Cardiology Residency in Italy: Choosing What Kind of Cardiologist to Become

Anyone starting a cardiology residency in Italy has to find their way among fields that have grown increasingly independent over recent decades: interventional cardiology (known in Italy as haemodynamics), electrophysiology and echocardiography now each have their own units, technologies and lines of research. In Italy, specialist medical training takes place in university residency programmes (scuole di specializzazione), which doctors enter through the national SSM exam; for cardiology, the programme lasts four years.

«When a resident decides to go into cardiology», explains Prof. Carlo Pappone, «they also have to decide what kind of cardiologist they want to be». Pappone directs the Cardiovascular Diseases Residency Programme (Scuola di Specializzazione in Malattie dell’Apparato Cardiovascolare) at Vita-Salute San Raffaele University. Over the four years, residents rotate through the network’s hospitals in Milan, San Donato Milanese and the province of Bergamo, and each hospital brings them face to face with a different clinical profile.

Becoming a Cardiologist Today: Which Subspecialty Is Right for You?

«In the past, a professor would know general cardiology and have no specific expertise in, say, haemodynamics or interventional cardiology», Pappone recalls. «Today cardiology has become highly fragmented», he continues, «and there are now divisions with their own distinct identity, so students have to choose the branch of cardiology that interests them most». The decision takes shape during residency, because rotations across units allow residents to see the work of an interventional cardiologist or an electrophysiologist up close before deciding.

The choice also depends on the doctors who work alongside residents on the ward. Pappone advises residents to pick, among the cardiologists they work with, one they would like to “take after”. The gesture is symbolic, but it has practical value. «By watching how that cardiologist works, in every respect, young doctors learn a method, both clinically and in how they relate to patients. They should learn from both the strengths and the flaws of the people who do this job, because flaws, too, can teach something useful and constructive».

Research on medical education confirms how much role models matter. A US longitudinal study of 427 medical students, followed from their third year until they entered residency, found that those who had worked alongside a physician they saw as a role model tended to choose that physician’s specialty (Journal of Graduate Medical Education, 2018).

A review of 39 studies, published in 2013 in Medical Teacher as part of the BEME (Best Evidence Medical Education) guide series, identified what makes a doctor a good role model: clinical competence, teaching skills and personal qualities. All three are useful criteria for assessing the mentors of a residency programme.

The Cardiology Residency Training Network at UniSR

Which units will each resident get to know first-hand? That depends on the training network. The network of UniSR’s Cardiovascular Diseases Residency Programme is centred on the Cardiology Unit at IRCCS San Raffaele Hospital in Milan. Residents also train at IRCCS Policlinico San Donato, Clinica Polispecialistica San Carlo, Istituti Ospedalieri Bergamaschi (Policlinico San Pietro and Policlinico San Marco) and IRCCS Ospedale Galeazzi-Sant’Ambrogio. Electrophysiology, interventional cardiology and general cardiology are present at both main sites, IRCCS San Raffaele Hospital and Policlinico San Donato, each with a different focus. Residents therefore choose the setting in which to practise as well as the discipline.

Interventional Cardiology and Electrophysiology

Interventional cardiology treats the heart through catheters inserted into the blood vessels. At Policlinico San Donato, where the service is led by Prof. Francesco Bedogni, it is especially strong in structural heart interventions, which treat diseased heart valves percutaneously, without opening the chest.

Electrophysiology, too, is offered at both sites, each with its own profile. At IRCCS San Raffaele Hospital, the Arrhythmology and Cardiac Electrophysiology Unit led by Dr Paolo Della Bella specialises in ablation of ventricular tachycardia, a catheter procedure that destroys the tissue where the arrhythmia originates. At Policlinico San Donato, arrhythmology is led by Prof. Pappone. «Our work with children is extremely intensive», he says. Alongside paediatric arrhythmias, the unit performs ablation for atrial fibrillation and treats inherited heart diseases, Brugada syndrome in particular. It also combines clinical work with molecular biology, offering anyone drawn to molecular cardiology and research a unique opportunity to work in translational medicine.

Cardiac Surgery: Approaches and Perspectives

Cardiac surgery has its own residency programme, but for cardiologists the cardiac surgeon is an everyday counterpart. When it comes to valves especially, surgery and interventional cardiology now work side by side. At IRCCS San Raffaele Hospital, the Cardiac Surgery Unit led by Prof. Francesco Maisano combines traditional surgery with transcatheter procedures. In Prof. Pappone’s view, «it is important for a surgeon to be able to use the tools of interventional cardiology too». At Policlinico San Donato, Dr Lorenzo Menicanti and Dr Carlo de Vincentiis focus on the most complex operations, where experience and surgical dexterity are essential. Over the four years, residents can witness the full range of heart surgery.

At IRCCS San Raffaele Hospital, Prof. Alberto Zangrillo heads anaesthesia and intensive care, including cardiothoracic and vascular critical care. «This is where the most critically ill patients are treated, including those who need mechanical support for the heart, even an artificial heart. It is a field in which cardiologists, cardiac surgeons and intensivists work together», Pappone notes.

Learning from the Doctors Who Developed the Techniques

At UniSR, residents can come into direct contact with doctors who developed techniques now performed around the world, and in some cases work alongside them every day. Prof. Ottavio Alfieri, for example, introduced the edge-to-edge technique for mitral valve repair in 1991: a stitch joins the free margins of the two leaflets and reduces regurgitation. Today’s devices for percutaneous mitral repair grew out of that principle. Alfieri led Cardiac Surgery at IRCCS San Raffaele Hospital from 1997 to 2017 and is still a senior consultant to the unit.

Prof. Antonio Colombo belongs to the generation of interventional cardiologists who defined the modern use of coronary stents. In 1995 he published a study in Circulation on high-pressure stent implantation guided by intravascular ultrasound, an approach that allowed patients to avoid anticoagulant therapy after the procedure.

Among his other contributions, Prof. Pappone helped develop atrial fibrillation ablation. In 2003 he published a randomised trial in the New England Journal of Medicine on prophylactic ablation in patients with asymptomatic Wolff-Parkinson-White syndrome. Alfieri and Pappone still work at UniSR, so residents can watch the techniques they read about in textbooks being performed on the ward by the people who helped develop them.

Doing Research During Your Cardiology Residency

For residents, the way into research is gradual and starts with data collection. Their role grows over the years, and those who discover a strong interest in a line of research go on to pursue it independently.

Residents can choose from many lines of research. «Our campus is full of opportunities», Pappone points out, «and residents just have to pick a direction. The research I have devoted my life to concerns inherited heart diseases, ablation therapy in children and, more recently, molecular biology, because we are trying to identify a biomarker that can flag patients at risk of sudden death».

Pappone’s group also develops new technologies and devices, from more effective catheters to new cardiac equipment. In other UniSR laboratories, researchers are developing innovative heart valves.

Brugada Syndrome: Targeting the Source of the Arrhythmia

Brugada syndrome is a genetic heart rhythm disorder that puts patients at risk of serious ventricular arrhythmias. For patients who have already had a cardiac arrest or episodes of ventricular fibrillation, the standard treatment is an implantable defibrillator, which terminates the arrhythmia when it occurs. Pappone’s group has studied an approach that targets the source of the disorder: epicardial ablation, performed on the outer surface of the heart.

The randomised trial, published in EP Europace in 2025, enrolled 40 patients, all already fitted with a defibrillator and with a history of arrhythmic episodes. They were randomised to receive ablation or to continue with the defibrillator alone. After a follow-up of about four years, 96% of patients treated with ablation were free from recurrent ventricular fibrillation, compared with 50% in the control group. The result should be read as an early signal that needs confirming in larger cohorts, but it is very promising.

Spending the Final Year of Cardiology Residency Abroad

International experience starts well before the final year: during the programme, residents accompany their mentors on assignments abroad. In the final year, Pappone adds, «they can decide to spend the entire period abroad», an option open to all residents and one the programme actively encourages. Training is also possible at centres outside the network, in France, Spain, Germany, the United States, Belgium and the United Kingdom.

A year at another centre also helps residents build professional contacts, something they value highly. In a study published in 2021 in American Heart Journal Plus, cardiology fellows in Connecticut ranked help with building a professional network among the most important forms of support they expect from a mentor, while mentors gave it less weight. Time abroad is a practical way to build that network first-hand.

The Cardiologist of Tomorrow: More Prevention

Pappone envisions a future cardiologist who is «more focused on prevention than on treating the damage done by time and disease» and looks further ahead still: «the hope is that, over the next fifty years, prevention will cut cardiovascular disease so sharply that it almost disappears».

There is still a long way to go. According to Istat, Italy’s national statistics institute, diseases of the circulatory system caused 206,119 deaths in Italy in 2023 and remain the leading cause of death, although the standardised mortality rate fell by 8.5% compared with the previous year. The World Health Organization points out that most of these diseases can be prevented by addressing tobacco use, diet, physical inactivity, alcohol and air pollution.

The Role of AI in Diagnosing Heart Disease

According to Pappone, artificial intelligence is accelerating this shift towards prevention, because it helps spot patients at risk before the disease appears. In a 2019 study in Nature Medicine, a Mayo Clinic team presented an algorithm that detects reduced pumping function of the heart from the electrocardiogram alone, with sensitivity and specificity of around 86%. Among patients whose heart function was still normal, those flagged by the algorithm had four times the risk of developing the dysfunction in subsequent years.

CORO-CTAIOMICS, a research project run by UniSR and IRCCS San Raffaele Hospital and funded by Italy’s National Recovery and Resilience Plan (PNRR), works in the same direction. Its algorithms analyse coronary CT angiography images, including the artery walls, any plaques and the fatty tissue around them, and combine the quantitative measurements they extract with the patient’s clinical data to estimate the risk of major cardiovascular events in the four years after the scan. In both cases the algorithm remains a support tool. Diagnosis and treatment decisions rest on conventional tests and on the judgement of the cardiologist, who must be able to interpret these results alongside all the others. CORO-CTAIOMICS has also contributed to the creation of an educational app that lets young people and adults put themselves in a cardiologist’s shoes.

How to Choose a Cardiology Residency Programme

When comparing cardiology residency programmes, what matters is the range of fields residents rotate through, the space given to research and the chance to spend a year abroad. Most important of all are the mentors residents will spend four years with, because they largely shape what kind of cardiologist each resident becomes.

For Pappone, cardiology has made more progress than any other discipline in treating disease: «even today, few disciplines can tell a patient you are cured, and that is a source of great satisfaction», he observes.

External sources

Yoon JD, Ham SA, Reddy ST, Curlin FA. Role models’ influence on specialty choice for residency training: a national longitudinal study. J Grad Med Educ. 2018;10(2):149-154. doi:10.4300/JGME-D-17-00063.1

Passi V, Johnson S, Peile E, Wright S, Hafferty F, Johnson N. Doctor role modelling in medical education: BEME Guide No. 27. Med Teach. 2013;35(9):e1422-e1436. doi:10.3109/0142159X.2013.806982

Belluschi I, Buzzatti N, Castiglioni A, Alfieri O, De Bonis M. The Alfieri’s edge-to-edge technique for mitral valve repair: from a historical milestone of cardiac surgery to the origin of the transcatheter era. Mini-invasive Surg. 2020. doi:10.20517/2574-1225.2020.48

Colombo A, Hall P, Nakamura S, Almagor Y, Maiello L, Martini G, et al. Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation. 1995;91(6):1676-1688. doi:10.1161/01.CIR.91.6.1676

Pappone C, Santinelli V, Manguso F, Augello G, Santinelli O, Vicedomini G, et al. A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-White syndrome. N Engl J Med. 2003;349(19):1803-1811. doi:10.1056/NEJMoa035345

Pappone C, Ciconte G, Vicedomini G, Micaglio E, Boccellino A, Negro G, et al. Epicardial ablation in high-risk Brugada syndrome to prevent ventricular fibrillation: results from a randomized clinical trial. Europace. 2025;27(5):euaf097. doi:10.1093/europace/euaf097

Odanovic N, Clapham KR, Gul B, Yong CM, Meadows JL, Altin SE. MENTOR study: matching expectations and needs to optimize relationships in cardiovascular fellowship training. Am Heart J Plus. 2021;4:100019. doi:10.1016/j.ahjo.2021.100019

Istat. Cause di morte in Italia. Anno 2023 [Causes of death in Italy, 2023]. Press release. Rome: Italian National Institute of Statistics.

World Health Organization. Cardiovascular diseases (CVDs). Fact sheet. Geneva: WHO.

Attia ZI, Kapa S, Lopez-Jimenez F, McKie PM, Ladewig DJ, Satam G, et al. Screening for cardiac contractile dysfunction using an artificial intelligence-enabled electrocardiogram. Nat Med. 2019;25(1):70-74. doi:10.1038/s41591-018-0240-2