The future of interventional cardiology

To this day, heart transplant is the treatment of choice in patients with heart disease and functional repercussions that is refractory to treatment (both drugs and electrical or mechanical devices) and has no contraindications. The milestone that made heart transplant take the spotlight in the management of these patients was the introduction of calcineurin inhibitors as basic immunosuppressants, which allowed the effective control of acute graft rejection. Immunosuppression patterns based on cyclosporine at the beginning and then on tacrolimus have led to really long survivals with means of up to 12 years.1 After acute rejection was no longer the main cause of graft failure and occasionally the patient, the long-term survival of the graft is basically limited by the development of coronary vascular disease.

Graft vascular disease represents an accelerated phase of the underlying fibroproliferative process that affects the entire coronary vascular bed diffusely. On the pathological analysis, its appearance is different from classic atherosclerosis of complex and multifactor etiology in that it includes non-immunity factors and, in particular, immunity factors.2 As a matter of fact, it is the most conspicuous manifestation of antibody-mediated late rejection, which is why it has sometimes been referred to as “chronic graft rejection”. Its incidence based on the angiographic data we have is over 30%-50% from the third to the fifth year after the transplant which has a significant impact on prognosis: it is the leading cause of graft failure and one of the leading causes of death in recipients with long survival rates.3 Also, the management of this process is relatively limited because of its diffuse nature that makes coronary revascularization procedures more difficult.

In the study conducted by Solano-López Morel et al.4 and recently published on REC: Interventional Cardiology, authors from 2 experienced groups revealed their results with percutaneous revascularization with drug-eluting stents in one of the most severe forms of graft vascular disease: chronic total coronary occlusion. The authors confirmed that the technique was feasible since it used state-of-the-art diagnostic and therapeutic technological means, although they restricted it to highly selected patients. The findings show that chronic total coronary occlusion has a low but still significant prevalence (12.2% of the patients), late onset (mean, 10 years after the transplant), and even in experienced hands it is barely eligible for percutaneous revascularization (13.5% of the patients with chronic total coronary occlusions). Although the angiographic results are promising (93% of initial success and 2% restenosis only), the prognosis of these patients is still poor (a 21.4% cardiovascular mortality rate with a mean at follow-up of 2.8 years) even compared to graft vascular disease without complete occlusion treated percutaneously (21.4% vs 8.3%). Although the study sample is limited, it would have been interesting to draw a comparison between patients with chronic total coronary occlusions treated percutaneous or medically.

The most important thing of the study conducted by Solano-López Morel et al.4 is that it is the first time that the feasibility of the recanalization of chronic total coronary occlusions in graft vascular disease is ever reported. The results are indicative that in these patients, percutaneous procedures are nothing more than palliative care sensu stricto whose effectiveness in clinical terms has not been confirmed yet (and probably never will). This comes as no surprise since graft vascular disease is a diffuse and progressive disease that affects both the epicardial coronary arteries and the intramyocardial trajectories and especially the capillary bed. Therefore, same as it happens with other conditions, the most effective management is preventive treatment targeted at well-known etiopathogenic factors including taking good care of the donor, preventing graft primary failure, preventing and treating cytomegalovirus-related infections, the universal use of statins (such as hypolipemiant and immunomodulating statins), and preventing antibody-mediated acute and chronic cell rejection through the use of individual immunosuppression therapies for each patient.5

CONFLICTS OF INTEREST

None declared.

REFERENCES

When Prometheus’ liver was daily devoured by the eagle that Zeus would send each day to the Caucasus mountains where the titan was kept in chains, pain was the price to pay for disobedience and immortality. Prometheus’ insurrection was sealed after he stole the fire from the gods and gave it to men so they could heat themselves, cook food, make utensils, and have a divine spark inside of them to become spiritual and intelligent beings, thus bringing them a little closer to the gods and away from the animal kingdom. The immortal nature of Prometheus would regenerate the liver only to see it devoured again the next day. Only Hercules put an end to Prometheus’ torment when he broke the chains of his sentence.

This Greek myth of the demi-god is a good analogy of the evolution of medicine from ancient to modern times. Suffering; disease; wisdom; hope; cure, and eventually immortality. It has been the greed shown by Homo sapiens that has tried to conquer the fire stolen by the Greek hero.

It is precisely this human exchange that has allowed us to evolve as a species. We have been able to conquer our planet, cure diseases, control epidemics, and fight our kind to the benefit but also to the detriment of our own world and at the expense of the extinction of millions of species, the very subjugation of death, and the suffering of millions of our own people.

Throughout history, doctors have been perceived by others has holders of some sort of a special talent. The first physicians were healers, shamans who understood the laws of the ancient universe and had a special connection with the divine. In addition to having a secret knowledge of plants, herbs, and minerals with healing potential, their wisdom had been transmitted through oral tradition from one family to the other or through genetic inheritance as some sort of natural selection of only those individuals with the necessary conditions to become healers. These were exceptional individuals among the ancient human groups who were measured by the highest standards and revered by the different societies. They were possibly Prometheus’ chosen ones as holders of that “extra fire”.

Medical science evolved with extraordinary advances for all mankind by drastically reducing child mortality at the end of the 20th century, improving life expectancy in most countries up to 75 years of age (by 2050 the estimates are that human beings will live up to 100 years old), and ultimately by managing successfully most of the diseases that plague the Homo sapiens.1

After the Second World War, medicine was revolutionized, a sort of golden age if you will, with the appearance of antibiotics, vaccines, new anesthetic agents, breaking surgical procedures, and new drugs. Doctors were respected and admired; the doctor-patient interchange was based on conversations and deep scrutiny of the intimate life of individuals and rigorous physical examinations following all rules of semiology.

These advances were followed by universal medical plans and health reforms, making medicine lose its human dimension of that doctor-patient relationship. Thus, the infamous “cost-benefit” ratio became a priority and technology was incentivized creating a gap between humanity and science and, on many occasions, verbal communication, so essential to understand each other, was simply gone and doctors became technicians or service providers overnight whose effectiveness was put under the microscope.

This was the birth of the so-called “junk consultation” that leads to countless complains from users (our patients) who are rushed inside a world of unnecessary tests, studies, and procedures that have an excessive, and in most countries, unsustainable cost for the healthcare system.

The irony is that by improving life expectancy we end up having more old patients who, on many occasions, suffer from loneliness and grief. With today’s medical approach, doctors simply cannot bring any remedies to them. Instead, nearness is needed here to examine the natural condition of man and be able to develop our profession fully by offering that lenitive as part of the medical prescription.

Ms. Ellen Trane Nørby, secretary of health in Denmark, one of the highest ranking countries in effective healthcare systems worldwide has said: “Something must be wrong in Denmark when we’re spending 50% of the healthcare budget in the last 90 days of a human life to delay the inevitable in just a few weeks.”2

Abandonment, sadness, and isolation in old patients who live in developed countries generates astronomical costs at the ER when they are actually looking for social support.

An article published on The New York Times3 has brought the program Element Care –non lucrative and for old adults– to everyone’s attention. This program provides those elderly who are eligible with one tablet with a software and a virtual pet that interacts with them, talks to them about sports and pastimes, shows them memories of their lives and, above all, tells them that they are loved.

The patients know that this device is connected to an emerging startup called Care Coach. They also know that the employees who operate this platform see, listen and give remote answers to them, but at the end of the day they come to love their little pet, feeling that they still mean something and that someone else still cares.3

Today’s society is on a non-stop rampage towards progress. We are modernizing consumption without having developed thought first and we are embarked on a technological frenzy that perpetuates itself and turns us into isolated entities that only interact with one another through cybernetic applications. Let us commit ourselves to becoming social individuals back again and humanizing artificial intelligence. Let us be a replica of our ancestors who lived their lives around the fire given to them by the good titan Prometheus.

As physicians I think we should look in the mirror for just a second and ask ourselves whether we are treating patients the same way we would like to be treated. If the answer is no, let’s make hugs last longer than our well-known narcissism.

CONFLICTS OF INTEREST

None reported.

REFERENCES

The optimal management of chronic anticoagulation is still controversial to this day both in clinical cardiology and particularly in interventional cardiology. The progressive aging of the population has increased exponentially the percentage of patients with an indication for chronic oral anticoagulation who undergo percutaneous invasive procedures to up to 5%-10% of the total. Also, most of them suffer from atrial fibrillation.1

Until the arrival of new direct-acting oral anticoagulants (DOAC), most of these patients were anticoagulated with vitamin K antagonists (VKA). Invasive procedures used to be performed after withdrawing oral anticoagulation and using bridging anticoagulation with low molecular weight heparin.2 We believe that this widely used strategy in our setting should be put into question though. In the first place, the prothrombotic rebound effect has been reported as associated with the withdraw and reset of VKA.3 Secondly, the interaction of anticoagulants with a different mechanism of action used in patients on bridging therapy can have pro-hemorrhagic and procoagulant consequences. As a matter of fact, the actual clinical guidelines recommend avoiding the concomitant use of unfractionated heparin in patients undergoing percutaneous coronary interventions (PCI).4 Also, more hemorrhagic complications associated with bridging therapy have been confirmed in patients treated with invasive or surgical procedures (1.3% vs 3.2%),5 in patients undergoing PCI (8.3% vs 1.7% and 6.8% vs 1.6%7), and in one meta-analysis (odds ratio, 5.40; 95% confidence interval, 3.00-9.74).8 Overall, none of these studies revealed more thromboembolic events associated with the absence of bridging therapy.5^-8 With the actual evidence available today, we should ask ourselves why many clinical practice protocols in our setting recommend the use of bridging therapy with VKA and low molecular weight heparin in patients on chronic anticoagulation

There is little evidence from the studies published so far that specifically compare uninterrupted strategies with anticoagulation and interrupted strategies without bridging therapy. We could argue that vascular access is safer if used in uncoagulated patients. However, the PCI is a low-risk of bleeding procedure9 when performed through the access of choice which is the radial access1^,4 (used in Spain in up to 90% of the cases).10 Also, yet despite the doubts of many interventional cardiologists, therapeutic warfarin treatment seems to provide sufficient anticoagulation for PCI, and additional heparins are not needed and may increase access site complications.11 Actually this is what the clinical guidelines establish when the international normalized ratio (INR) is above 2.54. In any case, we always have this possibility of adding heparin during the PCI, always bearing in mind that when choosing radial access, the incidence of bleeding is low, and the chances of radial occlusion or thrombosis of the materials drop.

Yet despite the growing use of DOACs in the clinical practice, the evidence available today for its use during the procedure is scarce in patients undergoing PCI. This contrasts with the benefit shown with the use of VKA in revascularized patients who need antiplatelet therapy12 or even as adjuvant therapy for the management of acute coronary syndrome.4 In an article published on REC: Interventional Cardiology, Ramírez Guijarro et al.13 talk about their own initial experience with same-day diagnostic catheterizations without DOAC withdrawal in patients on chronic anticoagulation. It is interesting that no differences were seen in the incidence of hemorrhages or radial occlusions compared to patients without prior antiplatelet therapy or with uninterrupted therapy with VKA. The way we see it, this is a pioneering strategy in our setting which, although it does not validate its use in PCIs with stent implantation, it provides evidence in the right direction. In our opinion, the uninterrupted strategy of anticoagulation when using the radial access has 2 main advantages. The first advantage is the simplification of the procedure for doctors and patients alike especially in outpatient same-day procedures. The benefit of this simplification is potentially higher in patients treated with DOACs since the monitoring of the INR is not necessary at admission and the complexity of withdrawal protocols is avoided based on the half-life of DOACs and renal function. The second advantage is the safety shown with its use since it reduces bleeding complications without improving thromboembolic complications.

In sum, with the evidence available today we know that: a) we should avoid prescribing systematic bridging therapy with low molecular weight heparin in patients undergoing catheterizations/PCI. When dealing with a procedure where there is a high risk of bleeding, the best thing to do is to withdraw anticoagulation without using bridging therapy in patients with non-valvular atrial fibrillation; b) we should keep VKAs during catheterizations/PCIs performed through radial access; c) stent implantation seems safe with VKA, but heparin can also be prescribed based on the INR and experience; d) diagnostic catheterizations on DOAC therapy seem safe.

In sum, we still need more evidence on this ongoing debate. Studies like the one conducted by Ramírez Guijarro et al.13 are extremely useful but future randomized trials should elucidate what the best antithrombotic strategy is for stent implantation in patients treated with DOAC or VKA. Similarly, clinical guidelines should come to terms on the actual recommendations based on the evidence available today since they do not agree on many issues as table 1 shows. The ultimate goal should be finding the optimal strategy which should be easy to implement, effective, and safe for our patients.

Table 1. Summary of actual anticoagulation recommendations in patients who are going to undergo invasive procedures

CONFLICTS OF INTEREST

None reported.

REFERENCES

Social media and the internet have changed the way we communicate with each other. We have never had so much information on this or that topic and never in such a direct, fast and global way. However, this new era does not come without risks and because everybody can be a potential creator of content, information itself has never been so susceptible to bias and demagogy.

The capacity of social media to expose information quickly and generate discussion among users has given rise to its application in the world of policy, business, radio broadcasts and academia world.1 Medicine is no stranger to this technological renewal and today we have doctors who are media-savvy. As it happens in many other aspects, cardiology is at the frontline of this trend.

As well as practical training and technical skills, essential for interventional cardiologists, theoretical training and constant update are also indispensable. The subjects covered in our core curriculum are increasingly difficult to apprehend since they include topics not only from general cardiology but also from interventional cardiology: physiology and coronary imaging, hemodynamics, techniques for the percutaneous treatment of coronary lesions (more and more complex) and structural cardiomyopathies, knowledge of devices and technical development, etc.

An ideal educational environment for interventional cardiologists should provide interesting and quality information that should be available to the largest possible number of users. Also, it should anticipate the participation of these users and update the contents in an ongoing basis.

Theoretical training that until recently was based on textbooks and printed articles has evolved into digital documents we can read in our computers or smartphones anywhere and at any time. In this context, social media provide a different teaching experience that is complementary and, at times, even better than the teaching experience provided through the traditional mechanisms by which academic information used to be broadcast, used and integrated in the routine clinical practice of interventional cardiologists.2

Today it is common that scientific meetings are announced in advanced, broadcast live and commented later on social media. At every meeting we see influencers competing to turn their contents into trending topics. This is how a series of results and comments end up in social media creating a virtual link between the attendees to these conferences and those who follow them digitally through viral terms such as #CardioTwitter.2

Aside from the immediacy and speed of broadcasting, the most significant difference between the on-site discussions that are held at meetings and those that take plance on the social media is the number of active participants. Probably in no other forum, interventional cardiologists on training can start peer-to-peer debates with the leading researchers of landmark studies.2

So, anybody with a real interest can be instantaneously briefed on the latest studies presented at the most important international meetings without having to actually attend the meetings. And even when it is not possible to watch live from social media, scientific online platforms such as PCRonline.com, tctmd.com, and hemodinamica.com give access to these contents after the meetings. We should emphasize here that we also enjoy these 100% virtual conferences through platforms such as eCardio, organized by the Spanish Society of Cardiology, with an increasing number of followers.

Over the last few years, an increase in the number of users and Twitter activity has been documented during the main scientific cardiological meetings. This not only has not had a negative impact on on-site attendance1 but has brought the attendees closer to the conferences, improved networking and spurred the wish to attend future events.3 These findings are indicative that the use of social media during scientific meetings improves communication and promotes educational and research efforts. Despite the early resistance from certain medical societies, the use of Twitter during these meetings has become an important and almost essential element for scientific broadcast and medical educational purposes.1^,2

Aside from the training that actually takes place in these meetings, scientific journals on interventional cardiology are second to none and they usually include, as part of their editorial team, community managers who run their social media. The number of followers on Twitter is more and more important to them and it has actually grown exponentially over the last few years. Today it is not unusual to see that the leading author’s Twitter account user name is one of the requisites established by these journals during the manuscript submission process.

Another development brought to this context by social media is the possibility to open up debates and create scientific review-like content trends about a specific subject on real time. Traditionally, the publication of this or that research was based on contributions from its authors and comments from selected reviewers and editors. Today, however, the critical analysis that follows the publication of landmark studies on social media has given rise to reviews coming from the CardioTwitter community. We have witnessed the almost surgical dissection of studies such as the #ORBITA (from pre-randomization medication to the design and details of its statistical analysis).2

This new way of broadcasting research studies has put into question what indicators should be used to measure the true impact factor of academic papers since now they are shared not only through traditional means but also through various alternative means including social media.4

Beyond meetings and journals, social media facilitate communication with other colleagues which is an essential tool of the learning process. This nearness among colleagues and the creation of scientific communities have become something common among cardiologists who are active on social media. The support expressed through comments, experiences and researches from others or simply by clicking like and retweet has built social bridges across the world in a way that facilitates and improves academic collaborations.2 In the past, technical or technological advances would take years after being discovered before being publicly implemented; today this process has been reduced to a matter of days. The percutaneous access through the distal left radial artery is an example. It was on social media before it was even made public through the traditional means of communication.5

Beyond all the potential advantages of social media as an educational tool, we cannot omit aspects that may be negative in this context. We should bear in mind that it is not always possible to confirm the validity of the content being broadcast and the accuracy of data provided. Also, fake news may travel faster on the social media as opposed to actual news.6 In cardiology, as it happens in other fields, the speed at which news travel on social media may be governed by factors unrelated to their validity.2 Also, the concision required by this type of platforms favors simplicity as opposed to accuracy and novelty as opposed to detailed information. The democratization brought by participating in these scientific debates where anybody can give their opinion can perversely lead to demagogy triggered by the popularity of the somehow most sarcastic or impacting comments.2

In sum, social media in general and Twitter in particular have given voice to interventional cardiologists from all across the field, created an open platform for the discussion and instantaneous review of academic and teaching materials on real time, and eventually improved the connection among the different communities that create and receive studies.2 However, the practical lack of filters and monitoring in the generation and transmission of these contents comes at a price. Even through the benefits of social media as an educational tool are evident, we should profit from it without losing sight of the complex training process that we, interventional cardiologists, have to go through where conferences, treaties, articles, mentors, teachers, colleagues, and patients are the sources of knowledge we learn from on a daily basis.

CONFLICTS OF INTEREST

The author declared no conflicts of interest whatsoever.

REFERENCES