Azeem Latib (senior interventional cardiologist, San Raffaele Hospital and EMO-GVM Centro Cuore Columbus, Università Vita Salute, Milan, Italy) started his career in South Africa, relying on the hard work of his mother, numerous weekend jobs, and a community bursary to support his studies, but moved to Italy after meeting his “life-changing” mentor Antonio Colombo. He speaks to Cardiovascular News about his career highlights and how transcatheter therapies for structural heart disease have been an important development in interventional cardiology.
Why did you decide to become a doctor and, in particular, why did you decide to specialise in interventional cardiology?
Growing up in apartheid South Africa, a very segregated society with extreme socioeconomic disparities, medicine was the best way to apply myself in helping others and bridging the racial gap. Also my father suffered for many years and eventually died from coronary artery disease, which I think subconsciously always motivated me. It was a very challenging time in South Africa both politically and financially for my widowed mum. At times, we questioned whether doing a degree that lasted six years was the best choice and whether the cost of my studies could be afforded. It was thanks to the hard work of my mother, my numerous weekend jobs, and a community bursary that I was able to support my studies. This was probably what motivated me the most to do well at medical school and I eventually graduated Cum Laude—I literally couldn’t afford to fail and only had one chance.
However, I must admit that I feel very fortunate to have found a profession that I am so passionate about and enjoy doing. I decided to do interventional cardiology because it gave me the right balance between doing invasive procedures and being a physician. It requires both diagnostic and therapeutic skills, and the results of intervention are immediately visible and beneficial to patients.
Who have been your career mentors?
I have been fortunate enough to work with amazing teachers and mentors who have helped form my career and played a decisive role in the choices that I made.
The first was Patrick Commerford, who was the head of Cardiology at Groote Schuur Hospital in Cape Town, where I worked for over 12 years and did my specialisation in internal medicine and cardiology. Pat made cardiology very appealing to me because of the strong department that he ran, and he taught me about professionalism, kindness, equality, leadership by example and patient-centred care. Furthermore, he persuaded me to keep going when I felt like ending my career in medicine after undergoing emergency surgery.
During my time in Cape Town, I also met and became friends with Bongani Mayosi, a cardiologist, who is the current chair of Internal Medicine at Groote Schuur Hospital and the University of Cape Town. Bongani encouraged me to pursue a career in academic medicine and research, and also pushed me to find an overseas fellowship in the best centre that I could find. I went to Milan to do a fellowship in interventional cardiology and was supposed to stay for only one year, but met there my most important mentor who would change my career and life forever: Antonio Colombo. The impact that Antonio has had on my career is immeasurable. He has taught me to be a scientist, a clinical researcher, and an interventional cardiologist. He continues to be a mentor and to help shape my career.
What do you think has been the most important development in interventional cardiology during your career?
The advent of transcatheter aortic valve implantation (TAVI) and the fact that percutaneous mitral valve implantation is on our doorstep is probably the most exciting development that has happened since the invention of coronary stents. The results with the first-generation devices have been reproducible and proven that TAVI is a life-saving technology, and now the availability of second-generation devices that address many of the shortcomings of the first-generation valves have made this a very exciting and innovative field. Percutaneous mitral repair devices, such as the MitraClip (Abbott Vascular) and Cardioband (Valtech Cardio) that simulate well-studied surgical repair procedures, are also worthy of mention.
Other than transcatheter therapies for structural heart disease, the next most important development is bioresorbable scaffolds. I think they are the next frontier in percutaneous coronary intervention and have the potential to revolutionise coronary intervention.
You’ve worked in South Africa and in Europe. Are there differences in the way that interventional cardiology is practised?
In South Africa, although coronary artery disease is frequent, there are other cardiovascular diseases that predominate and the health priorities are very different. Indeed the priority is providing primary care to a population where healthcare resources have historically been unequally distributed and communicable infectious diseases remain the most common cause of death. For example, HIV has had a profound impact on the profile of disease presentations to all medical specialities including cardiology. However, I worked at Groote Schuur Hospital, which is a tertiary referral centre and the main academic hospital for the University of Cape Town, and I believe that it would not have been possible to receive better clinical training in internal medicine and clinical cardiology.
As physicians working in Europe, we are very fortunate as there are less financial limitations and we have access to and can offer our patients almost every possible technology or device available. A very high level of healthcare is available to the majority, if not all, patients.
I strongly believe that physicians like myself that have had the advantage of having benefitted from the best of both worlds have a duty to continue to give back to developing countries, particularly as regards to teaching in advanced specialities such as interventional cardiology.
Of all the research you have been involved with, which piece are you proudest of and why?
I would like to believe that I have not done my most important research or written my most important article yet. I have been fortunate enough to be involved in so many different areas of research. However, if I have to choose from the research that I have done thus far, then it would be the BELLO multicentre randomised study of drug-eluting balloons versus drug-eluting stents for small vessel disease. The reason I am proudest of this project is because this was the first randomised study where I led every aspect from design, to writing the protocol, getting ethical approval, enrolling patients, analysing the data, writing and submitting the manuscript. I think that this is a very important milestone for any researcher.
You are on the faculty of several international meetings (such as TCT). Given that so much educational material can be accessed online, what additional educational benefits can attending such meetings provide?
I am fortunate enough to be on the scientific and organising committee of JIM and TCT, which in my opinion are two of the best interventional cardiology meetings in the world. They represent two ends of the spectrum of what an international meeting should represent with a varied and international faculty who are experts in their field.
I do not believe that online materials can fully compare to the learning opportunities that can be gained from attending meetings such as JIM and TCT. Also I still believe that live cases—like those shown at JIM—add significantly to our learning about how we approach and manage complex cases. Finally, meetings are important for networking, meeting colleagues from around the world and engaging in discussion with industry. I always try to spend time in the exhibition area to learn about new devices and technology that I could incorporate into my clinical practice.
SYMPLICITY HTN-3 has received a lot of attention this year, but what do you think the other major studies in interventional cardiology have been this year?
HEAT-PPCI has challenged whether bivalirudin has any advantages over heparin. In this study of primary PCI, bivalirudin was associated with higher rates of major adverse events, predominantly due to higher rates of stent thrombosis and reinfarction. Contrary to previous studies, bivalirudin did not lower the risk of bleeding compared to heparin, which is explained by the low (about 15%) and real-world usage of GP2b/3a inhibitors in this study. This study has impacted my practice and changed the policy at our centre with regards to antithrombotic therapy during primary PCI.
The CoreValve High-risk study is the first randomised study to show that TAVI may be associated with better survival at one-year as compared to conventional surgery and hopefully will pave the way for more patients to be treated less invasively, in particular intermediate-risk patients. Finally, the DISCOVER registry demonstrated that next generation TAVI devices may virtually eliminate aortic regurgitation, which was one of the major limitations of the first-generation devices.
What advice would you give to someone starting their career in interventional cardiology?
Never give up. Find a mentor. Train with the best and keep on until you are fully trained. Continue to be curious and ask questions as your education never stops. Interventional cardiology is not just about performing procedures but, more importantly, knowing when they are indicated, performing them in the most optimal and evidence-based way, and knowing how to prevent and manage complications.
What has been your most memorable case and why?
The most memorable cases for most interventional cardiologists are the ones that went badly or where we had important complications. However, on a more positive note, a memorable case was when I first did a TAVI procedure as a primary operator. The fact that I had just implanted an aortic valve on an awake patient was unforgettable and left a lasting impression. This sensation was recently superseded when, along with the excellent team at San Raffaele Hospital, we performed a first-in-man implantation of a Direct Flow valve in the mitral position. The patient had a radiolucent annuloplasty ring with severe mitral regurgitation. In the literature, only balloon expandable valves have been previously implanted in mitral rings, but in this case, this would have been challenging as the annuloplasty ring is not visible on fluoroscopy and reduces the chance of having a successful procedure. Thus, we decided to perform the procedure with a fully repositionable and retrievable valve. The procedure was performed transapically and the implantation was performed in a very controlled and relaxed manner. The final result was excellent with no residual mitral regurgitation or paravalvular leak and the patient was discharged from hospital five days later.
Outside of medicine, what are your hobbies and interests?
I have three amazing and beautiful women in my life (my wife Nicole and daughters Olivia and Emma) who are the source of my inspiration and happiness. I try to spend all of my free time with them. We love the outdoors and being in nature. Going for walks in the forest and hikes in the mountains is regenerating. When we lived in South Africa, we went to the bush very often, especially the Kruger National Park, which is one of the most amazing places in the world. When we moved to Europe, I learnt to ski and this has become our passion during winter.
2011–present: Co-director of research, interventional cardiology department, San Raffaele Hospital, Milan, Italy
2010–present: Senior interventional cardiologist, San Raffaele Hospital and EMO-GVM Centro Cuore Columbus, Università Vita Salute, Milan, Italy
2009–present: Honorary senior lecturer, Department of Medicine, University of Cape Town, Cape Town, South Africa
2008–2009: Research Associate, San Raffaele Scientific Institute, Milan, Italy
2007–2008: Masters in interventional cardiology, (masters fellow), San Raffaele Hospital and Università Vita Salute, Milan, Italy
2008:Masters in interventional cardiology
2005:Certificate in cardiology, College of physicians of South Africa
2002: Fellow of the College of College of physicians of South Africa (MM Suzman Medal)
1995: Bachelor of medicine and surgery
Societies and memberships
2014: Associate Director & Scientific Committee of the Transcatheter Cardiovascular Therapeutics (TCT) meeting
2014: Faculty at AfricaPCR, Cardiovascular Research Technologies (CRT), TCT Russia
2013–2014: Faculty at EuroPCR
2012–present: Fellow of the American College of Cardiology
2011–present: Fellow of the European Society of Cardiology
2007–present: Faculty and Scientific Committee of the Joint Interventional Meeting (JIM)
2006–present: Faculty at the TCT meeting