Ingenuity and Inspiration

Corresponding Author

In this issue of JACC: Case Reports, Chatfield et al. (1) present an illustrative case of left ventricular (LV) outflow tract pseudoaneurysm in a patient with a remote history of endocarditis initially treated with a surgical valve replacement with 2 subsequent reoperations. Chatfield et al. (1) describe a percutaneous LV apical approach with deployment of an atrial septal occlusion device that successfully treated this condition.

LV pseudoaneurysms occur when cardiac rupture is contained by adherent tissue. Most often, LV pseudoaneurysms occur at the site of a myocardial infarction (2). Very rarely does such a pseudoaneurysm involve the outflow tract, usually as a complication of surgical aortic valve replacement, chest trauma, or endocarditis. Given their complexity and high mortality, these lesions were historically treated surgically, if at all. Use of percutaneous LV apical access and deployment of an occlusion device for this indication has been previously described (3).

Use of modern imaging techniques, access approaches, and interventional devices has expanded the scope of conditions that can be treated using “off-label” techniques. Novel solutions are reported in coronary, peripheral, and structural heart procedures almost on a daily basis. According to published case reports and social media postings, it may seem that “off-label” applications are universally beneficial. It is important to remember that unsuccessful uses are rarely published or posted. The role of the scientific community (medical journals, reviewers, publishers, and conference organizers) in each country and discipline is often that of an arbiter of what is “innovative” versus what is “reckless” or “dangerous.” Off-label use is not encouraged because of safety, legal, and ethical concerns. Conversely, the history of interventional cardiology is almost entirely defined by “trial and error” leading to refinement and advancement (4). Many techniques have evolved from initial off-label use (5).

As Chatfield et al. (1) describe, novel applications of ideas that are based on simple inspiration can lead to positive patient outcomes. These ideas influence the engineering of future medical devices and stimulate modifications to older devices. The cycle repeats itself when the interventional cardiologist uses the “new” device, thereby generating novel applications (and case reports) that lead to further evolution. This process can induce a positive cycle in the field of interventional cardiology (6).

Clinicians are given great latitude when treating patients. In collaboration with their patients, physicians must balance risk and reward when prescribing therapies. Routine cases are best treated with routine therapies; however, unique or rare clinical scenarios can require creative solutions. Ingenuity and inspiration should be valued as much as any other research.