It is my pleasure to introduce Volume 6 Issue 1 of Interventional Cardiology. The contents of this fascinating issue highlight the continued excitement and diversity that exist in our field.
For a period of over a decade, from the advent of bare-metal stents, culminating with the triumph of drug-eluting stents, interventional cardiology had a virtually unbroken winning streak. However, in 2006, perhaps because of this unbridled success, dual assaults on the field – the controversy over late stent thrombosis with drug-eluting stents and the misrepresentation of the context of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial – put the field on the defensive. Happily, the last five years have produced rigorous clinical investigations that have taken the field in unexpected directions into new areas of life-saving therapy that were not anticipated. At the same time, many areas that appeared quite promising in the middle of the previous decade have languished and do not seem to have fulfilled early expectations and the euphoria that surrounded them.
As one surveys the table of contents in this journal, one can note several important emerging trends: the advent of percutaneous aortic valve implantation as a new life-saving therapy and the rapid and unexpected widespread adoption of left main percutaneous coronary intervention (PCI) as a viable alternative to surgery – to name but two. Moreover, in spite of some initial scepticism, drug-eluting balloons have clearly defined their place in the periphery and in the coronaries for the treatment of stent restenosis.
In some areas, however, progress has been much slower. In spite of years of investigation, the place of stenting in the treatment of extracranial carotid stenosis remains controversial in most patient subsets, and clearly will not supplant carotid endarterectomy. The place of renal stenting and the treatment of renovascular disease is even more fraught with controversy, and further clinical trials and a better understanding of the pathophysiology of this entity are clearly necessary. Ironically, it seems that the skills developed in the treatment of renal artery stenosis will be readily applied to the area of renal denervation, which may very well be one of the most effective therapies in the treatment of hypertension and could emerge as one of the most transformational percutaneous treatments since the advent of coronary angioplasty itself.
What lessons are to be learned from this period of heterogeneous progress? First is that science frequently takes us in expected directions, and careful attention to unmet clinical needs and the establishment of a strong evidence base, mainly through randomised clinical trials, are key to the advancement of our field. Equally important is attention to the development of reproducible, safe and generalisable techniques that can allow such trials to be conducted in a manner that maximises the benefits of a specific technology. This has certainly been the case in carotid artery stenting and careful attention to trial design and proper training was vital to the success of the Placement of AORTIC Transcatheter Valve (PARTNER) trial demonstrating new life-saving benefits of transcatheter aortic valve implantation. Thus, it is vital to the success of our field that active practitioners with excellent technical skills who are consistently struggling with the clinical needs of our patients maintain an active role in the clinical trial process, both as participants and in particular in the leadership and design of such trials.
I invite you all to dive into this volume and gain an excellent insight into the status and progress in all these diverse areas of our very exciting field.