Author + information
- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions⁎ ()
- ↵⁎Address correspondence to
Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions, Fuqua Heart Center of Atlanta/Piedmont Hospital, 1938 Peachtree Road, NW, Suite 705, Atlanta, Georgia 30309
Why interventional cardiovascular medicine? The question could also be, “why cardiology?” As the fund of knowledge and skills required expands, it is not possible to master them as a generalist. Subspecialization develops in every field in response to these pressures. But interventional cardiovascular medicine’s journey to the present and its pathway to the future has been unique and its impact on medicine profound.
“Like a pebble in a pond”—the analogy fits Andreas Gruentzig’s (Fig. 1) audacious act of commitment and conviction in inflating a balloon in the coronary artery of a brave 38-year-old, Dolf Bachmann. The “ripples” from this event have spread throughout medicine in ever-expanding ways to influence our lives now and well into an unknown future. Let us look at 4 of these ways.
Impact on Patient Care
It is estimated that percutaneous coronary interventions are now performed on 2 million patients worldwide each year. To what effect? There is not a more effective therapy for disabling angina pectoris. Restoration of the supply side of ischemic heart disease has enabled full and vigorous lives for patients previously cautioned to restrict necessary, enjoyable, and beneficial physical activity. Acute coronary syndromes have been stabilized without the fear of impending myocardial infarction. Acute myocardial infarction is interrupted and sometimes aborted by prompt primary angioplasty, saving countless lives everyday. Patients who could not walk due to claudication are walking. Those with rheumatic heart disease and congenital heart disease are having their hearts repaired without necessity of surgical intervention.
Impact on Education
Mentoring of clinical decisions and procedural skills has long been a tradition in surgery, but this was brought to new heights when Gruentzig’s openness and communication skills were coupled with the medium of television. The demonstration courses begun in a small auditorium in Zurich and expanded at Emory University in Atlanta provided the initial training for the first wave of interventionalists. These teaching methods grew and became available to virtually all interventionalists through the “new device” demonstration courses in Santa Barbara and Monaco in the late 1980s and early 1990s, and through the interventional mega courses of Transcatheter Cardiovascular Therapeutics, EuroPCR, Complex Cardiovascular Therapeutics, the i2 Summit/Society for Cardiac Angiography and Interventions symposium, and many others. Academic training of interventional cardiologists was formally established in the late 1990s, with approval of the curriculum by the Accrediting Council on Graduate Medical Education and the certifying examination of the American Board of Internal Medicine. The American College of Cardiology, the Society for Cardiac Angiography and Interventions, the Society for Vascular Surgery, and others have developed training materials and courses to prepare for these examinations. To date, almost 6,000 cardiologists have become board certified as competent in interventional cardiology. Other specialties have progressed in establishing similar tracks.
Impact on Research
The relative value of an interventional approach to ischemic heart disease has been studied in more clinical trials than almost any other field in medicine. Basic research has been stimulated by the new diseases produced by angioplasty. Acute endothelial and vessel wall damage produced a clinical correlate of the experimental Foltz model of arterial thrombosis that necessitated antithrombotic research. Coronary interventions provided the “laboratory” for evaluating heparins, antithrombins, antiplatelet agents, and others. At the same time, the healing response led to overdevelopment of tissue leading to restenosis. Discovery of the central role of cell growth led to research on agents to inhibit this process to include antimetabolites, genetic alterations and antisense oligonucleotides, radiation therapy, and ultimately cytostatic and cytotoxic agents coupled with a controlled-release mechanism (i.e., drug-eluting stents). This wave of success produced its own imperative: research on the solution to impaired endothelial healing. Much of the funding for research in vascular biology, angiogenesis, myogenesis, and related processes has been stimulated by the ripples (problems) emanating from interventional cardiovascular procedures.
Impact on Innovation
Opening an artery with a balloon seemed much too simple to many with innovative minds. The era of new device development for endovascular exploration and therapy is continuing with a long list of failures and a shorter list of successes. Consider directional atherectomy, extraction atherectomy, rotary ablation, laser ablation, laser balloons, spectroscopy, intravascular ultrasound, angioscopy, optical coherence tomography, distal protection devices, vascular occlusion devices, and stents. Outside of the coronary arteries, stent grafts, mitral clips, mitral rings, atrial appendage closure devices, atrial and ventricular septal closure devices, devices for occluding arteriovenous malformations and aneurysms, and many others have been developed. Placement of prosthetic aortic valves may soon enable safer treatment of the expanding population of elderly patients with high-risk aortic stenosis. Less invasive innovations seem to be driving the entrepreneurial spirit.
Pharmacological innovations have not been far behind, with glycoprotein IIb/IIIa agents, thienopyridines, low-molecular-weight heparins, 10A inhibitors, direct antithrombins, and thrombolytics all being stimulated by the promise and problems of interventional cardiovascular medicine. Future implantation of progenitor cells capable of regenerating myocardium holds out promise for those with severe heart failure.
One should not assume that the pebble thrown was a completely de novo event. Gruentzig’s act would have not been possible without the innovations of Roentgen, Forssmann, Sones, Favalaro, Dotter, and others and would not have been successful without extensive experimental preparation. Likewise, the ripples that affect so many aspects of medicine are not unidirectional, but reflect off distant shores and off each other to create new waves for the future.
This journal is in recognition of the accelerating expansion of interventional cardiovascular medicine and is offered as a vehicle for communicating the continuing ripples—waves—tsunamis, emanating from “a pebble in a pond.”
For an accompanying paper on the “Celebration of Interventional Cardiology,” please see the online version of this paper.
- American College of Cardiology Foundation