Abstract
The spectacular innovations in technology in this century have fuelled the exponential growth of cardiovascular medicine in all dimensions eclipsing its conventional boundaries. Optimal diagnosis and management of cardiac patients is currently critically dependent on the interaction with sub-specialties in this field and contribution from other disciplines of medicine and engineering.
The large burden of heart failure (HF) population has exposed the challenges in diagnosis, stratification of risk and economic prudence in utilization of healthcare resources. Advances in Radiology in the areas of cardiac MRI and positron emission tomography (PET) have succeeded in meeting some of these challenges. Late gadolinium enhancement (LGE) in cardiac MRI (CMRI ) has proven to be a reliable surrogate of myocardial scar which is the essential substrate for sudden death and worsening HF.1, 2 Detailed imaging inputs from CMRI have helped to precisely define the endocardial and epicardial scar, assess accurately the ventricular function, and finely delineate the arrythmogenic channels in the substrate. Further it has aided substantially in prognostication in patients with substrates like hypertrophic cardiomyopathy and non-ischemic cardiomyopathy (NICM). Similarly PET has contributed immensely in diagnosing sarcoidosis in patients presenting with new onset of HF, ventricular arrhythmias and conduction blocks. Further sophistication in imaging technology will undoubtedly refine the diagnostic criteria, and ease decision-making algorithms. Imaging has also enabled the clinician to understand and effectively correlate the anatomy in conceptualizing strategies for interventional procedures. This is particularly true in dissections and aneurysms of aorta, and trans-catheter interventions for aortic valves. The increasing safety and better outcomes of the procedures relate as much to the imaging technology as to the increasing operator experience. Ventricular tachycardia (VT) is a fatal arrhythmia conventionally treated with drugs, ablation and implantable defibrillators. Refractory VT and electrical storm is a challenging clinical problem with a high mortality, and radiotherapy has emerged as one of the least expected contender in the rescue of this difficult clinical problem. Stereotactic radiotherapy has shown to be effective in treatment of selected refractory VT. 3 Similarly specially trained anesthesiologists have used percutaneous stellate ganglion ablation to save patients from malignant VT storms. 4 Careful extraction and detailed analysis of DNA from the saliva of patients with VT has helped geneticists to hypothesize a genetically common pathway of sudden death shared by inherited syndromes of SCD. 5 Vasovagal syncope (VVS) is a common clinical situation and over the years several conventional therapeutic strategies from pacing to medications have been unsuccessfully attempted in the management. Recently our group involved cardiac rehabilitation specialists and demonstrated the use of yoga maneuver “Tadasana” in the prevention of VVS episodes. 6
CAD is the most important pathology responsible for cardiovascular mortality and morbidity. Identification of coronary plaques which rupture and lead to acute coronary syndrome (ACS) has always been an intriguing clinical challenge. The interest of fluids engineers in attempting to find an answer to this question is noteworthy. An engineering model by researchers from Texas demonstrated that turbulence in the area of a coronary plaque is responsible for shear stress and its rupture leading to ACS. 7 Artificial intelligence and machine learning are the tools from computer engineering which are all set to revolutionize the practice of cardiology. These tools aided by mobile sensors will make cardiology practice more personalized, effective and easy. From diagnosis to therapy selection to research, their potential is immense. 8
The words of 17th century poet John Donne “No man is an island” is almost prophetic in the context of today where the practice of any branch of cardiology cannot aim to reach perfection in isolation. Cardiologists can hope to achieve lofty heights in research and incremental enhancement in patient care only by interdisciplinary work. Cardiology training programs need to have a futuristic vision and design their fellowship curriculum by integrating inputs from medical and engineering disciplines. The future of cardiology undoubtedly lies with interdisciplinary work and research.