Teaching old dogs new tricks.

Transradial catheterization, transcatheter aortic valve replacement (TAVR), and chronic total occlusion intervention (CTO) are but just a few techniques that have recently evolved into routine use in interventional cardiology. These new tools are not just minor tweaks of pre-existing technology. They typically require time and effort to master. Once fellowship ends, these commodities become scare. The cardiologist in practice can be at risk for ossifying in place and miss out on potentially valuable new ideas. Frustration may even result in Luddite-like behavior by some, as has been seen in some instances such as transradial techniques, resulting in ostracizing the new technology in the face of evidence to the contrary. The lack of standardized, noncommercialized approaches to disseminating new technical skills remains a major gap in lifelong learning for the cardiologist. While the professional societies have made attempts at defining best practices and guidelines, the teaching of cutting edge techniques has been in general relegated to industry-sponsored courses. In this issue of Catheterization and Cardiovascular Interventions, Karmpaliotis et al. [1] conducted a prospective, nonrandomized, observational analysis of a high volume, multiple-operator program developed for CTO procedures at a single center in the United States. This was a collective effort to establish a CTO interventional program consisting of five operators who established procedural strategies and guidelines for quality improvement. The authors reported an overall success rate of 85.6% with low procedure-related adverse events. These results approximate the new higher success rates reported in recent prospective studies from the United States, Europe, and Japan [2–4]. Multiple factors contributed to the outcomes reported in this study. First, one cannot discount the improved technology available to present operators. Procedural techniques including retrograde wiring through collateral channels, antegrade or retrograde subintimal tracking, ultrasound-guided wiring, and re-entry techniques have resulted in improved acute success and better long-term patency of totally occluded coronaries after catheter-based intervention. The introduction of drug eluting stents (DES) has also dramatically reduced the restenosis and occlusion rates compared to bare metal stents and that is reflected in this cohort (DES use >95%). Second, success began with a commitment by the group to embark on this new technology cooperatively rather than as a band of individuals. In specific, several important attributes of their program were identified. (1) Both onand off-site didactic training with proctoring by more experienced colleagues, (2) adoption of advanced technique and device technology in carefully selected cases, (3) provision of catheterization laboratory policies, and (4) inclusion of all outcomes as part of a quality and performance initiative. Potential adverse events associated with CTO procedures such as higher contrast volume, longer procedural and fluoroscopic times, and incidence of procedure-related adverse events particular to the CTO procedure such as type I coronary perforations were monitored as quality improvement. Protocols to minimize both radiation exposure and use of contrast volume were invoked to avoid radiation-related adverse events (for patients and operators) and minimize contrast induced-acute kidney injury. Comparable to other modern experiences, coronary perforation rate remained at a very acceptable rate (<1%), despite the learning curve, through the decreased use of stiff wires in these interventions. Beyond the dissemination of technical skills, this group was also able to evaluate the economics of