Triston Smith, MD

Triston Smith, MD, is pursuing a 1-year fellowship in interventional cardiology at Allegheny General Hospital (Pittsburgh, PA). A graduate of the University of Cienfuegos (Cienfuegos, Cuba) and the Higher Institute of Medical Sciences of Villa Clara (Santa Clara, Cuba), Dr. Smith completed his medical and general cardiology training at Allegheny General Hospital, where he served as chief cardiology fellow. Dr. Smith is a past recipient of the Charles Denbow Young Clinician Award from the Caribbean Cardiac Society and is actively participating in several initiatives with the American College of Cardiology. His postfellowship career plan is to practice interventional cardiology, beginning in July 2015, at Wheeling Hospital (Wheeling, WV), where he plans to start their structural heart disease program.

What has surprised you most about becoming an interventional cardiologist?

The complexity of the cases. I am being trained at a tertiary institution where we see a variety of very complex cases—not just in coronary but also in structural heart disease and peripheral vascular disease. General fellows and residents see cases when they are complete and do not always appreciate the precision of thought that goes into performing a complex coronary PCI or structural heart disease case. This is something that struck me when I started interventional cardiology. You really need to plan ahead but also be able to improvise when you are doing cases.

Describe your most meaningful clinical experience thus far.

About a year ago I was on call and admitted a young man, about 48 years old, who had an out-of-hospital arrest. It was difficult to decide whether we should take him to the cath lab, especially because we were unsure of his downtime in the field and whether he would have any meaningful recovery. We took him to the lab after all, and he had a proximal LAD lesion, which we successfully stented. He underwent the hypothermia protocol and did not have any perceptible neurologic activity. Over the course his intensive care unit stay we performed multiple EEGs, and the consulting neurologist stated that he was brain dead.

After about two and a half weeks of futility, I walked into his room and his eyes were open—he was looking at me and able to follow commands. We were able to extubate him the next day and he eventually left the hospital walking. That underscores to me not only how far we have come in medicine and interventional cardiology as a whole but also how little we still know about these processes. Unfortunately, he was incarcerated and is still a prisoner, so I have not been able to see him again, but I would have loved to follow-up with him.

What is the best piece of advice your mentor has given you?

My mentor in interventional cardiology is my program director, David Lasorda, DO. The best piece of advice he has given me is that before doing any intervention, whether complex or simple, I should make sure I “look the patient in the eye.” If you cannot do that because the patient is intubated or incapable of responding, you have to have that sit-down meeting with the family. Look them in the eye, and let them know what to expect, so that everyone is on the same page in terms of expected outcomes. You do not have to paint the glossiest picture. Instead, you have to let them know exactly what your plan is and the chances of complications happening. By doing so, the patients and their families respect you more.

Additionally, my mentor says that your responsibility as a physician does not end with the procedure or on discharge. My mentor calls his patients at home even months after discharge, even if they do not come back to see us at this hospital. That is very meaningful to them and shows his humanity and empathy for his patients. 

What is the biggest challenge facing interventional cardiology fellows today?

The biggest challenge facing interventional fellows is becoming effectively trained to enter the new era of interventional cardiology. The scope of interventions today is vastly different from 5 to 10 years ago. As coronary PCI volumes decline due to improvements in primary and secondary prevention measures, peripheral interventions and structural heart disease interventions are increasing. With the advent of TAVR, mitral valve repair, and percutaneous left atrial occlusion, we are at a crossroads where we have to be well trained in performing coronary PCI but also gain enough exposure to other types of procedures. This will allow us to be well-positioned as practitioners who will be equipped to advance the field of interventional cardiology. Even if we do not get all the necessary training during our fellowship, at least we have a working knowledge that we can build on when we are in practice ourselves.

If you were not an interventional cardiologist, what else could you see yourself doing? 

Probably marine biology. I'm from Grenada in the Caribbean and grew up in a small town called Gouyave, which is set close to the beach. I grew up swimming, diving, and exploring the coral reefs. So it makes sense that I have an appreciation for marine life. If I did not go into medicine, I likely would have gravitated toward that. It is adventurous and you get to see a lot of new things every day. It’s also an expanding field, just like interventional cardiology.

What his program director, David Lasorda, DO, says:

Triston has superior leadership skills and has the ability to start and complete projects he initiates with enthusiasm and determination. He has taken an active role as an advocate for fellows with the American College of Cardiology, both locally and nationally. Also, Triston has been very active with clinical and basic science research. Over the last 2 years, he has presented multiple abstracts at national meetings and has had several manuscripts published by peer-reviewed journals.

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