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The Recalibration of Interventional Cardiology During COVID-19: An Opportunity for a Future Paradigm

Published:December 02, 2020DOI:https://doi.org/10.1016/j.mayocp.2020.11.023
      A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.Winston Churchill, 1938
      To the Editor: As a consequence of the coronavirus disease 2019 (COVID-19) pandemic, hospitals have had to reconfigure the role for cardiac intensive care unit (CICU) staffing to meet the health care needs of their communities.
      • Vallabhajosyula S.
      • Friedman P.A.
      • Bell M.R.
      Cardiovascular health in the COVID-19 era: a call for action and education.
      Interventional cardiologists (ICs), among other specialists, have been redeployed in the CICU to take care of a primary respiratory illness with multiorgan failure.
      • Vallabhajosyula S.
      • Friedman P.A.
      • Bell M.R.
      Cardiovascular health in the COVID-19 era: a call for action and education.
      ,
      • Vallabhajosyula S.
      • Kapur N.K.
      • Dunlay S.M.
      Hybrid training in acute cardiovascular care: the next frontier for the care of complex cardiac patients.
      These physicians are required to be skilled with ventilator management, end-organ injury, fluid and electrolyte balance, and end-of-life care. Even before the COVID-19 pandemic, the CICU had noted dramatic shifts in its landscape and started to resemble a medical intensive care unit population with a primary cardiac illness complicated by multiorgan involvement and intensive care needs.
      • Vallabhajosyula S.
      • Kapur N.K.
      • Dunlay S.M.
      Hybrid training in acute cardiovascular care: the next frontier for the care of complex cardiac patients.
      • Morrow D.A.
      • Fang J.C.
      • Fintel D.J.
      • et al.
      Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association.
      • Klein L.W.
      • Rab S.T.
      • Anderson H.V.
      • et al.
      The implications of acute clinical care responsibilities on the contemporary practice of interventional cardiology.
      This contrast has been further amplified by the ongoing pandemic.
      How then must the IC seek the opportunity within this difficulty? Interventional cardiology has increasingly become subspecialized with training programs for complex coronary, structural, and peripheral interventions. Increasingly, the IC has been required to serve as a leader of the acute cardiovascular team caring for patients with acute coronary syndrome, cardiogenic shock, cardiac arrest, and pulmonary embolism.
      • Vallabhajosyula S.
      • Kapur N.K.
      • Dunlay S.M.
      Hybrid training in acute cardiovascular care: the next frontier for the care of complex cardiac patients.
      ,
      • Klein L.W.
      • Rab S.T.
      • Anderson H.V.
      • et al.
      The implications of acute clinical care responsibilities on the contemporary practice of interventional cardiology.
      In the catheterization laboratory, rapid decisions such as vascular access, hemodynamic evaluation, mechanical circulatory support, internal cooling, mechanical compression devices, and vasoactive medications are often made while performing diagnostic or therapeutic coronary interventions. In such circumstances, the training and knowledge in critical care cardiology are of great additional value for the treating IC.
      • Vallabhajosyula S.
      • Kapur N.K.
      • Dunlay S.M.
      Hybrid training in acute cardiovascular care: the next frontier for the care of complex cardiac patients.
      ,
      • Klein L.W.
      • Rab S.T.
      • Anderson H.V.
      • et al.
      The implications of acute clinical care responsibilities on the contemporary practice of interventional cardiology.
      Studies have shown that there is clear need for critical care cardiologists; however, there are only 400 critical care cardiologists in the United States.
      • Vallabhajosyula S.
      • Kapur N.K.
      • Dunlay S.M.
      Hybrid training in acute cardiovascular care: the next frontier for the care of complex cardiac patients.
      • Morrow D.A.
      • Fang J.C.
      • Fintel D.J.
      • et al.
      Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association.
      • Klein L.W.
      • Rab S.T.
      • Anderson H.V.
      • et al.
      The implications of acute clinical care responsibilities on the contemporary practice of interventional cardiology.
      • Panhwar M.S.
      • Chatterjee S.
      • Kalra A.
      Training the critical care cardiologists of the future: an interventional cardiology critical care pathway.
      In comparison, every major center in the United States employs an IC. In lieu of these established paradigms, we propose a novel training pathway of an acute care cardiologist with dual training in interventional cardiology–critical care cardiology. The requirements for interventional cardiology–critical care cardiology can be achieved in 4 years (Figure) as against interventional cardiology–heart failure or heart failure–critical care cardiology, both of which require 5 years.
      • Vallabhajosyula S.
      • Kapur N.K.
      • Dunlay S.M.
      Hybrid training in acute cardiovascular care: the next frontier for the care of complex cardiac patients.
      ,
      • Panhwar M.S.
      • Chatterjee S.
      • Kalra A.
      Training the critical care cardiologists of the future: an interventional cardiology critical care pathway.
      Prior position statements have highlighted the need for a hybrid training paradigm in interventional cardiology–critical care cardiology.
      • Vallabhajosyula S.
      • Kapur N.K.
      • Dunlay S.M.
      Hybrid training in acute cardiovascular care: the next frontier for the care of complex cardiac patients.
      • Morrow D.A.
      • Fang J.C.
      • Fintel D.J.
      • et al.
      Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association.
      • Klein L.W.
      • Rab S.T.
      • Anderson H.V.
      • et al.
      The implications of acute clinical care responsibilities on the contemporary practice of interventional cardiology.
      • Panhwar M.S.
      • Chatterjee S.
      • Kalra A.
      Training the critical care cardiologists of the future: an interventional cardiology critical care pathway.
      These physicians serve as an internal referral for acutely ill cardiovascular patients who need percutaneous therapeutic options because they are too sick for surgical therapy. These high-risk operators serve as the connecting link between the 2 acute care realms of the CICU and the catheterization laboratory. This proposed paradigm requires significant intellectual, logistical, and academic commitment from institutional leadership and may remain unique to high-volume centers that are able to confer holistic experiences in both domains.
      Figure thumbnail gr1
      FigureProposed training paradigms during a 4-year period in interventional–critical care cardiology.
      In summary, we propose a unique training pathway that will serve the acute care needs of the contemporary cardiovascular patient while not burdening the cardiovascular trainee with additional years of training. Although this may have been the logical course of evolution in the decades to come, the COVID-19 pandemic has provided impetus to this change and will likely mark a watershed event in acute cardiovascular care paradigms around the country.
      • Vallabhajosyula S.
      • Friedman P.A.
      • Bell M.R.
      Cardiovascular health in the COVID-19 era: a call for action and education.

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