A viewpoint from Prof. Jens Flensted Lassen, MD, Ph.D., thought leader, Interventional Cardiologist, and Clinical Director of Ischemic Heart Diseases.
A viewpoint from Prof. Jens Flensted Lassen, MD, Ph.D., thought leader, Interventional Cardiologist, and Clinical Director of Ischemic Heart Diseases, Department of Cardiology, Odense University Hospital.
For the last twenty years, Jens has been the team leader of 75% of the angio suites in Denmark, and he is one of the founders of the European Bifurcation Club.
I am an Interventional Cardiologist (IC) and chair professor of Cardiology at Odense University Hospital, Odense, Denmark, and one of the founders of the European Bifurcation Club. I have trained and educated a significant part of all ICs in Denmark during the past twenty years, focusing on technical skills. During the last thirty years, I have been a part of the development of IC both in Denmark and internationally.
IC has a significant impact on patients' health with coronary artery disease, especially in the acute setting where we save a lot of patients. It is one of the greatest improvements we have seen in the last twenty years in this field. The one-year mortality rate from ST-elevation myocardial infarction (heart attack) has declined from 30% to 2-4% in regions where the final step is the coronary vessel stenting procedure done acute in a cath lab.
In the past, patients with coronary artery diseases underwent coronary artery bypass grafting, which is a huge procedure involving a heart and lung machine. Recovering from this type of procedure was lengthy. Today, this type of procedure can be replaced by balloon angioplasty and stenting for most patients. This type of intervention takes approximately one to one and a half hours, and the patient can almost leave the hospital right after the procedure. This is a significant improvement in the treatment of ischemic heart disease. It is a technically demanding procedure that requires trained staff and operators, and it is essential to ask ourselves: How can we make sure that this technique is used in the right way to ensure the optimal result for the patient?
It depends on the type of cardiologist. Mostly it is chest pain, effort angina, or loss of breath during exercise. These symptoms are very broad but mostly cover the risk of having a narrowing in a coronary artery. If you have a narrowing of the artery, you do not get the amount of oxygen and nutrition you need for exercising. The human body can raise its heart rate during exercise, and the heart rate is a muscle contraction of the heart, which requires oxygen and energy.
There is a positive expectation for life after a procedure if the patient arrives in time and in a stable condition at the hospital. It will not reduce your expected life range since it is not just the intervention that should be considered here. It is also preventive activities that are very important to introduce on top of the treatment, such as lowering cholesterol levels, regular exercise, a healthy diet and lifestyle, no smoking, etc.
The access to this type of care is good. However, there are still geographical differences and inequalities. The procedure itself is not that expensive; it is the setup that is extremely expensive. From a global perspective, access is limited. Important to highlight is the limited possibilities to train operators in many parts of the world.
There seem to be fewer women than men that get this type of interventional procedure when looking into the epidemiological background. All over the world, women are shorter than men, and what is fascinating is that their hearts are smaller. The diameter of women's arteries in the coronary is smaller than that of men's. This is remarkable if you go back to the mathematics behind flow profiles in tubes. If you have a smaller vessel, much less atherosclerosis is needed to impair the flow. There are also technical differences between the genders. Since women's coronaries are smaller, it requires more technical effort to make a proper stent result.
There has been extensive research on these topics in the Nordic countries, initiated by the European Society of Cardiology (ESC). ESC has subcommittees and groups working specifically on gender differences concerning access to healthcare services within cardiology.
I have been working a lot with out-of-hospital cardiac arrests and how to increase the chance of survival. Interestingly, more men than women survive an out-of-hospital cardiac arrest if the arrest happens at home and if they live with a partner. If it occurs outside the home environment, in the community, on a railway station, in a supermarket, etc., there is no difference between the genders at all. Women have a longer life expectancy than men and outlive their partners. Therefore, an old woman is more likely to live alone, and if she has a heart attack at home, she is not likely to survive.
Men tend to get more examinations than women.
An interesting question in the context of gender and geographical differences. When treating a patient with a technical intervention and placing a device, there is a risk for a device biology interaction: How will the human body accept and react to the stent that is an alien object?
Presently, it is enough if the procedure is successful, which is what we measure in all our quality insurance programs. There is no evaluation of the final quality, just that the stent was placed successfully. Why is that interesting? This means that the training on how to do proper technical stenting is based on the physician on call or in the lab that day, with the help of the staff.
Poor technical implementation may correlate strongly with problems in the long run, and the issue of post-procedural complications must be addressed. We need to ask ourselves: are we trained enough? Are we doing everything the proper way? Do we have systems to evaluate our proficiency? How do we educate new ICs?
Stenting requires a "three-dimensional mindset" for orientation, good tactile perception, good hand-eye coordination, and multitasking skills. It is a very complex setup. In the past, when we were to train in a patient-free environment, we mostly used silicone tubes. In the silicone tubes, it was possible to see what you were doing with the stents, but you missed the training of everything besides the stenting itself and the mental aspects. The concept of team training in this setting is great, and I especially like the idea of developing a training environment that is as close to the real-world experience as possible. We have traditionally been trained through a fellowship: following a mentor, being trained and supervised, being exposed to cases, being evaluated, and so on. Further down the line, a few fellows get skilled enough to earn a final position in the team. That is it. Since there is no recertification or retraining, there is no further discussion once the fellow has qualified for the team. The same goes for the adoption of a new technique. There is no real training, just learning by doing. I believe that there is room for a lot of improvement here.
Bifurcation stenting is a high-risk procedure. One of the purposes of EBC is to educate and train physicians on the proper way of stenting within bifurcation.
Bifurcations are the most challenging area within coronary procedures, with the highest need for training. Simulation training within mentorships and fellowships has usually been with silicon tubes in a "dry training simulation," never in a complete setup (like Mentice solutions) that simulates the situation in the cath lab or with the ability to simulate a bifurcation stenting virtually. To have these simulation solutions available now is fantastic. From my perspective and role in the EBC, this is a giant leap forward in promoting the most essential training platform within bifurcation stenting.
There are different methods of treating a bifurcation lesion, and they all have pros and cons. It is difficult to predict the result of a procedure when at the beginning of it. We have conducted several clinical trials to figure out which method is best in which situation. Clinical trials have clarified what works and not, so we have therefore gained insight into what to recommend. These recommendations are published in consensus documents. However, there is a huge gap between what is recommended to do and what is possible for the operator during a procedure. How do we best transfer theoretical knowledge to real-life procedures? This is where training has an important role.
For many years EBC has hosted live sessions in conferences and has an annual meeting dedicated to discussing new complication management techniques with colleague experts. This knowledge is then used to build clinical trials.
An excellent environment for training the whole cath lab staff is to use a simulator where the tactile feeling is as close to the real experience as possible, within the angio suite and running different patient scenarios. This is a safe and patient-free learning environment where the team can train repeatedly. Simulation training enables recertification and brings fellows to a higher level of proficiency before they can start treating real patients. The main reason why the EBC is so pleased with Mentice simulators is that they enable this type of immersive team training in the angio suite. It was not possible with the old school training in silicon tubes. Mentice simulators are close to reality and provide that hands-on experience within the actual working environment, with all the equipment, devices, and your team. I expect that team training will improve a lot in the future, both for the fellows and the senior physicians. High and low-volume hospitals will have great use of simulation training, as they can increase their virtual patient volumes with the help of simulation.
We need to share the information discussed in this article with the owners of simulators or the healthcare authorities. The quality assurance systems we have in Western countries do not evaluate the result of the procedure nor evaluate the cost of the patient. I believe there is a need for and willingness to improve the quality assurance systems in the future.
From a political point of view, if you put effort into these improvements, you will not see the result until five years later. Therefore, there is no real driver for these projects and no reason for anything to change. In my opinion, we have a massive responsibility as professionals within the clinical community to take the lead in this discussion.
I believe that most ICs want to train, but they have not previously had the opportunity to do so close to the procedures. Now, these training possibilities are available. One of my mentors and a very close friend was happy when he performed a procedure on a Mentice simulator in Brussels this year (2022). He was very thrilled, and he explained that it was such a great experience to have the same tactile feeling in his hands, see the screen, and see the balloon react in the way it should when he inflated the device.
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