Welcome to this issue of European Cardiology. First, let me draw your attention to the brilliant article by Marc Monagham on the role of echocardiography in interventional cardiology. Interventional cardiologists used to work in their cath lab as if it were an ivory tower, keeping at bay new developments in other fields of cardiology, from pharmacology to non-invasive imaging. The last two years have seen a complete change of direction, with more and more specialists integrated in the work of the cath lab. Five years ago we laughed at crowded operating theatres where large teams would be busy for hours fixing a patient, during which time 10 angioplasties had been performed by a single operator in the cath lab. Now the situation is completely different, and busy cath labs shared by anaesthetists, the anaesthetic team, consultant cardiac surgeons, interventional cardiologists and specialists in cardiac imaging are commonplace in centres where transcatheter valves are implanted. During the last EuroPCR meeting in Paris, the sessions on structural heart disease and transcatheter mitral valve repair/aortic valve implantation were always busy. When Dr Silvestry, an echocardiography specialist active in the EVEREST 2 trial, was asked what was the most problematic aspect of co-operation with cardiologists, he answered: ”Having them turning their eyes from the fluoroscopy screen to look at the transoesophageal live recording”.
It is counterintuitive for somebody used to relying on angiography for all stages of a procedure to realise that during MitraClip implantation the role of fluoroscopy is almost nil. Instead of pushing a control handle and rotating the angio tube as desired, we must learn patience – very rare among interventionalists – and wait for the echocardiographist to adjust the transoesophageal echocardiography probe according to our needs. Unless real co-operation develops within the team, the echocardiographer adapts to the fast pace of the cath lab and the interventionalist learns to ask for a bi-caval, two-chamber or outflow tract view instead of a left anterior oblique or right caudal view, life in the cath lab during a MitraClip procedure can be dreadful.
New skills and knowledge are now required for the growing range of procedures falling into the realm of interventional cardiology, but the most important change is in the mentality of interventionalists. Rather than being the absolute ruler of his or her small kingdom, the interventionalist is now a constitutional monarch who shares responsibility for the patient’s care and discusses every step of the procedure with his or her team. There are drawbacks, of course, but some are pseudo-drawbacks. All procedures now need the agreement of the heart team, and interventionalists may have a hard time convincing their consultant colleagues that a still experimental transcatheter aortic valve implantation procedure is better than a well tested aortic valve replacement in subjects below 60 years of age without prohibitive co-morbidities. Is this a problem? Maybe it is better now than when there was no rule, with self-referral and little control from other physicians. It is time to get out of the ivory tower, appreciate that other subspecialities in cardiology have progressed to the same extent or more than interventional cardiology and join forces for the patient’s benefit.
Beyond interventional cardiology, this edition of European Cardiology includes valuable contributions from across the cardiovascular spectrum. I hope that you will find topics of interest in your own specialism that make a contribution to confronting the challenges that lie ahead.