Mayra Guerrero (Mayo Clinic, Rochester, USA) speaks to Cardiovascular News about her life and career. Shaped by her upbringing in Mexico, Guerrero realised early on in her career that interventional cardiology, and more specifically structural heart interventions, were her life’s calling. Here she recollects witnessing the first transcatheter aortic valve replacement procedure in the USA, and how this shaped her work in the mitral field.
What was it that drew you to medicine and to interventional cardiology in particular?
I grew up in San Luis Río Colorado, Sonora, a small agricultural town in Mexico at the US border. My parents were government employees—my mother a schoolteacher and my father worked in administration. From an early age, I was drawn to science. I loved taking things apart to understand how they worked. For Christmas, I’d ask for chemistry sets or a microscope, which I still have to this day.
At 16, I decided I wanted to become a physician—it was the perfect intersection of science, teaching and service. I applied to the Universidad Autónoma de Baja California in Mexicali (Baja California, Mexico). As the neighbouring government state university, they only had five spots to offer to students from other Mexican states. They made it clear that I had to score really highly on the admission exam to get selected at that school. I studied like never before, took my exam at 16, and got into medical school at the age of 17.
Early during my third year, I encountered a 52-year-old man with a ST-elevation myocardial infarction (STEMI), treated with thrombolysis. I watched the ST-elevation normalise and it was mind-blowing. That moment at age 19 made me decide to pursue cardiology. Later, during the first day of my first cath lab rotation as a cardiology fellow, I knew I had found my calling—I realised I was born to be an interventional cardiologist. I found the cath lab intellectually stimulating and it was fascinating to see the immediate impact we had to improve the health of patients.
I was fortunate to be given the opportunity to train with Cindy Grines and Bill O’Neill at William Beaumont Hospital in Michigan, where the landmark PAMI (Primary angioplasty in myocardial infarction) trial was conducted, establishing primary percutaneous coronary intervention (PCI) as the standard of care in STEMI. It was there, on 10 March 2005 during the second year of my interventional cardiology fellowship, I witnessed Bill perform the first transcatheter aortic valve implantation (TAVI) in the USA alongside Alain Cribier. The moment that I saw the balloon inflating during the transcatheter aortic valve deployment for the first time was literally life-changing for me. Many thousands of connections happened in my brain at once during the five seconds of valve deployment—I saw the future. From that moment, I realised that I would dedicate the rest of my career to transcatheter valvular interventions.
Who are the mentors who have had the biggest influence on your career to date?
Cindy Grines and Bill O’Neill have, without question, been my most impactful mentors. They believed in me and accepted me in their interventional cardiology fellowship programme.
After completing my training, I worked at Henry Ford Hospital and set out to build a structural heart programme. It wasn’t easy. When it came time to perform our first TAVI cases, Bill accepted the invitation to proctor them. Soon after that, he accepted the invitation to join our team full-time.
He also supported my vision to perform the first transseptal transcatheter mitral valve replacement (TMVR) in mitral annular calcification (MAC). In 2013, I met an elderly woman with severe mitral stenosis in MAC. She wasn’t a surgical candidate, and we had no good options. I proposed a transseptal valve-in-MAC using a TAVI valve—something that had never been done. Sadly, the patient passed away before the procedure.
That same day, the first report of a transapical valve-in-MAC came out. I remember reading this publication and thinking that perhaps we could’ve saved her had we attempted transseptal TMVR.
Weeks later, a similar patient came in. This time, we acted. We performed the first successful percutaneous transseptal valve-in-MAC procedure in the world. It worked—and it changed everything. That case led to the multicentre TMVR in MAC Global registry, then the MITRAL (Mitral Implantation of TRAnscatheter vaLves) I early feasibility study. We learned a lot during that study and we are now about to complete the MITRAL II pivotal trial.
What do you anticipate will be the next big advance in the development of transcatheter mitral valve therapies?
My hope is that transseptal repair and replacement will eventually become the first option if the anatomy is favourable and that the guidelines will change to reflect this.
For rheumatic heart disease, the first choice is percutaneous balloon valvuloplasty—if the anatomy is favourable—and not surgery. For aortic stenosis the guidelines now suggest TAVI as the first therapy for most groups. My hope would be that treatment options would become the same for the mitral valve, that if someone has anatomy that is favourable for transcatheter repair, this will be the first choice, and if not, a transcatheter replacement.
Another big step would be a mitral repair device that does not preclude additional interventions. That is one of the weaknesses of transcatheter edge-to-edge repair (TEER).
Which are the trials to watch in transcatheter mitral valve intervention?
There are two specific mitral repair trials that I am involved in that offer a transseptal repair with very impressive results without closing the door to any further transcatheter intervention, whether it is repair or replacement. One is CardioMech (CardioMech)—a transseptal chordal repair system. The results can be impressive, the patients we have treated went home the next day.
The other one is Silara MiBridge (Silara Medtech)—a transseptal direct annuloplasty system. We performed the first case in January in Hermosillo, Sonora, Mexico through a new academic collaboration between Mayo Clinic and CIMA Hospital in Hermosillo Sonora and the National Institute of Cardiology in Mexico City. Being able to participate in this trial in Mexico is one of the most important accomplishments for me, as it means a lot more than just pushing the technology. It means providing a treatment option for my compatriots. There should not be borders in science. Hopefully this is just the beginning, and we can do more in this collaboration.
“There should not be borders in science.”
Which recent cardiology trials have caught your attention?
EARLY TAVR is an important study that gives us a lot to think about and highlights other things that are untapped or untested. In addition to providing the concept that early intervention before symptoms develop can be beneficial to decrease heart failure hospitalisation, it makes me think about how to get a treatment to the people we are not treating because they are not even referred to us for evaluation.
That is another challenge that we need to work on. We need to explore options like artificial intelligence (AI), for example, to try to get to patients before it is too late.
A very important area for me is the role of TAVI in younger patients. I have been advocating since at least 2019 for a randomised TAVI versus surgical aortic valve replacement (SAVR) trial in younger patients aged 50–65 years.
The low-risk TAVI trials, PARTNER 3 and EVOLUT Low Risk, had a mean age of 73 and 74 years, but only around 9% of the patients were younger than 65 in the PARTNER 3 trial. There are very little data on the patients who are younger than 65 and, despite that, many of those patients are being treated with TAVI in the USA. If it is going to happen anyway, we may as well do it in an organised way and generate the data to inform those important decisions. There is also a need for another TAVI trial among women of child-bearing age.
How important is it for aspiring interventional cardiologists to see people in senior positions who reflect their background?
When I was training, I was trying to become something that perhaps did not exist. There was no such thing as a female, Mexican interventional cardiologist working in the USA at that time that I know of. I think it is very important that we have role models.
Many things have changed in the 20 years since I started, and I am happy to be able to look back and see all the things that we have been able to achieve. The progress in technology has been great, but the progress in the representation of women at many levels—whether it is as physicians in the field of interventional cardiology, in academic positions, or in leadership positions—has been very slow. This has an impact in patient care and the inclusion of women in clinical trials. Most trials only recruit around 20–30% women, and that is a big disparity that has not changed at the pace we would want.
We have to participate at all levels. Societies need to provide support and funding, agencies need to put up guard rails and ensure that trials meet requirements to include women. A 20% enrolment rate is not good enough, and that goes into the design of the trial.
We also need to ensure that there is diversity in the leadership of trials too. When teams are diverse everybody wins, and diversity in leadership positions is essential to improve enrolment of women and minorities in trials. Unfortunately, this is all going to take time. We are making progress, and we need to keep trying harder and not give up.
For those who were able to achieve what they wanted it is also our responsibility to help the next generation. It wasn’t until I got to Mayo Clinic that I started to analyse the 20 years of my career, and I couldn’t believe how far I had made it. That is when I realised how difficult it was, and it helped me understand that it should not be that way.
We need to make it easier for the next generation. At the same time, I have a profound feeling of gratitude that I was given this without looking for it. That is what makes me want to give back.
What does your life outside of medicine look like?
I love riding my bike, especially around the Lake Shore Drive in Chicago. Now that I am based in Rochester, I cycle the trails in nature. But, I also spend time in Chicago, almost every weekend that I am not on call or traveling for meetings. I love seeing sun rises and particularly running whilst the sun comes up. Wherever I go I wake up early, go for a run, and watch the sun rise at least once during that trip. I have so many pictures of sun rises.
Spending time with family and friends is the most important thing to me. As physicians, we spend a lot of time at the hospital. When you work hard at the hospital, taking care of really sick people, it helps you to appreciate a regular day with your family and friends on a deeper level and to be grateful for all the blessings you have.
FACT FILE
Current appointments
Professor of Medicine Mayo Clinic, Rochester, USA
Associate Program Director Cardiovascular Medicine Fellowship, Mayo Clinic
Vice Chair for Diversity, Equity and Inclusion Department of Cardiovascular Medicine, Mayo Clinic
Previous appointments (selected)
Director of Cardiac Structural Interventions Evanston Hospital, Evanston, USA
Founder and Director Structural Heart Disease Program, Henry Ford Hospital, Detroit, USA
Clinical trials
TMVR in MAC Global registry, National principal investigator and sponsor
MITRAL EFS and MITRAL II pivotal trials, National principal investigator and sponsor
PARTNER 3 Aortic Valve-in-Valve registry, National co-principal investigator
PARTNER 3 Mitral Valve-in-Valve registry, National co-principal investigator
ENCIRCLE pivotal trial, National co-principal investigator
CardioMech EFS, National co-principal investigator
