Dr. Adnan Chhatriwalla is an interventional cardiologist specializing in coronary and structural interventions. He serves as the Medical Director of Structural Intervention and the Director of Interventional Research at Saint Luke’s Mid America Heart Institute. He’s also a Professor of Medicine at the University of Missouri-Kansas City and actively participates in clinical trials and outcomes research for coronary and structural device therapies.

Thinking back to when you finished residency and fellowship, were there any therapy areas or clinical subjects that you felt were lacking in your education? Alternatively, do you think there’s a specific area that current fellows should focus on more in their training?

During my general cardiology fellowship, I was focused on interventional cardiology. And this was quite common. The electrophysiology, or EP, folks were focused on EP procedures. We'd even swap rotations. Fellows interested in EP often traded their cath rotations for EP rotations. I did the same. I was so focused on that, I paid less attention to echo imaging and CT imaging, thinking I wouldn’t need them. 

Now that I’m in structural cardiology, which I didn’t anticipate 15 or 20 years ago, I'm reading more echoes and looking at more CTs than anyone else in my practice except the dedicated readers. I had to relearn that stuff, or in some cases, learn it for the first time because I hadn’t paid enough attention initially. Finding myself doing things I never thought I would do during my training was a huge surprise. I didn’t get certified in these areas like many others do. A lot of people go through training and try to get certified in everything to be qualified for any opportunity. I just didn’t see it that way back then.

You’re known as a leader in medical research. Do you have any advice for medical students or residents interested in following your path?

It's tough because so many people want to get involved in research. Both the training and the jobs are very competitive now. People have so much more on their resumes now.

There are a few things I’d advise. The first is that leading a project and just being one of 10-12 authors listed on a project are very different. What I’m looking for when somebody is interested in research is for them to have the opportunity to have a meaningful role leading a project. Even if they don’t have the clinical training yet to fully understand the clinical implications of the questions we’re tackling, the ability to take responsibility and push things forward is different from being one in the middle of a group of authors. You can tell by the resume if someone is the first author, meaning they led the project, versus being the sixth author, which probably means they didn't do much. 

Second, persistence is key. When I was a fellow, I collaborated with a mentor to get into the clinical trial space, which is even more selective than general research. I wrote clinical trial protocols for several drug studies, like statin drugs. Despite the hard work, the trials didn't take place but my mentor noticed my effort. You just have to keep working at it. 

Then, when I got to St. Luke's, we weren't leading clinical trials, just participating in them. My research shifted to comparative effectiveness research. I had some protected research time—20% of my time was dedicated to this. Initially, I wasn't finding success, so I considered focusing solely on clinical work. But through a series of chances, I got into research related to the impact of bleeding on PCI outcomes. This led to meaningful papers and presentations. I then shifted to structural research a few years ago. The point is that persistence is crucial. Every opportunity won't work out, but you need to be ready when the right one arises. Research is tough, and you need passion and persistence. 

There's also a lot of bias in publication—successful or positive studies are published, while studies that are perceived negatively aren't. Not every opportunity will work out, and sometimes people don't see that. About 15 years ago, I wrote a paper on stent fracture with first-generation drug-eluting stents. It was important because stent fractures led to clinical outcomes, helping us understand which stents to use or improve. I presented those data at TCT that year, which was a big deal for me. But no one wanted to publish the paper at a high level. It eventually got published, but not in the journal I hoped for. 

Similarly, one of the best papers I ever wrote was about barriers to physician use of risk modeling during PCI procedures. We developed models for bleeding and restenosis, but many interventional cardiologists didn't use them. We conducted a study interviewing interventionalists with access to the data and models, asking why they used them or not. Their responses were eye-opening—many believed they were smarter than the models or didn't trust them, and ego played a big part. We wrote up the paper, but it faced resistance because it could be seen as criticizing interventional cardiologists, even though it was all anonymous. Still, I think it's one of the best papers I've ever written.

Next question is a bit more specific. Regarding IVL and its use, how often do you use it on a percentage basis for transfemoral access? Also, do you see potential promise for IVL in structural heart applications?

I think IVL works well; I have no issues with its effectiveness. In our experience, two things stand out. First, we are very comfortable with transcarotid access for TAVR, so we don't push transfemoral access as much as other places might. Although 90% or so of our cases are still transfemoral, we typically don't use IVL. It's not that it doesn't work, but we are just very comfortable with transcarotid access. 

In cases where transcarotid isn't a good option, we use transfemoral. Our case plans often include right transfemoral access with or without IVL. We start the case, see how it goes, and decide if we need IVL. We've almost never had to use it, which might be due to case selection or other factors. I think the technology works and is helpful, but there are also acceptable alternatives to using IVL for transfemoral access. 

Beyond vascular applications, I'm particularly interested in using ultrasound energy to modify calcified valves and the annulus. Some preliminary studies and dedicated technologies are being explored in this area. I would be excited to see where that goes, especially since mitral annular calcification is such a big problem for us to deal with.

Moving on to some career-related questions. Early in your career, were there any business aspects you wished you knew more about?

From a business standpoint, I think one major area where we lack training is in how to interact with administration. It's like speaking two different languages. I'm very passionate about the clinical aspects—trials, research, all of that. For example, we just got two tricuspid technologies approved, and I've been telling everyone about it. But I don't speak the language of spreadsheets, return on investment, and other calculations that administration uses to allocate resources. Ideally, we should have some of that knowledge and work with our administrators to get our messages across in an effective way. This is definitely an area where we lack training. 

Another area is billing and coding. We don't get training on these during fellowship. Sometimes, we underestimate what we're doing because we’re not documenting correctly, or it could be the opposite—we overbill, which can lead to serious issues if someone investigates. This is crucial knowledge that we miss out on. 

On a different note, two things I tell fellows, not necessarily business-related but important for clinical work, are: First, the work is way harder than you think. Graduating fellows are eager to start earning a bigger paycheck and have more independence, but the procedural world is tough. Complications and decisions are on you, and there's no one else responsible. It’s much harder than most people appreciate. 

Second, in a clinic, every patient is new to you because you’ve never seen them before. This morning, for instance, 80% of my patients were ones I had seen before, which is easier because you're not starting from scratch. But as a new practitioner, every patient is new, and the stress is higher than you think. I tell people to schedule some vacation time right away within the first 4-6 weeks to manage the stress.