Javier Escaned (head of Section, Interventional Cardiology Unit, Hospital Clinico San Carlos, Madrid, Spain) is a co-course director of EuroPCR (17–20 May, Paris, France). He talks to Cardiovascular News about the highlights of this year’s meeting, discusses the SYNTAX II trial, and explains the influence that the Greek philosopher Aristotle has had on him.
Why did you decide to become a doctor and why in particular, did you decide to specialise in interventional cardiology?
I decided to study medicine as a result of an early interest in life sciences and a vocation to care for people. An inspiring teacher at the School of Medicine in Santiago de Compostela planted my interest in cardiology, and I found my calling for interventional cardiology during my specialty training at the Queen Elizabeth Hospital in Birmingham, UK.
Who have been your career mentors?
My mentors are Dr Man Fan Shiu and Professor Bill Littler in the UK (interventional and clinical cardiology, respectively), Professor Patrick Serruys in Rotterdam (clinical research) and Professor Carlos Macaya (Hospital Clinico San Carlos, Madrid). Professor Jean Marco was my reference in education long before I joined the PCR team.
What have been the most important advances in interventional cardiology during your career?
Firstly, there is the coronary stent—“the great equaliser” as it was once called. The dissemination of interventional cardiology in the 1990s was largely a result of the standardisation and increase in the safety of percutaneous coronary intervention (PCI) procedures, expansion of PCI subsets, and shortening the operator training time associated with the availability of stents.
A second important development has been the indication of primary PCI for patients in the acute phase of ST-segment elevation myocardial infarction (STEMI). This means our job, as interventional cardiologists, has been upgraded to being a life-saving one.
Thirdly, there has been the development of intracoronary imaging and physiology that has circumvented the limitations of coronary angiography and, fourthly, there have been technical advancements (which is something that I believe is still unknown to many physicians) for the recanalisation of chronic total occlusions. Out of coronary interventions, I consider transcatheter aortic valve implantation (TAVI) the most important development during my career.
You did your training in the UK, your PhD in the Netherlands, and you now work in Spain. What are the similarities and differences between these countries in terms of way that healthcare is practised?
The main similarity is that these three European countries have outstanding public healthcare systems. I like very much the pragmatism and methodology of UK cardiologists, the multidisciplinary and creative spirit of those working in the Netherlands, and the skilfulness and versatility of Spanish interventionalists. I am very fortunate to maintain successful collaborations with colleagues and friends in these countries.
Of the studies you have been involved with, which one do you think has had the most important clinical impact?
If I stick to the multicentre trials that have been launched by our team at Hospital Clinico San Carlos, probably the DIABETES (Randomized comparison of sirolimus-eluting stent versus standard stent for percutaneous coronary revascularization in diabetic patients: the diabetes and sirolimus-eluting stent) trial, with my colleague Manel Sabate as principal investigator, had the most immediate influence on practice. It was the first to show the importance of using drug-eluting stents to treat coronary lesions in patients with diabetes.
You are one of the principal investigators of the SYNTAX II study. What are the aims of this study and how does it differ from the first SYNTAX study?
The main aim of SYNTAX II is to assess to what degree contemporary state-of-the-art PCI improves outcomes in patients with triple vessel disease compared with the PCI used in the original SYNTAX trial. This is an important task, since the results of SYNTAX had a strong influence on guideline recommendations and therefore modulate our everyday practice even though first-generation drug-eluting stents have been superseded. The SYNTAX II study tests a holistic PCI approach that incorporates a clinical and anatomical procedural risk assessment (SYNTAX II score) during heart team sessions, ischaemia-driven revascularisation based on instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR), use of a third-generation drug-eluting stent, and procedural intravascular ultrasound (IVUS) guidance. Participating centres have dedicated chronic total occlusion operators to maximise completeness of coronary revascularisation.
The third-generation stent used in SYNTAX II has a biodegradable polymer. What are the potential benefits of stents with biodegradable polymers given that second-generation stents have such good safety and efficacy data?
Unfortunately, we all see patients who have received a second-generation drug-eluting stent presenting with stent failure, often with dramatic consequences. Despite an overall improvement since the first-generation drug-eluting stents, the absolute figure of stent failure has increased as a result of more stent implantations performed worldwide, and this is why we need improvements in stent technology.
The use of a biodegradable matrix was introduced in some second-generation drug-eluting stents to address the problem of polymer-related events. The third-generation drug-eluting stent (Synergy, Boston Scientific) used in SYNTAX II combines a thinner biodegradable polymer abluminal coating, engineered to complete its degradation within four months, with other important features such as very thin struts and everolimus as the antiproliferative drug.
Of the studies published in the last year, which do you think has been the most interesting and why?
I would select the TOTAL (A randomized trial of routine aspiration thrombectomy with PCI versus PCI alone in patients with STEMI undergoing primary PCI) trial. The lack of benefit observed with thrombectomy in TOTAL means that the theory of thrombotic plugging of the microcirculation as a main determinant of myocardial damage during primary PCI is over. My impression is that theories that point to reperfusion injury, intra-myocardial haemorrhage and microcirculatory compression as a cause of myocardial damage during primary PCI are reinforced after TOTAL.
Furthermore, TOTAL confirmed the findings of the TASTE (Thrombus aspiration during STEMI) study, which was a randomised registry performed in the Scandinavian countries that addressed the same research question as TOTAL. However, TASTE was performed much faster and at a far lower cost than conventional trials such as TOTAL. Therefore, in the future, TOTAL will probably be seen as the first validation of the randomised registry—a new type of extremely cost-efficient study design inaugurated with TASTE. This is of great importance for clinical research at a time of economic scarcity.
You are a co-course director of EuroPCR. What were the highlights of this year’s course?
In the coronary field, I would highlight the sessions dedicated to sharing practical knowledge and personal experiences on bioresorbable scaffolds, the reporting of studies on imaging and functional guidance of coronary procedures (including the 15-year follow up of FAME), and the great interest of the attendees about recanalisation of chronic total occlusions.
In structural heart disease, there was the favourable two-year results of the NOTION study, which anticipates the expansion of transcatheter aortic valve implantation (TAVI) to intermediate- or low -risk cohorts; also, the reported superior results of third-generation TAVI devices. I would also highlight the presentation of new intraoperative fusion imaging technologies and, overall, the growing partnership between interventionalists and imagers in structural heart interventions.
Given that so much information is now online, what is the added value of attending meetings?
I feel that online information cannot replace personal contact and on-site engagement in educational activities held in meetings. Typically, when we follow a congress via the internet we search for newly released studies or guidelines that provide broad recommendations for our practice. It goes without saying that this is important for all of us, but the bulk of our challenges as practising physicians are made up of questions that cannot be answered only with that information: it is made up of questions related to the singularity of the patient, before whom we are responsible for our decisions, and this need is better addressed by sharing the extensive experience accumulated by our colleagues. This interaction is also key for the adoption of new technologies. Of course, the first task of course organisers is to set the conditions that make possible successful interaction between peers, to facilitate what in PCR is known as a transformative educational experience.
What has your most memorable case been and why?
I remember that, just after optical coherence tomography (OCT) had been introduced into clinical practice, I saw a lady in her 40s with mild ECG changes, raised troponin levels and angiographically normal coronary arteries, with the exception of a long, smooth mid left anterior descending narrowing. I explained to her that I was unsure her problem was atherosclerosis and that we might be able to obtain more insights with a new diagnostic tool. I also explained the small risks associated to it. She told me: “Well doctor, since I will have to live with it, I would also like to have more certainty about what the problem is. So let’s have a look”. I was struck by the clarity of the situation: both of us were confronted with a problem, she as the patient and I as the physician. The OCT revealed a long left anterior descending haematoma in an otherwise normal coronary artery, free of atherosclerosis. We successfully managed the patient medically. Three months later the artery was completely normal both in angiography and OCT. This was one of the first of a series of similar cases unravelled by OCT at our institution. I learned how the generosity and curiosity of the patient contributed to both personalised treatment and to advance in our knowledge.
Philosophy is one of your interests. Who is your favourite philosopher and what influence have they had on your career?
I guess I am Aristotelian in the sense of giving contemplation and friendship a central role in life. As a cardiologist, philosophy has been important for me, for example, to understand social representations of heart disease and the way patients put in words their symptoms (George Lakoff), or why new scientific propositions like iFR generate first so much turmoil but are eventually accepted (Thomas Kuhn). The philosophy teacher I am most indebted to is Nelly Schnaith.
Outside of medicine, aside from philosophy, what are your hobbies and interests?
I love music, particularly jazz. I play saxophone and I am very lucky to have many opportunities to play with my wife (double bass), my daughter (singing) and many musician friends.
- Head of Section, Interventional Cardiology Unit, Hospital Clinico San Carlos, Madrid, Spain; Associate Professor of Medicine, Complutense University of Madrid, Spain
- Co-course director, EuroPCR
- Treasurer, European Association of Percutaneous Cardiovascular Interventions (EAPCI),
- Nucleus member of the ESC Working Group on Coronary Pathophysiology and Microcirculation
- Queen Elizabeth University Hospital, Birmingham, UK
- Walsgrave Hospital, Coventry, UK
- Thoraxcenter / Rotterdam, the Netherlands
- ADVISE II
- DEFINE FLAIR
- PILOT SECRET
- SYNTAX II
Steering committee/DSMB Member
- EURO CTO
Scientific publications and books
- 217 publications indexed in PubMed
- Editor, Coronary stenosis: imaging, structure and physiology textbook (2nd edition 2015)
Major fields of research
- Coronary imaging and physiology
- CTO and complex PCI
- Atherosclerosis and acute coronary syndromes
- Coronary stents and bioresorbable scaffolds