Ashok Seth (chairman, Fortis Escorts Heart Institute, New Delhi, India) is the immediate past president of Cardiological Society of India and is the principal investigator of the Absorb First registry. He has been awarded the “Padma Shri” by the president of India, one of the highest civilian honours of the Government of India, and talks to Cardiovascular News about performing his father’s angioplasty, his mission to make Delhi state a safer place to live, and the importance of planning ahead to avoid complications.
Why did you decide to become a doctor and, in particular, why did you decide to specialise in interventional cardiology?
I come from a family of doctors and I was interested in medicine since my childhood—my father once caught me, aged four, attempting to operate on a friend! Also, I was fascinated to see how grateful my father’s patients were when they became well after he had treated them. Therefore, I always wanted to be a doctor.
However, becoming a cardiologist was more something that happened by chance when I went for my postgraduate training to England. Initially in early 80s, I was determined to become a gastroenterologist but switched to cardiology when I did not get a job that I wanted as a gastroenterology registrar. At the time, I did not realise the potential of interventional cardiology but I soon realised that the field was going to expand and held tremendous potential.
Who have been your career mentors?
I have had two mentors. The first one was Dr Man-Fai Shiu at the Birmingham University Teaching Hospital (where I worked in England), who taught me to plan every procedure and think ahead as to how to avoid complications in the balloon era when angioplasty was in its infancy. By following his meticulous approach to planning and assessment, I am not surprised by problems encountered during a procedure. The second mentor was Dr Geoffrey Hartzler. I attended one of his courses in Kansas City (USA) in mid 80s and I was amazed at his skills and results with what he could achieve with the crudest technology of those times. He demonstrated to me that complex angioplasty could be performed safely with good results and that one needed to have creativity, clarity, confidence and conviction.
What do you think has been the most important development in interventional cardiology during your career?
The improvement in the safety of angioplasty has been dramatic. The procedures we performed at the beginning of my career were primitive compared with what we are able to do today. Thirty years ago, we were concerned about patients having acute occlusions, myocardial infarctions or requiring emergency bypass surgery during the procedure. Death was a reality. These days, angioplasty has become so safe that we no longer need to rely on bailout devices or to have an operating theatre on standby. In fact, many centres these days do not even have cardiac surgery on site. It is a day procedure and the improved safety and efficacy is due to not one but numerous developments in the art, science and technology of angioplasty.
Of all the research you have been involved with, which piece are you proudest of and why?
I am most proud of the work that I am currently doing with the bioresorbable vascular scaffold (Absorb, Abbott Vascular). I believe that this technology may be the biggest breakthrough because it does not leave metal behind—it is many steps beyond the existing technologies. Compared with the first-generation of metal drug-eluting stents, the latest generation have now achieved a high level of safety and efficacy. Therefore, we need to show that the bioresorbable scaffold is as good as the best metallic drug-eluting stent in the short term and superior in the longer term.
As principal investigator of the Absorb First registry, I am using this stent in many complex patients in real life to evaluate its advantages and limitations. I am very hopeful that we will show that the bioresorbable scaffold is as good as the gold standard drug-eluting stent in the short- and mid-term, and better in the long term.
As someone who has pioneered several angioplasty techniques, what do you think are the most important factors to performing successful angioplasty?
The hardest thing to do as a doctor is to inform a patient’s loved ones and relatives that the patient has not survived a complex or lifesaving procedure. Therefore, you want to do your best to achieve the best result with safety. Firstly, as previously mentioned, you have to plan every aspect of the procedure and consider the problems or complications that may occur and the possible solutions in hand—that way, your hand and your mind work in tandem, avoiding complications where possible. You also need to be aware of the limits of your expertise; you need to know when a procedure is beyond your competency and you need to know when to stop a procedure because it is not working. There should be no “ego battles” between the “complex lesion” and the “interventional cardiologist”.
What are the challenges of providing an interventional cardiology service in India given that while the country is one of the world’s fast growing economies, poverty and poor healthcare are still major issues?
At the moment, our goal is to ensure that people in India have access to quality medicine and the latest technologies in interventional cardiology at an “affordable cost”. We are focusing on the middle class of this country (eg. teachers, shop workers, or factory workers) because the wealthier class can already afford these technologies and those living in our rural areas or are poor have more basic priorities (eg. access to clean water and good sanitation, hygiene and infection control). One way to improve access to technologies is for India to develop its own devices, which are also manufactured in India. We now have good Indian-made drug-eluting stents, in the future we will have Indian bioresorbable scaffolds and transcatheter aortic valve implantation (TAVI) devices—making it more affordable for the common man in India to receive these treatments. I am actually working with some Indian companies to develop these indigenous devices in India and am already in process of putting them into clinical trials.
You are the immediate past president of the Cardiological Society of India. What do you believe were your key achievements during your presidency?
One achievement was to develop three guidelines specific to India and this region including one for rheumatic heart disease (a condition that is highly prevalent in India) and for permanent pacemaker implantation. Previously, the only guidelines that were available were ones that had been developed with Western populations in mind. Therefore, we need national database, registries, guidelines that were more applicable to South Asian populations. I also helped to formulate national policies to control coronary artery disease—for example, policies to raise awareness of the health risks associated with smoking and other risk factors. My biggest contribution may be making the state of Delhi a safer place live to by teaching the public how to perform basic cardiopulmonary resuscitation (CPR). By working with the Government of Delhi and device companies, our goal is that, through widespread education, 75% of the population (approximately, 17 million people live in Delhi) will know basic life support within three years.
What has been your most memorable case and why?
One memorable case was doing my father’s angioplasty. I believe I am one of the most experienced interventional cardiologists in the region, so I thought I was the best person to do the procedure. During the procedure, I was able to forget that the patient was my Dad and did everything very meticulously and professionally. But when I finished the procedure, I suddenly became aware of what I was doing and started to think of all things that could have gone wrong—it felt like the blood drained out of me! As a result of this sudden realisation, I missed a simple step in the sealing of the arterial puncture site (a procedure that I routinely do several times) and ended up having to press my father’s groin for the next three hours to try and stop in bleeding! Eight years on, my now 90-year-old father is still doing well but I still shudder to think about what could have gone wrong! As a religious person, I am thankful to God.
Another patient was a 44-year old civil servant who was in cardiogenic shock and we air lifted him from a north-eastern state of India and had to put him on extracorporeal membrane oxygenation (ECMO) during the procedure to keep him alive. I had to perform one of the most complicated and difficult techniques to treat his severe disease process. I was not sure that he would survive, but his family were convinced that the procedure would work and insisted that I do it. Afterwards, it was a week before he was off the ventilator and three before he was able to leave hospital. A year later, he walked into my office with his young wife and his lovely teenage children and I could not believe it—I had to ask him if he was the same person! He is now working as a high-ranking civil servant and regularly goes jogging. I admire the family for having the faith—whether it was in me, God, or whoever—that the procedure would work. Because of their faith in the procedure, the young man and his lovely family can be together and that gives me joy.
Outside of medicine, what are your hobbies and interests?
I love to go scuba diving and have dived at many places, including the Great Barrier Reef and Sharm el-Sheikh.
I also enjoy performing traditional Indian songs that are a form of romantic poetry transferred into music. They are slow songs that contain a lot of emotion. I actually performed for an audience of 400, which included the chief minister of the state and many other dignitaries.
Fact File
Appointments
Chairman, Fortis Escorts Heart Institute, New Delhi, India
Chairman, Cardiology Council, Fortis Group of Hospitals
Honorary professor of Cardiology, Gandhi Medical College, Bhopal; Medical College, Raipur; Medical College, Bilaspur; Padmashree Dr D Y Patil University, Mumbai; Bangladesh Medical College, Dhaka, Bangladesh
Fellowships
Fellow of Royal College of Physicians of London (FRCP, Lond)
Fellow of Royal College of Physicians of Edinburgh (FRCP, Edin)
Fellow of Royal College of Physicians of Ireland (FRCP, Irel)
Fellow of Cardiological Society of India (FCSI)
Fellow of American College of Cardiology (FACC)
Fellow of European Society of Cardiology (FESC)
Fellow of Society for Cardiovascular Angiography and Interventions (FSCAI)
Fellow of Asian Pacific Society of Interventional Cardiology (FAPSIC)
Honours and awards
2003 Padma Shri award’ (fourth highest civilian award by the Govt. of India)
2010 Mason Sones Award (Society of Cardiovascular Angiography & Interventions)
Officer’s Cross Order of Isabella the Catholic’ (national award of Spain)
2011 LIfetime achievement award for vocational excellence in the field of medicine (Rotary Club of Delhi)
Special award for outstanding contributions in cardiology (American Association of Cardiologists of Indian Origin)
2012 Global Pioneer of Interventional Cardiology Award’ by the Asian Intervention Cardiovascular Therapeutics (AICT)
Societies
2004– Founding board of governors, Asian Interventional Cardiovascular Therapeutics (AICT)
2010– Founder course director, India Live
2011 Co-chair, SCAI international committee
2008– 2011 Board of Governors, SCAI
2011 Nominating Board Member, SCAI
2011–2012 President, Cardiological Society of India
2012–2015 Member, American College of Cardiology India advisory board (representing Cardiological Society of India)
2013–2015 Vice president, Asian Pacific Society of Cardiology
1996– Founder member & board of Trustees, Asia Pacific Society of Interventional Cardiology
