Mark Nicholls

Cardiologists and airline pilotsMark Nicholls speaks to interventional cardiologist Dr Bill Lombardi about what the profession can learn from the airline industry

your first grant and that is a crisis, particularly at a time when our young physician scientists are looking around at their classmates from university and seeing them in entrepreneurial situations where they have done very well. It is a deterrent for them embracing a research career’. Young trainees often come out of the unsubsidised US university system with the ‘enormous burden’ of

Dr Jassim Al Suwaidi, in Doha, Qatar

250 000 of debt not being unusual after completing medical school and residency, though the NIH does have a loan repayment program which allows trainees engaged in investigation and research to receive up to

Back to the Future with Munich 2018

12 000 dollars a year in funding to pay off their student loans. He also suggests that there is no great pressure to deliver results from basic science research. ‘It is very difficult to predict what basic research will spin off in dividends. Everyone says in the grant applications and papers that they are working towards a new therapy or new diagnostic tool, but no-one gets called to task because they do not produce that’, says Libby. The three basic types of NIH funding mechanisms with different levels of ‘attached strings’ are: grants, cooperative agreements and contracts with varying degrees of flexibility and specified ‘deliverables’. Califf holds the personal view that in general, the operations of industry-funded clinical research are higher quality than NIH-funded projects, producing a better technical product because of better funding and the critical role of regulation and oversight by regulatory agencies. ‘NIH studies are often under-funded, leading to ‘cutting corners’ but the questions asked by industry are generally biased by the need to support the corporate goals rather than the societal perspective’. Accountability for research impact is greater than ever before, but concerns remain that ‘too much focus on short-term results may stifle creativity and block pursuit of risky, long-term ideas’ and a ‘more measured approach to high quality research could be better in the long run’.

EHRA 2018 and new regulations

were in persistent AF at the end of the trial. There are however a number of important caveats before rolling out ablation to all patients with AF and heart failure. All the patients in the CASTLE-AF trial had symptomatic AF and the majority had previously failed antiarrhythmic drug treatment. Over 3000 patients had to be screened to identify 363 patients to take part in the trial. The quality of the rate control in the pharmacological group has not been published and there were still active attempts to maintain sinus rhythm in this group. AV nodal ablation was rarely used in CASTLE-AF. Indeed at 5 years, 20% of the patients randomized to pharmacological rate control were still in sinus rhythm and only 56% had persistent AF. The mortality benefits of ablation only appeared relatively late in the trial by which stage only191 of the original trial patients were still being followed up. There were potentially significant differences in patient characteristics between the groups, with a greater incidence of diabetes and ischaemic cardiomyopathy. Some sub-groups also appeared to do less well with ablation. In particular, patients with an ejection fraction of less than 25% appeared to have no benefit from ablation.

Petr Widimský MD DrSc FESC

regimen in patients after drug eluting stents (DES) for stable coronary artery disease (CAD) or acute coronary syndromes MITRA-FR, demonstrating no outcome benefit for Mitra clip implantation when compared with medical therapy in patients with secondary mitral regurgitation and severe systolic heart failure SCOT-Heart, showing a reduction of 5-year myocardial infarction rates in patients who were randomized to receive coronary CT angiography as part of their workup for suspected CAD.

Steven Nissen MD

The European Heart Rhythm Association (EHRA) meeting in Barcelona was a significant occasion. Whilst research and study findings were presented, the mid-March event also marked the first annual congress for EHRA after several years of pairing with Cardiostim in Nice, or at a venue chosen by EHRA, on alternate years. However, the eyes of the cardiology world were on this event for another reason; one that could prove a watershed moment in medical congresses and have an impact on society meetings beyond that of the EHRA and the European Society of Cardiology (ESC). It was the first meeting held since the MedTech group of organizations, representing manufacturers of medical devices, such as imaging devices, catheters, pacemakers, ICDs, and echo machines, implemented a ruling that its members would no longer directly sponsor physicians attending such meetings. With the EHRA clearly in the spotlight, President Professor John Camm outlined the initial impact along with potential longer-term implications, as well as steps being taken to off-set the fall-out from the ruling. While there are clear financial implications and great potential for falling delegate numbers at meetings, EHRA is keen to stress that it is not against the principles of the code but is keen to work constructively to plot a path to ensure a positive ongoing working relationship with the MedTech sector so that it can continue to stage successful congresses and meetings in future years. Professor Camm, Professor of Cardiology at St George’s University of London, explained: ‘The EHRA annual congress in Barcelona in March was the first large cardiology meeting to fall under these new regulations from MedTech. We have known about the regulations for several years, so they were not a surprise to us. . .but we were the first group that had to try and cope with them’. Professor Camm said the essence of the agreement was not particularly controversial. ‘Essentially, amongst other elements, the MedTech code seeks to ensure that any sponsorship activity from medical device companies cannot be seen as a “bribe” to physicians to purchase products from those specific companies that provide the sponsorship’, he continued. ‘Instead, a physician who benefits from device company sponsorship should not know where the support is coming from. Throughout the period of the evolution of this code and its subsequent implementation, the assurances from the medical device companies were that they had no intention of harming the professional society meetings, and that they intended to make sure that their sponsorship remained sufficient to ensure the continued presence or continuation of these events over time’. Whilst acknowledging that there were other factors surrounding the March meeting that were remote from the MedTech code, such as moving the event to a point earlier in the year, Professor Camm said: ‘One of the huge problems was that although the code had been available for some time, companies had done very little to try and work out how the agreement would be implemented. It was as if they knew what they could not do—but did not know what they might do instead’. Over the last year, the EHRA has been in dialogue with companies and offered—with the ESC—to act as an intermediary. Suggestions included accepting funds from industry and allocating them to individuals who applied to attend the congress. To this end, the EHRA assembled a selection committee and a set of criteria, though this idea foundered as some industry sectors were not comfortable with monies being distributed anonymously while others made detailed stipulations about the type of person they wanted the funding to go to. Another proposal was for funds to be sent to a third party in a department of cardiology, hospital, or university to allocate funds. In some cases this worked, he said; in other instances this was against national or local rules. Eventually, a few hundred delegates were sponsored to attend the Barcelona meeting via this mechanism. ‘Because EHRA is so device-heavy and relatively drug-light, I would say at least 50% of congress attendees would normally be sponsored by device companies and perhaps another 10–15% sponsored by pharma and then a few by their own study leave arrangements’, he said. Attendance for the EHRA Congress would be 5500, and more for the former joint meetings with Cardiostim in Nice. In Barcelona, attendance was closer to 4000, with the ESC and EHRA delving into reserve funds to sponsor some 500-plus places. ‘This was paid for out of funds held in reserve for research, document preparation and educational projects’, he said. ‘The main reason we spent our reserve funds on bringing people to the meeting was that we argued that we should not let the meeting be a flop because once you have a reputation for having meetings that do not come up to expectations that would stick. EHRA/ESC sponsorship of our meeting could save our face until we and industry have time to think how better to do this in future’. CardioPulse 2443

Karolinska Institute, Stockholm, ResearchPart II. The Karolinska Institute in Stockholm, Sweden has been delivering high-level cardiology research for many decades. Professors John Pernow and Cecilia Linde reflect on the ongoing work of the centre

Petr Widimsk y, Head of the Cardiocenter and Dean of the Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady at Prague in the Czech Republic speaks about his career to Mark Nicholls. It was the summer of 1968 and the Widimsk y family were on vacation in Sweden. All seemed well on their Scandinavian sojourn, where Petr Widimsk y was staying with his father, the renowned cardiologist Jiri Widimsk y—who was considering temporary work in Gothenburg away from their home in Czechoslovakia at the time—and his mother Dagmar, who was a radio reporter. But as they switched on the TV on 21 August, they were shocked at the images flashing back at them. ‘We were seeing pictures of Russian tanks occupying Prague’, recalled Prof. Widimsk y. ‘My father immediately received an offer for a permanent job in Gothenburg. Even though much later, due to family reasons, we decided to return to Czechoslovakia, I realized that a good physician can find a job anywhere and that this profession is not under the influence of politics, as many other jobs were during the Communist regime’. Petr was considering studying biology or chemistry rather than medicine but switched to the latter, inspired in part by the circumstances on the streets of his homeland and the opportunities he felt a career as a physician would offer. As a medical student, he started to work in a nursing position in a specialized emergency ambulance service focused on cardiac patients. This ‘interesting work’ in what was effectively a mobile coronary care unit, led to his decision to become a cardiologist and enter a field where he was to have a pioneering influence, initiating a major change in the organization of acute cardiac care and the implementation of primary PCI in most European countries. Professor Widimsk y’s landmark PRAGUE 1 study was the first to demonstrate the benefit of regional networking on acute cardiac care services. Born in Prague in 1954, he has lived in the city for most of his life, apart from two-and-half years in the Netherlands expanding his professional experience. His father, now 92, was a Professor of Cardiology and head of the prestigious cardiology department in Prague (IKEM) from 1971 to 1983, and between 1980 and 1984 was also vice-president of the European Society of Cardiology. His brother, also Jiri, is Professor of internal medicine and currently president of the Czech Society for Hypertension. Prof. Petr Widimsk y, who is Head of the Cardiocenter (Departments of Cardiology and Cardiac Surgery) at the Charles University and the University Hospital Kralovske Vinohrady in Prague, emphasizes that his father did not actively influence him to go into the profession, leaving him with absolute freedom to make his own decisions, but added, ‘I have seen how he loves his work, and I have seen some of his patients, who became his friends.’ He underwent his medical training at the University Hospital Kralovske Vinohrady and the Faculty of Medicine of the Charles University, with a year spent research training at the ThoraxCenter at Erasmus University in Rotterdam, and for PCI training he spent a year in Zwolle in the Netherlands. He also recalls an enjoyable visit accompanying his father, when a 4th year medical student, in February 1977 to the meeting of the ‘Osterreichisches Kardiologen Treffen’ in Bad Gastein, organized by the Austrian Society of Cardiology. ‘That was my first visit from behind the “iron curtain” after our return from Sweden in 1968. I was very much impressed by the open, friendly atmosphere of the meeting, where the Board of the European Society of Cardiology participated. I met such famous people as Henri Denolin, Paul Hugenholtz, or Franz Loogen and besides listening to interesting lectures I also experienced a lot of fun with them’. There were a number of people who influenced him along the way, including his father; Paul Hugenholtz, ‘great person with visionary approach to cardiology’; and Harry Suryapranata, a skilled interventionalist and excellent teacher of research methods. Over the years, Professor Widimsk y’s research has covered a wide area of cardiovascular medicine; from echocardiography with a focus on myocardial function and perfusion and then to interventional cardiology and acute myocardial infarction, and more recently on acute stroke and its interventional treatment. But it is in the area of STEMI that he has gained renown as a pioneer. In 1993–94, during his PCI training in Zwolle, he saw the pioneering work of Felix Zijlstra, Harry Suryapranata, Menko-Jen De Boer, and Jan

Return home to Lebanon

Once named by Time Magazine as one of the world’s top 100 most influential people—some feat for a cardiologist—Dr Steven E. Nissen has been an inspirational figure, sometimes addressing controversial topics, in the field of cardiology and cardiovascular research. He has made significant contributions to advancing knowledge in the assessment of progression and regression of coronary atherosclerosis via the development of intravascular ultrasound (IVUS) and published several manuscripts on drug safety. Politically active, he continues to combine research and a clinical schedule with the administrative duties of his role as Chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic and Professor of Medicine at the Lerner College of Medicine of Case Western Reserve University in Cleveland, Ohio. His learning curve in medicine began at an early age. Born in Toledo, Ohio, in September 1948, Dr Nissen explained that his father Dr Edward Nissen was a GP but switched to specialize as an obstetriciangynaecologist later in his career and moved the family to Southern California. ‘I think I was always destined to be a doctor’, said Dr Nissen. ‘When I was quite young my father would take me to the hospital when I was 5– 6 and he taught me the names of all the bones in the body’. Later, receiving his medical degree from the University of Michigan School of Medicine, Dr Nissen completed his internal medicine internship and residency at the University of California, Davis in Sacramento, where his interest in the heart began under his mentor Dr Tony DeMaria, who was his attending physician in the coronary intensive care unit. ‘He was a very good physician and an accomplished academician’, he continued. ‘As I was finishing my residency, he had accepted the job as Chief of Cardiology at the University of Kentucky and approached me to be one of his first Fellows in cardiology there. I jumped at the chance because it was an opportunity to be in on the ground floor of something new and probably have more responsibility at a younger age than I would have otherwise’. He stayed at the University of Kentucky for 9 years before moving to the Cleveland Clinic in 1992, where he served in various roles including Section Head of Clinical Cardiology and Director of the Coronary Intensive Care Unit. Citing Dr DeMaria, who became President of the American College of Cardiology (ACC)—as his most influential mentor, who appointed Dr Nissen as ACC Scientific Sessions co-chairman in 1988, eventually leading to his role as ACC President (2006–2007). A key area of research for Dr Nissen has been the development of IVUS, which allows researchers to see and measure atherosclerosis that cannot be detected on an angiogram. That was triggered through contact with a company while at the University of Kentucky that had the idea of placing an ultrasound transducer on the tip of a catheter to deliver ultrasound images of coronary arteries. ‘At the time, a typical ultrasound transducer was the size of your fist’, he said. ‘I realized very quickly that this could be revolutionary. No-one had ever seen an atherosclerotic coronary plaque in a living patient, but they had a technology with the potential to visualize the arterial wall’. Initial animal studies with ‘the earliest rather crude intravascular ultrasound catheters’ began, but progress was slow and did not produce any useful images for several years, but he persisted and with interventionist Dr Cindy Grines, succeeded in producing the first images in humans in 1990, attracting mainstream media attention when presented at the ACC meeting in 1990 with a front-page article in USA Today. ‘They described it like the old cult movie Fantastic Voyage, starring Raquel Welch, offering the opportunity to look inside the body’, he recalled. ‘We then had the idea

Eduardo Marbán MD PhD

Internationally recognized research has underpinned activities at the Karolinska Institute (KI) for many years in areas such as coronary artery disease and atherosclerosis with a special focus on diabetes, and also a large research program on heart failure. Professor Cecilia Linde explained: ‘The centre is particularly renowned for ground-breaking clinical trials regarding the importance of diabetes for coronary artery disease and novel treatments and care of these patients. The centre also has a history based on the first pacemaker implantation. This field has continued to be an area of expertise, in particular due to the leading role that investigators have played regarding the development on treatment with cardiac resynchronization therapy (CRT) for heart failure’.

Three-dimensional imaging and printing in cardiology

After spending several years conducting innovative techniques and procedures in prestigious European heart centres, Dr Antonio H. Frangieh has returned to his home country of Lebanon to help develop a new structural heart disease program in Beirut. Cardiologists at the Hotel-Dieu de France, Saint-Joseph University Medical Center, in Beirut already regularly carry out procedures such as MitraClip and left atrial appendage occlusion (LAAO) and expect to reach their first 100 transcatheter aortic valve implantations (TAVI) soon. Now, explains Dr Frangieh, the goal is to transform the structural heart disease program into a centre of excellence, performing advanced and complex interventional procedures and acting as a teaching and training centre for the Middle East. Having undergone training in Zurich and worked at the German Heart Center in Munich, Antonio Frangieh is now back where his medical training began, with the goal to take cardiac care onto a new level for the people of Beirut and Lebanon. Born in Zgharta, a city in the northern part of Lebanon (in 1985), he grew up in a family with no medical background before moving to Beirut when he was 18 to study in the Faculty of Medicine of SaintJoseph University (one of the oldest academic institutions in the Middle East, founded in 1883). His interest in becoming a cardiologist developed at an early stage of his studies in a region with high incidence of coronary artery disease and prevalence of familial hypercholesterolaemia. Antonio Frangieh received his medical degree in 2010 and did his internal medicine and cardiology Fellowships at the Hotel-Dieu de France, Saint-Joseph University Medical Center, followed by a Fellowship in interventional cardiology (2014–2016) with Professor Thomas F. Lüscher and his team at the Andreas Grüntzig Cardiac Catheterization Laboratories at the University Heart Center Zurich and Zurich University Hospital. In 2014, he was awarded a prestigious Swiss Federal post-doctoral excellency scholarship that provided him with full tuition for training in Switzerland, allowing him in addition to complete additional medical training focused on Structural Heart Interventions including TAVI, MitraClip, and LAAO at the German Heart Center in Munich. Along the way, he was influenced by a number of people, including members of the interventional team at Hotel-Dieu de France Hospital who trained in institutions in France and the USA and returned to Lebanon to build one of the first cath-labs in the country, performing a high number of procedures, participating in several studies, and presenting at major European and American meetings. Dr Albert Markus Kasel at the German Heart Center was a significant influence, as well as ‘a great teacher and friend’ and Professor Lüscher gave him the opportunity to participate in multi-centre studies, receive high-level training and reach his goals. Research interests for Antonio Frangieh, who is an interventional/attending cardiologist and responsible for the Structural Heart Program for the Cardiology Department and Heart Center at HotelDieu de France, focus on structural heart disease interventions. While in Zurich he was involved in research projects on acute coronary syndromes, bioresorbable scaffolds, Takotsubo cardiomyopathy, MitraClip, and LAAO, publishing more than 30 papers as first author or co-author in medical journals. ‘My stay in the University Hospital Zurich with Professor Lüscher was a great opportunity for me to “boost” my research work, in addition to receiving excellent training in CardioPulse 2339