Feb 17, 2016 | Devraj Sukul, MD, and John J. Lazarus, MD, PhD
Career Development

Stanley J. Chetcuti, MD, FACC, serves as the Eric J. Topol Collegiate Professor of Cardiovascular Medicine, and director of the cardiac catheterization laboratory at the University of Michigan Health System. In his interview, he discusses his path to interventional cardiology, as well as career advice for FITs.

Could you tell us about your training and the path that led you to general cardiology and eventually interventional cardiology? What continues to excite you as an interventional cardiologist?
During medical school I discovered a passion for critical care medicine and began training in anesthesia and critical care medicine in Malta and planned to continue my training in the UK. Shortly after beginning my training, I realized I was not interested in all facets of anesthesiology, thus I opted to pursue internal medicine training in the U.S. with the goal of continuing to care for critically ill patients. I completed my internal medicine residency at the Mayo Clinic. During my time there, I became fascinated with cardiology given the breadth of care provided – from acute to chronic care.

I continued my education and training in general cardiology at the Cleveland Clinic Foundation. It was here that I was fortunate enough to work with interventional cardiologists whom I looked up to, such as Eric Topol, MD, FACC; A. Michael Lincoff, MD, FACC; Irving Franco, MD; Murat Tuzcu, MD; and Stephen G. Ellis, MD, FACC. As interventional cardiologists, I saw them visibly, and often drastically, affect the lives of their patients. This is what drew me to interventional cardiology.

To this day, I am fortunate enough to have never had a day where I have felt bored with my occupation. I am excited by the thrill of always pushing the envelope and interventional cardiology has never been, nor will it ever be, a static or dying specialty. It is forward-looking, forging new paths.

How do you see the field of interventional cardiology changing over the next decade, particularly with respect to novel treatments for structural heart disease?
Not surprisingly, I believe structural heart disease will serve as a large component of what interventional cardiologists will be doing in the future. From a coronary perspective, percutaneous coronary interventions will become more complex; particularly as we begin to understand which patients benefit the most from treatment of chronic total occlusions (CTOs). Furthermore, our tools for CTO treatments will also continue to improve and evolve.

From a structural heart disease standpoint, clearly transcatheter aortic valve replacement (TAVR) has dominated the field, and its indications will continue to expand. Mitral valve therapies are already here and mitral valve replacement therapies will likely be here within the next couple of years. From a training perspective, we need to focus on management of the left atrial space including atrial septal defect closures, atrial appendage occlusions/closures, and the treatment of paravalvular leaks.

Looking very far down the road, the sky is truly the limit. In your lifetime, I would not be surprised with the creation of truly customized valves made for individual patients using 3-D printing technologies and other advancements in science. Lastly, new technologies will make cardiac catheterization safer from an occupational exposure standpoint.

Are there any new percutaneous support devices in the pipeline for patients with advanced heart failure and pulmonary hypertension?
Some of these devices for acute right ventricular support are already here and in use. Of course, we also have the TandemHeart, Impella and extracorporeal membrane oxygenation for mechanical support in selected patients in cardiogenic shock. These devices will continue to be developed, providing greater amounts of support with less risk.

Importantly, we must think hard about how we should utilize these devices in clinical practice. There is a clear paradigm that we have created for the delivery of TAVR through the use of Heart Teams. In my opinion, we need to begin forming these "teams" for the proper utilization and prompt delivery of these advanced circulatory support devices. I foresee the creation of "circulatory support heart teams" or "shock teams." In fact, there are many institutions that have already adopted this paradigm. If tertiary care centers are going to optimally care for these complex patients, who frequently require multidisciplinary care, these types of "teams" need to be created.

As you noted above, multidisciplinary "Heart Teams" are currently the mainstay for the management of patients with complex valvular disease given the various surgical and percutaneous options. What are some of the pros and cons of this interdisciplinary approach, and do you foresee the use of this approach for the management of other complex conditions?
Without a doubt, I believe these multidisciplinary teams will become the mainstay for the management of various complex cardiovascular conditions, particularly those with treatments provided by multiple disciplines. I think the pros are obvious in that surgeons and interventional cardiologists can arrive at the optimal treatment modality for each individual patient. One of the cons, though, is that we have surgeons and interventionalists that come to a mutual decision about each patient; understandably, each side is coming in with their own biases. I think this is inevitable, and over time the team tends to become aware of the various biases, which I believe ultimately leads to improved care.

With the successes we have seen using the Heart Team approach for TAVR in aortic stenosis (AS), I believe the next, and most logical, step will be the use of the Heart Team for all AS patients to evaluate the clinical nuances of each patient and determine the optimal treatment. For example, we are now contemplating the use of TAVR at younger ages, potentially with the plan for a repeat TAVR years down the road. Obviously, these considerations should be made in a multidisciplinary manner. As mentioned previously, there are many complex cardiovascular conditions that could benefit from the utilization of Heart Teams including shock, endocarditis, and congenital heart disease to name a few.

Do you feel interventional fellowship training for one year is sufficient? Is a separate, dedicated year for structural heart interventions necessary and/or desired?
I do not believe one year of interventional training is enough for one to be fully trained and comfortable with coronary, peripheral and structural interventions. I agree that a dedicated year of training is both necessary and desired for optimal training in structural heart disease interventions.

With that said, one important piece of advice I have for FITs is that they should have realistic expectations regarding their career, especially early after interventional training. The days of finishing one year of fellowship and "running a program" is over as more and more people are being trained in these complex interventions.

The way I see it, there are two predominant career pathways after interventional training, particularly with respect to structural heart disease. One pathway is to go to a small-to-medium size hospital that has a good surgical program and needs to start a structural program. Here you can probably perform 50 structural heart interventions per year. You may have to send the complex patients to tertiary institutions. Most importantly, this should be an environment that is challenging and allows for personal and professional growth. The other pathway would be one where you join a large, complex academic practice. Here you should not expect to be the "head honcho" right away. Instead you may need to wait three to five years before becoming the man or woman that takes on the bulk of the structural heart interventions.

The training for structural heart disease interventions must be formalized. Without an Accreditation Council for Graduate Medical Education (ACGME)-sanctioned fellowship, there may be places where the balance between education and service is skewed in favor of service. Here, at the University of Michigan, we are working on creating a formal, ACGME-sanctioned, structural heart disease fellowship. The surgical director of the structural heart program and I (the cardiology director) are trying to determine the prerequisites for the program. We are also working on a curriculum that provides substantial exposure to the breadth of structural heart interventions and reinforces the multidisciplinary aspects of structural heart disease care.

The really exciting part is that structural heart disease training is still in its infancy. Therefore, we must establish this training program with great care and thought so that 15 years down the road we haven't setup a situation that is catastrophic. We must sit back and try to think forward about what is going to happen 15 years from now.

What advice can you give fellows interested in a career in interventional cardiology?
Most importantly, you must be a good general cardiologist who is comfortable with all aspects of cardiac care. Next, choosing your training program for interventional cardiology is very important. You must look for a program that has a diverse mix of cases, enough volume, and most importantly, a set of faculty who can serve as personal and professional mentors that will provide you with a broad exposure to the field. Having faculty who have a diverse and complementary set of skills is beneficial from a training standpoint. Every attending believes they have the "best skills in the world" and then when you leave you will find your "best skills." Ideally, you want to learn from attendings with slight variations in their practice.

One very important thing to understand that interventional training should not simply teach you how to "do" a procedure, but whether it is appropriate to do a procedure. You really must learn whether what you are doing for the patient is right. Just because you can do it, doesn't always mean you should do it.

Finally, looking for a place that has a good relationship between cardiology and cardiac surgery is very important. You want to go to programs with strong Heart Team concepts so it gives you the tools to build such a program down the road if needed.

Given your training experience at various institutions throughout the U.S. and Europe, what are the strengths of a diverse training environment for FITs and how does training for interventional cardiology differ in other countries?
Full disclosure, I never received any training in interventional cardiology in Europe. In my opinion, training in the U.S. is very good because we have a set of academic standards that each training program is required to meet. Up until a few years ago, Europe was ahead of us in terms of access to new technologies in interventional cardiology. Over the last few years, because of changes at the U.S. Food and Drug Administration, we have now finally begun to have access to novel devices to benefit our patients and advance the field.

Finally, what advice would you give cardiology fellows as we try to strike a balance between our personal and professional lives?
I am lucky to have a partner that took a big brunt of raising our family, but that is not a template for success. Just like writing a grant, when you divide your time, you must consciously factor in time for your family. We must all understand that a fulfilling family life is integral to a successful career. Seeing your children and being there for soccer practice and dance recitals is very important.

You have to stay away from the trap of putting lesser importance on your family life, because 25 years down the road you will look back and regret it, and it is something you can never get back. Fortunately, the culture now is different from when I was training. Now, as junior faculty, if you take time to be with your family, you will not be thought of as a social pariah. Personally, I believe taking a vacation every six months and taking a break from my email and phone is very important for my sanity.

Having said that, it is also very easy to get trapped in the other way because I think most of us really enjoy what we do. When I am in the lab, wearing lead, with an acute lesion in front of me, I could not be more excited. There is not a single day in my life that I have regretted my career choice.

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This article was authored by Devraj Sukul, MD, and John J. Lazarus, MD, PhD, fellows in training (FITs) at the University of Michigan.