Originally from Argentina, Flavio Ribichini (head of the Cardiovascular Interventions Unit of the University of Verona, Italy) moved to Italy to see “more of the world” and decided to stay because he wanted to climb the Alps. He speaks to Cardiovascular News about being involved in the first use of primary angioplasty in Italy and how his belief in the “learning-teaching continuum” informs his clinical practice.
Why did you decide to become a doctor and why, in particular, did you decide to specialise in interventional cardiology?
Although medicine is not genetically transmitted, it is certainly highly contagious. Indeed, as in most cases, my father, who was a pathologist, inspired me to be a doctor. I remember him leaving home in a WWII jeep with his colleagues and friends—a dermatologist, a lab technician and a nurse—into the deep of the impenetrable forest (we lived in the subtropical region of north-east Argentina close to Paraguay and Brazil) to take care of indigenous people with leprosy, and returning days later covered with dust, joy and pride. My kids see me leaving home to go work with a helmet, a back pack and the motorbike and although this is much less romantic than what my father was doing, I perceive that they feel the same sense of pride that I felt when I saw my father.
I really liked most of the clinical branches of medicine but at a certain point, I had the impression that cardiology was the simplest, the most intuitive and logical, and nothing could be clearer than thinking on the consequences of an occluded artery and the potentials of opening it. Then, when you see that with a local anaesthesia and special catheters you can fix the heart and vessels, and the patient is standing some hours later, there is no way back. At this point it is difficult to imagine something more fascinating and attractive than doing interventional cardiology.
Who have been your career mentors?
When I started studying at the University of Turin, I met Professor Gianni Bussolati—director of the Department of Medicine at the time. He taught me that “the most difficult task for a young researcher doing his best is to learn how to be forgiven for his success”. I did not understand his words at that time, but he was telling me all about the “adults of the professional world”.
William Wijns and his colleagues Bernard De Bruyne and Guy Heyndrickx, in Aalst Belgium (where I was a research fellow), have also been mentors to me. They showed me the strength of a team, and William provided me with the best example I have ever seen of “how to be” and showed me that “to be a good doctor, you must be a good person”.
Back to Italy, my current director Corrado Vassanelli gave the opportunity to run a cath lab and get into the academic world, a position that is very difficult to obtain for a foreigner in Italy. Under a technical point of view, when I perceive that something is “simply impossible”, I invite Eulogio Garcia to my lab, and he “simply” shows me how to do it. I hope to be able to learn at least some of his tricks and experience to pass them on to future generations.
Why did you decide to move to Europe for your cardiovascular training and why did you decide to stay and work in Italy?
Argentina is a wonderful country and I love it, but I decided to leave at the age of 25 despite having a lovely family, a good job, and fantastic friends because I needed to know more about the world outside. I grew up during the total repression of a military dictatorship. Everything was forbidden and all around us was depicted as being “dangerous and bad”. I felt the need to change, to meet different people, to leave behind all the sad I had seen and heard. When I arrived in Italy, I went to Turin where some friends of my father helped me to start my career. I saw from piazza Gran Madre the marvellous spectacle of the Alps all around the city. They were so close that I almost felt the smell of the snow. I decided to stay in Turin to study cardiology and to climb mountains.
In your view, are there major differences in how interventional cardiology is practised in Europe and how it is practised in Latin America?
The level of healthcare in Argentina has always been excellent, following the American model of learning and training. However, in my opinion, the main differences are the organisation of the health system and the access to complex care.
In Latin America, medicine at a high complexity level, such as interventional cardiology, is mostly granted by private institutions. Public hospitals receive weaker budgets every year and hardly grant basic services. Interventionalists are employees of a businessman (often a colleague) and are paid for services. Patients have to pay for healthcare either directly or through a certain kind of insurance. This creates obvious differences in the kind of medical care that is provided to the population. In Europe, and particularly in Italy, healthcare is seen as a basic human right and we offer all people the same treatment, from a primary percutaneous coronary intervention (PCI), to a transcatheter valve implantation or a heart transplantation regardless the patient’s nationality, race, religion, social or economic state.
Working for the people in need is a privilege and turns true my ideal of being a doctor, and teaching in a university is more than what I would have expected. But, the dark side of this system in Italy is that you work for a “frozen salary”, which is the same irrespective of the quality or the quantity of the work you do, and that is the lowest in Europe. Indeed, if one were not in love with his job, one would immediately quit the Italian public system.
You were involved in publishing the first experience of primary PCI in Italy in 1993–1995. How has primary PCI evolved over the last 20 years?
When we started doing primary PCI in a small hospital without access to cardiac surgery on site (the closest cardiac surgery centre was more than 100Km away!), we were criticised not only by clinicians, but also by most interventionalists from bigger and more important institutions. We were just trying to follow the examples of the group of the Mid America Heart Institute in Kansas, and the Zwolle group in the Netherlands, but we were in Italy, and often judged as irresponsible. But, as always happens when something is right, primary PCI rapidly become the firstline treatment and now it has evolved to be performed worldwide as a routine intervention around the clock.
Of the research you have been involved with, which piece are you proudest of and why?
Certainly the development of primary angioplasty without surgery on site was one of the most exciting periods of my working life. We contributed, from a small city in the western Alps, to convince interventionalists about what they could do, that this was better than fibrinolysis, and that this change would save many lives. The enthusiasm of my colleagues and the visionary support of the chief of this small division of cardiology, Professor Eugenio Uslenghi, allowed me to be the protagonist of one of the most important changes of our interventional story.
Then the study of the mechanisms of restenosis and in particular, the dedication to the anti-inflammatory therapy with immune-suppressors helped me to enlarge my knowledge in the fields of vascular biology and gave me the chance to work with my most beloved “experimental human model”: Dr Renu Virmani. I am aware of how lucky I have been to know her and work with her.
Regarding large interventional studies, our centre has been the top enroller in Italy for the EXCEL trial, a study that has compared surgery with PCI in patients with left main disease, and this year we will start working on cell therapy. I think these are indicators of the high level that our institution has achieved.
What are your current research interests?
I do believe that the next challenge for emergency vascular medicine will be the treatment of stroke. Despite some similarities with the treatment of acute myocardial infarction, there are many real obstacles to overcome before a cardiologist can become a member of an interventional stroke team. Slowly but steadily, I am working on this, and together with some of my best friends, we are dedicated to the diagnosis, and the treatment of, the “coronary and cerebrovascular syndromes” through a collaborative group called, in fact, FRIENDS (Finalized research in endovascular strategies). We have done some nice work together, and we try to divulgate this new way of thinking among interventionalists to set up the basis for a change.
What has been your most memorable case and why?
Well, certainly the most compelling under an emotional point of view is the PCI I did to my father on the distal left main a three vessels. Apart from this special case, I still remain astonished when I realise, time and again, of the endless potentials of endovascular medicine. I am lucky to work in a place where we do structural, peripheral and paediatric interventions other than coronaries, and this makes you develop a different view of our job.
You state that you believe in “the learning-teaching continuum”. Can you explain what this is and how you apply it to clinical practice?
In a few words, I think that the best way to learn is to teach. If you are able to explain something is because you have really understood it; otherwise, the others will not get your message or will perceive your uncertainty. Teaching students makes this very clear, and when you have your own kids, the sense of this becomes obvious. In our interventionalist’s world, learning is the product of our experience, is the result of repetition and constant improvement, and is the understanding of what went wrong and remembering this forever to avoid repeating mistakes. The top level is reached when you are able to predict potential errors.
Our mistakes have a very high price, and an expert interventionalists is priceless. This is what I mean with a learning continuum, and this must be followed by a teaching continuum, to transfer the precious learning that we derive from our work, from our patients, to the difference between excellent and good, between acceptable or bad, and in the extreme, is about life or death.
Outside of medicine, what are your hobbies and interests?
I like going trekking with my friend Luca and walking with the kids, and still hope of doing an expedition to the Andes when my kids are older. My camera is one of the fundamental ingredients of any trip and in my life in general, it is always in my backpack and I do not mind carrying its weight to come back with a good shot.
In daily life I have fun riding my old motorbike. I use it all year long regardless of the weather conditions and it gives me a great sense of freedom.
Also, cooking is my most relaxing and funny activity by the end of the week, and I generally take care of the dinner on Fridays and Saturday when I am at home. I like trying new recipes and tastes while sipping a good glass of wine.
2014–present: Director of the PhD. School of Life and Health Care of the University of Verona, Verona, Italy.
2006–present: Associate Professor of Cardiovascular Medicine, University of Verona, Verona, Italy.
2006–present: Director of the Cardiovascular Interventions Unit of the University Hospital, University of Verona, Verona, Italy.
Assistant professor and director of the Catheterization Laboratory at the University of Eastern Piedmont, Novara, Italy.
1997–1998: Research fellow of the ESC in Aalst, Belgium.
1993–1996: Training in Interventional Cardiology in Paris (France), New York and Stanford (USA).
1992:Board in Cardiology, University of Turin, Piedmont, Italy.
1989:School of Medicine, University of Turin, Piedmont, Italy.
1986–88: Fellow in Internal Medicine in Argentina.
1986: Graduated in Medicine at the National University of Còrdoba, Argentina.
Society and journal boards
- Member of the Task Force of the European Society of Cardiology (ESC) guidelines in myocardial revascularisation
- Member of the Task Force of the American Heart Association (AHA) guidelines in cardio-pulmonary resuscitation in 2000.
- Member of the editorial board of the European Heart Journal.
- Member of the scientific board of TCT-Russia.
- Member of the scientific programme committee of Euro-PCR.
- Winner of the TCT Best Challenging Case Award in 2011 and 2013.
Wandering, observing, doing (Andando, vedendo, facendo).
- Do not eat sweets.
- “Invent” free time for staying in contact with nature, and “waste” time with your friends.
- Formula to make free time: do not watch television, do not waste time on the telephone, do not waste time on the internet, and try to do things once, the right way.