In the past 15 years, there has been a tremendous increase in the role of catheter-based interventions to treat all aspects of cardiovascular diseases. Although the initial thrust of these therapies were aimed at coronary artery disease, interventional therapies now play a prominent role in the treatment of valvular and arterial diseases.
Traditionally, catheter-based interventions were solely the domain of interventional cardiologists. However, many of these new interventions such as transcatheter aortic valve replacement (TAVR), require active surgical support, and not merely “back-up,” as was the case with percutaneous coronary intervention. What then is the best method for cardiac surgeons to acquire catheter-based interventional skills during their training?
To address this issue, Rubens and coworkers surveyed the experiences and expectations of cardiac surgical trainees in acquiring catheter-based skills during their cardiothoracic training fellowship, and report their findings in this issue of the Canadian Journal of Cardiology.
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Eighty-eight percent of responders expressed the need for more exposure in catheter-based rotations and 67% indicated that they would have preferred greater exposure in the catheterization lab. Only 56% of respondents were comfortable in performing a diagnostic catheterization independently. Less than half of the residents were comfortable in performing percutaneous balloon angioplasty or stenting of peripheral artery lesions, embolectomies, or thrombectomies of peripheral vessels, or an endovascular aneurysm repair. Eighty-two percent of the residents would consider a catheter-based fellowship if they could work in a hybrid catheterization laboratory after their training. All the program directors believed that a rotation through the catheterization laboratory should be mandatory for cardiac surgery trainees.Although the conclusions of the survey were limited by the fact that only 45% of residents and 64% of program directors completed it, the survey strongly suggests that current cardiac surgery trainees believe that their exposure to catheter-based skills are inadequate to meet their goals. What are these goals, and what are the best methods to achieve them?
It is unrealistic to expect, nor is it advisable, for cardiac surgeons to learn to perform diagnostic catheterizations or insert coronary artery stents upon completion of their residency training. The worst thing that we can do is to train a fellow superficially in catheterization techniques to lead them to believe that they can perform these procedures in clinical practice and then obtain suboptimal results. As one of my cardiology colleagues has said to me “If you let me perform a coronary anastomosis, I will let you insert a coronary stent.” Neither approach, however, would be in the best interest of the patient. Surgeons who have excelled in these techniques have taken a fellowship after their surgical training to work with interventionalists in an organized program. They have had the support of the interventionalists and surgeons in their own hospital and have been assured of a position in that practice when they complete their fellowship.
There are currently 3 areas in which catheter-based skills are necessary for performance of cardiac surgical procedures—thoracic endovascular aortic repair (TEVAR), TAVR, and to achieve arterial access for cannulation for cardiopulmonary bypass in open and minimally invasive surgical procedures. Catheter skills for TEVAR might be best acquired in the interventional radiology suite. Although basic skills for TEVAR might be acquired during a 1-month rotation in the interventional radiology suite, a formal fellowship is likely required to develop the proficiency required for TEVAR interventions in daily practice. Similarly, skills needed for TAVR might also be best obtained from an organized postresidency fellowship in conjunction with interventionalists and surgeons who are proficient with this technique. Possibly the most valuable interventional skills would be those necessary to perform arterial access for cannulation of the femoral, axillary, and subclavian arteries and the ascending aorta, necessary during minimally invasive and open surgical procedures. These skills are readily attainable during a 1-month catheterization rotation and would allow surgical trainees to perform these techniques proficiently and with minimal morbidity.
Surgeons should not be in competition with interventionalists to perform diagnostic catheterizations and coronary artery stenting. Instead they should be working with their cardiology colleagues in the capacity of a “heart team” approach to achieve successful outcomes in procedures that involve surgical and interventional expertise. During their training, residents should learn the fundamentals of catheter-based techniques and be comfortable inserting Swan-Ganz and arterial monitoring catheters, cannulae for initiating cardiopulmonary bypass, and achieving access for TEVAR and TAVR interventions. Surgical residents who wish to develop more expertise in TAVR and TEVAR should pursue specific postgraduate fellowships in these areas with the understanding that they will have the support of their surgical and interventional colleagues to practice these techniques upon completion of their additional training.
At present, it is clear that surgeons and interventional cardiologists will be integrally involved with hybrid coronary and TAVR and transmitral procedures. The best methods to acquire these catheter-based skills will continue to evolve. A close working relationship between both specialties, which is the core of the “heart team” approach, will be mandatory to achieve the most optimal patient outcomes from these procedures.
Disclosures
The author has no conflicts of interest to disclose.
Reference
- Catheter-based educational experiences: a Canadian survey of current residents and recent graduates in cardiac surgery.Can J Cardiol. 2016; 32: 391-394
Article info
Publication history
Published online: August 13, 2015
Accepted:
August 5,
2015
Received:
July 31,
2015
Footnotes
See article by Juanda et al., pages 391-394 of this issue.
See page 290 for disclosure information.
Identification
Copyright
© 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
