Five Questions with Dr. Michael Collins, Associate Director of the Cardiac Cath Lab

We spoke with Michael Collins, MD, about his work as a proceduralist in the Cardiac Cath lab here at Columbia's Interventional Cardiovascular Care program - NewYork-Presbyterian Hospital.

How would you describe what you do?

There are different sections within interventional cardiology; I'm in one of those sections, treating the coronary arteries. There are two other main areas: structural, which is basically the heart valves, and endovascular, which deals with blood vessels outside the heart, such as the legs, neck, or kidneys.

I really just work in the heart. For 43 years, all I have done are diagnostic and interventional procedures. So, my day looks a little different from the other doctors on the floor. Everybody else on the floor has a clinic; they see patients as outpatients. I am the only one in my group here who only does procedures, so I'm in the Cath lab every day—I don't see patients in the office or on Zoom. I take care of these patients through my procedures; I do it with catheters, balloons, and stents, and then I send the patients back to their referring physicians.

But if somebody asks me what I do for a living, my answer is: I make decisions, and I solve problems. So, it's more with my head than with my hands. There is always continuous innovation and development in this space: new techniques and procedures, new tools in the toolbox. But the best outcomes are going to be based on who can make the best decisions using these tools. It's about having the judgment and the experience to use them wisely. Just as not all plumbers are the same and not all carpenters are the same; it's the same with cardiologists. Some are better technically, and some have better judgment about what to treat and what not to treat. 
It is fun and rewarding, but it is important to remember that we are never more than the blink of an eye away from a problem, so it must be taken very seriously. Here at Columbia, we have the strongest group in the country for intervention; we do phenomenal cases, we do very difficult cases—complex cases that get turned down everywhere else—and we do them very well and very successfully. But because these are often very serious cases, we have to anticipate issues and problems. A proceduralist must be ever mindful of that.

How do you know when someone needs an interventional procedure?

For coronary artery disease, we deal with people who have angina, people who have chest pain, or people who have symptoms relative to decreased blood flow to the heart. So, that could be pressure in the chest, in the arm, or in the jaw. It could be shortness of breath. It could be fatigue. They might say, "I don't have as much energy as I had six months ago, I get winded easily, or I get chest pressure when I walk up a flight of stairs or run for a bus."

So, that would alert us that there may be a problem. 

We do a full history and physical examination, and depending on the nature of the complaint, we might recommend a stress test. Sometimes, we do what's called a CT-angio—it's like a form of a CAT scan. But ultimately, if there is enough concern based on the history and these noninvasive tests, we would generally recommend an angiogram—a heart catheterization. 

For that procedure, we use special tubes in the vasculature of the body to take measurements of pressures and to take pictures. Catheterization is the insertion of the tube and directing it to the proper place. Then, for the angiogram, we inject a liquid called contrast dye through the tube so that it goes out either into a chamber in the heart or into the arteries around the heart. 

It's done under local anesthesia, either from a little puncture in the artery in the wrist or at the top of the thigh. We pass a thin wire through the needle. The needle comes out, and then we pass what's called a sheath; it's basically like a drinking straw that has a stopper on the end of it. 

The sheath's got a little insert in it that allows it to go into the artery. And through that, we can then pass a wire, which is our train track. And we direct the wire where we need the catheters to go. And then, we pass the catheters over the wire. A catheter is nothing more than a hollow tube. They have many types with preformed shapes to allow us to place them in different places. 

The catheter gets positioned in the part of the heart that interests us, and then we take the wire out and then we can inject a dye through the catheter and fill up the artery or the heart muscle to look for abnormalities. 

We look for abnormalities in the arteries, like blockages or narrowings. A normal artery would look like a garden hose; if there's a blockage, the tube narrows like an hourglass. 

How would that be treated?

Depending on the severity and the location of the blockage and the patient's symptoms, we would make a recommendation for treating that either with medication, with stenting, or with bypass surgery. 

There are certain types of blockage that are treated with surgery. We don't do bypass surgery in the Cath Lab; that goes to the heart surgeons. But now, there are more types of blockage that are treated with either medication or with stents. The medication doesn't take the blockage away, but rather, it fine-tunes the heart and the body to work better with the blockage that's there. So, in essence, having a coronary blockage would be like a car with a pinch in the fuel line. Putting in a stent would be like opening up the fuel lines; giving medication would be more like turning down the idle on the engine.

We start by guiding a wire through the vasculature to the aorta, but the wire doesn't go into the coronary artery. If we're doing a diagnostic procedure, we'll pass a diagnostic catheter over the wire and then remove the wire. We carefully position the catheter at the opening of the artery on the outside. 

Then, we inject the contrast dye through the catheter so it goes into the artery. It's like filling a clear garden hose with blue dye; if you could look through the hose, you'd see the dye going through. So we look at it using an X-ray camera as the patient is lying on a table. 

If we find a blockage, we may decide to stent it. We start by passing a thinner wire through the catheter. We direct it into the artery and across the blockage. That's the train track; we use it to pass special tubes that have a deflated balloon on the end. We pass the balloon through the blockage over the wire.  

When the balloon is in the proper position, we inflate it with a mixture of water and dye; that lets us see the inflated balloon using the X-rays. That will spread the blockage open. Then, we deflate the balloon and remove it, sliding it back out over the wire. 

Now it's time to add the stent, which is a metal mesh sleeve wrapped around the deflated balloon. Stents come in different lengths and different diameters, depending on the size of the artery and the length of the blockage; we have to pick a stent that will cover the length of the blockage.

We feed that whole apparatus again over the wire, this time with the stent wrapped around the deflated balloon. We guide it back to the area where we spread open the blockage. When we are in the proper position, we inflate the balloon. The balloon spreads the stent out against a wall of the artery. We take the balloon down and out, and the stent is left against the wall of the artery, like a scaffold. It holds the artery open and lets the blood flow through it. 

What happens on the day of the procedure?

When the patient comes in, they'll be seen and evaluated beforehand by a nurse and a PA, or physician's assistant. They'll take the patient's history, do a physical exam. They might draw lab work and start the IV. They might give them pre-medication. They get them ready to go. Then, we take them to the procedure room.

During the procedure, there are two nurses, one in the room with me and one at the control desk, watching the monitor and logging everything that's done. I also have an angioplasty assistant with me—that's a technician who's trained in doing these procedures with the doctor. I might also have a cardiology fellow with me who's learning how to do the procedure; we're a major teaching hospital, so we teach the procedure as well as perform it. There might be as many as five people in the procedure with the patient; we're doing the procedure as a team, and each team member has their role. 

Then, when the procedure is completed, and I'm satisfied with the results, the artery is open, and if there are no complications, we carefully remove the tubes. To do the procedure safely, we have to give a blood thinner to prevent clots from forming. But that means that after the procedure is over, we have to remove the catheter in a patient who has blood thinner in their system. We have little plugs or sutures that can do that in the leg, and a special wristband for when we use the wrist. Wherever the entry site is, we have to make sure the artery doesn't bleed. 

After we're all done, we watch the patient carefully. If all is well, they're taken out of the Cath lab, and they go to the recovery area, where they are monitored both by nurses and PAs. For elective procedures, after a suitable period of observation, depending on the time of day, they might go home. 

If somebody was unstable when they came in, more than likely, they are going to spend the night and go home the following day. If somebody is really sick and has other problems like lung disease or kidney disease, they may not be ready to go home the following day. But from procedures, in straightforward elective cases, patients often go home in six hours. 

We also treat what are called Complex and High-risk Coronary Intervention (CHIP) cases, which are far more complicated—the length of the blockage, the number of blockages, and the number of arteries affected. It might reflect the configuration of the blockage; they may involve branch points. Sometimes, these blockages are heavily calcified, so they can be hard, like plaster. 

Sometimes, an artery is completely blocked for a sustained period of time. For those blockages, we have to put tubes in two different arteries to look at the blockages from two different sides. There's a whole strategy involved. 

And then some people are simply very sick—they've got very low blood pressure, somebody who's in shock or has previous heart damage. There are three arteries to the heart; somebody might have two arteries damaged and now has a blockage in that third artery—the last remaining blood supply. With the right approach, it is manageable, but if the heart muscle has been damaged, the stakes are much higher. 

How do you train doctors to manage those risks?

Have you ever seen the movie "The Karate Kid?" I use the analogy for my fellows: Wax on, wax off. Mr. Miyagi had Daniel wax his cars in a very specific way. After Daniel did it for eight hours on eight cars, Mr. Miyagi went at him, and under pressure, he instinctively did what he had worked on: Wax on, wax off. So, you need to do the repetitions to get the technique—you have to get in on the procedures to get the judgment. You learn the mechanical skills from people who know what they're doing. And then you've got to do the cases. 

Here at Columbia, we have more experience as a group than just about any other group anywhere. Somebody can be technically very adept but not have good judgment. And there are people who have very good judgment who just can't do it. For our level of expertise, it requires a melding of those two skill sets.

We offer what's called a clinical fellowship. When someone finishes their residency training program, they begin a cardiology fellowship. It's a three-year program. And those three years include a certain number of weeks or months for these fellows to rotate through the Cath lab. We teach them the fundamentals and the basics of what I've been describing to you.

At the end of those three years, if a fellow is interested in becoming an interventionalist, they would apply for an interventional fellowship. They would do one year of interventional fellowship, where they just do the coronaries, and they just do the ballooning and the stenting. Then, after that one year of interventional fellowship, people often decide to specialize further: CHIP, endovascular—which is the aorta, the legs, the carotid artery in the neck—or structural, which is the valves of the heart. 

Bonus Question: What advice would you give to young residents or fellows who are considering interventional cardiology as a career? 

Think of it this way: What's your favorite ice cream? I like chocolate peanut butter. Before you had ever tasted your favorite ice cream, you didn't know how good it was. There was something else you liked best the day you tasted it. You woke up not knowing anything was going to be different that day. 

And then you tried that new flavor and thought, Wow, I like the way this tastes better than any other ice cream. That wasn't a choice; it was a response. You have a choice in ordering your favorite ice cream flavor; you didn't choose to like it; you responded to it. 

Before that first day during my fellowship training, I had never seen a Cath lab. I saw one case, and I went home that night and told my wife, "I just found what I was born to do." I did not choose this. This chose me. So, I advise the residents and fellows to trust your instincts, listen to your heart, trust your gut, respond to what resonates within you.

That will tell you what feels right. If it doesn't fit you, if it doesn't fit your personality or your nature, you probably are not going to be very happy doing it. 

For many people, their job is just a job. And I feel bad for them. For me, this is no longer just what I do. This is who I am. And I am completely fulfilled doing this. Because of this, I can tell you that I have never worked a day in my life because I enjoy what I do so much. And that's what I recommend to people: take the time to explore what works best for you.