Bernard Chevalier, interventional cardiologist, Cardiovascular Institute Paris-Sud, Jacques Cartier Hospital, Massy, France, talked to Cardiovascular News about his career, current research and innovations in interventional cardiology. He also spoke about a special interest in bioresorbable stent trials and his hobbies, including collecting fine wine.
Why did you choose medicine as a career? And why interventional cardiology?
My choice was strongly influenced by my uncle, who was a GP in the countryside in Brittany in the sixties. At that time, his job was really a challenge. During my fellowship in Paris, in the early eighties, I heard about this new era of interventional cardiology that seemed to be promising for a few pioneers and decided to move in this direction.
Which innovations in interventional cardiology have shaped your career?
I was trained in 1985–1986 when the only tool was the balloon. At that time we could only play with the size and duration of inflation. Crossing the lesion was frequently a nightmare in complex cases. Urgent coronary artery bypass graft (CABG) was the only bailout strategy. Therefore, all new techniques and devices have been significant landmarks in my practice.
Who were your mentors and what advice of theirs do you still remember?
I completed my training in a department headed by one of the French pioneers, Dr Bernard Lancelin, and continued to work with him for another 10 years. Together, we gained experience with all the new techniques. The strongest lesson from him that I still apply is to weigh up the risks and benefits of a procedure for the patient before making any decision regarding interventions. One of his key sayings was “Always think about what could happen to the patient if this artery was occluded during the intervention”.
Can you describe a memorable case?
Certainly, it was the first bailout stent I implanted. It was in 1988 and I was treating a young patient, previously grafted, in three vessels. He was unstable, with occlusion of three native arteries, only one patent graft in the left anterior descending artery, and the ejection fraction was very low. A severe dissection and recoil occurred after several balloon inflations and I failed to stabilise the situation with prolonged inflations using a perfusion balloon. We had just received the first few Palmaz-Schatz stents and decided to use the device as the risk of urgent CABG was extremely high. It was clear to us that that tiny device saved his life.
In your opinion, are stents with a biodegradable polymer the way forward? Will there be a place for them if bioresorbable scaffolds prove successful?
It is now clear that bioabsorbable polymers are a good answer to the biocompatibility issue raised in the early era of drug-eluting stents. However, some durable polymers achieve similar results. Also, bioabsorbable polymers do not have the potential to overcome the long-term issues related to the permanent nature of the current stents, even bare metal ones. Only a bioabsorbable stent can play this role but we need to consolidate its validation with much more data, particularly in complex lesions. It is intuitively obvious that this technology is interesting for young patients.
You have been involved in the investigation of new TAVI devices. How are these devices tackling the problems still seen with TAVI?
Most of the new devices are focused on two issues: the size of vascular access and the positioning/recapturing properties. Dedicated accessories are also important, like specific sheaths to limit contraindications to transfemoral approach. We learned a lot from multislice computed tomography for sizing strategies. The most important and recent innovation is not a device but the development of direct aortic approach, which has the potential to eliminate the use of the transapical route. Moderate aortic regurgitation remains a challenge for TAVI and few new valves are aiming to address this issue.
You are one of the directors of the CERC (European Cardiovascular Research Center). What is the objective of this organisation and what has it achieved so far?
The major objective of the CERC is to develop clinical research in our field on the basis of a network of interventional cardiologists working in Europe, Middle East and Asia Pacific. This medical council, now with 18 cardiologists, is the major specific feature of our structure. We aim to develop and conduct trials from first-in-man to large registries and randomised controlled trials. We have a specific interest in improving the development of physician-initiated trials to obtain similar standards achieved with industry-sponsored randomised controlled trials. A recent example is the EuroCTO trial, conducted by the EuroCTO club. CERC is now working on 27 trials that include more than 16,000 patients.
In terms of imaging for coronary intervention, which new technologies will you be watching closely in the future?
It is clear that optical coherence tomography (OCT) has the potential to improve our knowledge of coronary artery disease. Moreover, its combination with functional assessments such as FFR is very promising. However, the main limitation of these technologies is their cost-effectiveness. It is too early to understand the role of multislice computed tomography-based FFR in our practice but if the preliminary data are confirmed, the potential of this approach is huge.
What are your current topics of research?
New drug-eluting stent technologies, bioabsorbable stents and TAVI are my main interests. The next step is mitral valve implantation!
For you, in terms of content, what was the main highlight of EuroPCR 2012?
I think the most important feature of PCR is the quality of the educational tool. You can easily customise your programme to your specific needs whatever your level of expertise. The 2012 edition raised the bar in terms of interactivity, which is a tough challenge for a meeting of more than 11,000 attendees!
Of the clinical trials you have participated in, which did you enjoy most, and why?
Certainly, the ones I enjoyed most are the different trials evaluating the BVS absorbable scaffold. This technology has the potential to be the fourth revolution in percutaneous coronary intervention if the financial aspect does not preclude a large application in young patients.
The LEADERS-FREE trial, sponsored by Biosensors and organised by CERC, is also a groundbreaking study: it is a double-blind, randomised, controlled trial comparing a drug-eluting stent to bare metal stents with one month of dual antiplatelet therapy in patients with contraindications to long dual antiplatelet therapy.
What advice would you give to young physicians training in interventional cardiology?
Put the patient (and not only his/her coronary arteries or his/her aortic stenosis) at the centre of your focus. Mindset is the key: open mind and self-criticism are crucial. In this fast moving field, we are always learning, even after 25 years of practice. That makes our job exciting and gives us the mental strength to, sometimes, make the decision not to intervene.
What are your interests outside of medicine?
As for many other interventional cardiologists, it is difficult for me to get free time for hobbies. Time with my family, of course, remains the top priority. Whenever possible, I like to drive my motorbike, even in crowded Paris. I also enjoy sailing on the Atlantic coast, particularly in Brittany, from where my family originally come from. I like to travel around the world and have a special interest in Asia. Another of my hobbies is collecting fine wines and managing their ageing process. The few thousands of bottles I have give me a very different sense of time, very different from the permanent rush we experience in cathlabs. The last challenge will be to learn piano, but that is another story!
1981–1986 Cardiology fellow, Paris Hospitals
1987 Assistant of Paris Hospitals, Cardiology Department at the St Antoine hospital, Paris
1988–1990 Assistant in the Interventional Cardiology Department at Versailles Hospital
1990–1994 Assistant professor, Interventional Cardiology, Marie-Lannelongue Hospital
1995–2008 Co-director of the Interventional Cardiology Department in Centre Cardiologique du Nord, Saint-Denis
2008–present Institut Cardiovasculaire Paris-Sud
2009–present Interventional Cardiology Creil
1987 Cardiology board
1994 Executive member of the French Society of Cardiology
1997–2001 Co-director of Interventional Cardiology graduate training Paris University
2002–2004 President of the Interventional Cardiology Group of the French Society of Cardiology (GACI)
2003–present Fellow of the Society for Cardiac Angiographies and Interventions
2004–2010 Chief medical editor, PCRonline
2006–present Board member of EAPCI (European association for percutaneous cardiovascular interventions) – Chairman of communication committee (2010–present)
2008–present Fellow of European Society of Cardiology
2012–present Fellow of American College of Cardiology
- Principal investigator/co-principal investigator of French trials (Hemostase, Corsica, Open) or international trials (Class, Lobster, Slide, Trends, 5F registry, Secure, Brillant I and II, Milestone I and II, Elutes III, Zomaxx I, Nobori I, Export, Cristal, Giant, Absorb II)
- Member of steering committee of Rescut, Elute I and II, Carina, Besmart, Caress, Angioxx registry, Spirit V, Nobori II, Proency
- Director of CERC (Centre Européen de Recherche Cardiovasculaire)
1991–1998 Member of organisation committee of “Journée nationale du groupe de réflexion sur la cardiologie interventionelle”
1997–1999 and 2004–present Member of scientific committee of European Congress of Cardiology
2002–present Member, scientific committee/programme committee of EuroPCR
2000–present Member of organisation committee of “High-Tech” congress
2003–present Co-director of TOPIC (Japan)
2002–2004 Member of the organisation Committee of Journees Européennes de la Société Française de Cardiologie