Cath Lab Digest - October 2007 - (Page 23)

23 Letter to the Editor To the Editor: I read with great interest and considerable consternation two recent editorials by Dr. Morton Kern in Cath Lab Digest. His observations that left ventriculography (August 2007) and crossing the aortic valve (September 2007) are today often considered obsolete by the cardiology community deserves serious discussion. Unfortunately, I believe he accurately summarizes the current views of many cardiologists, especially those trained since the early 1990’s. Without question, echocardiography, Doppler, and nuclear testing are excellent clinical tools for assessing left ventricular function and aortic valve disease. Without doubt, contrast ventriculography and trans-aortic pressure measurements have limitations. However, these techniques continue to provide useful hemodynamic information, especially in situations when non-invasive techniques may be inaccurate. Optimal clinical decision making recognizes that all diagnostic tests may be imprecise in specific circumstances, and knowing how to interpret disparate results is the foundation of good clinical judgment. In part, the discrepancies that Dr. Kern highlights are generational. It is probably unavoidable in medicine that a senior generation considers its juniors “uneducated” in some skill that no longer is a paramount clinical method, while the younger one thinks of its elders as hopelessly “outdated” in its insistence on using tests that have been supplanted by newer practices. Previous generations definitely bemoaned the loss of expertise by later generations of several skills they found indispensable, for example, the stethoscope, phonocardiocardiography and even the electrocardiogram. Moreover, it is clear to me that the fault in this situation lies entirely with us, the teachers. Our students watched as we pushed the limits of coronary intervention while relegating pressure waveform measurements to the computer and their interpretation to the lecture hall. We have taught the next generation of cardiologists how to intervene on practically any coronary stenosis in any clinical context, but not how to diagnose complex disease states properly. Once, hemodynamics was a discipline, not a series of great board exam questions. An expertise worth developing to make a complete cardiac assessment has metamorphosed into a roundsmanship “game” few today take seriously as a method relevant to actual patient care. The fact is that Dr. Kern could easily make the same case about any number of catheter-based diagnostic techniques: right heart catheterization, cardiac output measurement, aortography and shunt detection are just a few which are today considered “quaint” and “old-school.” As someone often asked to lecture to cardiology fellows on their value and performance, it is apparent to me that these subjects are often viewed by other faculty as out-of-date and by the trainees as impenetrable. Hence, although I concur entirely with Dr. Kern’s remorse about the widespread deficit in understanding these techniques, I have concluded that, in the long run, this battle has already been lost. Cardiac catheterization today is about vascular angiography and intervention, not valvular heart disease or determinants of cardiac performance. All of the editorials, board exams, review courses and lectures will not alter the predictable consequences: hemodynamics as a field now resides in the echo reading room, not the cath lab. We have purposely nurtured catheterization into a therapeutic radiological/ surgical specialty, and our success is overwhelming. Inevitably, a field as dynamic as ours evolves rapidly, jettisoning underutilized but timehonored techniques mercilessly while favoring others of less proven but newer provenance, leaving its most experienced practitioners to wonder at the inexorable power of time. Sincerely, Lloyd W. Klein, MD, FACC, FSCAI Professor of Medicine Rush Medical College Chicago, Illinois Letters to the editor should be addressed to: Rebecca Kapur, Managing Editor, Cath Lab Digest Email: rkapur@hmpcommunications.com; Fax: 216.393.0445 Mail: 7427 Winding Way, Brecksville, OH 44141 Currently, this ability to compare dosages over a six-month period is only utilized in the cath lab. The interventional radiology department has expressed interest in sharing data so a more complete picture can be maintained on each patient seen throughout the hospital. It is our hope that in the future, St. Luke’s Episcopal Hospital will be able to offer this to every patient throughout the hospital. In conclusion, maintaining a patient database for cumulative doses for a six-month period has resulted in a more accurate identification of those patients who may receive higher doses of radiation. When patients are identified as potential candidates, steps can be instituted to lessen the amount of radiation received during a procedure if it is deemed necessary to continue with the procedure. Also, when patients are identified before their procedures, the physician has the ability to reconsider the medical necessity and discuss with the patient the alternatives available. This patient education results in the patient having a better understanding of the benefits versus the risks of having another procedure performed. In the end, the patient, whose care is enhanced, is better educated; the physician is better informed, and the department has better control over radiation safety for not only the patient, but the entire staff. Finally, in conjunction with policies and procedures requiring a mandatory annual radiation safety in-service to all cardiologists, cardiology fellows and employees who work in environments where patients are exposed to ionizing radiation, these actions enhance the safety of patients who have been exposed or may be exposed to ionizing radiation during invasive and interventional cardiac procedures. ■ The authors can be contacted at dduree@sleh.com. Note: This article underwent doubleblind peer review by members of the Cath Lab Digest Editorial Board. competence statement on optimizing patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: A report of the American College of the Heart Cardiology/American Association/ American College of Physicians Task Force on Physicians Task Force on Clinical Competence (ACCF/AHA/HRS/SCAI Competence Statement Writing on Committee to Develop a Clinical References 1. The Joint Commission. (2007). IV. Reviewable Sentinel Events. Sentinel Event Policy July and 17, Procedures. 2007 from Retrieved Fluoroscopy. Am J Coll Cardiol 2004;44:2259–2282. http://www.jointcommission.org 2. Amis ES, Butler PF, Applegate KE, et al. American College of Radiology White Paper on Radiation Dose in Medicine. J Am Coll Radiol 2007;4:272-284. 3. Hirshfeld JW, Balter S, Brinker JA, et al. ACCF/AHA/HRS/SCAI Clinical How do you document patient dosage? Does your hospital have a space on a patient electronic record showing cumulative dosage, incorporating data from the cath lab, invasive radiology and other departments? Keep the discussion going in CLD! Email us at: cathlabdigest@aol.com. http://www.jointcommission.org

Table of Contents Feed for the Digital Edition of Cath Lab Digest - October 2007

Saints Medical Center Fibromuscular Dysplasia in Children and Adolescents Cerebral Vascular Accident Following a Pulmonary Embolism: Search for the Hidden Patent Foramen Ovale Contents Clinical Editor’s Corner Meetings Calendar CEU Education Center Radiation Tracking in the Cardiac Catheterization Lab Letter to the Editor Carotid Stenting: An update Release from Stent-jail: Beneficial Snow-Plowing? Patient Management Guidelines Searching for a Cardiovascular Position? Tips for Creating a ‘Stand-Out’ Resume Long-Term Implications of Short-Term Closure Decisions – The Evolution to Vascular Access Management and the Boomerang Catalyst System The Ten-Minute Interview with… Angie Bowles, RN, CCRN CMS Issues Final FY 2008 IPPS Rule ACVP• Membership Page Experience with a New Workhorse Guidewire Ask the Clinical Instructor: Q&A for Those New to Cath Lab A Glimpse of the Future of Clinical Education: Boston Scientific’s SimSuite Bus Visits Carnegie Institute 2007 Educational Fair Held at the Washington Hospital Center Research Update: Original Contribution Abstracts from The Journal of Invasive Cardiology What Do You Think? A Virtual Cath Lab Viewer (VCL): The Development of an Online 3D C-arm Simulator and Coronary Anatomy Viewer Clinical & Industry News Cost-Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterization

Cath Lab Digest - October 2007

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