Dr. Liberato Iannone is the Director of Cardiac Catheterization at Mercy Hospital in Des Moines, Iowa. He has been in the field of interventional cardiology since its early days. Dr. Syed Ahmed asked Dr. Iannone to share his personal experience in the field with Cath Lab Digest.
How long you have been working as an interventional cardiologist?
I did my first left heart catheterization in 1970 and coronary intervention in 1979.
Where did you receive training for coronary intervention?
Initially, I attended the Dr. Andreas Gruentzig course in Sweden. Later, I visited different radiologists and cardiologists who were “experimenting” in this field. I should point out that what you see in interventional cardiology today is the fruit of years of experiment, discussion, and sharing of knowledge.
How did hospital administration respond when you first started the cath lab in Des Moines?
Well, it was not smooth sailing. It required a lot of discussion, understanding, and teaching. I also invited physicians who already had established a cath lab to come to our cath lab and help convince our administration of the need for a cath lab where percutaneous intervention could be done.
How was the hospital staff response when you first started percutaneous intervention in the cath lab?
They were motivated after seeing positive outcomes. Once we started doing ST-elevation myocardial infarctions (STEMIs), more and more people wanted to work in our cath lab.
How many cardiac catheterizations and coronary interventions have you done so far?
It is difficult to determine the number of cardiac catheterizations and interventions I have done in my career. At Mercy Hospital, we do 4-5,000 coronary and peripheral interventions per year. All interventionalists do almost an equal number of cases within that number.
How did patients respond when they first learned about the existence of the cath lab?
They were excited to have another option besides having open-heart surgery. When I did my first angioplasty, I had my cardiovascular surgeon stand by me. He felt he would lose his job if this procedure became standard. Well, the vessel closed after 15 minutes and the patient became symptomatic, requiring urgent coronary artery bypass graft surgery. This patient went on to live for 12 years and die of cancer. My second and third patients are still alive and heart-wise, doing well. Now there are more cardiovascular surgeons and interventional cardiologists than we had 35 years ago.
Were you involved in training physicians for cardiac catheterizations and coronary interventions?
We had our own fellowship program from 1990 to 2002. Now fellows from accredited programs such as the University of Iowa and University of Nebraska rotate into our lab. We also get practicing physicians from low-volume centers who want to sharpen their skills in the field of interventional cardiology.
Was it difficult to continue on after complications occurred?
As they say, “Good judgment comes from experience, experience comes from bad judgment.” You want to learn from your mistakes. So, after a complication, I like to review my whole case and discuss it with my colleagues to see what went wrong and how to avoid it in the future.
How many cath labs are at Mercy Hospital in Des Moines?
We have four designated coronary and peripheral labs in the Mercy main hospital, and one in the Mercy West Lakes hospital. There are two electrophysiology labs in Mercy main and one in the Mercy West Lakes hospital.
How many interventionalists and cath lab staff are there?
Nine interventionalists work at both campuses. There are 19 registered nurses, 18 radiology technologists, and 5 ancillary staff who rotate in coronary and EP labs in the Mercy main and Mercy West Lakes hospitals.
As you have seen so many technologies either stay or go, how do you incorporate new devices or procedures into your practice?
We have 9 interventionalists at the Mercy campus and a total of 16 interventionalists in our group working in other facilities. Every other month, we have mandatory meetings in which literature review of new and existing technologies is discussed. A majority of interventionalists must suggest we incorporate new technology and similarly, a majority must agree in order to remove existing technology from our cath lab. Also, our interventionalists often attend didactic or hands-on experience courses, and when they return, they share their experience with me. From time to time, I will discuss it with other interventionalists in the group and hospital administration.
Do you have any advice for new physicians working in the cath lab?
Three words: persistence, dedication, and satisfaction. You may lose the excitement of doing STEMIs after the first few years of practice (especially if you need to work in the middle of the night). But, if your dedication and persistence continues, you will earn a lot of respect from patients, and your colleagues, hospital staff, and community. You may be walking in a public place with your family and someone greets you, and tells his and your family, “This man saved my life!” You will feel proud of yourself and immensely satisfied. It feels like all of your hard work has paid off.
Any thought about the ergonomics of your work and how it has evolved over time?
Cardiac catheterization could only be done under fluoroscopy in the beginning. Patients would lay in a cradle and the patient would have to move so we could obtain different views. Now we have tables that can slide and C-arms that can rotate. Cardiac catheterizations were done with 8 French sheath in the 1970’s, but now it can be done with a 4 or 5 French sheath. Lead jackets are a great deal lighter than before as radiation exposure reduced with improved technology.
How have you seen the roles of staff in the cath lab evolve over time?
As the equipment and and technique in interventional cardiology continue to improve, the role of cath lab staff continues to evolve. It seems like they are in much better shape to help interventional cardiologist in long, difficult cases.
Any final thoughts?
To me, interventional cardiology is the most rewarding field. If I had to choose my career again, I would choose the same.
Dr. Iannone can be contacted at email@example.com.
A sampling of Dr. Iannone’s publications:
- Iannone LA. Coronary arteriography. Circulation. 1973 Apr;47(4):913.
- Iannone LA, Duritz G, McCarty RJ. Myocardial infarction in the newborn: a case report complicated by cardiogenic shock and associated with normal coronary arteries. Am Heart J. 1975 Feb;89(2):232-235.
- Bates JD, Iannone LA, Phillips SJ, Anderson J, Murphy J. Postinfarction ventricular septal perforation: a case report. J Iowa Med Soc. 1976 Feb;66(2):55-57.
- Phillips SJ, Zeff RH, Kongtahworn C, Gordon DF, Iannone LA, Brown T. Myocardial revascularization in patients with unstable angina. J Thorac Cardiovasc Surg. 1977 Jul;74(1):159-60.
- Phillips SJ, Kongtahworn C, Zeff RH, Iannone LA, Brown TM, Kreamer R, Gordon DF. A new left ventricular assist device: clinical experience in two patients. Trans Am Soc Artif Intern Organs. 1979;25:186-191.
- Phillips SJ, Zeff RH, Kongtahworn C, Iannone LA, Brown TM, Gordon DF. Anoxic hypothermic cardioplegia compared to intermittent anoxic fibrillatory cardiac arrest. Clinical and metabolic experience with 1080 patients. Ann Surg. 1979 Jul;190(1):80-3.
- Zeff RH, Iannone LA, Kongtahworn C, Brown TM, Gordon DF, Benson M, Phillips SJ, Alley RE. Coronary artery spasm following coronary artery revascularization. Ann Thorac Surg. 1982 Aug;34(2):196-200.
- Iannone LA, Brown TM, Wickemeyer WJ, Gordon DF. Emergency coronary reperfusion for evolving myocardial infarction. J Iowa Med Soc. 1982 Aug;72(8):325.
- Iannone LA, Brown TM, Phillips SJ, Wickemeyer WJ, Zeff RH, Wheeler WS, Kongtahworn C, Rough RR, Skinner JR, Toon RS, et al. Percutaneous transluminal coronary angioplasty: an added modality for the treatment of the patient with coronary heart disease. Cardiologia. 1983 Jul;28(7):625-633.
- Iannone LA, Brown TM Jr, Wickemeyer WJ, Wheeler WS, Gordon DF, Rough RR, Phillips S, Zeff R, Kongtahworn C, Skinner J. Percutaneous transluminal coronary angioplasty: evolution and changing concepts. Iowa Med. 1986 Jun;76(6):271-275.
- Zeff RH, Kongtahworn C, Iannone LA, Gordon DF, Brown TM, Phillips SJ, Skinner JR, Spector M. Internal mammary artery versus saphenous vein graft to the left anterior descending coronary artery: prospective randomized study with 10-year follow-up. Ann Thorac Surg. 1988 May;45(5):533-536.
- Phillips SJ, Zeff RH, Kongtahworn C, Skinner JR, Toon RS, Grignon A, Kennerly RM, Wickemeyer W, Iannone LA. Percutaneous cardiopulmonary bypass: application and indication for use. Ann Thorac Surg. 1989 Jan;47(1):121-123.
- Phillips SJ, Kongtahworn C, Zeff RH, Skinner JR, Toon RS, Grignon A, Spector M, Iannone LA. Disrupted coronary artery caused by angioplasty: supportive and surgical considerations. Ann Thorac Surg. 1989 Jun;47(6):880-883.
- Phillips SJ, Tannenbaum M, Zeff RH, Iannone LA, Ghali M, Kongtahworn C. Sheathless insertion of the percutaneous intraaortic balloon pump: an alternate method. Ann Thorac Surg. 1992 Jan;53(1):162.
- Iannone LA, Rayl KL. Peripheral vascular disease. Iowa Med. 1992 Jun;82(6):261-262.
- Iannone LA, Anderson SM, Phillips SJ. Coronary angioplasty for acute myocardial infarction in a hospital without cardiac surgery. Tex Heart Inst J. 1993;20(2):99-104.
- Iannone LA, Toon RS, Rayl KL. Percutaneous transluminal angioplasty of the innominate artery combined with carotid endarterectomy. Am Heart J. 1993 Dec;126(6):1466-1469.
- Iannone LA, Underwood PL, Nath A, Tannenbaum MA, Ghali MG, Clevenger LD. Effect of primary balloon expandable renal artery stents on long-term patency, renal function, and blood pressure in hypertensive and renal insufficient patients with renal artery stenosis. Cathet Cardiovasc Diagn. 1996 Mar;37(3):243-250.
- Smith LG, Duval S, Tannenbaum MA, Johnson Brown S, Poulose AK, Iannone LA, Larson DM, Ghali MG, Henry TD. Are the results of a regional ST-elevation myocardial infarction system reproducible? Am J Cardiol. 2012 Jun 1;109(11):1582-1588.
Cath Lab Digest also had the chance to speak with Dr. Iannone. We share some of his memories, below:
What was the field like in your early days of working as a cardiologist?
At that time, as a cardiologist, all you did was angiogram and call the surgeon, which is basically what we did at Walter Reed.
Coronary artery bypass was a big issue in the late 1960’s/early 70’s. The surgeons did a procedure called the Feinberg, where they took the mammary artery and implanted it. You didn’t hook it up, you just buried it and sewed it into the muscle. It seemed to work. There was another procedure called talc poudrage. The poudrage was when a surgeon would open up the chest and open the pericardium, and sprinkle talcum powder on it, which would irritate the heart and cause pericarditis, and it would give angina relief for several months.
I came to Des Moines in 1974. One center in Washington State had just published studies on acute myocardial infarction (MI) surgery. We started taking people to surgery at Mercy Hospital right off the bat in 1975. What we changed, however, was that if the patient in the ER had a heart attack, a cardiologist was called, not an internist. We would come and immediately transfer the patient if they weren’t at a hospital with surgery on site. We would try to get them done very quickly, that still was the idea in those days — of course, it wasn’t anything like what we are doing now. We would squirt the coronaries and make a decision, and most of the time, the decision followed along these lines: if the patient has single-vessel disease, probably we can get away with medical management, but if it is double-vessel, probably bypass. We published our experience with acute MI surgery in Circulation in 1979. The interesting part of that article was that the death rate was around 3%, which is almost unheard of at that time. Then Massachusetts General Hospital confirmed our experience. The problem at university centers was that the patient would come to the ER and see the ER doc, then the medical resident, and then the cardiology fellow, and by the time he decided to do anything, it was already 12 hours later. Now, of course, we are looking at opening up the vessel in 90 minutes or less.
The first angioplasty was done at Mercy Hospital in 1979. There were perhaps a few hundred people present for the first case. We did the first two cases with Dr. Gerry Dorros. In the first case, we had only one 3.75 mm balloon. The catheter had a small little wire on the tip, perhaps ½ inch long, and you could bend that to try to steer it. There was another hole in the distal part of the catheter in front of the balloon to measure the translesional gradient.
Dr. Andreas Gruentzig asked, how do you know if you are done? We used to have to put a Swan Ganz in the pulmonary artery to find out which vessel was the LAD. We would measure the distal pressure, and once it was reduced to less than 20 mm, then we knew we were done. We had a cardiac surgeon present for our first patient. He looked at the result and said, Oh, I’m going to have to learn how to do gallbladders! How prophetic that was! There we were, patting ourselves on the back, and in 15 minutes we hear a “ohhh” and we went in and took another shot, and the vessel had a huge spiral dissection. We sent the patient off to surgery. He died 12 years later, of cancer.
We were not deterred, however. Our second patient is still alive today. We claimed him as our first successful case. There was a big article in the paper, and we couldn’t get a picture of the balloon, so there was a picture of me holding a Swan Ganz with that balloon expanded. I also remember our third case well, because it was a nurse’s husband. He is now 74.
The first year, from November 1979 to November 1980, I did 13 cases. Nowadays, you do 13 in a day, but that’s how it started. Then we ran into the problem of the acute MI, and this was probably 1981 or 1982. Des Moines is out in the middle of nowhere, and the next cath lab south of Des Moines is 200 miles away in Columbia, Missouri. It’s mostly farm country. We just opened up a cath lab an area south of Des Moines, which is about 70 miles south and east of Des Moines, but that didn’t exist then. We had patients flown in by helicopter, on multiple drips, with an acute inferior infarction, and of course, we would take these patients to surgery. I called the surgeon with one female patient, and told them her pressure is 60 and her vessels looked all pruned from 5 different pressor medications. They said no to surgery, feeling she was too sick and would never survive.
I put in a catheter, went down the right coronary, blew it up, and I walked out of the room not knowing what was going to happen. About 3 minutes later, the nurse yells out, her pressure’s 180! I think, It can’t be! I go in the room and there is flow down the vessel. We started doing acutes in the early 1980’s. It was not like we did these cases left and right, and we didn’t understand the concept that clot existed beforehand. The big argument in those days was that pathologists said the clot occurred after the heart attack, but our surgeons kept telling us about clot they saw in the arteries, and they were eventually proven correct. We didn’t have clopidogrel, we didn’t know anything about the clotting mechanisms that were occurring, or the concept of unstable plaque. Patients would just come in with clots and we would try to fix them up and get flow down the vessel. If they had multivessel disease, we still might send them to surgery.
In 1998, the TIMI-3 trials came out and said, you shouldn’t do acute MIs. At that time, tPA data just started to come out from the Cleveland Clinic with Dr. Eric Topol. There was a mishmash of information out there regarding what to do with these acute cases. At Mercy, we still were doing acute MIs; however, we couldn’t keep them open. There were had higher restenosis rates; patients would clot again, and in those days we would be giving them heparin, Coumadin and aspirin, and they would frequently experience bleeding complications.
Of course, we were trying thrombolytic therapy, but it was complex. Patients had bleeding problems, and a great deal of dissection and flow problems that we, in some ways, resolved with perfusion catheters. Before we had perfusion catheters, we would put the balloon in and use that as a scaffolding to keep the vessel open – I would have the nurse inflate it to 1 atm every 10 minutes or so to see if the vessel would stay open, because often it was torn so much that even the surgeon didn’t feel he could find the true lumen. As a result, we decided if the catheter is in the true lumen to take the patient to surgery. It was a very cooperative venue. We couldn’t do this without the surgeons helping us out and encouraging us. It was a team approach.
Newer devices and different catheters kept arriving. The monorail came in and I visited Dr. Geoff Hartzler, who sadly died this year. He was at St. Luke’s in Kansas City. Dr. Hartzler taught several courses. He was a novel operator who trained out at the Mayo Clinic, and actually first focused on electrophysiology and then got into interventional procedures. At that time, he had done about 100 angioplasties and I had done 35. We were sitting there with an old Gruentzig catheter. It just wouldn’t go, it was a retrograde circumflex, and they are tough even with the wire. He said to a technologist, “Give me that wire from Simpson.” A wire came out with a balloon on it, and I said, what the heck is that?! Within two minutes, he was down the vessel. This was probably 1982 or 1983. Of course, John Simpson, out in California, started the company ACS. He developed the over-the-wire technique, DVI, and many atherectomy devices. Simpson had a brilliant mind. That was the first time I saw over-the-wire, and it changed a lot of things, but we still had the problem of vessel tears and high restenosis rates until the stent came along.
We were starting to put stents in long before they were approved. They were called biliary stents, because the radiologists were putting them in the biliary ducts. The first one I put in, the patient was deceased. He was a bypass patient that had died on the table as we were going to the cath lab. I said to the fellow, let’s stent the left main, so we stented it, and it looked great. That’s the first stent we put in the left main coronary and I don’t want to call it illegal, but it was certainly off-label. Stents weren’t on balloons in those days; we had to hand-crimp them on. I remember times when we were putting the catheter up and the stent would slide off. There is a Bernouli effect in the aorta as the blood goes down, pumped by the heart. If you put a catheter in the center of the aorta, the stent would go up, and we would be chasing it to make sure that it didn’t go up to the brain. We lost many a stent down in the profunda. It was always fascinating how it would go in the profunda, stay there for years and never cause a clot. Stents weren’t premounted and they slipped off. We had to become extraction experts.
Before stents, 3-5% of the cases we did would go to emergency surgery because of tears. We couldn’t keep the vessel open, and sometimes a patient would crash on the table and we would be doing CPR. The OR was right across the hall, but it still took us 40 minutes to get the patient into surgery. People had to get the room ready, move the patient, take them off the cart, and so on. Many times, we would be doing CPR, and the surgeon would come in and be pouring iodine over our hands as we pressed on the chest. We would move our hands, the surgeon would open up the chest, and then start squeezing the heart.
One of the big things that came out of the work that Topol did back in the 1980’s was the randomized trial. Up to that time, there were very few studies done in that manner. It was more like, I have 10 patients, see how good they look and see what happened to them. But then we had to ask, what about the 10 who didn’t receive that treatment? How did they do? The changes in medicine that have occurred with the new devices and a more scientific approach are huge.
Today, I am 71 years old. I still take call. I did what they call a level 1 acute just this morning and I am still running around the cath lab most of the time. In the late 1980’s when we were a smaller group, I was doing close to 2,000 caths/year, and I remember that one year, I intervened on over 700 patients.
We have also trained 40 fellows; they were here at Mercy for about a year before the boards came out. You have to go through an approved program, and I tried to tie in with the universities, but we are 100 miles from any medical school that has a cardiology program. It just never worked out.
I was in the military for 4 years. It was OJT, on the job training, because there were no training programs. You have to see what works, what doesn’t work, and have a cooperative venue with the surgeons to back you up, and not say, Oh, look what you did!, versus saying hmmm, that’s interesting, we’ll take the patient to surgery and solve the problem. Better not do it that way again! We were stumbling all over the place, but you can see how it turned out. It took a great deal of science and new devices. I remember as an intern in 1967, if someone had a heart attack, they were in bed for 6 weeks, and couldn’t even move for three of those weeks. The nurse would have to turn them. Now patients are home in three days.
One of the fortunate things about being in the military is that the responsibilities you get are amazing. I had two years of medicine and two years of cardiology. After I left Walter Reed, I was sent to El Paso, Texas, to William Beaumont Hospital, which is part of Fort Bliss. It was a 500-bed hospital with a cath lab, and I was in charge of all inpatient services for both the ICU and CCU. I had to intervene on children, too, and that terrified me like you wouldn’t believe. I was involved in training all the staff, both the coronary and the cath lab staff, who are integral to the work we do. When I left the military and William Beaumont, they gave me a bullwhip. I didn’t think I was that nasty, but maybe I was! The staff is an essential part of the team. Today, at Mercy Hospital, we cross-train everyone. The cardiovascular or x-ray technologists don’t give drugs, but they do everything else: operate the monitoring machines, do blood pressure monitoring and data collection, and get the drug for the RNs to administer.
It sounds like you still enjoy your work.
Yes, who gets the chance to keep so many people alive? And to be able to still do it and enjoy it, and still come in the middle of the night. I have been the cath lab director at Mercy Hospital for close to 30 years now. This morning, I cathed a woman who was 50 years old and she told me I also took care of her father. She had a heart attack. It took literally minutes to open her vessel. Before, she would have gone to surgery and it would have taken them four hours. You get in there, throw a wire across, balloon it open, the vessel is open, pain goes away, you stent it, you are done.