Change or Die!

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Everything changes. This holds particularly true in the field of interventional cardiology. Every day, new procedures are being implemented and “old” procedures are being improved upon, offering treatment options to patients who until recently were considered to have limited or no options. Transcatheter aortic valve replacement, renal denervation, left atrial appendage occlusion, percutaneous mitral valve repair, left main, and chronic total occlusion interventions are some of these procedures. 

There are several approaches to change: (a) ignore it; (b) fight it; or (c) embrace it. Ignoring or fighting change can be harmful for the patient who is not offered access to treatments that could benefit him/her, but also the physician and the institution who may become obsolete and lose competitiveness (change or die…). In the same way, embracing and developing expertise in new procedures can benefit patients, physicians, and institutions alike. Embracing does not imply blind acceptance or adoption, but rather a critical evaluation of the associated risks and benefits and careful implementation of the procedure, starting from patients who are likely to derive the most benefit.

However, more often than not, change is not embraced for several reasons, such as the time and effort required for implementation, lack of institutional support, and uncertainty about the best way to implement the change. In his book, Change or Die, Alan Deutschman highlights 3 “keys” for successful change: relate, repeat, and reframe (the three Rs). Relate refers to relationships with a coach, mentor, or support group. Repeat refers to practicing the new action/procedure over and over. And reframe suggests painting the picture of the new reality (new procedure in our case) in a new frame.

Let’s use chronic total occlusion (CTO) percutaneous coronary intervention (PCI) as an example. For many years, retrograde CTO PCI was the topic of “exotic” presentations by Japanese operators that mesmerized audiences. Attendees of those presentations or live case demonstrations were impressed, but reluctant to apply these techniques. And for good reason, since the techniques were evolving and not yet ready for general adoption. However, the retrograde approach to CTO has now been demystified and high success and low complication rates are achieved not only in Japan, where the technique was pioneered, but also in Europe and the United States (US).¹ Practical, step-by-step descriptions of the technique have been published.² Moreover, another CTO crossing strategy — antegrade dissection and reentry — has gained increased popularity through the availability of dedicated new technology. With these new techniques and tools, CTO interventions can be performed with high success and low complication rates, yet only a few centers have established CTO programs in the US.

What is the “secret” to successful implementation of a CTO (or other novel procedure) program? Using the framework of the three Rs, relationships are important: CTO operators in the US have formed a very closely knit support network by exchanging ideas and techniques not only at meetings, but also continuously through personal communications, proctoring, and a pioneering online collaboration forum at www.ctofundamentals.org. Repeated frequent performance of the procedure is, of course, critical, as with any other interventional procedure. Many operators starting CTO programs are concerned about how to increase their CTO PCI volume. Beginning is always the hardest part; once the program starts and success rates increase, so do referrals by both physicians and the patients themselves! Reframing is next: many operators dread CTO interventions because they fear failure and risk for complications. On the contrary, seasoned CTO operators are excited to perform CTO interventions, as they are prepared to deal with the related challenges and are confident that they can succeed in most cases. 

Alan Deutschman argues that “facts, fear, and force” may enable short-term change but not long-term. The fear of being left behind and intense peer pressure to adopt new procedures are unlikely to lead to permanent change (ie, to establish a viable and growing CTO or other novel procedural program). We are afraid of change, because we are most afraid of what we do not know. The best way to overcome our fears is to embrace the new technique and study it in a thorough and detailed manner. This will improve the outcomes of our patients and will also help us improve ourselves as operators. Experienced CTO operators invariably argue that the CTO experience has “spilled over” to non-CTO interventions, making them feel much more prepared and confident to perform any complex coronary intervention. Frequently, CTO techniques (such as the balloon trapping technique)² are used routinely in all interventions, and some other techniques (such as subintimal dissection and reentry) can be used as bail-out when complications occur.³  

Having the opportunity to learn and perform novel procedures and techniques is a privilege of interventional cardiology. Taking advantage of this privilege can help the patients and ourselves. So what are we waiting for?!

References

1. Karmpaliotis D, Michael TT, Brilakis ES, et al. Retrograde coronary chronic total occlusion revascularization procedural and in-hospital outcomes from a multicenter registry in the United States. JACC Cardiovasc Interv. 2012;5(12):1273-1279.
2. Brilakis ES, Grantham JA, Thompson CA, et al. The retrograde approach to coronary artery chronic total occlusions: a practical approach. Catheter Cardiovasc Interv. 2012;79(1):3-19.
3. Martinez-Rumayor AA, Banerjee S, Brilakis ES. Knuckle wire and stingray balloon for recrossing a coronary dissection after loss of guidewire position. JACC Cardiovasc Interv. 2012;5(10):e31-e32.

Emmanouil S. Brilakis, MD, PhD is Director of the Cardiac Catheterization Laboratories at VA North Texas Healthcare System and an Associate Professor of Medicine at the University of Texas Southwestern Medical School. Avantika Banerjee is an undergraduate at Emory University. Email: esbrilakis@yahoo.com

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. Dr Brilakis discloses speaker honoraria from St Jude Medical, Terumo and Bridgepoint Medical/Boston Scientific; grant support to his institution from Guerbet; spouse is an employee of Medtronic.