Interventional Heart Failure – Has Its Time Come?

Believe it or not, I initially went into cardiology to treat heart failure. In fact, as a medical student at Brown University, I spent all my free time traveling to and working at Mount Sinai Medical Center, under the tutelage of Drs. John “Jay” Fallon, Allan Gass, Billie Fyfe and Val Fuster as part of the heart failure and transplantation team, performing basic science, clinical outcomes and pathology research. I was fascinated with the idea of helping those at the “end of the road,” offering them hope in the form of cardiac transplantation. During residency, I remained steadfast in my decision and immediately accepted an offer to train at the University of Pennsylvania, at that time the busiest transplantation program in the country, and learn from Dr. Mariell Jessup. Somehow, however, and as she would most certainly say, I “went to the dark side” and by second year switched to interventional cardiology. Oh, I certainly remained fascinated by the hemodynamics of complex heart failure management, and the ability to logically utilize those measurements as well as my clinical exam and judgment to improve the signs and symptoms of heart failure, but ultimately felt that interventional cardiology might better provide the means to actively treat these patients now and in the future. Indeed, I thought, could there be a role for the interventional heart failure specialist? Now almost a decade later, there is increasing talk, and I think rightly so, about how interventional therapies may be able to improve cardiac function and reverse heart failure. Examples abound, and include (1) percutaneous cardiac assist device therapy to facilitate multi-vessel high-risk intervention and complete revascularization or as a bridge to recovery with reduced infarct size in acute myocardial infarction, with or without cardiogenic shock; (2) percutaneous aortic and mitral valve repair and/or replacement to reverse or halt negative remodeling and improve cardiac output; (3) stem cell and gene therapy delivery to improve ventricular function; (4) cardiac resynchronization to improve stroke volume; (5) atrial septal defect closure, paravalvular leak repair, and other advanced congenital defect treatment such as coarctation repair; and (6) alcohol septal ablation for hypertrophic cardiomyopathy to reduce outflow tract obstruction and improve both mitral regurgitation and diastolic function. Personally, I think the time has come for interventional cardiology to take its rightful place in the comprehensive and multi-disciplinary management of patients with heart failure. After all, heart failure is now the great epidemic, and remains primarily due to hypertension, valve or coronary disease. Indeed, while we’ve been “up to our necks” in coronary intervention for some time now, we are certainly now at least “knee deep” in valvular disease and at least “dipping our toes” into hypertension. Medications will remain a mainstay of heart failure management, and rightly so, but they should ideally be complementary to other forms of treatment that further unload the heart or reverse the primary disorder. So where do we go from here? I think we need to re-integrate advanced hemodynamics and heart failure management into the curriculum of interventional cardiology, and make sure we teach this science, including basic coronary and cardiovascular physiology, at all of our scientific sessions. Most importantly, though, we must start to work hand-in-hand with our heart failure, imaging, and electrophysiology colleagues to not only better understand what works, but in what sequence. Together, perhaps we will not only prevent some forms of heart failure from developing, such as that which occurs after a large myocardial infarction, but produce robust and sustained cardiac function recovery in those who already suffer from the disease, such as those with chronic ischemia and ventricular dysfunction or ongoing hemodynamic stress from valve dysfunction. Dr. Srihari S. Naidu is Director of the Cardiac Catheterization Laboratory, Interventional Cardiology Fellowship Program and Hypertrophic Cardiomyopathy Center at Winthrop University Hospital, and Assistant Professor of Medicine at SUNY – Stony Brook School of Medicine.