As one of the UK’s leaders in interventional cardiology, David Hildick-Smith (University Hospitals Sussex, Brighton, UK) has been a contributor to important research in areas including patent foramen ovale (PFO) closure, transcatheter aortic valve implantation (TAVI), left atrial appendage occlusion (LAAO) closure, and coronary angioplasty. Currently serving as the president of the British Cardiovascular Intervention Society (BCIS), Hildick-Smith tells Cardiovascular News about his life and career.
Why did you choose to become a doctor and why, in particular, did you choose to specialise in interventional cardiology?
I chose to be a doctor somewhat by default really. I was good at science at school and I did not want to be a teacher or a proper scientist. I really wanted to be an astronomer and spend ages pondering the universe, but that was not very practical. Finally, I did medicine partly because all my sisters had also done that and partly as a way to get a degree of some sort, whether I went on to be a doctor or not.
Who were the biggest influences on your early career?
Two people really come to mind—Michael Petch and Len Shapiro, both at Papworth Hospital (Cambridge, UK). Michael Petch took a chance on appointing me to a good post when my CV looked rather lacklustre—I had been a journalist, an anaesthetist and a wanderer, so I was very lucky that he took a chance on me. I also really admired his clinical skills, and the way he could see about 50 patients in a clinic. Len Shapiro was just great at doing interventions. He did not always know quite how he had managed to make something work, but he usually managed it. He also had a lack of interest in petty bureaucracy or internal politics. He was interested in creativity and innovation and I aspired to have his interventional panache.
What has been the most important development in interventional cardiology during your career?
This one is easy—it has to be transcatheter aortic valve implantation (TAVI). It has been a massive transition for patients to be able now to have a valve replacement done through a 6mm blood vessel. Patients still find it amazing, and so do I if I sit down to think about it—the technological engineering is incredible. Patients often think we are the clever ones but it is the engineers who have done all the hard work. It has been amazing to be part of the TAVI experience right from the start in 2002. The excitement in 2007 when we did our first TAVI cases in Brighton was palpable.
How do you see TAVI evolving over the next 10 years?
TAVI will gradually become more routine, and lower risk, as valve profile, positioning and durability improve. However, rather paradoxically, the lower risk group of patients (aged 60 to 70) not uncommonly have the most problematic anatomy, and many of these would still be well advised to have surgery as a first option. It is hard to know how best the increase in volume should be handled. TAVI requires a sizeable team to be able to deliver high volume and rapid turnover with good results. This means structural heart centres offering five days a week structural programmes, which is not yet common. There is also a discussion to be had about the number of patients with very limited life expectancy currently being referred for TAVI, and whether this is sensible.
What has been the biggest technological disappointment?
It would be a bit harsh to say it has been mitral Intervention, but it has been mitral intervention! We did our first percutaneous mitral valve interventions nearly 10 years ago, but still the number overall are tiny, and no one has solved the big problems inherent in designing a valve that works. I remember in 2010 confidently predicting that mitral clip therapy only had five years left in it before being superseded by a full valve implant—how wrong I was! But, progress in the mitral valve area is definitely slow and there have been technologies that have come and gone. No one has yet fully solved the fact that the pesky anterior leaflet of the mitral valve has to get out of the way to let the blood out of the heart. Design by natural selection is still beating the best that human engineering can come up with—but it is also fantastic being part of the journey trying to solve these problems.
You have been instrumental in research in the field of PFO closure. In your view, should the procedure be restricted to patients under the age of 60?
It is of course, ludicrous to restrict the procedure on the basis of age alone. And in due course that will be challenged—maybe even in the courts! I understand why the age restriction is there, because that is the population studied, but the purpose of randomised trials is to try to answer a defined question in a rigorously clean set of circumstances, and then apply it to the wider population in an intelligent manner, case by case. There are very many people over the age of 60 who merit PFO closure and I have no doubt that as time progresses there will be more pressure from stroke physicians and neurologists to consider PFO closure in patients over the age of 60.
What important insights has the EBC MAIN trial (see page 19) added to our understanding of the treatment of left main bifurcation coronary artery disease?
I hope that EBC MAIN has been an important study for interventional cardiology. It is rare that things are made better by being made complicated, and intervention of the left main bifurcation was in danger of being routinely overcomplicated. Cardiologists like to do challenging things but the overall patient outcomes are what matters most and there was a tendency to commit to a dual-stent strategy right from the beginning of a left main intervention, rather than take it step by step, stopping when you had a good result. It has been a problem for cardiology that the angiographically lovely result at the end of the procedure is not necessarily the one that serves the patient best in the long term. So EBC MAIN should make people pause before routinely considering a two-stent strategy, and that is a good thing.
What are your current research priorities?
I remain very interested in research around LAAO and PFO closure, both of which I think are going to expand greatly over the next ten years, particularly LAAO. In the coronary arena, I am struck by the continued price that is paid for stent implantation. It is not so uncommon to see patients coming back with a complication related to a stent that was implanted 10 years ago. The constant drip of inflammation related to the presence of a foreign body in the arteries is something which is going to get a great deal more attention in the next five years and I am currently looking to run a big European trial on drug-coated balloon technology for coronary bifurcations.
What has been the most important paper published in the past year?
Rather than pick out one I would simply say congratulations to anyone who has had an idea, written a protocol, sought funding, cajoled others into participating, collected the data and finally published their findings. It is a massive, sometimes thankless and solitary endeavour!
You are serving as president of BCIS—how important has membership of societies been to your career, and do you have any goals for your presidency?
I have always really enjoyed being part of BCIS in order to try to have a say in influencing development of services. I have also contributed to many other societies to try to bring about change. For BCIS, the biggest challenge professionally for cardiologists is the primary angioplasty service. It has been extremely beneficial for patients but providing the service is bringing many cardiologists and allied health professionals to their knees. We need to ensure that services are sustainable and are staffed by enough people to make rotas survivable for a career. Regional network planning of rotas should address minimum numbers for sustainability. Given the known harm of night-time call, days off after being on call should be written into job plans in accordance with existing BCIS guidance.
There is an unfortunate exodus of talented and experienced older cardiologists. Much of this of course relates to the arduous nature of being on call. In order to continue to attract the best people into cardiology and the cath lab environment, we need to make sure that they can see something other than an entire career of night-time primary angioplasty ahead of them. We need to discuss rota management such that colleagues can, for example, share an on-call slot aged 55 and, for example, come off night time on call aged 60 (and perhaps do weekend days instead). Otherwise we will continue to lose older cardiologists prematurely, while failing to attract some of the brightest young trainees into the specialty.
As regards career development, every cardiologist needs to be able to see opportunities ahead. Over the last decade, most interventional opportunities have been focussed in regional hospitals. In district hospitals, opportunities have been fewer. There are opportunities, though, to introduce innovative treatments to a district hospital setting. Stroke intervention, pulmonary embolectomy, renal denervation, peripheral angioplasty, coronary sinus technologies etc. should all be available as options that need to be spread through many hospitals in the country, just as some other treatments need to be available in all surgical centres.
What can interventional cardiology do to attract young physicians to the field?
See answer above! Of course the daytime work is extremely rewarding and we are very lucky in the work that we do. We still have the respect of the patients and most of them are extremely grateful for our efforts. The night-time work is a problem. It definitely puts off some excellent trainees, and I am not surprised. I do think there are options for limiting the amount of work that consultants do at night, being regularly woken from sleep to go in to the hospital is a peculiar form of torture, and it is definitely bad for your health. As a trainee you want to see some “open road” in front of you, when things will be easier, and worth working for. At the moment we do not have that balance right.
Outside of medicine, what are your hobbies and interests?
I like music, I play the guitar and piano a fair bit and have a Spotify channel. I also like to play poker, though I am pretty bad at it as I do not have a poker face. I play cricket about once a year though I like to think it’s more often. I garden and like to pretend that I live in a Mediterranean climate by trying to grow peaches and lemons (and failing) and I have inherited a small pond which takes my time as I do battle with the algae and try to get the tiny solar pump to work. I like to walk, spend time with my family, and try to spend time not pondering the world too much but applying the power of now (and usually failing too!).