no
Details:

To be compliant with the EU regulation 36-2005, does the applicant need to speak the
native language of your country?
yes / no
If yes:
Required level:
Basic / Fluent
Is this level required upon his/her arrival already?
yes / no
Does the applicant needs to provide a certificate on the native language of the country to
be able work on patient?
To reduce the burden of cardiovascular disease in Europe through Percutaneous Cardiovascular Interventions.
The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France
Website: www.escardio.org/EAPCI - Email contacts: EAPCI@escardio.org
European Association of
Percutaneous Cardiovascular Interventions
a Registered Branch of the European Society of Cardiology
yes / no
If no:
please indicate which language(s) the applicant needs to speak:
please be aware that compliance with the EU regulation 36-2005 remains the
responsibility of your centre and EAPCI cannot be held responsible for any information /
requirement that you have not mentioned.

Other requirements?
18. As part of the Programme, the Department will be requested to publish documents in the
Eurointervention (or in any other equivalent peer review journal) and/or to submit one abstract at
the EAPCI official congress (EUROPCR). Results of the training shall be jointly owned by the
ESC/Association, the host institution and the fellows. Acknowledgment of the grant will be
stated in all these materials.
Please give the references of three recent papers on Interventional Cardiology published from
your institution in an international peer-reviewed cardiology journal (authors, title, journal,
pages):
ACCEPTANCE AND CONDITIONS
I am aware that as a Training Centre in the EAPCI Training and Research Fellowship Programme, for all
fellows appointed by EAPCI, there will be a contract (employment, training) between the host institution
and the fellow to be countersigned by the ESC and the EAPCI.
The centre is responsible for the set up of the legal framework of the fellow in accordance with local
regulations and the fellow will be subject to the terms of employment of its host institution.
I confirm that I have read and understood the Rules for the EAPCI Training and Research Fellowship
Programme for interventional cardiology and that, if an appointment is made, the fellow would be
accepted in the Department in connection with the agreement to be arranged with him.
I confirm that the department will be in a position:
 To set up contract (employment, training) with the recipient
 To meet any expenditure related to the training programme exceeding the amount provided by
the ESC
To reduce the burden of cardiovascular disease in Europe through Percutaneous Cardiovascular Interventions.
The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France
Website: www.escardio.org/EAPCI - Email contacts: EAPCI@escardio.org
European Association of
Percutaneous Cardiovascular Interventions
a Registered Branch of the European Society of Cardiology
Personal Data Privacy
The information collected is subject to a computerised process to record, evaluate and track your grant application. The recipients of the data are:
• The staff in charge of processing « EAPCI Training Fellowship» applications and, where a grant is awarded, the staff in charge of paying the grant
monies.
• Persons to whom the request will be sent for review and evaluation.
In accordance with the French law N°78-17 of January 6, 1978, amended in 2004, relating to the protection of individuals with regard to the
processing of personal data, you have a right to access and rectify information concerning you, which you can exercise by contacting:
Customer Services
European Society of Cardiology
Les Templiers, 2035 Route des Colles
06903 SOPHIA ANTIPOLIS. FRANCE
You can also, for legitimate reasons, oppose the processing of data about you.
Signature of Head of Department:
Date:
Signature of Supervisor:
Date:
Signature of Administrator:
Date:
Please indicate whether health insurance (sickness and accident) is:
Provided by the employing Institution
Taken out by the applicant on his/her own discretion and obligation
Please indicate the status of the candidate during his/her research period:
To reduce the burden of cardiovascular disease in Europe through Percutaneous Cardiovascular Interventions.
The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France
Website: www.escardio.org/EAPCI - Email contacts: EAPCI@escardio.org