CORRESPONDENCE: LETTER TO THE EDITOR
The Morphed Specialist—An Androsphinx?
Ganesh Shanmugam, MBBS, MS, MCh, FRCS*
* Department of Cardiothoracic Surgery, Glasgow Royal Infirmary, Glasgow G31 2ER, United Kingdom (Email: sgunpat{at}hotmail.com).
Dr. DeMaria in his editorial (1) on the morphing of cardiovascular specialists rightly points out that there will be a blurring of the borders between specialties. Newer technological developments will render the diagnosis of coronary pathology less risky; however, these are still diagnostic procedures—and there still remains the problem of treating these lesions—a problem with which we still grapple. Although Dr. DeMaria’s editorial elegantly describes the roles of the cardiologist and the radiologist in specialty training and the delivery of services, one must also consider the role of the cardiac surgeon as the specialty evolves.
The only constant factor about the specialty is change. The introduction of percutaneous techniques that address mitral regurgitation is akin to the situation when balloon mitral valvuloplasty was introduced in an era where surgical mitral valvotomy was the norm for mitral stenosis.
One needs only to examine a severely calcific aortic or mitral valve to realize that replacing such valves involves far more than a simple percutaneous substitution. Various issues require resolution prior to the clinical application of these approaches. These include the problem of the small aortic root, peripheral vascular access for the introduction of larger delivery systems, determination of device blow-out pressures, quantification and limitation of blood loss, backup procedures, and others (2). These difficult procedures are intolerant to the smallest error of judgment or technique. The potential pressure to adopt new technological advances could be detrimental and may encourage premature application of some technologies before their role and limitations are clearly established.
Beyond percutaneous valvular techniques, perhaps the biggest changes will occur in the interventional approaches to the ablation/isolation of atrial fibrillation and the novel interventional techniques that address the failing heart.
Immaterial of what we call the "new animal" and no matter what skills the "morphed" cardiologist may possess, there are problems that he or she must surmount. The combination of cardiological and radiological skills might not be necessarily adequate to handle high-risk patients—the presence of surgical skills might also be called for.
Beneath all this, of course, are patients who are now less forgiving and less tolerant of complications arising as a consequence of any procedure, let alone a novel intervention. The accumulation of good evidence is then a natural prerequisite to the more widespread application of these procedures in clinical practice.
It is critical, however, that we anticipate these future changes, and Dr. DeMaria should be congratulated for doing exactly this and recognizing the need for change in the way we train and deliver holistic cardiovascular services.
Finally, Dr. DeMaria suggests that the morphing of cardiovascular specialists will be consistent with the apparently widely held current concept that it is better to know everything about something than something about everything. But this in itself is a hugely time-dependent phenomenon. Although it is always possible to know something about most things (if not everything), will it ever be possible to know everything about anything—let alone something?
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References
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1. DeMaria AN. The morphing of cardiovascular specialists (editorial) J Am Coll Cardiol 2005;45:960-961.[Free Full Text]2. Von Segesser LK. Direct percutaneous valve replacementthe next step?. Eur J Cardiothorac Surg 2004;26:873-874.[Free Full Text]
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