A Program Director Talks About Interventional Cardiology

Session 196

Dr. Edward Toggart is a Program Director who specializes in Interventional Cardiology. He shares his story and what life is like on a day-to-day basis.

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[01:26] Interest in Interventional Cardiology

His interest in becoming a cardiologist started when his father had a major cardiac event when Edward was in medical school. And as he went through medical school and internship and residency, cardiology just kept his attention. He liked the available therapies for the kind of diseases one sees in cardiology. And he felt it was a good opportunity to step in and change people’s course, save lives and prevent morbidity.

Edward has been an interventional cardiologist for 35 years. He did fellowship before there was even an interventional cardiology board and interventional cardiology fellowships. And so, he learned all the procedures along the way from originally full balloon angioplasty through stents, and all the way up to structural heart disease.

All the advances that have come from cardiology in the last several decades are just amazing. From the treatment of myocardial infarction, chronic angina, and heart failure, to now structural heart disease with transcatheter aortic valve replacement (TAVR) and mitral valve repair.

[03:24] The Biggest Myths or Misconceptions About Interventional Cardiology

Edward says a lot of people see interventional cardiology as an interesting, attractive subspecialty until they hang around with them and see how hard they work. It’s a 24/7 job. It’s fairly stressful. It’s long days, and lots of night calls and lots of acute cardiology problems to deal with. So it’s very taxing. And that actually scares people.

Edward adds it takes a special person that has that kind of commitment and interest, almost a surgical bent because a lot of what they do is procedural.

'What we do is procedural in interventional cardiology. More and more, we're treating valvular heart disease not only coronary artery disease.'Click To Tweet

[06:18] Types of Patients

Up until the last several years, interventional cardiologists would treat patients with coronary artery disease. It’s either chronic coronary artery disease with angina, and patients with acute coronary syndrome such as non ST elevation MI and ST elevation MI.

They also do diagnostic work for patients with other types of heart disease such as cardiomyopathy and valvular heart disease.

Over the last several years, there have been some amazing advances in technology. They’re now able to treat patients with aortic stenosis via catheter-based technology as opposed to surgical intervention. And that’s a huge advance. Patients have severe aortic stenosis and heart failure or severe limitations. And within about 10 seconds, they fix the valve, and the patients get up out of bed for six hours and they leave the hospital the next day. It’s truly incredible.

[07:54] Hospital-Based or Community Outpatient?

Edward explains it’s not only hospital-based as they also have their own clinics. With aortic stenosis and valvular heart disease, for instance, they have a structural heart team. So then the interventional cardiologists man the clinics with other cardiologists. They evaluate patients with valvular heart disease. They also see patients pre and post coronary stent procedures. So there is a fair amount of outpatient work as well.

[08:35] Typical Week

Since they take calls 24/7, they go on call Wednesday night and get off Wednesday night for an emergency call so it’s anytime a day or night. They usually deal with acute heart attacks.

They also take care of the patients in the hospital on the cardiology service who need to have a heart catheterization and intervention. On other weeks, they have a TAVR program. So on Tuesdays, they do valve intervention, which takes a whole day.

They also have a couple days off. At the end of the 24/7, they get Thursday to Sunday off. Then the rest of the time is pretty much clinic. Edward has administrative responsibilities where he does quality improvement projects.

[09:59] What They’re Looking For in Their Fellowship Program

As the fellowship program director, Edward says they’re looking for candidates that can exhibit some sort of calmness and the ability to handle acute situations in a reasonable fashion. They have to have the ability to make critical decisions in a rapid timeframe.

They should have good manual dexterity skills and the ability to manipulate catheters and put wires down arteries and cross aortic valves. However, Edward explains that not everybody has that capability so they rely on evaluations by cardiologists that have trained the candidates in general cardiology.

Everybody gets to go to cath lab rotations. Sometimes, people select themselves out if they don’t want to do this kind of thing. There are also people interested so they need to rely on their attendings and mentors in their fellowship to find out about what their dexterity of manual skills are.

As a medical student, medical students have three years of internal medicine to go through before they get to cardiology. That being said, they spend a significant amount of time with each candidate, who is interviewed by three or four of their faculty. And then they meet as a committee and make selections.

Edward adds that if people are interested in interventional cardiology, they have an opportunity to spend more time in the cath lab as they get elective time. And so, he strongly recommends this. Work with the cath lab director and all the other attendings. Talk to them and tell them you’re interested. Ask if you could drive a catheter and use the attendings as your guide. Hopefully, they will be honest with you to say if it’s for you or maybe it’s not the best thing for you. That’s very helpful, rather than embarking on something that may not work out.

[13:46] The Training Path

To become an interventional cardiologist, you spend four years of medical school, three years internal medicine, and three years cardiology. Then you do at least one year of interventional cardiology fellowship. If one wants to do structural work, which is TAVR and other valve procedures, that’s going to be another year so two years after cardiology in total.

[14:50] Overcoming Negative Bias Towards DO

Edward clarifies that the quality of the people is very much the same, MD or DO. And so, he thinks that difference is going to go away, if it hasn’t gone away already in terms of practice. So his advice to DO students is to be optimistic and keep your eye on the ball and see what’s happening in terms of ACGME and osteopathy.

Structural Heart Intervention is really relatively new to Interventional Cardiology. The most common procedure now that’s been widely disseminated is a transcatheter aortic valve replacement (TAVR). And there are other technologies on the way for treatment of mitral and tricuspid valves. Edward thinks that when a lot of people finish their interventional training, particularly these days, they should consider doing another year of structure, because that’s really in the future.

[16:51] Turf Wars with Cardiothoracic Surgery

Edward explains that TAVR started as a combined multidisciplinary approach. And so, the cardiologist and cardiac surgeon work together to evaluate the patients to make a decision, and then do procedures together. So there’s always a cardiologist and a CT surgeon at the table.

And so, you have to realize that everybody brings different skills because it has strengthened the heart team. People don’t look at cardiac cardiothoracic surgery and interventional cardiology as being different anymore. They collaborate frequently, not only on bowel disease, but also coronary disease.

'People don't look at cardiac cardiothoracic surgery and interventional cardiology as being different anymore.'Click To Tweet

[18:19] Message to General Cardiologists

Edward says the main area that’s a little fuzzy between general cardiologists and interventional cardiologists is who can have a stent procedure and who’s better off being treated with surgery or continuing medical therapy? And what they frequently do in terms of talking about patients is to discuss the best mode of treatment. Hence, they need to look at angiograms together to make that assessment.

[19:11] What He Wished He Knew Before Getting into the Field

If he would have done anything differently, Edward says it would be to try and make a better life balance.

'One can get really wrapped up in interventional cardiology, and miss out on a lot of things outside.'Click To Tweet

[19:58] The Most and Least Liked Things

Edward says he likes the satisfaction of curing immediate problems. They often don’t cure coronary disease, but they can stop a heart attack. They fix a heart valve, and patients immediately feel better and they save lives.

On the flip side, what he likes the least is how physically demanding the specialty is, in terms of hours. You’re on your feet for hours and hours wearing a lead apron. So it takes a toll. You can get fatigued and the hours can be long.

[21:06] Major Changes Coming Into the Field

Edward explains there are lots of potential options for transcatheter treatment of valvular heart disease, not only the aortic valve, but mitral valve. Even mitral valve replacement is a possibility and treating tricuspid valve disease.

All those things are in the future and are being developed. There are also repair-type procedures, such as plugging holes in the vasculature with little vascular plugs that also can be life-saving.

The treatment of coronary disease has sort of leveled off. They have very good stents, and there will still be progress. But the major steps have been taken. Now, they’re looking forward to maybe having a bio-absorbable stent, so people don’t have something permanently in their arteries. But that’s what’s coming in the future as well as further treatment of different valves.

[22:19] Final Words of Wisdom

If he had to do it all over again, Edward would still be an interventional cardiologist. Finally, he encourages people who might be interested in the field to follow their passion. Sometimes it’s easy, sometimes it’s hard. But if that’s really what you want to do, then make every effort to succeed.