How I Became a CTO Operator
Why were you interested in learning how to perform CTO PCI procedures?
When I began training in interventional cardiology, it quickly became clear to me that I really loved coronary work. When you’re truly enjoying something you’re doing then I think it’s natural to want to continue pushing further with it; to want to remain challenged and engaged through expansion of your skillset, growing your abilities, taking on more complexity and becoming familiar with a larger armamentarium of equipment.
I like to be self-reliant and I wanted to get myself closer to ‘where the buck stops’ when it came to interventions that my patients might need. I did not want to have to always send the most challenging cases to my colleagues. I wanted to do them myself and to learn to do them well.
I enjoy studying CTO anatomy too and thinking through approaches, almost like solving a puzzle with a set of appropriate possible solutions. I enjoy the atmosphere of creativity and innovation surrounding complex PCI. As someone whose initial interest in interventional cardiology was not universally judged a “fitting” pursuit, engaging in more complex intervention helped steer me further along a path that would help better solidify my own belief in my abilities as I grew increasingly able to perform successfully on the challenging end of the spectrum of coronary work.
Ultimately, CTO PCI and I get along because I fundamentally enjoy it, because I feel challenged enough by it, and I suppose I seem to have the right sort of brain wiring for it. I enjoy helping this patient subset experience improved quality of life. I am also pretty calm in the cath lab and an active and adaptive thinker, and that probably helps–nothing gets me too worked up and I like caring for sicker patients and acute care situations.
Where did you first learn to perform CTO PCI procedures?
During my general interventional cardiology training program, I first got some basic exposure to CTO PCI participating in occasional cases with the individuals at my program who performed these procedures. This was one of the ways I started to think I would really like to get more focused in complex PCI. During that time, I would also make an effort to attend meetings focused on CTO PCI. I recall I flew down to attend what used to be called the CHIP-Seattle course (now the Interventional Complications Course) and I remember being so engaged by what I was being exposed to there and thinking this was for me! I also started reading about CTO PCI and when I would have to present educational rounds during training, I would often manage to make the topic somehow relate to CTO-CHIP so I could have more time to read around the things I liked.
Due to logistics, I had to delay my CTO-CHIP fellowship for a year and during that time when I first worked independently in the cath lab, I did perform a small number of low complexity CTO cases. However, I would not say I first properly “learned” CTO PCI until I formally began my dedicated CTO-CHIP fellowship. Everyone’s experience can be different; it depends on your center and who you are working with as to when you may first get some real exposure to these procedures.
Another thing I would highlight is how things have changed with respect to finding training opportunities for CTO-CHIP. When I knew this was what I wanted to do, finding a fellowship (and I do mean finding) was difficult. I had to ask around to people I knew about what might be out there. It’s not as if there was a list of programs on a website or as if I was connected to the world of CTO PCI. I was just someone flying under the radar, really, who was very interested and who was not connected within the field. I had no idea which, if any places might be interested in taking me. After some investigation, I emailed a number of people and I was surprised at how many replied. Back then (only a few years ago), many programs were informal or just on the verge of being created. Columbia had established their program and kindly corresponded with me, but as a Canadian, I had no source of independent funding and for that particular year this was a limitation. Seattle kindly responded to me as well, but later cancelled their intake that year. Canadian options I knew of were full. I did not properly explore opportunities outside North America. Thankfully, I had learned from someone that Dr. Emmanouil Brilakis at Minneapolis Heart Institute might still be taking trainees in this area. After I introduced myself at a meeting and later had a formal interview, I was very lucky to be accepted to train at MHI. I then had to delay my fellowship by a year due to the lack of funding which made Visa issues complex. A possible opportunity came up in Detroit that was funded, but I felt committed to training at MHI, so I worked in Canada for a year and then was able to train at MHI by simultaneously doing another general interventional cardiology fellowship which was funded. Clearly, this was all a bit of a process and I am so pleased to see that more programs have developed with clear intake processes and that initiatives exist like the SCAI–WIN CHIP fellowship.
Did you have a mentor/mentors along the way or were you primarily on your own?
The key and ever-appreciated dedicated mentorship I have received in terms of properly delving into CTO PCI was through my training with Dr. Emmanouil Brilakis and Dr. Nicholas Burke at MHI. That was an invaluable experience and enough cannot be said about the value of a dedicated year of training in this field, particularly if you have had only initial exposure during the general fellowship. As far as mentorship now that I am in practice, I would say that maintaining connections with my previous mentors and establishing new connections with fantastic, recently trained colleagues at various junctures has been, and will remain, really important. I am always looking for ongoing mentorship opportunities and will probably make some trips in the future to observe and learn from cases being performed by more experienced operators. I have realized there are a lot of kind people out there who will offer you opportunities. I am also lucky to have a senior staff at my institution who took extensive educational initiatives to train himself in CTO PCI over the years when formal training programs did not exist and he has been supportive and helpful when approaching cases at my center.
What is the environment at your institution in regard to performing CTO PCI procedures?
Like at every institution, there is always a range of beliefs about CTO PCI and its value among cardiologists. That being said, I have been lucky in that my senior colleague already built the foundations of our CTO program and has been supportive. In addition, there has been a lot of shift in attitude and support since another young colleague of mine, who recently formally trained in CTO PCI, came to work at our center.
The environment has been supportive towards taking on complex cases in general across a wide range of patient scenarios as we do have significant pathology with the highest incidence of CV disease in Canada. Having the skillset to tackle more complex anatomy and in higher risk individuals is certainly an asset. We have a fairly positive relationship with our cardiac surgeons and generally a good team-based approach to deciding on revascularization/treatment options. We are the only cath lab for our entire province of over 500K people and are a high-volume center with long wait lists for all cath lab procedures. Integrating CTO PCI into such a system clearly presents its challenges.
Overall, I would say the environment has been receptive and we are working to continue to grow our program and discover the best ways to make things work within the constraints of our system. We generally schedule dedicated time slots for CTO PCI and with patients assigned to a specific operator(s), though sometimes we have to integrate cases into the regularly scheduled case load which is a challenge.
What are your personal goals in growing your knowledge and skills around CTO?
I think one of my main goals in the near future is to do cases, cases and more cases! This relates to continuing to build independent confidence and skill as an early career operator. I think volume is critical when you are starting out, along with, of course being a safe operator. I want to gradually increase the complexity of the cases I take on as I gain experience. In addition to doing things safely and growing proficiency in managing complications, I want to improve my overall procedural efficiency over time. In general, I think it is always important to think about what one could have improved after a given CTO PCI in any aspect of the case.
I will continue to regularly attend meetings in my field. I will continue to keep up my reading. At this stage it is important to periodically review key algorithms for managing commonly encountered challenges in CTO PCI. Writing also helps me continue to learn and I enjoy creating educational material in CTO PCI. It can be helpful for others and it is always a helpful review for me! I am also looking to get more involved in research and may explore courses or training to enhance my own fundamental skills in that area.
Another area I want to grow my experience in is supported PCI and hemodynamic support in cardiogenic shock. This is something that I was more exposed to during my fellowship that I have not yet translated as much back into my current practice. I am interested in exploring percutaneous ECMO insertion in the cath lab and re-exploring other support devices for our center which mainly has ready access to IABP at this time. If we get into more complex support devices on an increasing basis, I would like to up my skills in alternate access. During my time at MHI I briefly got some exposure to peripheral intervention which is something I might look at again down the road–it is an important skillset for treating vascular complications or for facilitating vascular access.