Spencer King, III, MD joins Georgia Heart Institute as a Cardiovascular Grand Rounds speaker during the CME lectures for 2022. Dr. King is a professor of medicine, emeritus at Emory University School of Medicine in Atlanta, Georgia. Dr. King leads us through a half century journey of Coronary Interventions and the speculation of where interventional cardiology could lead to in the years to come. To receive CME credit for this presentation, please visit the survey link. [https://www.surveymonkey.com/r/9T6YWSM]
Good morning everyone. Welcome to Georgia heart grand rounds. We thank boston scientific for supporting today's activity. The planners and presenters have disclosed no relevant financial relationships with any commercial interests to claim. CmI credits today answer the survey evaluation. If you are viewing via online, the link will be put into the chat. Those attending in person will receive the link at the end of this morning's activity. If you have a question for the presenter please type it in the chat section and we will read it at the end. And now dr samity will introduce to you our guest speaker. Well good morning everyone. It's it's a privilege to be here this morning. And this is uh the second of our cardiovascular grand round series at the Georgia Heart Institute. Um And it's honestly my distinct pleasure to introduce um sort of an icon of cardiology. Um certainly an icon of interventional cardiology but um also one of the most amazing people I know um And he's been a friend and a mentor for me over the years and just with the interactions you've seen here um He's he's really an amazing person. So with that said dr Spencer king is currently professor emeritus um at Emory University. Um Spencer. Um I think spencer you grew up in the macon area. And um so he's he's the son of Georgia and he um he uh initially came to Emory University to train. Um And at the time he was telling us at dinner last night that there was really no coronary angiography. Most of the catheterization work was sort of valve work that was being done. Um But Spencer was always at the cutting edge, has been a pioneer and coronary angiography, which he really was one of the leaders to help develop pioneer and interventional cardiology. And some of you may have seen the multipurpose catheter that folks have been using. Well Spencer was a co developer of that. Um And over the years he has trained more than 100 and 50 cardiology fellows. In 1972 he became the first director of cardiac catheterization laboratory at Emory University Hospital. Um I understand a few years before that he used to come to Gainesville to do some moonlighting in the er um So in 19 late 19 sixties as a fellow at Emory used to come up here in moonlight in the er and stitch outpatients at Hall County Hospital. Um But over the years amongst his many many accolades um is that he recruited Andreas forensic Um who in 1980 came over and with Spencer King. And and really his mentee John Douglas. Um they opened up and revolutionized the field of medicine and and and really launched interventional cardiology. Um Spencer was the was the chairman of the East trial which was the N. H. L. B. I. Trial that compared coronary bypass multi vessel angioplasty many years ago. Um He um in 1998 was president of the american college of cardiology. Uh And a year or two later he became president of the Society of cardiac angiography and interventions um for those of whom who have taken the boards and interventional cardiology. He was um the chair of the interventional cardiology boards of A. B. I. M. For 10 years from 97 to 2007. So if there any complaints, you know who to go to. But the founding of that and then he really was behind um the concept of taking the Journal of American College of Cardiology and creating a jack cardiovascular intervention. Um And he became the founding editor in chief of that journal in 2008. As you know, that journal is is now the highest impact cardiology interventional cardiology journal in the world, the most circulated journal. And for a decade he poured passion um and expertise and leveraged all the people he knew around the world to really elevate our field to that level through that journal. Currently. Uh Spencer as chairman of the new york state cardiac registry, which as you know, has published some very very profound and impactful work on on all aspects of cardiology and some aspects of cardiac surgery. Um and he's participated in many many committees at the American Heart Association American College of Cardiology and the NH L. B. I. Spencer has co authored more than 600 papers. Um he's edited and co edited more than 12 books um including interventional cardiology hearst the heart. Um and um most importantly, um he's gone back to his roots and he's gone to mercer university um and for the for 2017 and 18 with chairman of the Board of Mercer University. He's now a lifetime trustee of mercer. And um in addition to the really momentous impact he's had on our field, the whole concept of coronary breaking therapy that was initially um a thought to try to treat restenosis on the early days of restenosis. Almost every drug that was tried. Um Spencer was involved during the cutting edge of that. Um And amongst many honors his master of the american College of Cardiology got the lifetime achievement award at T. C. T. And and and on and on I want to say um that I met Spencer in 2003 um when I we were interested in coming back to Atlanta and we had interviewed at Piedmont Hospital at the time he was there um and then of course I met him when I moved to Emory in 2005. Um but I can tell you that and in my travels um you know he is probably one of the one or two people in the world that I think has impacted our field and almost everyone he's touched. So it's it's with a great pleasure and distinct honor for me to ask Spencer to really launch these grand rounds series for us and to talk to us about coronary interventions a half a century journey Spencer. I was enjoying that so much. I didn't want it to stop. I hope you film this. I hope you got all this down and I'm gonna use it in the future. Well yeah, it is a great pleasure to be back here. Uh, I say back here because yes, I did work for Hall County Hospital back in the day and tried to sew up all the, all the teenagers who were crashing their cars up in in the mountains. And now I drive by here frequently because we have a place up in lake Burton. So, uh, I think it's important that I have a chance to actually stop here and see what goes on also. Uh, uh, physicians were very important and when I came back to me and started the cath lab at Emory, there's nobody else uh, in town doing coronary telegrams except who was doing it down at ST joe's infirmary, which was downtown Atlanta. And so uh, dicks dribbling, uh, sam poole, Henry Jennings. These guys in Janesville were major refers to me at Emory and we got to help me get the cath lab going at that time. So it's a, it's good to be here. Uh, I think you've heard the best part of this already. So, uh, the rest of it may not be so interesting, but I hope, I hope you'll find it interesting. So we're talking about a half century, half century as I counted. It goes back to 71. I came to Emory in 72. So, this is not an autobiography, but but there will be some personal aspects to it as well. And the one thing, the only thing I didn't do, and as we prepared this is to figure out how to change the slides. So there we go. Uh So, what I'm gonna talk about is not all of interventional cardiology, but uh coronary revascularization and how it started and how we got to where we are. And perhaps uh some speculation about where we may be going. Certainly, it all started with Broonzy, but before there were people that were critical um and they came from different disciplines. Forsman, you remember, there was the German who first put a catheter in his heart, his own heart, and back in 1929, and just showed that it could be done. We were doing a course in the Mediterranean one time, Willis Hurst and Bruce Logan uh Ellis jones and I were out there and we were given these lectures and there was a fellow who attended the lectures from Kentucky was a german man from Berlin, originally from Berlin, and he had known Forsman and uh the quote I remember was forced mine, yes, the stupidest man ever to win the Nobel prize. That was that was his assessment. Uh But uh we grandson would never have gotten there without without mason sones figuring out how to do coronary artery ah graffiti, direct coronary artery ah graffiti. And without Renee Cavallero figuring out what to do about it. I mean there were other attempts at bypass surgery but Renee for Valero certainly deserves a credit for uh putting bypass surgery on the map in my view. And then there were people who said can we do it a different way, Can we open up arteries, charlie, Adada radiologist uh was passing catheters into the leg trying to open up the iliac arteries and federal arteries. But by simply taking the diagnostic catheters various sizes and shoving up through a lesion and opening them up and then having a telescoping catheters like that and many many others have contributed of course and and some of those are here uh The approach we use now uh is the selling approach. Regardless of whether we're doing it from the leg or arm or whatever, we do it by putting a needle in and then starting the procedure. Melvin judkins created a lot of the catheters. We use some people uh don't know this, but you know those curves on the on the judge judkins. Catheters. And you see there's a radius to those curves that judge jones left and right and particularly left has a certain radius on return. And and I asked his technician once uh what how did he come up with that? It's brilliant because they seem to fit and work well he said well in the cath lab there were these three quarter pipes that came and we would heat up catheters and bend them around those pipes. And that's why the that's why they're shaped that way. And we just did that to see what would happen. Uh verner Forsman was a was in Berlin and he was uh had this idea that grinchy later incorporated the idea was what if you could put a catheter in and then uh not to have to be like the uh daughter technique, you didn't have to have a huge catheters to open up a large hole in the artery, you could go in and then expand your catheter. So he had regular catheters with slits cut in them uh in a balloon inside to try to stretch the artery. I don't know if it was ever used, but he did come up with some gadget like that, but ever heard Zeitler who who adopted the the daughter technique, although it was dropped in the U. S. Hardly anybody did it because daughter was perceived as being a bit out of left field, He had an article in uh look magazine uh which made him look like a crazy scientist. And and uh he was a bit of a century uh and people said we're not gonna do that, but in in europe people were doing it and thank goodness that ever heard Seidler was doing it because Eichler eventually met Andreas Grundy or Grundy met Zeitler and here's grune Z talking to Ziggler on the left and and charlie daughter and and Broonzy, crystallized this idea of how to develop a technique that could eventually be used in the coronary arteries, started out in the peripheral arteries. And uh it was developed literally on his kitchen table in his own flat, in Zurich. Uh this is probably a recreation of some of the stuff that he used, but he made these catheters, they were uh plastic material. He he learned how to mold them, he put them in his own oven. Uh this kitchen table of uh sat out many times. Even in recent years, his wife still lives in the same flat, but he made these catheters. Uh you say, you know, garage, garage industry? Well, this was actually a kitchen table industry And uh in the peripheral circulation. These things were applied. And starting as early as uh as 1973 and four, he was doing this kind of work, But in 1976, he came to the american Heart Association for the first time to show his experimental work in making it work in the coronary arteries. And this exhibit, which this poster uh was on on one roll and on the back of it. Uh I had a poster and someone came to my poster and said, you gotta see this thing, there's a guy over there that's putting a balloon and coronary arteries and trying to open them up. So I went, and uh this was a dog experiments whereby he litigated the coronary artery with with with a ligature and then put a balloon in and blew it up and broke the ligature. And showed the physiology of uh of doing that. So the premise of gradient go down open the artery and he has some histology on this poster and what's not this post. I've had all these years since Andres died and currently it's on exhibit at the American Heart Association American College of Cardiology in Washington uh prominently displayed there. The idea was finally a year later uh uh taken to the patients. I I told Andrea's when I saw this poster in the time this picture was taken I said that this thing is never gonna work. But a year later he showed up again at the American Heart Association to give another talk about the experimental work. But in the published poster there's nothing about patients but he showed for for examples that he had done and one of them was what was his first patient? Mr Bachman. And uh he had this proximate L. A. D. Lesion. But the balloon in blew it up you see above the uh the precursor of fractional flow reserve. You see the you see the pressure was there the pressure gradient before he crossed the legion, no gradient. Then he crosses and you see it and then blows the balloon up and the the gradient is relieved. These balloons uh did not have guide wires, they did not have a central looming for guide wire but they had a lumen for pressure from the tip of the catheter back. And so you could hook up uh to that loom and to get distal pressure and then you got proximal pressure from your guide catheter. And that's the way these catheters worked. Well once this was done and that was a huge event at the at the meeting in uh in my in american art meeting that year. Everybody wanted to go to Zurich to learn about this. And uh this is actually the third meeting in Zurich. And there we all are in there listening that they got bigger and bigger um Everybody would like to go and sit in with him. But people in Zurich said you know you can't do that, it's disruptive. So he began to have these live courses and he had four of them, they are in Zurich. And if the uh third course, the one is pictured here, which was January 1980. He sat down beside me and uh in a train and said you know I think I'm gonna leave Zurich. And I said where are you going? He said I'm either going to Germany or to the U. S. I said if you go to the U. S. Where you gonna go? He said well, Cleveland clinic is very interested and that's the most famous place for bypass surgery. And I think that would be perfect place for me. So I said well that's that's great uh what what what do you really want to do with this? He said I want to be able to guide this procedure, I think it'll get out of hand, I think people will ruin it and I want to be involved in all the early development and I want to be a professor. Now some of you have been trained perhaps in europe, have been to places and understand that the european concept of professor is different from ours. Uh the the professor kind of controls everything including the money in a lot of universities in europe. And he wanted to be a professor. So at that point I said well you got a problem, you can't be a professor at Cleveland clinton. And he said why? I said Cleveland clinic does not have a medical school which they did not. And uh it kind of stopped him and he said uh oh my goodness! So what should what do you think I ought to do? And he had had office from boston and and stanford in different places. I said why don't you uh you know give us a call, you're gonna be in America next week at the snowmass meeting and said why don't you give me a call? And he did, he called and he said I found out I can get a flight back to Zurich through Atlanta and I'm gonna do that. So he came and uh so I said oh now what did I do? Because I hadn't told will anything about this. So Andres was at my house and I go over and I say uh dr hurst this fellow Grimsley guys is I want you to meet him and he said oh no no no wait a minute. He said I've heard a lot about this guy's a prima donna, I don't want you to get involved. I said well as a matter of fact he's at my house and I appreciate if you would just meet him, so uh take him over. Uh he met Willis hurst and Willis Hirst was was in love with him immediately. Uh Andreas was very charismatic and uh and and very clear with his interest in the science of of this whole business. So this began our recruitment effort and we finally were successful. This is a picture of my wife and his wife and his daughter up at his little cabin overlooking the lake of Zurich. And and uh so uh this was uh that summer after that part of our recruitment effort, Gail stayed with him for a week. Eventually they decided to come to America and we started these courses. I'm impressed with this screen because one of his requirements was that we have a uh big auditorium, some of you have been in the auditorium at Emory and the woodruff building and uh all these people want to come and see it and he says, I want to have a screen for the video images from Catalan and also the live image of himself speaking or whoever is doing it. So uh we had this uh these two rare project screens that have talked to uh you're the guys hear about. There were state of the art at that time, high high resolution, quote high resolution. Uh but we to do that uh we couldn't transmit the signal by satellite or anything. Uh So we had we had a fiber optic cable which still exists between the Cath lab and this auditorium to take the direct video image and pipe it into the auditorium so that we could have high quality images for people to see. And those courses where some lectures very little because there's very little information to pass on from a lecture. But there were primarily cases that we did. Here we are. This is uh Dick Mylar uh next to me and Andreas as we did of course. Is there something idea address? Yes. You're ready to go. We're ready for you. Let's go ahead. We already have done our and dr stenosis is here. This is just a continuation of the stenosis is to diagnose. So we have already here at the capital here. Train your regulated the whole thing is taking this way and this way. So how's your chest? You must it worked. Yes. What do you feel now? What kind of pain can you describe the location of pain? But wait a minute behind the chest. There are two interests in conflict. You may see this the interest of the patient wants to know how it's going and I want to know how the pain was. So, there are two interest conflicts here. The patient is always right. So, we answer his question. I think it's going all right. We have crossed, just inflate the balloon it, open it up. Yes, but we are not finished yet. Now, you answer my question. This is the last we are using to protect us from uh, from x ray radiation with side classes as well. Then we have also something here which I'll show you is to protect our can you see, protect our variation, the other things. Other things are routine at a very, very intrinsic component of the whole procedure or those shoes without it. You will never make it to the shoes. The shoes without those shoes. I did something. Okay, okay. Andres we'll see you over here. So, he was quite a showman, as you see. And uh a lot of people came to these courses and and we did we did cases and and they watched and sometimes things went well. Well, uh the first course we put on the last case was one now and I said, well, let's send them away with something that these guys are gonna start. So, we had this type a lesion L. A. D. Very simple straight forward. Of course with the kind of equipment we had in those days you had to be fairly straightforward. Uh He said, well tell so he's doing the case. I'm I'm making the presentation. I said now if you're gonna start this is the kind of case you should start with. So Andrea's Catherine blows the balloon up. That the vessel totally includes patient goes into ventricular defibrillation. I cut this transmission and anyway, positions uh survived. But I think we did a favor because all these people probably half of them decided they didn't want any part of this. So we probably saved a lot of lives for people that didn't go into interventional cardiology. So I this is all history. But uh since that balloon, I often think about what is the most important development. And uh actually Patrick Sarah has asked me this question once we got to thinking about it. And of all these things, uh the most important development is a guide wire, not just guide wire, but steerable guidelines. And that's what enables all the things that can be done today. And that's why we have this uh fight between surgery and angioplasty on some patients about who should have which one. Because prior to that it was a very small number of patients who actually could have angioplasty because you couldn't get to the lesions. But now now you can. And I look at the what's happened since those early days in in in four different decades. Once the balloon of course, 2nd 10 years had to do with new devices, all kind of things, cutter scrapers, uh a threat to me devices, lasers of all types and the one that came out of it with stents. And then we go into the stent era and finally something to oppose. Restenosis, name of the drug, eluting stent era. And now some other new ideas are coming coming to the fore uh In the 80s, uh, angioplasty evolved a bit to have a potential to compete with surgeries. As said, we we uh Andreas had proposed a trial before he died in 85. It was not a approved by by the NIH, but in 86 we uh reapplied for it. Uh We made change as we put in a very high level um data and safety monitoring board, including Larry Cohen, who was the chairman from Yale and uh uh Sabiston from Duke and people like this. So we got some heavy hitters there to go to to NIH and try to get this approved. And we did get the first uh R. 01 to study this question of angioplasty versus surgery done with balloons only no stents. You know, just what we had starting in in 87 when we began doing them. And then uh um So but before Andreas died, he perceived that the balloon was not gonna be the end of this story. So here's a little uh interview with him about what he thought about things that most of our province at the present time. The balloon catheter is quite a good answer. But the more we depart, as I said, two more diffuse disease, the more we have to change our directions to additional catheter systems, catheters or instruments, which then could solve problems like getting rid of a dissection, which is like a flap hanging in the lumen, obstructing the blood flow catheters who are able to to eliminate mobilisations, plucks drawn by etcetera. So we have to have more armamentarium that the balloon catheter only. We need more than that. So indeed uh new things came along. There were so many things that everybody came up with and we used to have put on a course in santa Barbara, a nice place to do it. But all we invited everybody that had developed something and they came and we did this for about eight years in santa Barbara and published a few books related to that. There were lasers of all types there, everybody had some kind of laser gadget and we, the kind that's available now was one of them. But there were things including uh balloon laser. Uh Richard spears came up with the laser was inside a balloon And uh most of these things didn't work. Uh 11 was called spark erosion and this is like a bovie just to burn your way through. Uh now cycle has gone through now in structural heart disease. That's kind of technology is being applied but not in the coroner's uh threat to me. John Simpson's device uh was a big splash for a while and then faded out. So many other, there are a lot of these kind of devices but the one that survived was the stent uh stent was first brought before Andres down 85. This fellow caesar Gianturco radiologist brought this state. He had developed a peripheral circulation and it was a just a wire coil that was back and forth. And uh it looks something like a the spring on a pin or something like that. You see a picture of it here with the scanning electron microscopy. So we we studied this thing in the experimental lab and pigs and saw the healing of it and and and what it did with platelet adhesion and so forth with keith Robinson doing most of the work. And Gerry Rubin was a fellow then with us and he worked on it. So that was that was our first exposure to stents. But when we put these stents in, we created another problem. The stents by the way, were not designed to cure restenosis. And stents were designed to solve the major problem, we had which during our first two years we sent 6% of the patients for emergency surgery and you can imagine how popular we are. We're particularly friday afternoon, both with surgery and and anesthesiology. So these were two to solve that that that issue. And indeed we we we did a got approval for a single arm study of stenting of a patient to noticed as a patient had an acute closure at the time of the procedure. Uh we would still go to surgery but we put a stent in to open the artery and maintain it open till it got to the O. R. And it stayed in of course. So we did 10 cases like that and that kind of got us going. But then it became clear that putting stents in really resulted in more neo animal proliferation than than uh than if we didn't put a stent in. So In 1989 or 90, you know, here's where we were in our thinking about restenosis or perhaps by utilizing compounds that will tag two things that are in the vessel wall that will stay there over a period of time and perhaps by placing stents or some other polymer material in the vessel wall that will elude drug over a long period of time. In conclusion, I would say that restenosis is a multifactorial problem that I think will be solved by number one improving the initial result of angioplasty, both by utilizing diagnostic and new therapeutic tools to end up with an artery that indeed is open. And it's not like some of these who died that Bruce Waller has shown you secondly, there must be a biochemical approach to hold that artery open and reduce the proliferating response. It may be that the key to that is in thrombosis, it maybe it's in a combination of reducing thrombosis and also treating a long ongoing proliferated stimulus that may come from many sources, including inflammatory cells, including autograph uh effects from dying smooth muscle cells themselves. Uh And it may be that once the potent therapies have been found that we will discover that they're too potent for systemic use, which will spur on new development in interventional cardiology to find delivery systems for drugs to be placed directly in the artery. Thank you very much. So this was a symposium where I mentioned thrombosis, valentin Fuster had given the talk right before me and he said it was going, it was all thrombosis, we needed to find a way just to block the thrombosis and restenosis would go away. But so but we were convinced that this was a wound healing kind of problem and that we really needed to block the uh the cell growth. And and the idea of breaking therapy came from the fact that uh plastic surgeon's dermatology and so forth, that people had figured out that if you got key Lloyd scars and you remove them, you radiate the skin, you could block the redevelopment of the key Lloyd, you could treat the iridium on the cornea with radiation. And so the the concept was from that that we started this and this was effective in and for a while until of course uh drug eluting stents came along and and were much more efficient and effective way to deal with the restenosis problem. Now this is this is after the first drug eluting stents were restudied six month restudy of patients done in Sao Paulo brazil. Here's Eduardo Sosa uh opening once campaign bottle in patrick's arrows on the other side. And everybody celebrating the fact that the patients, they restudied 15 patients at six months and none of them had re stenosis. And so there was this big celebration going on about this. Of course, interventional cardiology has developed many other techniques and critical among those have been intravascular imaging, uh diagnostic things such as uh ultrasound, which uh is now still underutilized. But uh I'm sure you all are doing a lot of this uh to optimize the selection of therapist for the artery also to judge the outcome optical coherence tomography gives these incredible images of the vessels. Uh The physiology that the fractional flow reserve for the pressure gradient across lesions has has been uh very important development in interventional cardiology helps us understand whether lesions really need to be treated. And and now clinical trials if have indicated that at least for angioplasty. Uh the treating treating the allegiance with with significant obstructive uh physiology is more is more helpful than just going and treating things based on the angiography. So where are we now, 43 years or more later, coronary interventions have progressed. Uh no question about it. Uh and despite the dominance of surgery and in clinical trials in the past, uh it's still hard to figure out whether to do surgery or angioplasty in some patients. And I've watched this and now that I'm not doing it anymore, I've become a bit more philosophical about how you are going to decide these things in a fast moving changing field. Uh The uh in the East trial, we saw that There was a comparable outcome initially. But as we followed patients with diabetes, even in east, that was a small group of diabetic patients. The whole trial was 400 patients. But we saw the diabetic patients did not do as well with angioplasty, even balloon angioplasty, the kind we had and the kind of lesions we chose back then. And that's remained true through a lot of these studies up to the present time. But as I watch what you all do, I began to wonder uh what what where is this all going? Because lesions like this? Left main disease bifurcation lesions now are treated uh routinely with interventional techniques. Is that the right answer or not. We've got trials. Now that suggest it may be okay for a lot of left main lesions like this. Uh The use of support devices that scene here uh has uh is still being evaluated, how helpful how necessary that is. Uh These are very expensive technologies that we continue to wonder about uh severely calcified long severely calcified diseases. Now treatable formally this would never have been uh successful to treat these things. But now you've got a threat to me devices that you can do this with um chronic total occlusion czar, the most common thing that move a patient from a pc I. Candidate to a surgical candidate. And I picked out an extreme of this. But here's a patient that for some reason uh surgery was not done basement had a total occlusion of the circum flex. The right and the L. A. D. Here you see the sir complex artery uh opened up and then the right coronary artery uh opened up somehow the L. A. D. Opened up. So the fact that these things can be done has has made it uh now really important to question their their new technologies still that we are just getting into. Uh I just looked at a paper reviewing all the shock wave that little trip see uh papers trying to come up with an answer is this good? Is this better than a threat to me is it's better than a rotor blade er for for these calcified lesions. And the conclusion is that it's really good. But the conclusion is totally flawed because nobody's compared these things directly head to head in randomized trials. But it may be who knows that the idea, I've always had this idea that uh in fact, I had a nice video took out the second time. But I always we tried everything in the early days of angioplasty. How do we open the artery better? And yet you gotta clean opening and yet not dissect the artery and not cause trouble. And we tried all high pressure, uh long inflations, all kinds of different techniques. And I always thought that this is a calcified mess and just pressing on on the on the pavement will not will not open it up. And what opens it up is this guy with the jackhammer going with this pulse style force. I said this, we need a jackhammer in the coronary artery shockwave is is kind of what that is now. Uh the drugs we delivered, do we always need stents in there, We can block richness. We drug eluting balloons. These things are all just coming around and to use in a way that we can decide when and if they need to be used and whether they're gonna improve things at all or not. So, as we struggle with the idea of who, to how to revascularization people and at the present time, how do we get to that? So, I was invited to participate in this uh review of the subject with Patrick Roy's and we looked at a lot of things that I talked to you about about this historic breakthroughs and perspective in publishing Jack a couple of a few months ago. And uh we uh but in there we looked at something for the sake of time. I'll just mention one of the things that we I found very interesting. And that is there's a conflict and left main disease between trials is a is the exhale trial showing that the endpoints are about the same between surgery and Pc. I. So left main. Okay, that's fine. Then there's a noble trial uh from europe that says uh no surgery look better. And you say hi, is this how do we get this disparity? Well, it's most a lot of these trials relates to what the endpoints are and how they are adjudicated. And you can see here that in the bottom left of the where it says Sky or Excel definition. That's the that's the definition that was used in the in the Excel trial comparing surgery and P. C. I. And that that definition uh you if you had a peri procedural M. I. Based on enzyme elevations of a certain type. Uh You were you went down as having an infarct and if you use that definition on the in this case the Centex patients, that very famous trial Syntex. If you just apply that definition, what you get is what you get on the bottom left. That is that surgery and Pc I are the same. On the other hand, if you use the definition that's now more commonly used. The fourth universal definition of M. I. Where it's much harder to get a defined definition of a para procedural M. I. You have to have not only elevation and enzymes but other supporting evidence. Then you see looking at it that way surgery is is significantly better than PC. I. So a lot of these trials you look at, we need to be very careful about how the endpoints are indeed adjudicated. Uh If you look at meta analysis of all the trials of drug eluting stents, uh you say, well, how how do we decide based on certain characteristics? And one of those characteristics is patients with diabetes. And you see that if we look at uh one of the most current and complete meta analyses. The surgery still does better with diabetic patients. Same thing we found 30 plus years ago in the east trial. A very small number, but it still remains the case uh for diabetic patients, patients without diabetes, you can't show that the randomized trial show comparable outcome at five years. And then you see a divergence depending on whether it's left main disease, which ironically seems to be a little better and plastic seems to to do do better than their comparable to surgery. And this put those trials together. Triple vessel, particularly uh extensive disease does better with surgery. These are great generalities of course, but we still are uh learning now to compare where we are today uh to those trials though it's difficult because the fields are moving so rapidly. Not only in uh the initial therapy but medical therapy patients are getting and so forth. So here you see if we took the Syntex trial, Syntex PC. I at the top you see a certain number of events. And then a trial called Centex too, which was a single arm trial. But using the same kind of patients that done years later after Syntex. You see that the Syntex to P. CI patients uh did about as well as the Syntex uh surgery patients did from the original trial. So you might say from that. Gosh, we've caught up with surgery. Things are fine and everybody ought to have P. C. I. But the surgery doesn't stand still either. The bottom. You see the uh the uh the Syntex of surgery patients again there in points compared to the Excel uh left Main patients. These are this is all left main disease. And you see that left main disease treated at the time of Syntex had one outcome. And uh now in the Excel trial and much much improved outcome. So uh both technologies are improving slide didn't work. But it showed what I just told you that diabetes worked. So finally we do have a trial of the current stents, the second generation stents much of what I showed you and that other slide including the Syntex trial were with stents that were first generation, not as good as we have today. But now we have a trial of the current modern stent. We have a trial that also includes the use of fractional flow reserve uh only treating the significant lesions that with P. C. I. Was found to be helpful. And uh that's coast called Fame three. That was just published in the new England Journal. Uh And And what we saw in Fame three was that the composite endpoint which in this case uses the uh the definition of para procedural M. I. That's very much like that. Uh Fourth universal definition which does not punish surgery. Uh So if you use that definition uh with and you also include repeat revascularization as an endpoint. Uh You see that surgery does better than P. C. I. At one year, wow this was a trial of non inferiority. It did not meet non inferiority. Uh I'm speaking of it like a superiority but it clearly looks like it's better and uh with with surgery. And when we look at the kinds of patients that we're doing and go back to the things that we worry about in our selection process uh namely diabetes here. You see the diabetic patients seem to do better with surgery and patients without diabetes do about the same. And this has been true throughout the entire period. Although there are other, you know smaller studies that that challenge that concept. Uh And again that's that's the average outcome? That's not what every patient's gonna do. Uh What else? How about um the Syntex scores is one of great interest. How severe is the disease? Uh The Syntex trial divide provided patients into three terse isles the most severe the intermediate and the and the low risk. These are all patients. Uh Here we're looking at with three vessel disease. But the ones that the low risk did not have a significant difference. Whereas the ones with higher Syntex score did have a better outcome of surgery. That's in line with what we what we have gained from previous trials and meta analyses. So even with this uh trial which were set out to look at the new stent and the new methods of treatment and the new uh medical therapies that we're applying more vigorous anti atherosclerotic therapist. This is what we get. So this is the evidence. This is evidence to deal with as we select patients for surgery. P. C. I. But it only informs the decision. And uh as I think about it, every patient is different. But also every institution is different. And uh I've talked about this for years even before. The evidence with angioplasty was as good as it is in japan and china and whatnot. And uh I would show for certain patients advantage of surgery. And then we had finished my talk and uh with a present a patient which clearly should have surgery and then I'm dead. They all had P. C. I. Because they weren't doing surgery hardly. So what what happens at the local level to the patient depends on what the capabilities are and the results are in the in the local experience and the evidence which sounds like the gold standard thing of the randomized trials are critical and informing us but it cannot be applied independent of local experience. So let me conclude by talking about where we may be going. Some of the things what about what the real endpoint that I always talk about with? Uh Habib is uh what I want to know. Uh Not so much uh things about re stenosis and re intervention and what not. What I want to know about is who has events? Who has real serious cardiac events? Who has heart attacks. And as we look at patients to select for revascularization in the first place. Uh That's that's a curing engine as is one important one. I think we're all on the same boat the same page there. But also how do we prevent events in the future? And the question is how many of those uh events occur in places that were not physiologically obstructive or even an geographically obstructive. And now we have some evidence that we knew more about the plaque. And we knew more about the physiology. We might understand which plaques are gonna get us in trouble. Uh So in this study looking at the at the lipid content and the plaques uh and also the mass of the plaque. Uh They were able to show some difference in outcomes. Not hard outcomes. Most of this was just who who uh had revascularization and so forth. But this is certainly an interesting area. Now the real question is are we gonna be doing our imaging in the Cath lab where we're gonna be looking at all these things non invasively with C. T. And geography. And of course we are looking at that uh the Cath lab folks here not out of a job yet but at some point we're getting more and more towards uh looking uh with uh with these with these methods and of course this is an area of extreme interest to the group here at at the Georgia part institute with Georgia Heart institute actually I love that name. Uh A lot of the work done in the lab in the beeps lab at Emory elected this and look at the impact of share forces how the blood flows over these plaques of how plaques form also how plaques rupture and this kind of uh flow dynamics has been a critical component. Also characteristics of the plaque. Some solid characteristics like the low attenuation plaque. The positive remodeling the amount of plaque you have the the calcification. Spider calcification. All these things may be important. Uh Kind of the one of the most important ones is the thickness of the cap over the over the plaque. And that one, I don't think we've solved yet. But there are technologies, technologies that may be able to take the patient do noninvasive imaging come up not only with whether you have obstructive disease, but what the prediction is just like the Watson computer that tells you if the elevator is gonna fail or the airplane's gonna engine is gonna fail to tell you if the current order is gonna fail somewhere in the future. So where does this leave our specialty? Where does this leave the interventional cardiologist? Uh You mentioned that I share this new york state registry and I looked at our data and for elective patients in new york state, we've declined uh this much in elective cases over the past decade. So, elective interventions have actually gone down, not because surgery went up, surgery went down as well, but uh it went down primarily because uh things like the ischemia trial, things like more confidence in medical therapist modifying uh the progression of disease may be influenced things certainly emergency. Uh Kath unstable syndromes have not gone down and stem e of course it remains high. So what are the prospects for the future? I think for stem E is probably stable. I think virtually every stem e that happens ends up in the cath lab uh you know, with with some exceptions, but nobody's doing throwing politic therapy. We have cath labs everywhere. You know, people can get to E. M. S. Has gotten better. I hear it's fantastic here, acute coronary syndromes. I think that's also a stable situation because most already being referred. Uh they've also been renamed we we used to have a lot of stable scheming heart disease but because of the reimbursement for hospitals, um you get a lot better reimbursement if you're unstable. So I find that very few people are stable anymore. Um The true stable elective things, as I pointed out, probably declined. Uh redo revascularization is going up because of the technology. You can do these things surgeons, surgeons, surgeons don't want to re operate lots of times. And there are techniques to deal with patients that had surgery years ago, that angioplasty many times before. So the redo field. Okay. That's that's that's a business for the future. And what about this asymptomatic patient? What about interdicting plaques? What about elective stinting or some other intervention to try to prevent events in the future. That's a that's a whole speculation depending on on multi scan ct and physiology and perhaps other diagnostics that will tell us uh eventually when we have trials of that sort of thing, whether we can actually do anything about it. So there's an area that for those who are early in their career in interventional cardiology. You may not have to go totally to to taffy and other things to keep you in business. There may be coronary work related to that. Uh but these advances may indeed make diagnostic coronary artery grams obsolete somewhere in the future. And if noninvasive imaging, physiology and biomarkers ever able to identify which patients are going to have events in which are not. The new question will be. What will P. C. I add uh to advanced medical interventions. We've come a long way from Andreas Poster presented in 1976 and Sean here in the heart house in in Washington. And we've come a long way from Mr Bachmann, the first patient and went angioplasty. Still he's doing fine. He had his angioplasty done with the simplest crudest technology you can imagine. But he's still kicking and looking probably better than Bernie Meyer, who was the person who identified that patient and took him to Andreas. Bernie was a fellow, was a resident in in Zurich at the time and certainly better than the old guy on the other side. So, coronary interventions I think still have a bright but a very different future and it will be up to some of you to determine what that future will be. Thank you very much how that was amazing. Um So um I I obviously have a few thoughts but I'd love to open it up for questions. Um And do we have a microphone? Suzanne dr King. Um Thank you so much for sharing your wisdom and um experience with us. I mentioned this to you before. Please share with us how you look so good and so healthy at your age. You don't have to share your age. But I just want to make a comment. You just uh, agree with her baby. You're an icon, the cardiology into the field of cardiovascular medicine And it's an honor for you to be here sharing your wisdom with us. I don't know how to look, but, but I am uh, whatever have garlic is due to my mother. Not to me. Yeah. Because everything I talked about the course pales in comparison to what what happens to our bodies when, when we inherit uh, bad luck or when we uh misuse them in various ways, which we all, which we all do. Uh, I don't know. I've never had to answer that question. So I obviously don't have a very good answer. But thank you for the question I will say though that I saw that there was one of the photos that you showed in terms of recruiting groans sick um, is where you really deployed your secret weapon? Who spent a week in Zurich. No, my wife spent the week. That's what that was your secret weapon. That's that's part of the reason. No, I mean Gayle and Spencer. Let me, let me, let me dwell on that. So I didn't mention this part. But after he did those first cases, We had this outfit called this uh South Atlantic cardiovascular society. Some of you may have heard of this still exist apparently. And we put on meetings and I was in charge of this meeting in Kiawah Island in South Carolina in 1978. And somebody said to me, um, we gotta have a speaker. We should have somebody come and and and and give this talk. And what about that guy that did the answer places anybody know him? I said, well I met him when he showed this poster, I'll ring him up. So I did. And he said, well it's in august, you know, august europe is closed in august, so maybe I'll be able to come. But I don't know, I can't tell you right now. So time went by and I didn't hear anything. And the people who were the local organizers in South Carolina kept bugging me, said, you gotta get, we don't we don't have this outside speaker because the rest of the talks were just members of this small group had about 80 people came to this meeting from Florida to Virginia. And uh, I said, okay, well I'll do something. So I knew Peter Block had had some rabbit experiments with, with balloons. Uh, so I rang him up and I said peter would you like to come down to this boondoggle boondoggle thing in south Carolina and do this talk. He said, yeah, I'll come and bring Betsy and that'd be fun, bring the phone up five minutes later, the phone rang and it was Andrea said, okay, I can come, I'm bringing my wife and my child and we're flying first class and we had budget of about that big to handle this thing but we had sucked it up and and he came and when he was there uh I picked him up at the airport in charleston. He was absolutely irate because the issue of hearst the heart had come out and it was a chapter that he had just seen on balloon angioplasty written by his boss and nemesis in Zurich who really was putting his thumb on Andreas and I let him do anything. Andreas had no knowledge of this chapter. His chief hans Peter Cranfield had never done an anti plastic but had trained at Grady in in the past. And Willis knew him in context said, well you're at the place. So the guy who wrote the chapter Andreas was I said, well this is the end of him. I'll never, you know, but he came and had a great time and he met Ellis jones and joe Craver, Some other colleagues. And so he says, I think he developed a sense of uh you know, not being against him and certain people were against him. And uh he the surgeons were a great help in uh in recruiting. Andreas I think because of that. And then once he once you know in 80 they joined in the the throwing of people who wanted to welcome him. Yeah I did. I wanted you to comment a little more about that because in my years at Emory, both you and john always talked about the collaboration with cardiac surgery that really made all this possible. You mentioned 6% rates of emergency coronary bypass in the early days. But then joe craver um uh and Dr ellis were both cardiac surgeons. Um talk talk a little more about that relationship. Um and and how you know, john Douglas always says that there appeared to be a trap door in the Cath lab where when the vessel could not be maintained open there just push this button and within minutes they were in the operating room. Uh yeah, several minutes. I mean, but uh yeah, no, it there was, I mean we're all friends. I mean, I came to Emory to start the catholic, there's no no catholic hospital. So I came as the catheter riser. People said I came actually with a deal of appointment in radiology and and medicine and people said, are you a radiologic cardiologist or cardiological radiologist or whatever. I said, no, I'm a surgical pimp. And so I had had some credits street credits there for the uh with the surgeons. You know, we've been, we I mean struggling Jennings pool all these people send it, you know, we we got along quite well. So there was a challenge with some things. But the main challenge we had was with uh cardiac anesthesiology. They did not want to be surprised for the failure uh that they didn't know about. So there were some there was some face offs and things like that, but uh and bob and I didn't mention, but of course bob, we was our key guy in the in the East trial. He headed up the surgical piece of it. Um So that was yeah, that was a lot of fun and games in those days. I should mention that robert biden um followed in the footsteps suspense, sir, john Douglas and got the lifetime achievement award at the Georgia A. Cc. This year a couple of weeks ago, which was wonderful to see um any other questions from the audience? Uh Suzanne, I I can see a couple of people wanting? Well, well maybe if you can bring the mic down in case dr Hastings has any comments to make. Um So Spencer just talk about the future. Um you talked a little bit about where um interventional cardiology is going and and how, you know, a CS is probably here to stay. Um how far away do you think we are from some of these non invasive tools and potentially some biomarkers, identifying high risk patients, high risk plaques. And I know you've been thinking about ways to stabilize these high risk plaques. Do you think it's still sort of a far fetched dream? Or can you that that wonderful prediction you made on restenosis in 1990 now give us your prediction on on this new chapter, how many years away are we at identifying those plaques and potentially locally treating them if at all. Well, I'd like to think, you know, we're not so far away. But uh, but my hope is that we, it'll be unnecessary. My hope is that uh, you know, Brown and uh, Goldstein has told us a long time ago that coronary atherosclerosis was cured because we were gonna just treat the LDL cholesterol and that was all we needed to do. And uh, that's been a big, big story, but it's not the end of the story. But now we have so many things obviously that are targeting atherosclerosis and so we will continue to modify what we decide to do invasively by what we need to do. And, and that's where I think we, we need a lot more studies. A lot more information Is the patient that can be stabilized. If we, if you think about it right now, The psychology, I think among patients and physicians is still, I got a blockage. I gotta get rid of it. Why? Well, I've heard people have heart attacks and they die from that. I don't want that to happen. And my uncle did or my aunt and my parents did. If the psychology ever moves to the point of uh, I'll use, I'll use Covid as an analogy. Uh, we're all terrified. We, we don't, we got a mask on off? We don't know what to do. We can't go anywhere why we saw people were dying of this thing. Uh, if it ever evolves to the point that it's a bad cold or something, we won't, we won't focus on that area, taking it back to coronary interventions if our preventive are preventative, our secondary preventive therapists start stabilizing black to the point that, yeah, you got atherosclerosis, your coronary arteries don't look like they did when you were a kid, but neither does your forehead. Uh, you know, you look different on the inside. You look different, but the inside difference is not gonna kill you. Now, if that psychology comes through, we're all uh, you know, I don't know, we're not out of a job. We're into a different job in the job of applying those kind of therapist. So, uh, where is all coronary revascularization going? It's gonna depend on what we can accomplish with with medical therapist. But during that time, advances to occur, uh, advances of some of these things will occur only if they're profitable because we live in America. And actually, if we lived in china would be the same thing, it would probably or wherever, but we, we've got to show that not only is it possible to interdict plaque and whatnot and you can show that can be done. And, and even, but then you've got to compare that to your most vigorous therapy without intervening on plaque. Then you gotta have studies that prove that. Then you've got to pay, um, you know, multiple billions of dollars to get that done. Um, so I think where we're going, it's hard hard to, you know, like, like Yogi Berra said it's hard to make predictions, especially about the future. But, but, but I've learned later that he wasn't the first, I think Nostradamus or somebody probably said that as well. So I don't, I don't know. But I think it's, it's fun to think about because the plaque is uh, we know so much about it that if we can, if we can non invasively identify it, think about what we do today, patient and Clayton Georgia gets uh, you know, stress test and it's positive or something. Cause he says, well, I've had a little chat, I'll tell you what we're gonna send you down to Gainesville to have a hard cast. And this old mountain air up there says, uh, yeah, what does that do? Well, they put a thing in your legs. Just send them nothing to it. Take these pictures. But by the way, you know, we don't know what they'll find. So take your family with you because you know, they may have to put stents in you and they may have to open and operate on you. And the guy says, give me a break doc just give me some pills, do something. I don't, I don't want to go there. I've seen that, that syndrome. My wife is from south Georgia. So I've seen her relatives who are reluctant to go to Atlanta going to Gainesville may not be as as threatened. But uh think about it if you had noninvasive imaging, if it was like a uh mammogram and we'll send you off and get an X ray and see and then we'll tell you what we think and we get it. If you could go and have a noninvasive ct that will tell you not only the coronary anatomy, but uh how obstructive your lesions are and even potentially how threatening some of them are. And whether despite the fact that your symptoms are now controlled, it still may be important to consider an intervention or you clearly don't need an intervention. But all those things are decided without you getting on the table and not knowing if you're gonna get stents or surgery. And I'm my hope is that we'll get to that point because I think doing that will enable us to uh to to get the patients earlier and and probably probably save some lives. Well we talk about patient centric care. You just talked about it right And and and Spencer's always puts the patient in the center and in this case that person would stay in plate and get the care they need. Well there are many more questions I'm sure we all have. But um I just wanna thank you so much for coming and enlightening us and stimulating us to think and and keep working. So thank you very much for coming. Well I wanna and I want to thank I want to thank you because and and tell you guys that uh the um Gainesville is not your grandfather's Gainesville and uh this is not Hall County Hospital and it's not even uh uh well I won't I won't make any other analogies, but you're on the cutting edge of all these things we're talking about uh with uh with what you're doing uh in the on the investigation side and on the device development side. Uh So uh congratulate uh the Georgia Heart Institute and Habib thank you so much.
