Off Script: Focusing on the Future
Amidst the important but small gains on display at TCT 2017 are the hints of a larger future of interventional cardiology.
Most advances in our field are small and incremental, inching progress ever so slightly forward. Much good work has been presented here, with some additional clarity on multivessel PCI in cardiogenic shock, left main bifurcational technique, and drug-coated balloons for in-stent restenosis. Amongst these short-term gains, though, there are glimpses of a paradigm-shifted future, as we struggle to try to bring it into focus.
An important change seems to be occurring for the near future as we begin to look at the effects of our efforts on not just mortality and adverse cardiovascular endpoints, but on quality of life. Our approval and consensus process has for too long focused on the hard endpoint and finality of death. We seemed to have forgotten the second half of our philosophical endeavor in the promotion of health for our patients: “Live long, feel good.” There should be equipoise in these twin, and sometimes competing, goals. To take an extreme example, would you rather live with Class 4 symptoms for a year or with Class 2 symptoms for 3 months? The relief of suffering has worth, and we should aspire towards it.
In the realm of procedural registries, it is time we zoom out to the larger picture. Too much has focused on outcomes of patients only when we decide to act. This myopia has encouraged hesitancy and conservative behavior at times precisely when we should be aggressive, for some hope is arguably better than none at all. The double-edged sword of public reporting, despite being fundamentally well-meaning, has on occasion led to harm. It is time we considered the tracking of outcomes whether we act or choose not to. The omission of care when inappropriate should be equally weighed. Such a system will encourage true synergy of a heart team and decrease turf battles occasionally seen based on volume rewards.
In today’s world, we have become increasingly used to the performance of an act remotely. We turn on our cars, unlock our homes, water our plants, order our patient’s medications, read their studies and yes, now, we can deploy our stents. Robotic assisted percutaneous coronary intervention has taken the obvious leap with the demonstration of a series of PCI procedures performed remotely. Once you disconnect the cables, how far away is too far? The widespread adoption of this practice remains obviously fraught with many issues. What do you do if there is a complication? How do you ensure digital security? How do you ensure competency? The possible benefits though are profound with the ability to extend the reach of PCI, and most importantly primary PCI to remote territories. Could you even bring the cath lab to a patient who calls 911 for the ultimate in symptom-to-reperfusion time?
In the current era of iterative drug-eluting stent design improvements, the reported 1-year performance of the Combo stent (OrbusNeich, Hong Kong) was met with much interest. Although the clinical results were likely equivalent when compared to current generation DES, this stent may represent a paradigm shift with the unique implantation of CD34+ murine antibodies on the surface of the stent, designed to encourage healing by capturing passing endothelial progenitor cells. Evidence for this concept was reflected in the superior healing profile seen on OCT at 1-year. Could this represent the beginning of a shift towards specific molecular targeting on stents akin to the move away from systemic chemotherapy and targeted immunotherapy in cancer? It is too early to tell, but I am intrigued by the possible future of matching a biologically active stent to a specific lesion type and a specific patient.
Finally, this morning’s live case demonstrated the co-registration of a 3-D TEE image on a fluoroscopic image, overlaying the three-dimensional spatial boundaries of the heart over a fluoroscopic image, a concept which I have long felt was overdue. We have seen co-registration change the precision of image interpretation in IVUS and OCT imaging, giving depth to flat, two-dimensional images. These imaging developments are critical for clarity and will continue to close the gulf between the procedure as concept and the hard truths before us.
Focus on and find the future at TCT.