Letter to the Editor

Lloyd W. Klein, MD, FACC, FSCAI, Professor of Medicine, Rush Medical College, Chicago, Illinois
Lloyd W. Klein, MD, FACC, FSCAI, Professor of Medicine, Rush Medical College, Chicago, Illinois
Unfortunately, I believe he accurately summarizes the current views of many cardiologists, especially those trained since the early 1990’s. Without question, echocardiography, Doppler, and nuclear testing are excellent clinical tools for assessing left ventricular function and aortic valve disease. Without doubt, contrast ventriculography and trans-aortic pressure measurements have limitations. However, these techniques continue to provide useful hemodynamic information, especially in situations when non-invasive techniques may be inaccurate. Optimal clinical decision making recognizes that all diagnostic tests may be imprecise in specific circumstances, and knowing how to interpret disparate results is the foundation of good clinical judgment. In part, the discrepancies that Dr. Kern highlights are generational. It is probably unavoidable in medicine that a senior generation considers its juniors uneducated in some skill that no longer is a paramount clinical method, while the younger one thinks of its elders as hopelessly outdated in its insistence on using tests that have been supplanted by newer practices. Previous generations definitely bemoaned the loss of expertise by later generations of several skills they found indispensable, for example, the stethoscope, phonocardiocardiography and even the electrocardiogram. Moreover, it is clear to me that the fault in this situation lies entirely with us, the teachers. Our students watched as we pushed the limits of coronary intervention while relegating pressure waveform measurements to the computer and their interpretation to the lecture hall. We have taught the next generation of cardiologists how to intervene on practically any coronary stenosis in any clinical context, but not how to diagnose complex disease states properly. Once, hemodynamics was a discipline, not a series of great board exam questions. An expertise worth developing to make a complete cardiac assessment has metamorphosed into a roundsmanship game few today take seriously as a method relevant to actual patient care. The fact is that Dr. Kern could easily make the same case about any number of catheter-based diagnostic techniques: right heart catheterization, cardiac output measurement, aortography and shunt detection are just a few which are today considered quaint and old-school. As someone often asked to lecture to cardiology fellows on their value and performance, it is apparent to me that these subjects are often viewed by other faculty as out-of-date and by the trainees as impenetrable. Hence, although I concur entirely with Dr. Kern’s remorse about the widespread deficit in understanding these techniques, I have concluded that, in the long run, this battle has already been lost. Cardiac catheterization today is about vascular angiography and intervention, not valvular heart disease or determinants of cardiac performance. All of the editorials, board exams, review courses and lectures will not alter the predictable consequences: hemodynamics as a field now resides in the echo reading room, not the cath lab. We have purposely nurtured catheterization into a therapeutic radiological/ surgical specialty, and our success is overwhelming. Inevitably, a field as dynamic as ours evolves rapidly, jettisoning underutilized but time-honored techniques mercilessly while favoring others of less proven but newer provenance, leaving its most experienced practitioners to wonder at the inexorable power of time. Sincerely, Lloyd W. Klein, MD, FACC, FSCAI Professor of Medicine Rush Medical College Chicago, Illinois Letters to the editor should be addressed to: Rebecca Kapur, Managing Editor, Cath Lab Digest Email: rkapur@hmpcommunications.com; Fax: 216.393.0445 Mail: 7427 Winding Way, Brecksville, OH 44141