William “Bill” Lombardi, MD, FACC, is a clinical professor of medicine in the Division of Cardiology and the director of Complex Coronary Artery Disease Therapies at the University of Washington (UW) in Seattle, WA. Widely considered one of the founding fathers of modern chronic total occlusion (CTO) percutaneous coronary intervention (PCI), he has helped develop over 20 novel CTO technologies and was fundamental to the inception of the “hybrid algorithm” to facilitate reproducibly successful outcomes in CTO PCI. (Read more in his bio here.)

I talked with Dr. Lombardi about his incredible professional journey and his advice for younger cardiologists.

Tell us about your life before becoming a doctor. Where did you grow up? What were your passions?

I grew up 45 minutes from the University of Washington campus, in a town called Kent. I always wanted to be a fighter pilot in the Air Force. I actually flew a plane by myself before driving a car. I got a nomination to enter the US Air Force Academy from both my senator and my representative. When I went down to get my flight physical, I found out that I was 1 diopter off on vision, and that was the end of my Air Force career. So, I got lost a bit, but found when I got to undergrad that I really enjoyed biology and I liked boating. It was a choice whether I wanted to do marine biology or go into medicine, and I ended up choosing medicine.

You trained at the University of Utah. Before becoming an interventional cardiologist, you also took a fellowship in heart failure/cardiac transplant, which is remarkable as it is not a common path for most interventionalists. Can you tell us about the unique aspects of that period of your life and how such training shaped your subsequent professional practice?

The University of Utah was one of the leading transplant centers in the US, and I really enjoyed it because transplant is like “super-medicine” –patients need great endocrine care, great renal care, etc. I loved the pathophysiology of heart failure, and we had great leaders in the profession, many of whom have ultimately helped me in the CTO journey.

I was trained by people who were contrarians and visionaries. Most of my mentors were the people who developed beta-blockers in heart failure and had been ostracized by the heart failure community and told they were crazy. Then suddenly they were told they were brilliant. They taught me that you should never accept that you’re right or wrong, and you shouldn’t follow the status quo: you just keep trying things and moving forward. These lessons were helpful as we got into CTO PCI and started to “break the rules” and realize that most of the rules were not true. When a lot of people would have just quit, I kept going and moving beyond what is considered normal in our space.

Your main clinical focus for over 15 years has been CTO PCI. Was that your passion since the beginning of your career as an interventional cardiologist? How did it start?

When I started, I just wanted to be a good interventional cardiologist and enjoy my life in a small town. I got into doing CTOs after a brief exposure to peripheral intervention, as I was searching for something else on top of regular PCI. As a heart failure specialist, I was seeing a lot of patients with ischemic cardiomyopathy with unrevascularized territories. I just didn’t want to say “no” to people anymore. I wanted to be able to offer a therapy to make them feel better, rather than just looking them in the eyes and saying, “I can’t do it.” As a result, I decided to take on the challenge of how to fix CTOs.

In 2011 you hosted a workshop that changed the way CTO operators approach this challenging lesion subset. On that occasion, a dozen CTO enthusiasts that you had been mentoring met in Bellingham to perform a variety of CTO interventions and came up with a procedural algorithm – now called the “hybrid algorithm” – to homogenize and facilitate teaching of CTO PCI. How was CTO intervention practiced before this milestone, and how has the hybrid algorithm impacted the community?

Prior to this time, the Japanese were doing IVUS-guided antegrade re-entry and parallel wiring and they were much more aggressive with the retrograde approach. The Americans and Europeans were mostly focused on technology and devices to solve issues. I chose to follow the Japanese and I tried to do their techniques, particularly the retrograde approach. But, as I got more and more into the field, and I met people like Drs . Craig Thompson and Aaron Grantham, and then Tony Demartini and Mike Wyman, we realized that there was no consistency in the message and it was very hard for people to learn. Chad Kugler, inventor of the Stingray system, allowed us to put together the meeting in 2011 with the idea that five of us would do the cases and the other eight would observe.

What was unique about our approach is that all 13 of us decided before the case that we would go through the anatomy and pick what would be the first strategy, the second strategy, the third strategy and when we would switch. We randomly picked the front operators and then the back operators, and no matter what their skillset was they had to go execute what the group felt. And as the days went on, we ended up doing 17 cases, all of them successful, and what we realized was that we had developed an algorithm that allowed for a systemic approach consistent education and training.

But the hybrid algorithm was never supposed to be set in stone. That was the first algorithm for CTO PCI, and there have been others that followed. Many are still trying to come up with their algorithm, because they want to make their own name. Evolution is about change and about doing things you can’t do yet. It is important to understand that you should not criticize something just because you don’t know how to do it, or you don’t understand it.

Teaching is another of your passions. Besides training one or two CTO fellows a year, you host several practicing interventional cardiologists at your institution from the U.S. or overseas. How does this initiative work, and what is the impact on clinicians when they go back to their institution?

Learning how to do CTO PCI is hard. There are a lot of different skillsets that you need to develop. While many of the industry-led training programs help, the percentage of people who start applying what they learn in these programs is only about 5%. In addition, very few other centers would allow other doctors to come in after they graduate to work with local experts. We wanted to change this, and we wanted to give people an opportunity to learn.

The training program is also good because it prevents us from becoming siloed. We are always being challenged to demonstrate that what we are doing is the safest and most effective way to do things. Another great part is the cultural piece that allows us to learn from each other and share different perspectives related to culture and experiences. We want to understand where each person is coming from professionally and we strive to incorporate and teach purposeful practice that gives each person one to two things to work on and improve when they go back home. Over time, people can come back to learn the next skillset, or we can go to them and scrub with them. This is an ongoing post-graduate training program to help people continue to evolve and be the best version they can be.

A very important thing is that when you “graduate” from this program, you should not stop training. I really encourage people out there and keep their focus on wanting to serve patients better, whether that’s getting technically better, personally better, better at leadership or better at professional interactions. There are a lot of different “betters.”

CTO intervention is a tough subspecialty, which makes you humble on a constant basis, by means of failures and complications. In your opinion, what are the qualities that a CTO operator should have (or develop) in order to better serve their patients, and maintain personal and professional balance?

I don’t think people can maintain professional balance without keeping personal balance. But if we are going to look just at the professional characteristics of people who can excel at CTO PCI, what you are really looking for are people with grit and a growth mindset.
You need individuals with a great amount of confidence but also a great amount of humility, in a very equal balance. You need people who can accept that as they go along they’re going to fail.
The people who are good at this specialty are not those who are keeping a scorecard of success and saying “hey, look how great I am!” The people who are truly great are the ones that are looking at themselves, looking at what they’ve done, and trying to figure out how to do it a little bit better.

If you had to choose one or two values that have been pivotal for you in your career as an interventional cardiologist, what would those be?

Every patient is somebody’s mum and dad, and when you’re doing stuff, make sure that you treat them like your mum and dad. It is also really important not to hold on to all your information and make yourself great. Your job is to make others better.
So, the leitmotifs of my career are to focus on patients and being better for them and disseminating everything I have learned to everyone I meet to help them get better faster.
The legacy I will leave will not be people remembering who I am, it will be leaving a culture. That’s all that matters.

You have treated thousands of patients with CTO, trained hundreds of physicians, impacted thousands of others at workshops and conferences, and collaborated in the development and testing of several devices for PCI. What are your main goals in your professional and personal life in the next few years?

I am trying to put more boundaries at work. Trying to spend a lot more time with my wife, and trying to focus on my own mental health, and things that are important to me. I have sacrificed a lot of myself personally, and my wife and children for my career. I also want to focus on mentorship. My job is not to be a technical wiz and do another thousands of CTOs. What I really want to do is to teach and mentor physicians around the country, because they are the ones who are going to treat thousands of patients and train the next generation.

I know that you have many other passions besides medicine. Can you share what those are and what you like doing the most in your spare time?

I run mostly for mental health. I wouldn’t say I am passionate about running, but I do it for self-preservation. I also really enjoy fishing, especially fly fishing because it’s very calming. For the same reason, I really like to be on my boat. I also like traveling with my wife and hiking and mountain biking