The essence of geriatric cardiology

Because it is a recent and not widespread specialty, Geriatric Cardiology is often confused with Geriatrics that is practiced by a cardiologist or simply with Cardiology that is applied to elderly patients. Although this is part of the discipline’s core, it does not represent the whole picture. It would be more adequate to define it as integrated and age-adequate cardiovascular care, centered on the patients and their functionalities – a concept previously presented by our colleagues^,– that has been evolving and taking shape, as a result of the use of specific and predetermined tools.

Objectively, one could consider it as cardiology practice integrated with the Geriatric’s 5 Ms: medication (focusing on prescribing the absolutely necessary, targeting at reducing polypharmacy, minimizing interactions and adverse reactions; following Beers criteria to select appropriate medication for the elderly), mentation (vigilance, prevention and treatment of cognitive disturbances), mobility (valuing and implementing strategies that seek to maintain the patient’s mechanical functionality), multimorbidity (approaching the patient not only by looking up the cardiovascular system, but also by considering the occurrence of multiple comorbidities to be the rule, not the exception, in these individuals), and last, but literally not least is matters most (always consider the patient’s opinion regarding the benefits and burdens of the treatment, taking into account the biography and personal values, bringing the patient into the center of decision making). We would also add a sixth and last M, multidisciplinary, for the care of the elderly, remembering it must be coordinated in a horizontal fashion by a professional, but never concentrated in only one person, giving due importance to the participation of other specialists and healthcare professionals. At our institute, in the Geriatric Cardiology Unit, we perform in all patients a Comprehensive Geriatric Assessment with the aid of the 10-TaGA (10-Minute Targeted Geriatric Assessment) tool.^,

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Training in structural heart disease imaging

Although training in multi-modality imaging has been well outlined, there are no specific training guidelines and/or requirements for SHD imagers as demonstrated by the results of a recent European survey. Some of the challenges currently faced by cardiology fellows who look for SHD imaging training include finding training centers with enough high-risk clinical volume and exposure to a variety of high-risk procedures so they can train beyond traditional TAVR procedures. This brings an inevitable question of whether adequate SHD imaging training should therefore be reserved to a small number of centers with sufficient knowledge and experience in these procedures. What should constitute the minimal portfolio of procedures, their degree of complexity, the number of cases performed for procedural planning and for intraprocedural guidance to achieve adequate proficiency are some of the questions whose answers remain unclear.

The majority of high-volume programs can provide comprehensive exposure for adequate training, particularly in TAVR, Atrial Septal Defect (ASD) and Left Atrial Appendage (LAA) closure procedures. Transcatheter mitral valve repair with MitraClip system (Abbott Vascular, Menlo Park, CA) is also becoming increasingly more commonly performed and should become a standard part of the SHD imager training. On the other hand, transcatheter procedures such as paravalvular leak closure, transcatheter mitral valve replacement and percutaneous tricuspid interventions are more complex and less frequently performed, and therefore should involve different expectations for what is considered the minimal requirement to achieve proficiency.

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The Arquivos Brasileiros de Cardiologia (ABC) has been the official publication of the Brazilian Society of Cardiology for more than 60 years, and has proved to be one of the most prestigious scientific journals in Latin America, approaching all aspects of cardiology, including the surgical ones. In August 1986, the Revista Brasileira de Cirurgia Cardiovascular (RBCCV), specifically directed to the surgical aspects of heart diseases, began to be published. Thus, the editorial policy of the ABC has progressively privileged publications focused on the clinical treatment of cardiovascular diseases over surgical publications of common interest to cardiologists and cardiac surgeons. Despite the substantial changes in the treatment of heart diseases, deriving from the appearance of new drugs and percutaneous devices, cardiac surgeries are still the treatment of choice to a substantial number of heart diseases, mainly the congenital, valvular and even coronary ones, whose onus of surgery indication is invariably on cardiologists. Thus, those specialists should be aware of several aspects of cardiac surgery, mainly those concerning their risks and results, so that they can base their indications on evidence.

The great majority of cardiologists might know that the use of bilateral internal thoracic arteries (BITA) for coronary artery bypass grafting improves survival as compared to the use of only one single internal thoracic artery (ITA). Thus, the optimization of arterial grafts has been widespread with the use of the radial artery (RA) and composite grafts. However, only few professionals are aware of the controversies involving risky situations, possible limitations to the use of BITA, the patency index of RA grafts and their influencing factors. The RA was the second arterial graft introduced in the clinical practice for coronary artery bypass grafting, and has drawn the interest of Brazilian surgeons since the 1990s. Skeletonization of the left ITA (LITA) can favorably change the flow capacity of the graft, leading to the assumption that the behavior of the RA, as a coronary graft, is similar to that of the skeletonized LITA. Considering the potential role of the RA as a second option of coronary grafting and the concept of complete coronary artery bypass grafting with the exclusive use of arterial grafts, Bonini et al have carried out a prospective randomized study comparing 40 patients distributed into two groups. In group I, skeletonized RA was used in 20 patients, and, in group II, RA with adjacent tissues was used in 20 patients. After the surgical procedure, flow velocity was measured. The results showed that the morphological and pathological characteristics, as well as the hemodynamic performance of the free RA grafts, regardless of being skeletonized or having adjacent tissues, were similar. However, a larger number of non-obstructive lesions was observed in the group with the RA graft preserving the adjacent tissues.

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