COMMENTARY

The Yin and Yang of Interventional Cardiology: Physician and Proceduralist

Jaya Mallidi, MD, MHS

Disclosures

February 20, 2019

Jaya Mallidi, MD, MHS

Monday morning, 7:10 AM. I am late for the weekly cath conference. Again. I see the long queue at the coffee shop and decide against getting my morning drip coffee. I hurry up to the second floor, open the conference room door cautiously, and peep inside. All heads are turned to the large screen at the center of the room, projecting the coronary angiogram of the patient being presented. I tiptoe softly to the back of the room and take a seat. The arteries filling with the black dye against the whitish-gray background appear smooth, dancing like the tentacles of a hydra to the rhythm of the beating heart. On the next image, I see a transparent catheter with a dark tip extending into a pigtail, joining the dance synchronously with the arteries. Another Impella case.

I do not register any of the clinical details of the patient being presented. My thoughts start drifting to the patients I consulted on the previous call night. I feel the weight of the fuzzy, jumbled ball of clinical decisions I made in my head. I remember the white pearl bracelet and the manicured, auburn-red-polished nails of my patient as I took her hand and felt her thready pulse. Her face had an unusual serenity despite the blotched mascara and the green endotracheal tube protruding from her cyanotic lips. She lay calmly on the cold emergency room bed, oblivious to the beeping and commotion around her. She had survived a cardiac arrest after 50 minutes of heroic resuscitation efforts involving 12 shocks. Her lab results were consistent with significant oxygen deprivation to all of her organs—systemic hypoperfusion with markedly elevated lactic acid.

After careful consideration of the available clinical data, I was able to halt the momentum of system-based processes of automatic cath lab activation. I contacted her daughter and we discovered her do-not-resuscitate order. The patient passed away peacefully in the middle of the night.

The caffeine-deprived fuzziness in my head is getting worse and it brings on a flurry of zigzag, thoughts: What if I had taken her to the lab and done an Impella assisted intervention—would that have taken the serenity out of her face?

'Can I?' vs 'Should I?'

I refocus on the case presentation and catch the words "cardiogenic shock" and "Swan numbers." They transport me back to a time in the ICU when I was adjusting the Swan-Ganz catheter to obtain a pulmonary wedge pressure on another critically ill patient. She was a 30-year-old woman admitted after an attempted suicide from baclofen overdose, who subsequently developed aspiration pneumonia, multiorgan dysfunction, shock, and severely depressed left ventricular systolic function. She had beautifully dyed iridescent blue and green strands of hair over her face that reminded me of peacock feathers.

I was consulted for a possible Impella to improve hemodynamic support. After spending an hour at her bedside and carefully going over the entire clinical scenario, I recommended against the use of Impella as the patient's hemodynamic data did not support florid cardiogenic shock. When the intensivist asked me, "Why can't you just put in the Impella?", I replied, "I can. The more important question is, should I?"

The Patients We Don't Cath

The cath conference has moved on to another presentation. The stories of patients we don't intervene on are not "glamorous enough" for a presentation at cath conference. I have not done an Impella case in several months and I recently turned down the opportunity to do one. Am I being overly conservative? The proceduralist in me always wants to do more; I want to use new devices, learn new techniques, and do high-risk interventions. The physician in me, though, is thoughtful and cautious. Why do I see them as two distinct personalities? They are the yin and yang of interventional cardiology that go hand in hand and complement each other. My thoughts are interrupted by a text message from my husband: "Did you have coffee?" I concede that I cannot re-focus and leave.

I never attended a session titled 'Patients I Didn't Cath' at any national or local interventional cardiology conference.

Holding my hot cup of single-origin drip coffee from Ethiopia, I sit down at the windowsill in a pensive mood. I imagine the aromatic vapors of elderflower and pistachio disentangling the fuzzy ball in my head. I reflect on what I wrote in my personal statement 4 years ago, when I applied for an interventional cardiology fellowship: Interventional cardiology is a field in which one has to be an astute physician, know the patient well to determine whether to intervene or not, understand physiology and hemodynamics intimately, have a surgeon's hand with perfect technical skill, have the courage to try new techniques spontaneously, develop trustworthy intuition, and be humble enough to accept that sometimes there is only so much one can do. It is this unique combination and balance of good clinical decision-making and technical skill that draws me to this field.

Procedures Define Success 

In my 2.5 years as a full-fledged interventional cardiologist, I realize that the perception of a successful interventional cardiologist is skewed toward only the procedural component of our profession. Accurate diagnosis, balanced opinions based on all available evidence regarding the pros and cons of an intervention, critical thinking, and good clinical decision-making are not emphasized. In the zeal to perfect technical skills, procedural volume is the focus of interventional fellows. Unacknowledged peer pressure from conferences and Twitter feeds biases toward intervention; cases not taken to the cath lab are not presented. I never attended a session titled "Patients I Didn't Cath" at any national or local interventional cardiology conference. Human nature and the immediate gratification that accompanies "doing something" to help our patients inherently biases us toward intervention. System-based practices and metrics such as door-to-balloon time, which advocate for rapid action, bias toward some kind of an intervention. Randomized trials that favor interventions are often celebrated.[1] The focus on the procedural component of our profession is so dominant that the face of interventional cardiology is sometimes tainted in the public eye and the media.[2]

To me, it is as important to act fast and intervene in patients with cardiogenic shock or acute coronary syndrome as it is to slow down and avoid the cath lab in patients without an appropriate indication or with explicit wishes to forego heroic measures. The old adage Good surgeons know how to operate, better ones know when to operate, and the best ones know when not to operate also applies to interventional cardiologists.

With several forces that bias us toward action, it takes significant cognitive effort, critical thinking, strength, and wisdom to resist intervening. It is time for us to recognize the metamorphosis of interventional cardiologists to acute care cardiology specialists,[3] propagate, and teach our fellows the other side of our profession—to be a good physician. As I finish the last sip of my coffee, my mind now clear, I decide that I do not want to be known as a conservative or aggressive interventionalist; I do not want to be known as a high- or a low-volume operator. I want to be known as a thoughtful, patient-oriented interventional cardiologist with a good clinical acumen and technical skill.

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