Join Habib Samady, MD, and Spencer King, III MD as they discuss further the Cardiovascular Grand Rounds presentation given by Dr. King at Georgia Heart Institute on the journey of Coronary Interventions over the last 50 years and how the field of interventional cardiology has been shaped.
It's Habib Sanity from the Georgia Heart Institute. And I'm here today with one of the true icons of cardiovascular medicine and a great friend and a mentor of mine Spencer King. So Spencer, welcome to the Georgia Heart Institute. It's a great pleasure to be here. You're doing great things. Thank you. Well, you just gave us a phenomenal cardiovascular grand rounds on The 50-year journey of interventional cardiology. Um and amongst the many things you talked about is really shaping the course of our field interventional cardiology. Um Maybe you could just share with the audience um how it all came about when it started and how you managed to get forensic over to Atlanta. Yeah. Well, of course, Andreas was the man who invented interventional cardiology almost based on things had gone before, but he was unhappy in Zurich. We, we knew him, we met with him would have been over. He asked me to come over to his place. And, and so when he became unhappy there, he was coming to America, made the suggestion that he contact us at Emory. He did eventually and came and visited and uh got my chief Willis Hirst excited about it. And uh Andreas, I think, perceived emery to be a good place to come because uh we were receptive, we were enabling him and our surgeons were cooperative, which was an experience he had not had before. And his ultimate boss, Willis hurst was very much supportive as opposed to what had happened in Zurich. So that's how we enticed Andreas to come to Emory. And then we had to make things work in terms of the live demonstration courses and all that. And that involved some interesting activity. Uh Early, early work we did was all observation, all, eventually we did put it together in a trial. But uh when you knew nothing, it was very easy to learn something. And so we would be routinely putting in the maximum number of abstracts to American Heart and American College and publishing that stuff that today would of course never be published. Well, I mean, I just take us through the excitement of the time, right? So this was 1980 germinating came in, in 80. Um tell us about the first few months of getting started. Um and then how did you consent patients? What was the involvement of surgeons? There was a lot to do. A lot of it had to do. What kind of labs we had, we traveled around. I was, I was in Germany and also in Netherlands. And eventually Andrea said we gotta have a S a centric biplane Cath lab. The only people in the world made that was a company called C G R Company General Radiographic from Paris. The stuff was garbage. It was, I mean, the stuff was okay but it broke all the time. Eventually G bought that company out. But so anyhow, that was a challenge and then how to transmit the cases to the auditorium. So we could teach every six months, we had a course and we'd have four or 500 people from around the world come. And so we had laid fiber optic cable from the Cath lab. So all those technical things were a lot of, a lot of work, a lot of what we did and then the cases themselves were, you know, kind of things we could do. A lot of them worked. Some of them didn't work. We ended up going to surgery with 6% for the first two years. We had 6% of our patients went from the Cath lab directly for, for surgery. And, uh, that was, uh, that was problematic but tolerated by our surgeons. And so that also make things work. I hear earlier, you were saying that you got quite a few referrals from the Gainesville area from this group here. Henry Jennings Dix Troubling Sam Pool were physicians here. He saw a lot of cardiology and there's no Catholic up here, of course. So they sent, sent me all those cases that was probably kept me, kept me afloat. Well, amazing work that really launched the field. And then, and then you talked in your today about the various decades, right? You, you talked about the first decade being predominantly angioplasty, then a lot of other tricks were tried a threat to me, laser etcetera. And then you talked about the 10 years of stents and drug eluting stents, maybe take a couple of minutes and talk us through that journey over the last several decades. You know, we went through a period where the balloon didn't work. You try something else. It's sort of like device creep, right? Uh The balloon didn't work. We tried directional and threat to me or something like that. Uh tried laser on some things that didn't work. We try uh rotational uh threat to me. So, restenosis, what was happening commonly uh with the stents, of course, restenosis continued to happen a lot. In fact, it was more proliferated response. And once we discovered that it was a proliferated response, we tried to block that with radiation breaking therapy, which we had some success. Unfortunately, we also blocked the uh and ethereal healing and we had three robotic problems and things like that. Uh But I think breaking therapy did give insight into what could be done if you block the cell cycle because at that time, there was a conflict between, was this really uh cell proliferation problem primarily? Or was this a Thrombin Arctic problem where you form a thrombosis and it would be repopulated with smooth muscle cells. So, uh the fact that our anti thrombin attic therapist didn't work very well and the breaking therapy did I think was evidence that led others to say, well, we got drugs, we got things that we can put in that will block the cell cycle. So try gluing stats came along and that of course, is, is the primary therapy until today. It's absolutely remarkable. The link between the vascular biology and experimental work that was done a lot in, in your lab and other labs and how that all came together and it was pushed by industry. And ultimately, you know, the stents were developed and then anti thrombin Arctic therapies were refined at the beginning, you overshot, right? You, you, you blocked the platelets, you blocked thrombin, you blocked everything and that was eventually refined. And it's amazing that, you know, today, you know, we're at a point where you can do a trans radio P ci and send patients home the same day. I mean, it must have been hard to imagine back in the eighties. Thrombosis was a huge concern, not for restenosis, but for acute closure. And so we, we struggled with that and that led to a huge amount of development, you know, big real pro era and the and the small molecules and all that, which I think about today, when do we use these things? Hardly ever, very powerful agents? But the thing that was the most powerful anti robotic, of course, was a good open artery, smooth laminar flow without abnormal share forces and so forth that you're so focused on your research. So this was this was a more powerful and dramatic treatment than any of the drugs we had and has enabled us now to say, well, we don't need that so long, we can back back off and, and avoid a lot of those bleeding complications. Incredible journey. Um Tell me a little bit about, you know, this whole debate discussion that's ongoing about which patients should undergo bypass surgery versus PC I I know it's been evolving. There's a recent trial fame three that came out. But you've really been at the forefront of that, you've pioneered with this group at Emory, the first trial East trial and you've watched it develop. So my question to you is 2021 you have a patient that's non diabetic that has multi vessel disease, perhaps involving the proximal L A D A chronic total occlusion of the right and some disease and the cirque. How do you start making that decision with the patient? So we have, we have a lot of trials. All the trials we have are done on patients. Sometime in the past, we have technology that continues to advance and we have to use that evidence uh incorporated with what our local experiences. And so it's a, it's a complex decision. It used to be simpler because there were things you could do and things you couldn't do, you couldn't do them, you sent him to surgery. Now, the question often is why not do angioplasty? Not, not, you know, because we're able to do it in so many cases, then the question is, shouldn't we do it? Uh The most modern trials, including the, the one that was just released, the famed three uh still show us that in the most complex triple vessel patients, which is what that was studying. Surgery holds a certain advantage. The main advantage there is that you don't have to redo the patient but also the hard endpoints of, although it's not a significant difference, the hard end points of death and, and, and function and so forth, they're still, you know, uh not quite comparable between, between the two. So, uh however, uh even looking in that trial trial, you see that their patients who have more favorable circumstances and they do absolutely fine. So I think the trials are informative but layered onto it. Is that what is that specific patient have? Where do they fit within the within the bell curve of the trial? And what is the local experience on that kind of patient, both with surgery and PC I and then the collaborative decision making that goes on an institution like this between experienced surgeons and individualists to advise the patient uh in the patient, of course, is part of that team. Yeah, incredible, incredibly common but important decision that I think you, you really summarized very well and it's all about the patient and the patient needs to understand the various options and what would they, what would they would like? So, I do think that you're absolutely right that it needs to be patient central and we didn't address very much the need for revascularization in our talk because we're talking about which one, But that's also in the patient's mind. You know, do they really need this symptomatic patients that can't be solved, obviously can be helped. Uh asymptomatic patient, chronically asymptomatic patient. Uh A lot of those do get intervention because the disease is quite extensive and we, we all believe that we can help and then the risk benefit ratio uh changes. And we have to be able to be confident that device. So the patient has always faced with the knowledge that they've got atherosclerosis that they have obstructive arteries is always gonna be leaning toward. So something needs to be done, the fear of something happening. So that's where they experienced physician, even the physician who does all these procedures uh needs to be able to say to the patient. Look, I do this every day. You have this condition. Here's your outlook if we don't do either of these things but do aggressive anti arthroscopic therapy. Here's your situation. If we do it, please understand all this, take away your preconceived notions. Let me explain it to you and the patient. Uh Then hopefully you can make a more informed decision. Uh I do, I do worry that because of the initiatives, the incentives that are there in medicine. I do worry about people saying you've got a blockage, we can fix it. This is what should be done. Boom. This is not the way to practice medicine and I'm sure it's not the way it's practiced here. But the other thing I'm really fascinated about and you talked about in your talk today, is that okay? If you think about an iceberg of patients were at the bottom of the iceberg. Is your general population. 65 year old, non diabetic, several risk factors completely asymptomatic. And at the tip of the iceberg is the patient who comes in with anti histamine shock. You talked about how as you put your crystal ball and look forward, you feel like revascularization is going to continue to be required for those patients that are really sick with acute coronary syndromes. But in the middle of the pie, patients that are asymptomatic that may or may not have blockages, we might be able to treat with medical therapy. But you also talked about being able to predict future events. So you might take someone who's completely asymptomatic but may have a high risk plaque or may have a genetic predisposition and so forth and talk to me for the next couple of minutes about how you see the screening of asymptomatic patients or patients who are mildly symptomatic. And what should our focus be? Whether it's biomarkers, whether it's their genotyping, whether it's, you know, testing non invasively. Where do you see that going? Well, despite all the advances, we still have patients dying of heart attacks, we have patients dying of heart failure because of heart attacks in the past and we want to obviate that right now, the way we do it is we find the patient, we identify the patient through some means like a stress testing or something. Symptoms are now pretty well controlled or we know from past experience with that patient that they've got our thrust crosses. So the approach is you go for a diagnostic catheterization many times patients, particularly in rural areas or small towns, they go somewhere else and they go to that place with the instruction that you're going to have this calf. The cath will identify certain problems and they, the people doing it may recommend to you uh stenting surgery, whatnot, take your family with you. All these are things that will happen. This is very threatening to patients. I look forward to the day when diagnostic coronary work will be noninvasive, the patient will be told you're going for an X ray procedure. It's gonna find out whether you have blockage, how much, how serious it is. Also something about the plaques you have, how serious they are. Something about the flow characteristics and whether that can be improved and with all that knowledge, we can make a recommendation to you just as a patient would go and have a mammogram and they would say uh the mammogram, you have the mammogram, they're not gonna take your breast off that day. You're gonna have the mammogram. The mammograms are gonna tell you certain things. It's gonna tell you, we need to follow this. We need to do a biopsy, we don't need, but those are all things down the line. Uh You're going to have a colonoscopy, they don't take you to have a colonoscopy at the same time, we may take your Kahlan out. No. So for coronary work, I think the thing that will improve our ability to for a public health measure to be able to really help people personalize medicine. Uh We need to know what's going on. We need to know that independent of, of the final therapy, final intervention, be it surgery or P C I. So the non invasive investigations, uh I think with CT based with physiology such as the work you do with character characterization. These are things I hope will be the standard in, in a few years. Really, it's coming from the pioneer of interventional cardiology and coronary angiography to come full circle and now move that whole investigation non invasively is quite a journey. It is a journey and it's got that will move in that direction based on many things some of them will have to do with mundane, things like reimbursement, uh approval, you know, FDA approval of the different things, guidelines, understanding trials that show the the efficacy and safety of such an approach, all those things are important but uh for, for that to happen, they all have to come uh come together to, to change, change the way we do things. And as we identify those most vulnerable patients, many of whom are completely asymptomatic. Um there's also this idea that you can really dig into people's genetic background, right? You can do whole genome sequence saying you can do bionic so that you can really distill those patients that would then need screening non invasively. That's also undergoing a huge revolution in technology. And do you see that playing a role in the future? Well, I do, I mean, the hope is that combining those features with, with the imaging, I could really tell you what to do. Uh And it could, it could measure how you're doing over time. You can't change the genes, but you can change the expression. Uh And you can, you can monitor uh noninvasive evaluation. Uh It's not, I mean, we don't do can't serially on everybody every, every year, it's a couple of years A C T angiogram with, with the elements we've talked about, it could be done serially over people following along just like you do the mammogram, just like you did the colonoscopy just like you do so many things in medicine. Wonderful. Well, it's, it's been absolutely delightful to have you give our cardiovascular grand rounds at the Georgia Heart Institute, one of the real pioneers of cardiovascular medicine and a friend and a mentor and ultimately someone who always puts the patient in the center of things. So wonderful to have you and hope to see you again.
