The presenter of this year’s ESC Andreas Grüntzig Lecture in Interventional Cardiology, Professor Javier Escaned (Hospital Clinico San Carlos - Madrid, Spain), has spent over 30 years investigating and refining interventions to ensure they keep pace with emerging knowledge and address evolving patient needs.
What first made you interested in interventional cardiology?
It was luck, really. I left Spain in 1987 to do my speciality training at the Queen Elizabeth Hospital in Birmingham, UK, where my interest in interventional cardiology was sparked by my mentor, Man Fan Shiu, one of the UK’s pioneers of coronary angioplasty. Although we only had balloon angioplasty at that time, it was such an exciting and promising field. Having been hooked by interventional cardiology, I then moved to the Erasmus University in Rotterdam, Netherlands, to do my PhD under Patrick Serruys. Since then, although I’ve spent a great deal of time working in interventional cardiology, I still consider myself first and foremost a cardiologist. I do my best to communicate well with my patients, and I enjoy discussing their condition and the type of intervention or treatment that might be helpful. In this sense, I keep trying to improve as an educator for students or colleagues and for my patients.
What are the key themes of your lecture?
In my lecture, I will discuss the crossroads that I think we have reached with interventional cardiology in stable ischaemic heart disease. Percutaneous coronary interventions (PCI) have transformed the lives of huge numbers of individuals and are now a global standard. However, it is time to rethink when and how we use them – we have both old and new challenges, some of them rooted in the central role of angiography for decision making. In the aftermath of the ISCHEMIA trial,1 the question is not about the suitability of revascularisation in stable patients, but how to ensure that properly indicated, high-quality, effective revascularisation is performed. We have major challenges, such as PCI being suboptimal to control angina, a fact that hampers its most frequent main indication. Also, due to increased ageing and survival, the risk profile of stable patients in the cath lab has increased to a point where average operator skills and equipment may not always be sufficient to deliver a state-of-the-art PCI procedure.
What are the current challenges in your field?
Andreas Grüntzig’s before-and-after angiograms are so compelling that it is easy to understand the central role of angiography in the operators’ minds. Inertia that accumulated over the first 20 years of PCI history still affects the practice of interventional cardiology in 2022. One main challenge is changing the current mind set away from the rigid angiography-centred paradigm and this is going to require education. We should also encourage the development of innovative technologies to tackle the increasing number of complex cases. The use of a compendium of systematically applied best practices similar to that used in the SYNTAX II trial,2 integrating developments in physiology and imaging, competence in complex PCI subsets, risk stratification of patients and simulation of predicted outcomes, will be instrumental in improving PCI quality in stable patients.
Where do you think interventional cardiology is heading in the future?
We are working towards making the cath lab not only a place to deliver interventions more safely and effectively, even in complex cases, but also a valuable source of information to enrich our understanding of heart disease and inform patient prognosis. It is clear that many of the opportunities will come from non-invasive imaging, such as computed tomography angiography, and the interventional cardiologist will have to become proficient in these, as currently done with structural heart interventions. In addition, artificial intelligence is going to be vital in helping to identify more reliable predictive models of the risks and benefits to the patient of different interventions.