Avoid Reinventing the Wheel
Straight Talk | After 38 years, interventional cardiology has achieved maturity, right? Wrong! This specialty continues to evolve at a dizzying pace that would have amazed Dr. Andreas Gruentzig. New developments, especially in structural heart interventions, seem to come almost daily, as judged by submissions to JACC: Cardiovascular Interventions, and I suspect to the other journals as well. Training programs continue to differentiate to meet the needs of fellows who gravitate toward various components of interventional cardiology. Many techniques require exposure to an adequate case volume to master them, and concentrating that experience to specific committed trainees is important. However, it is not primarily fellows-in-training who will take up the new techniques, but established interventionalists who are viewed as experts, and therefore legitimate candidates, to try the new things. So how are these cutting-edge interventions to be mastered, who will master them, and how will it be done?
In the beginning of interventional cardiology, training courses in Zurich, Atlanta, Kansas City, and so forth were the first exposure. Then, the motivated practitioner would often travel to an experienced center to get more exposure to the technique. Now, we seem to have gone back to the future because there are many techniques that practicing interventionalists want to master. How do they jump into these uncharted waters without jeopardizing the patient's chance for success? Well, if someone has demonstrated a new technique that contributes to successful outcomes, others will want to come and observe them. I have always been heartened by the willingness of colleagues to share what they have learned. As in the early days, the learning curve does not need to be steep. Lessons and mistakes that are shared will enable some operators to successfully apply new methods.
When I was in practice in Denver in the early days of coronary bypass surgery, we observed early vein graft occlusion by a proliferative process. A short trip to visit Dudley Johnson, a pioneering cardiac surgeon in Milwaukee, taught us that gentle handling of the vein and avoiding forceful saline infusion to check for leaks was associated with absence of the vein graft complication. Adoption of this method solved our problem as the early graft occlusion disappeared. Perhaps this was a clue to restenosis for the new specialty of interventional cardiology to follow. The lesson of learning from others' successes has not been lost. I have observed numerous examples of this at my own institution. A fellow who graduated from the Emory program and subsequently became an expert in advanced chronic total occlusion intervention has returned to help some of his mentors become equally expert. A young faculty member who has become a national leader in structural interventions recently travelled to observe a specialized method for closing certain unusual cardiac leaks. Like a recipe for your grandmother's cake, sometimes you have to be there to master all the steps and ingredients.
As new technologies for addressing mitral valve disease, tricuspid disease, left ventricular dysfunction, and a myriad of other conditions arise, there will be a need to learn from the developers and "perfectors" of the methods. These highly specialized methods need not be mastered by all, and indeed they are best practiced by a relatively small group who can, by referral, be exposed to an adequate volume of cases. As innovators demonstrate that we can do what we never dreamed of doing, others will want to replicate it. Interventional cardiology has a proud history of sharing the secrets of successful innovation. For the sake of our patients, it is not necessary or even appropriate to reinvent the wheel. Keep teaching each other.
Article written by Spencer B. King, III, MD, who practices cardiology at Saint Joseph's Medical Group's Atlanta, Georgia location.
Keywords: CardioSource WorldNews, ACC Publications
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