Episode 157: Adriaan Kraaijeveld

Hello and welcome to Sensei Podcast. This is Manos Pilakis, discussing with leaders in the field of CTO and complex PCI. Sensei means teacher or master in Japanese. The goal of the Sensei Podcast. είναι να βοηθήσεις να βοηθήσεις και να βοηθήσεις την κοινωνική και κοινωνική PCI, ώστε να μπορείς να γίνεις το καλύτερο που μπορείς

Hello everyone and welcome to Sensei Podcast. It is my great pleasure to introduce our guest today, Doctor uh Adrian Kreveld from Wootrek Netherlands, great city operator, great friend. Adrian, thank you so much. Thank you for having me, Imanos. It's a great pleasure. Adrian, we'll start this podcast by having everyone just give us a little sense of where they started, how did they get into intervention, how they decide to go into this

complex world full of stress and other uh s um issues as well. Yeah, well, so I I've been practicing as an interventional cardiologist for m I think over ten, eleven years right now, starting with my fellowship obviously. Back in Leiden, Leiden University in the west of the Netherlands, I moved to Rotterdam to the Maastad Hospital, back then with Peter Smitsen, Martin van der Ande, and George Vlagajanis.

And yeah, um so I I did the last part of my fellowship over there and there was quite an uh an high volume PCI center off site. We didn't have uh cardiothic surgery. uh but there was an interest in complex PCI. Obviously the patients were there.

Um and yeah, that was like ten years ago and you just released your first manual of CTO interventions. We'll come to that later, I guess. Um yeah, and I I had this interest in this complex stuff and and well there was this still this vibe, uh it was all starting with the um the hybrid operators, that movement was gaining ground.

uh and I was interested in that and then I um I um uh I visited a a workshop by James Pratt uh back in Utrecht uh well it was in twenty fourteen or fifteen I think Um and and yeah, he really opened my eyes for for CTO intervention um and I started doing um or starting to get some experience with with these interventions. Also I I had to commute every day from Leiden to Rotterdam. most of the time by by train and by public transportation. Uh so it took me one hour back and forth.

Uh and it was a great opportunity to read your manual actually uh on on all the aspects of CTO intervention. So um yeah, I started doing uh doing these things, uh treating my first patients and also uh I started uh or or was proctored by uh well Paul Knapen and Alex Knap from uh from Amsterdam obviously. So I was one of the first which they proctored here back in the Netherlands and after that they they they proctored many colleagues in our country.

But I was one of the first. And then I moved to Utrecht and I got an academic hospital. I got more. room to yeah build my experience. So in Utrecht we had uh Pier Francesco Agostoni He left uh the department, so I was the replacement of Pre France Pier Francesco who already had a quite a good uh CTO program going, so yeah, it all went from there.

Wonderful. So a lot of uh uh, you know, familiar names and a lot of uh coincidences I guess, training and and then meeting other people and uh and moving on. But still doing the CTO procedures it is a fairly painful part, right? It can be long, it can be long cases. And you could much have a much easier life. So wha what made you want to get into this area? Yeah, well that's a good question. Uh yeah, so I never back down from any challenge.

that's my problem. So um when I see a challenge or when I see a c a clinical uh question asked and uh Yeah, we have these opportunities. Um I I yeah, I I have the tendency to go for it and and just uh see if I can help the patient but also gain and improve my own skills. uh to see to see if we can well tackle the problem and um yeah I I take some some pride or I like to to to go one step beyond where most of our colleagues

Well, don't want to go for whatever reasons or don't have the time to do it or whatever. Uh and unfortunately I'm in uh uh currently an environment which supports those um yeah decisions and uh where where you can do some complex work and there's room and time and and and funding and and personeel and all that.

to do more innovative things, not just CTO, PCI, but also other uh structure art things, etc. Um yeah, um it's it's a challenge and and and don't give up and and try to achieve Um well uh to the best of your uh uh skills, your best of your abilities. And were you always like this, that you always wanted to push the envelope? I think so. Ask the people in my environment, they would they wouldn't be surprised, uh, if you asked them the same question. They are so um

I've always uh been been a hard worker. Um not just for for CTO or cardiology in particular, but um yeah. And uh I I had to work hard at school as well. So uh medical school but also high school, you know, it uh I I really needed to study because otherwise I wouldn't pass, I'm not I'm not all with Einstein, so uh I had uh I really had to work hard for it. So uh yeah already a long history of just work hard and then you will get there.

And then um as you said, the environment is also critical. You were in a uh friendly environment and uh I'm sure Pierre Francesco also has been doing some nice work there before.

Um, how supportive were they and how important was that for you building up the program and getting it to the next level? Yeah, very important because um uh you see other role models uh teaching you and telling you how to do things, um also how not to do things, or when you see them do things you say and think to yourself, Well maybe uh I should do it in in a in a slightly different way.

But um uh supportive pairs are really, really important. So um Um also back in Leiden when I started doing my first uh angioplasty, etc. Uh I uh my well my trainer as we would call it, opleider in Dutch. He was really uh was a was a very strict man but he was also a great guy. And uh but but he gave me the opportunity to also just perform my first angioplastic and stemies.

and just just do it. And then all of a sudden he pulled out I don't know where he gathered them, but three uh anterior wall infarctions within two hours time. And just do it, do it, do it. And yeah, it builds you confidence. And at that time it was the most scariest thing I ever did. But um together with my colleagues we we did it. And um uh looking back n then you realize how important that that moment was and um

And soap for angioplasty per se. So having to deal with a very sick patient who well I d don't know what not in shock but still an anterior unfortunate. Um yeah, and so you you get uh you get a little bit of sense of of urgency and uh Uh so it helps building up this experience and uh yeah, once again, uh like I said, uh also in Rotterdam, which was a high volume center, they still were patient with me and just to try to to do the first steps in CTO, not directly retrograde.

because you need more time, you meet more um patience also not with yourself but also with with the team obviously um yeah and have good support i think it's really important to have good proctors because otherwise um yeah You don't learn it like the way you should. And I was very fortunate to be proctored by Paul Knapen and Alex Knap. And I also visited their lab. Back in Amsterdam interview a couple of times obviously and got the opportunity to participate and see.

Wonderful. Yeah, and a long line, as you say, long heritage, great operators, great teachers, which uh which helps a lot. Now, how about the stress? When you do those cases, sometimes things go well, sometimes they don't. uh h how do you deal with that part? Yeah, manos well um Um as you gain more experienced uh uh well well you have you've dealt with those computations a number of times obviously but In the beginning it could be very stressful and um Um yeah, what I I tend to do is just

Stay calm as possible. Always try to gain help from co-workers who are in the lab, also other cardia intervention cardiologists just to help you out in a difficult situation. So um But yeah, you have to make sometimes you have to make split decisions in or very quick decisions in split seconds, like today.

Well when you mentioned it we had a perforation of D L E D and uh it was a big perforation, tamponat, etcetera. Um and we dealt with it. Um and it was a team like effort. So um Yeah, how to deal with the stress, it's it's always there as an interventional cardiologist and you have to be comfortable with it p and you have to embrace it in a certain way because otherwise um life gets hard.

Um but still it's a demanding job. Um so yeah, try to uh unstress after work. That's really important. And also a a um Well, a learning environment helps, uh, an environment with your co workers together with the nursing staff try to discuss it and um in a professional way. Wonderful. Now, um, in terms of uh the preparation Are there any specific rituals or ways that you handle things?

uh or just look at the films. Is there anything that you do sp special that you evolve over time? How do you prepare for those cases? Well um uh so we always try to review the cases when we start the day with the whole team. So There could be one or two operators, uh, my colleague Tim van der Hoef and I do the complex CTO uh stuff and the and the and the chip cases. And we try to review every case upfront with our nursing staff.

And I even just recently also started with my CTO team just to let the nursing staff tell me what to do. So that's an indirect way of uh for them to learn as well. And that uh well it helps them uh uh or be engaged in the whole situation obviously.

But that's what we tend to do. Uh and and we just prepare the patients, uh um, take care that we're aware of the all the all the lab results, all the all the medication, etc., and just have a good review of the angiogram and uh come up with a good uh plan. So it's not we're not doing things ad hoc. Uh that's not how we operate uh here in Utrecht. Uh we try to plan everything as as well as possible and um yeah that's the that's the way we do it. Always a hard team discussion, etcetera. Yeah.

Perfect. And that's and that's the best way to go. And the beauty, at least for the CTOs, is that these are elective cases for the most part. So you do have the luxury of time and you can do the planning, which as you said, can help you uh a lot down the line.

In terms of learning, what did you find the most difficult thing? What was the thing that uh gave you the hardest time to learn any anyway? Well, I think it's just what the Germans call the fingerspitzengefühl, you know? You have to you really have to feel the plaque have to feel you have to be uh get this feeling of the different equipments, microcatheters, wires, etcetera, in relation with the patient or in relation with the plaque uh you're dealing with. And um it takes time.

For me it it it took some time obviously and now you just know okay, based on this and and that I can choose that wire because I know it will behave like this or that. And it's great that we still have this this improvement in wire technology and um that that's amazing. I think uh the Neo Gladius uh EX is is is uh unbelievable. Uh but but still yeah it

um you can't say I'm a CTO operator after 25 cases, for instance. You need this this to go through this this this pyramid and this this incline of learning and and for me it was well I I think especially Uh well when we're talking about a a specific technique, I think it was the most carries for me the uh the antiquary dissectionary entry.

just totally destroy this whole vessel with this uh this this crazy technique. But now I'm doing it more often and more and more and more. And um yeah, it's just one of the techniques which is in the Armentarium and that's it. Um but I don't know. There was uh uh well, a sense of fear for that technique. I don't I don't know why, because um it was f at first it was so crazy concept but um yeah.

Uh once you get to learn it it's uh it makes sense. And then um in terms of contrast, radiation, etcetera, have you had any issues? Do you do any special things to protect yourself on the team or? Um well what we do with contrast we try to um always uh calculate the maximum amount of contrast the patient may receive. It's it's not a hard stop but it Tells me, uh so the nurses tell me, well, we are at one hundred cc's, we're at two hundred cc's, etcetera.

Um and um yeah, I I try to limit it as as much as possible, obviously. So I I've seen operators which pour one up to one liter of contrast into a patient. Well that Crazy, you won't see me do that. Uh no but we try to be very aware of the amount of contrast in terms of radiation, um

Yeah, well we have our lead aprons, obviously we have all the lead protections. We don't have uh these these these movable um lead free um how do you call them ramparts uh like uh ramparts zero gravity the lead ponds etcetera. Um and one of the most important improvements in the future for us will be in the next month we will s receive two new Caf labs with uh new um uh I think it was will be Siemens uh hardware.

those will be also major improvements. So the so we're working now with with ten year ten plus year old um uh machines. Yeah, um it it that does not help. Um so new technology will definitely help us, but we're always using red pads, we're also always using uh goggles, um well, everything just to reduce. And when I look at my yearly uh amount of radiation, which we uh which is closely monitored, then I'm well below uh the the threshold values. So yeah.

And in terms of patience, um which is obviously also important, we try to well, vary the uh our the the the The the X ray uh beam. Um but we never exceed uh very dangerous amounts of radiation, which you also stated in your book obviously. Um But then again I think there is still a well sort of gray area that we we don't let patients, we don't see them back to check for any radiation-induced uh trauma or something like that. So uh we don't have a program for that to to really check on that.

Are there, Adrian, any cases, good or bad, that stick to your memory that taught you a lot and uh you you always remember? Yeah, yeah. Well, um uh for sure. Um But there was this one case which made a deep impact in the beginning and when I worked here in Utrecht. And uh well there was um a patient which w just came in for an LAD stand, we post dilated and the post dilation and the non compliant post dilation balloon wouldn't deflate.

So I asked the nurse, please deflate. She deflated, but the balloon did not deflate. So there was a and the patient immediately collapsed. So uh proximal ED and I tried to get the balloon out. I I I pulled gently and uh maybe I pulled a little bit too hard uh uh So the the catheter came out, catheter shaft, but the balloon was still stuck inside the patient. Inflated in the left mane.

Which was a bad situation. So um eventually the surgeon who got involved uh we put the patient on V E EGMO, etc. But in the end uh well the patient uh did not make it. uh a couple of days later. So um yeah, that would that had a great impact because there was also all the um the implications afterwards uh with the company who um made made the balloons etcetera. And it made a deep, deep impact on me. As a physician, um, as a doctor. Yeah, it's um uh well, I learned a lot. Uh

also not just to how to manage that complication, but also in terms of all the um uh the consequences which were involved, which were well quite major actually. So um That was from one side. Also very positive things obviously. Um we have helped many patients with with with really great uh uh procedures. imp seeing them improve is obviously uh well very rewarding, uh, but but in the end it's all about the patience. So um yeah.

We're using all the techniques. Every technique has been successful in one way or another. Um, yeah, we're just very fortunate to have all these techniques and all these possibilities to help our patients. Wonderful.

And also in terms of teaching, um How how do you choose the people who want to learn? I'm sure many people approach you and they want to learn and do and they have different levels of expertise or t or uh um hand uh hand uh skills. How how do you choose and what excites you and someone who wants to Yeah well um uh enthusiasm is uh the most important uh aspect for me. It all starts with enthusiasm and just presence, just being there, you know? Um fortunately we don't have a lot of

fellows right now that has something to do with budgets, etcetera and choices by the hospital. But we did have some uh colleague coming to our department to learn specifically uh CTO uh uh operations in the past. And these were all very dedicated uh uh colleagues who um yeah really wanted to learn and are eager to learn. And uh yeah, what we do is just just

Well scrub in, do the case together. And um well I I also uh like to coach a little bit from a diff uh distance just uh to to let my uh co-workers uh work on it and uh see if they can manage the case. And yeah, well uh it helped uh a lot of my my co uh we we we ha we we trained a a couple of uh coworkers and colleagues uh for CTO intervention. And uh I hope to have some uh well additional fellow anytime soon. Now, in terms of yourself, again demanding schedule, stressful cases, etcetera.

How do you keep yourself in good shape to deal with all this? Well, Manos, one of the things for me which works uh very well is running. Um we met each other in Nice as well and you were also running back there. So um now it it's for me it's it's really uh helps me to uh well, really unwind and just think about nothing or think about something for work or very private. I don't run with any headsets or whatever, no distraction, just run.

And uh and then with also with a goal to train for, well, a marathon or some some other run. And obviously family, but those are the two uh well important things now in my life, uh, next to this next to our demanding job indeed. Did you run any races recently or planning to run any races? Actually I I ran a marathon last Sunday, uh but it was not um well it was it was a great run, but it was not uh 100%

Uh and I'm planning to do some uh obviously some runs uh next fall and next spring again a marathon in Rotterdam. That's the most well known marathon in the whole of Netherlands. Um yeah, so um having some uh things to look uh to uh to be excited about. How many hours do you do you do you sleep every night? Not enough. No, I think um Yeah, I try to sleep at least seven to eight hours and um sometimes it's a bit less but um

If I if I don't do that I also notice during the week um that you build this sleep deprivation or sleep lag um during the week and I really need to well uh catch up in the weekend again. And the most difficult thing for me as an interventional cardiologist, I think, is when you're on call, let's say on Sunday night or Monday evening and you're get a call for a uh primary PCI in the middle of the night and you have to work Then you're done. so um so so there are um

We don't we are n we're a relatively small group, so we don't have a lot of intervention cardiologists, so our own calls are well quite frequent. Um yeah, and that that's a bit tough right now, but um yeah. Hopefully that will change anytime soon. Working on that. Wonderful.

Wonderful. Well it looks like you're fairly resilient with that. Um how about um uh any favorite books or any favorite movies that you have? Yeah, uh you sent me some of those questions already. So um Unfortunately I don't read a lot so uh literature uh right now. Um yeah, because of family work uh work, uh sports, running, etcetera. um films, movies. Um well, I don't think there are these many interesting movies released recently, so um

My m my my greatest memories go back to the nineties. Uh movies like that, like The Shawshank Redemption and Forrest Gump. And my kids also like these movies. So I think if if my kids like it, then it's really a great movie. There you go, perfect. And that's actually similar to what other people have said before. So um now in terms of uh right now and the future, what what are what are you most excited about in in your job and professionally and personally?

Um yeah, well uh our our team is uh well we're trying to reorganize a little bit, so our team will be expanded hopefully anytime soon. Um yeah, w we we'll probably have this uh restructuring of our department uh in the in the coming years, which will be uh quite exciting. Um We hope well we just proceed with our complex PCI programme. um we'll try to do some some more complex PCI but also some more

um structural hard interventions. So we're doing well, let's say the regular structural hard interventions like Taver and MicroClip, but we don't do um the mitral valve replacements quite frequently and we don't do any tricuspid intervention so that there's there's room for opportunity. But then again our centre is a a transplant center.

uh and an Lvad center. So we're focusing our focus of the the center is really on heart failure and um uh really advanced uh heart failure um So we'll we'll hope to well expand our expertise and our spend our uh um Yeah, the the opportunities we have for treatments uh uh with our patients uh even more on that side. Um yeah, and from a personal point of view it's just uh raising my kids and seeing

how they will grow up with all the fun things, but also the difficult things. It's totally free. You get it for nothing. That's great. Yeah. And it just had a Does anyone any of the kids want to follow your footsteps and uh Um it's a difficult boom they're at high school right now or two of them are high school. Uh No, I think um

Well, sometimes uh they s they they they uh s uh suggest something like that and I'm not saying they should. I also not saying they they shouldn't do it, but uh we'll see. Where no no I'm not pushing them uh at all. So uh just want them to achieve um well to their abilities and uh enjoy themselves as well. And then what are you most proud of of the things you've achieved so far? What are the things that you're most proud of?

Um yeah, well um here in the UMC Utrecht, so when I look from the the the the professional thing uh side of things I I helped organize a couple of projects. Let's say for instance uh just just getting Impella in. Uh we we started with Impella six years ago so we had VA Egmo and just uh well getting all the departments uh with the noses in the same direction. Uh just that's it uh r what I really like is to to pull a simple a relatively simple project and uh from start to finish.

with a very practical approach, you know. That that's what I like and that's what I think is one of my strengths. Um and well we had a SO in Pella is one of the uh the things we do we are started we started out with doing uh trombectomies in pulmonary embolism patients. Uh we uh started I'm a PI of a a a file in Adlins which uh uh examines uh thrombectomy and high risk pulmonary embolism patients versus thrombolysis, which is well, it's it's a really important clinical question.

And together with a great group of colleagues in the Netherlands we uh started this trial. So um yeah, those are also one of the things I'm uh I'm proud of and uh which the trial is currently including. So very excited to see what the results will be. Uh yeah. Wonderful. Well well looks like you've been very busy because

No, not just doing the complex cases but also expanding the research area. I mean that's a lot of um a lot of work. I think I'm quite proficient in the cath lab. Um So it's it's a it's a balance of of helping our patients and spending time in the cat lab, not wearing out and also doing some research and Right now research is uh like clinical work is there and research is there, and sometimes it's a bit more like this, so yeah. It's but it's demanding. Yeah.

It's always rebalancing and it's like the city also, you always find different pathways depending on how things evolve.

So Adrian, again, you done phenomenal work. If you had to give some advice to the new generation of people who are starting to do complex or more advanced procedures and they want to learn, what would you advise them to do? One, read your manual ma read your manual. Not once, not twice, but three times, at least, because repetition is it's all about repetition and just seeing and and knowing what knowing what to do, have the skills.

We also have this uh uh this great book, the CTO uh toolbook by Miay Kovacic, which is also great. Um just Read it and see what out there. You don't have to use everything. Just if you are proficient with, let's say, five or six wires.

Start out with that. Don't well, don't try to to get proficient with all of the wires all at once. Same holds true for microcatheters. So you can have ten different microcatheters in your Cav lab but Uh, for me it doesn't make sense because we have I think we have two or three and uh well I use them many times and I know what the properties are of these.

um uh this these microcators. So so don't go for all the materials uh use the materials with you which you you think you need uh so there has to be this this basis of obviously of of uh the tools you need you will need to be a good CTO operator uh because there's so there are so many things on the market. Um visit um One or two uh live course. per year. Not too many there are too many live courses, I think. So if you're a live course operator, that's great. But um

I think one or two of those meetings uh per year is uh sufficient. But it's a great learning opportunity because um yeah, y every time you see even now you see different cases and some of them are really well straightforward and simple. And you can well discuss those cases for two hours and there are really great complex cases which uh take a lot of time, also are c are complex and or are are complicated by well, various complications.

And I think it's a great way, but and and then proctoring, I think it's it's also really important just to uh or or or work and or work in two or three hospitals because every hospital works differently. Um so I I would suggest to well, take a look at least uh outside in one or two other hospitals to see how they work and how see to see how things are done.

And just pick out the things you think you'll need, uh and which which coincide with your well, uh the resources you have and the the s the skills you have, and it takes time. So it takes a couple of years I think to be really proficient. So be paying. So this is yeah, this is not something that's gonna happen tomorrow, right? You start doing this, but it's a process and takes uh and takes quite some time.

Wonderful. Well Adrian again, thank you so much. I really appreciate you spending the time with us today. Congrats on great on a great program that you've built. Looking forward to the results of your pulmonary embolism trial. Thank you, man. And uh look forward to running with you one of the upcoming courses. That's a that's a great idea. Thank you very much for your kind invitation. It was a great honor for me. Um yeah, and hope to see you anytime soon. And uh thank you for your opportunity.

Thank you. Thank you for listening to the Sunset.