Cardiac imagers, radiologists or cardiologists, do not receive adequate training or preparation for the harsh realities of running imaging programs and most of the training follows graduation where they are learning on the job and from their own mistakes. There are many factors and skill sets need to help imagers to run a successful and financially independent practice that are easily not easily acquired or researched independently. The intent of this review is to provide a checklist of steps recommended to create a successful program and to give insight into the financial considerations associated with workforce, equipment, training and sustainability. The challenges faced are broadly similar between practice types, but some distinct differences do exist within varying practice environments.