David Holmes, Mayo Clinic, Rochester, USA, is the past president of the American College of Cardiology. Principal investigator of the PROTECT AF trial, Holmes has been involved in several other studies in electrophysiology and interventional cardiology. He spoke to Cardiovascular News about his career, mentors, research and interests outside medicine including playing the piano and his favourite books.
Why did you choose medicine as a career?
One of the most important formative experiences in choosing medicine as a career came from the initiatives growing up where no road kill was safe from the Holmes’ boys. Anytime we saw road kill while driving, no matter how big or small, we would have our parents stop so we could pick it up and put it in the car (usually in the boot). They would then be subjected to analysis in the garage looking at different parts of the anatomy and then dissecting them and saving different parts in preservative solutions to be stored in the refrigerator, much to my mother’s horror.
Which innovations in cardiology have shaped your career?
There are several fundamental innovations in cardiology which have changed the field. The first from my standpoint was the development of intracardiac electrophysiology and the move from pacemakers being implanted by surgeons to being implanted by cardiologists. This dramatically changed my practice early in my career. The next related to the development of initial instrumentation within the coronary arteries pioneered by Andreas Grüntzig which led to the whole development of interventional cardiology and then the final innovation was the outward migration of the technologies brought along for percutaneous coronary work to other vascular beds.
Who were your mentors and what do you still remember from their advice?
Mentors are an incredibly important part of career development. Sometimes a mentor may be older, some of the time they would be in the same peer group and some of the time they would be younger. The two dominant mentors in my early career were Dr Robert Frye who was head of the Catheterization Laboratory, then head of the Department of Cardiology and then head of the Department of Medicine at Mayo Clinic. His advice was a piece of “living advice” where he was fully committed no matter how long things took to finding answers and finding solutions to problems. So his advice was a living advice. The second early mentor was Dr William P Baker, who was my chief of cardiology at the National Naval Medical Center. His living advice was to always ask questions and never be satisfied until you had distilled the important pieces of information and then ask additional questions based upon those pieces of information. He remains the epitome of clinical cardiology. A third mentor would be Dr Rick Nishimura. He would fall under the category of someone younger than I am. He mentors by being a living example of teaching and commitment to education. In terms of those skills, he is at the top of the field. He winds up being a mentor in that we continually try to re-invent our careers by choosing new mentors. Dr Nishimura is such a mentor who then is the shining example of interested communication, learning, education and passion.
As a young doctor, do you remember the moment in interventional cardiology that has marked you most?
A crucial memory winds up being a grateful patient early on who was told that he needed to have coronary bypass graft surgery who was then referred for the potential to be treated by a percutaneous approach. This then resulted in an incredibly successful outcome that has been long-lasting. The patient and family’s gratitude about this and the ability to change the face of medical care for this individual patient was a seminal moment.
In the last 10 years of interventional cardiology, in your opinion, what have been the three most defining randomised controlled trials for the specialty?
The three most defining randomised controlled trials for this specialty are SYNTAX, RAVEL and PROTECT AF trials. SYNTAX is a pivotal trial that has fundamentally changed the practice going forward of interventional cardiology; it has changed the practice of appropriate use criteria and it will continue to change the practice going forward as we engage patients and families in their medical care. The second was the initial RAVEL trial of drug-eluting stents, which dramatically changed the field with the hope that restenosis would be either cured or dramatically ameliorated. The third is the PROTECT AF trial of left atrial appendage occlusion. This trial, which looked at patients with atrial fibrillation at risk for stroke, documented several different things: the trial confirmed the hypothesis that in the setting of non-valvular atrial fibrillation, stroke results from thrombus that develops in the left atrial appendage and then embolises; it documented the fact that, indeed, approaches to occlude the left atrial appendage are non-inferior to what had been the standard of warfarin therapy; it documented the fact that in the space for stroke prevention, interventional cardiology as well as electrophysiology has the potential to make a huge difference to our patients in terms of preventing complications related to long-term anticoagulant use whether that be warfarin or the new anticoagulant regimens.
You have been principal investigator or co-investigator in several clinical trials. What is the research you have done that has been most rewarding? Which one has had the biggest impact in the field?
The PROTECT AF trial has been the most rewarding from my standpoint. I believe that is has the potential to change the field most dramatically. The burden of atrial fibrillation and stroke prevention is increasingly large. The development of new alternative approaches for stroke prevention in this setting will impact a huge number of patients worldwide. In terms of the patient population then, it is vast. In terms of the ability to make a difference, it is also vast.
What will the role of left atrial appendage occlusion devices be in the prevention of stroke in atrial fibrillation patients?
The left atrial appendage occlusion devices are still in the early stages of development. At the present time, we have perhaps 50,000 patients in aggregate who have been treated with new anticoagulant regiments. We have a small field of evidence of patients who have been treated with these devices for stroke prevention and atrial fibrillation. As I have previously alluded to, the patient population is vast and the chance to make a difference is also vast.
What are the honours that you have received that you look back on with pride?
The chance to give the James B Herrick lecture at the American Heart Association is one of the honours that I look back on most fondly. We both came from the same town. We both went to the same high school. On my way to high school, I used to walk by the place where he had been born and lived. I did not realise that at the time because I would not have known who Dr James B Herrick was. However, the chance to have read his autobiographies and biographies and then deliver that as part of the James B Herrick award winds up being a highlight in my career. The second honour that I look back on with the most incredible fondness is on the occasion of the Robert L Frey lectureship in 2003. As I have previously mentioned, Dr Frye was one of my earliest and most important mentors. When asked to give a lectureship in his honour at Mayo Foundation it was an incredibly moving and important point for me. The title of the talk at that time was “Now We See Through a Glass Darkly” and it then talked about the future of interventional cardiology. It was a hugely important opportunity to honour Dr Frye and then honour the field.
What are your other research interests?
Other research interests are acute coronary syndromes, the development of approaches for treatment of seizures using electrophysiologic techniques, the evaluation and treatment of pulmonary vein stenosis following atrial fibrillation ablation and the evaluation and testing of new intracoronary prostheses. Finally, the development of other cerebrovascular treatment strategies in terms of both carotid arterial disease and intracerebral lesions winds up being incredibly interesting.
What have you biggest achievements as president of the American College of Cardiology (2011–2012) been?
Identification of the focus being science and education is the biggest achievement. Asking and then receiving the acceptance by Drs Pat O’Gara and Rick Nishimura to be the co-directors for the annual scientific session of the American College of Cardiology in 2012 winds up being a highlight of the year. This was the best annual American College of Cardiology meeting that I have ever attended. Those two individuals, along with the rest of the programme committee, went all out to have that be the dominant meeting and I think they succeeded beyond wildest expectations. The second biggest achievement relates to the interaction with Dr Michael Mack, president of STS, in the development of new approaches for transcatheter aortic valve replacement and the development of the TVT Registry. This has been a seminally important adventure as this new technology was rolled out to make sure that there was rational dispersion of it.
As one of the investigators in the PARTNER trials, what are three key questions regarding TAVI that you would like to see answered?
I would like to see the development of well vetted risk stratification schemes to evaluate the question of frailty vs. futility in patient selection; the development of approaches working in concert with regulatory agencies to allow for expanded indications of TAVI, and prevention and treatment of aortic regurgitation.
What are the new techniques/technologies that you are watching closely?
At the moment I am mostly interested in carotid arterial protection devices for transcatheter valve technology, new technologies to prevent or to minimise transcatheter aortic valve regurgitation, new technologies for left atrial appendage occlusion, and radiofrequency devices for noninvasive telemetry of patient at risk parameters.
What are your interests outside of medicine?
Interests outside of medicine are a fundamental cornerstone of life and indeed are the continuing evolution of a classical liberal arts education. Such interests are spice as well as lodestones and they connect us to the real world. Such interests foster the development and nurture creativity. My interests include dreaming in the fashion of Walter Mitty and imagining what it would be like if…
Objects of the dreaming include a life led in the American West immersed in the culture of Stegner, painting visual pictures with words of poetry as well as prose and living as passionately as possible. More grounded but no less important excursions into life include reading about a wide range of topics, both fiction and non-fiction, relishing the word pictures, playing Debussey on our old grand piano, particularly The Engulfed Cathedral, vigorous exercise, and expanding the creativity of wildly creative grandchildren while helping them exercise their minds. My favourite books are Sea Runners by Ivan Doig and The Road by Cormac McCarty. A soft rock in my pocket for a sail and an anchor complete the tapestry. A sailing ship is not made to stay in the harbour.
Present academic rank and position
July 1978–present Consultant, Division of Cardiovascular Diseases & Internal Medicine, Department of Internal Medicine Mayo Clinic, Rochester, USA
July 1987–present Professor of Medicine, Mayo Clinic College of Medicine, Rochester
2003–present Master’s Faculty Privileges in Clinical Research, Mayo Graduate School of Medicine, Mayo Foundation for Medical Education and Research, Rochester
1963–1967 BA, Princeton University, Princeton, USA
1967–1971 MD, Medical College of Wisconsin, Milwaukee, USA
1971–1972 Straight Internship, Virginia Mason Hospital, Seattle, USA
1972–1974 Fellowship, Internal Medicine, Mayo Clinic, Rochester, USA
1974–1976 Fellowship, Cardiovascular Diseases, Mayo Clinic, Rochester, USA
Previous professional positions and major appointments
1976–1979 Instructor of Medicine, Mayo Clinic College of Medicine, Rochester
1979–1983 Assistant professor of Medicine, Mayo Clinic College of Medicine, Rochester
1983–1987 Associate professor of Medicine, Mayo Clinic College of Medicine, Rochester
1981–1985 Director, Electrophysiology and Pacing, Mayo Clinic and Mayo Foundation
1984–2003 Director, Cardiac Catheterization Laboratory, Division of Cardiovascular Diseases & Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester,
Honours and awards (selected)
1995 Transcatheter Therapeutics Career Achievement Award; Washington Cardiology Center
2003 Mayo Clinic Cardiovascular Division Teacher of the Year
2004 Mayo Foundation Research Career Achievement Award
2006 American Heart Association Affiliate Eugene Drake Award
2006 ACC Distinguished Scientist Award (Clinical Domain)
2007 James B Herrick Award of the American Heart Association Council on Clinical Cardiology
2010 Carl Wiggers Award
2012 Master of the American College of Cardiology (MACC)
2012 Medical College of Wisconsin Alumnus of the Year