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Hand and Brain Coordination: New Challenges for Interventional Cardiology and Echocardiography

EAPCI Column - EuroIntervention Journal - August 2010

The past: limited interaction and cooperation

There was a time when interventional cardiologists almost believed they were self-sufficient in their work, not requiring much input from other cardiology specialists, especially “non-invasive” cardiologists, the ones without access to their elected world of catheters, balloons and stents. Echocardiography replaced invasive haemodynamics in the assessment of patients with valve disease1,2, but nobody questioned the divine right of the interventionalist to dilate and stent whatever artery with a visually determined “significant” stenosis came to their attention. Certainly an echo scanner was available in the cathlab, but its use was limited to rule out pericardial effusions when a patient suddenly dropped his pressure and to monitor relatively rare procedures such as septal alcoholisation of hypertrophic obstructive cardiomyopathy3.

Invasive Coronary Imaging and Hemodynamics


New procedures demand integration of work

Everything has changed in a very few years. We examined, in a previous President’s page, the growing importance of multislice computed tomography (MSCT) for interventionalists4. Echocardiography poses no challenge in terms of direct visualisation of the coronary tree, but there are a growing number of clinical conditions where echocardiography has become a necessary and complementary tool. The only positive result for angioplasty in the COURAGE trial came from the evidence that patients with large reversible perfusion deficits with nuclear scans had a mortality benefit from angioplasty5. Stress echocardiography, shown to have similar predictive value to nuclear perfusion, has become a popular alternative, avoiding double radiation exposure, to establish whether patients with stable angina or suspected silent ischaemia need coronary angiography and angioplasty6. The big change in attitude towards echocardiography, however, came from the sudden interest in aortic stenosis and mitral insufficiency created by the introduction of effective catheter mounted aortic valves and the MitralClip.

The need for (re-)training in echocardiography

Grey-haired interventional cardiologists such as myself had to regret not having followed the development of new indices to quantify an elusive entity such as mitral regurgitation, and we are now confronted daily with the traps posed by establishing the severity of aortic valve stenosis in octogenarians, with poor echographic windows, massive calcification of the degenerated aortic leaflets and depressed left ventricular function. Interventional cardiologists have started to realise that the haemodynamics in valve disease patients is critically dependent on changes in cardiac output and pre/afterload and to appreciate the advantage echocardiography offers with the unique ability to perform serial studies and assess patients during exercise7. If the basics of transthoracic echocardiography has remained familiar to most interventionalists as part of their clinical routine outside the catheterisation laboratory, the more limited indications of transoesophageal echocardiography (TOE) have reduced the interest of interventionalists to maintain or develop skills to acquire and interpret it. TOE is much more than the gold standard for the assessment of left atrial thrombosis and aortic dissection, images familiar to all cardiologists. The reluctance to use general anaesthesia during percutaneous procedures has limited the use of TOE for intraprocedural guidance, used almost only for visualisation of the interatrial septum in centres practising ASD/PFO closure or left atrial appendage exclusion. The masters in the utilisation of TOE for procedural guidance, especially for mitral valve repair, have become the cardiac surgeons, who can correlate direct surgical observation with intra-operative TOE, performed by skilled, dedicated echocardiographers with cardiology or anaesthesiology backgrounds.

Conclusion:

Interventional cardiologists used to work in their cathlabs as if they were in an ivory tower, keeping at bay new developments in other fields of cardiology, from pharmacology to non-invasive imaging. The last years have seen a complete change of direction, with more and more specialists integrated in the work of the cathlab. Five years ago we laughed at crowded operating theatres where large teams would be busy for hours fixing a patient – during which time a single operator in the cathlab could already have performed 10 angioplasties. Now the situation is completely different, and busy cathlabs shared by the anaesthetic team, consultant cardiac surgeons, interventional cardiologists and specialists in cardiac imaging are commonplace in centres where transcatheter valves are implanted. It is counter-intuitive for somebody used to rely on angiography for all stages of a procedure to realise that during MitralClip implantation the role of fluoroscopy is almost nil14. Instead of pushing a control handle and rotating the angio tube as desired, we must learn patience – a virtue very rare among interventionalists – and wait for the echocardiographist to adjust the transoesophageal probe according to our needs. We must learn a common language, less familiar to some of us, and ask for a bi-caval, two-chamber or an outflow tract view instead of a right anterior oblique or left caudal view14. New skills and knowledge are now required for the growing range of procedures falling into the realm of interventional cardiology, but the most important change must be in the mentality of interventionalists. Rather than being the absolute ruler of a small kingdom, the interventionalist is now a constitutional monarch who shares responsibility for the patient’s care and discusses every step of the procedure with the Heart team. It is time to get out of the ivory tower, appreciate that other subspecialties in cardiology have progressed to the same extent or more than interventional cardiology and join forces for the patient’s benefit.

References

References

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