Jeffrey Moses, professor of Medicine, Columbia University Medical Center, New York, USA, has witnessed the transformation interventional cardiology has gone through in the last decades. In this interview with Cardiovascular News, Moses notes that percutaneous aortic valve implantation is probably the most transformative technology in the last 20 years and describes his father’s experience of undergoing a TAVI procedure. He also spoke about his career, influences, areas of research and his love for skiing and playing tennis.
Can you describe the journey into medicine and interventional cardiology?
My earliest aspiration was to be a mathematician. I had a gift for mathematics, and enjoyed the elegance of the problem solving and the ability to “see the answer” from broad concepts and then translate them it into numbers. However, when I hit adolescence people became more relevant, and I became much more interested in medicine. I think biology became more relevant to me in a variety of areas, and the impact of the application of science on people’s lives just seemed to be more gratifying than the abstract world of mathematics. So from the time of high school, through college, I think I was committed to the medical field, but did not know enough about the specifics of the individual specialties to really choose my path. One of my fascinations in medical school was with the interface between psychiatry and neurosciences. This was still in the heyday of psychoanalytic theory and behaviourism was just emerging. I think I was fortunate enough to be at Penn, where the behaviourists were emerging and applying a bit more practical scientific rigor to the work on psychiatric disorders. In addition, it was the dawn of psychopharmacology and that seemed to be a clear interface between neurology and psychology. I actually did a fair amount of advanced psychiatric work in my undergraduate and had a residency lined up, but at that time the residency was requiring me to skip my internship and I felt that would have been a waste of a medical degree, so I then turned to internal medicine. Ultimately, I think I fell into cardiology because in allowed an opportunity to apply cardiovascular physiology in everyday work. The Swan-Ganz catheters were just being used and the idea of titrating drugs, and other ministrations, to optimise cardiac parameters in real time, was very gratifying. At Penn, pathophysiology was strongly emphasised further whetting my appetite. Of course, as I am quite long in the tooth, interventional cardiology was in its infancy during my fellowship and I was privileged to scrub-in in some of the first balloon angioplasties done in Philadelphia. It was a very exciting time and quite fluid, when we think of the rigidity of clinical investigation in the current era. The idea of just taking a course and flying over from Switzerland and coming back with a bunch of balloons in your bag and joining an NHLBI registry as a form of trial for approval seems to be quite quaint now.
I was also, at that time, fascinated with electrophysiology, and did do a fair amount of work in the early days of invasive electrophysiology, especially during my first seven years at Cornell. But, I think, interventional cardiology ultimately seduced me because of my previous work in the animal lab, and the idea of being able to make observations in the coronaries of a living human was just eye-poppingly amazing to me. Now, today, when we have sophisticated imaging techniques, intracoronary physiology and the ability to manipulate the structure of a coronary artery almost at will, seems that my early fascination was justified. Ironically, one of my first bosses, who shall remain nameless, felt that Gruentzig’s work was “interesting”, but it was “monkey work”. Well us monkeys helped create a new field of investigation and treatment and were able to transform millions of lives.
Who are your greatest influences and what advice from them do you still apply to your career?
I can cite three individuals: one is Dr Jim Carter, who is an internist/endocrinologist at Penn. He was my Attending, as an intern and resident and really opened my eyes at what a well-versed, clear thinking internist could do for his patients. His comprehensive understanding of the patient and his systematic and deductive thought formed a model for me in my approach to my patients to this day, and I do not know if he realised the impact he had on me.
The second influences were a pair of individuals, who I came to work with my first year at Cornell. They were Michael Collins and Jonathan Goldstein. They were true “cath-jockeys” and in spite of my training as a fellow, I had never really encountered individuals who were truly fascinated with the technique itself. They taught me that cardiac catheterisation was not just a mechanical process, but actually had an artistic aspect to it. This was totally revelatory to me. Fortunately, Mike Collins and I have remained fast friends, and I worked with him again for the last 12 years, after he took a sojourn in Florida in private practice.
Lastly, I think the individual I think who was most formative in my approach towards interventional cardiology is Martin Leon. While he is my colleague and great friend, his vision when he was at the NIH and at the Washington Hospital Center, of integrating advanced techniques and scientific rigor into interventional cardiology, was something I adopted very early. It is because of his passion that I felt that integrating clinical research an essential ingredient for a successful programme and to render optimal treatment.
How has interventional cardiology evolved since you became an interventional cardiologist?
Well, I have witnessed its transformation from day zero, from the early days of unpredictable life threatening complications, endless battles with groin bleeding, sleepless nights concerned about abrupt and late closure, to the largely controlled environment we have now; with predictable outcomes with advanced coronary stent techniques and complementary physiology and imaging. It is the difference between a wooden sail boat and a space shuttle.
Amongst all of the technologies you have seen in the last 20 years, what has fascinated you the most?
I do believe, if I have to take one single transformative technology in the last 20 years, it has to be the percutaneous aortic valve. This is largely due to the fact that I had the good fortune to be involved in it at its inception, when it was a highly speculative and almost “crackpot” idea, and witness its evolution into a technique that is saving the lives of thousands of patients around the world. This has been the most fascinating scientific and clinical journey of my career.
This ties up into another question about one of my most memorable clinical cases. This had to be a recent procedure that my father had at Columbia. My father is in his mid-80s, and had known moderate aortic stenosis; he suddenly became symptomatic and quite limited as the aortic stenosis progressed. I remember the look in his eyes when I told him about his disease, and that he needed an aortic valve replacement. They were pleading with me to find a way to avoid surgery at his advanced age. It was heart rendering. My dad, “fortunately”, is reasonably healthy, but did have enough comorbidities to qualify for the PARTNER trial. He had a successful valve implantation and was home in two days. That, more than anything, gave me the sense of the impact of the work we are doing on the most profound and personal level. When you are thinking about the growing population of able elderly, with a simple problem of a stenosed aortic valve, and the ability to rectify that with a catheter based procedure, that requires minimal or no invasion, the personal experience with a loved one made this my most memorable recent case.
What is the most interesting paper you have read recently?
A little gem of a paper, McNulty et al JACC CVInt 2011,4;1020, which elegantly and simply highlights some of major flaws in some conventional thinking. This study looked at patients who had unprotected left main stenting, and compared outcomes of those who were inoperable, with the operable patients. They observed profound differences in mortality, as you would expect. The only problem with the data is that they demonstrated that the ACC-NCDR database failed to capture over 80% of the conditions elements that made the patients inoperable. This is fascinating to me because it undercuts the entire premise of the current comparative effectiveness initiative cross-correlating the STS and NCDR databases. If you cannot separate out the surgical from the nonsurgical candidates in the PCI database, how do you compare these apples to these oranges? This must be addressed but will not be I fear. It just indicates how, conventional wisdom can sweep along an entire field, without anyone questioning the basic elements of the data set. These rapid fire sound-bite solutions to some of the most complex medical questions, and the certainty that people have about “current evidence”, disregarding the nuances of data entry and quality, the quality of clinical trials and subtleties of patient recruitment is sending this field, in some ways, in some questionable directions. They just get fascinated with the statistical methods.
What are your current areas of research?
I am fortunate to be on the executive committee of the PARTNER trials and have worked, collaboratively, with our surgical, interventional colleagues, and our partners in industry. The current tack is to continue to investigate extending the potential of this novel technology from high to intermediate risk patients. In addition, we are working on further iterations of this technology and broadening its applications to other valvular diseases as well. I am also working with Dr Ajay Kirtane on the applications of ventricular unloading with the Impella technology, in limiting infarct size in a pilot study called the MINI-AMI study. In addition, I continue to work on advancing techniques on chronic total occlusions, with the applications of new wires and new methods and imaging techniques to help enhance our success rates.
As director of Vascular Intervention for New York Presbyterian, what are the rewards and challenges of being in this supervisory position?
There is no question that the day-to-day gratification of rendering care to some of the sickest patients in the world and beginning to apply advanced technologies to rectify, what are sometimes “hopeless” situations, is a daily gratification; one which I do not think I could ever give up. I am still a very busy interventional cardiologist, doing well over 600 interventions a year and really cannot get enough of that. Obviously, the challenges of this position involved in enlisting a complex organisation to focus on the patient when there are so many other demands on the direct caregivers, especially with the overwhelming amount of documentation and bureaucracy that is necessary to move the patient through the system. In addition the economic challenges are growing and, what Paul Teirstein refers to as the “war” against PCI, presents an enormous challenge in reeducating both physicians and the patients to the true benefits of our phenomenal interventional technologies.
Can you predict whether transcatheter valve implantation of aortic and mitral valves will eventually be better than surgery in standard risk patients?
I think this is a two-part question. The aortic procedures certainly, I think, can be extended into more intermediate risk patients, especially with the minimisation of the size of the devices, innovative new designs, as well as embolic protection. Whether it would be better in standard risk patients is an open question, given the extraordinary low mortalities seen in competent surgical hands. I think this is a way away, and I do not think that will happen within the decade. The mitrals have proven to be much more elusive. I think the idea of a transcatheter mitral valve is very appealing in its very early stages of development, but clearly almost a decade behind the aortics. I do believe the MitralClip is certainly an advance, but not for the standard risk patient. It will serve a robust niche in the area of functional mitral regurgitation in poor surgical candidates.
Interventional cardiologists now perform lower limb and renal interventions, two fields shared with interventional radiologists and vascular surgeons, in your opinion, who should do what?
While the short answer to this question is everyone should do everything, the one thing that we have certainly learned from the PARTNER trial is that collaboration between all elements of surgery, interventional and clinical cardiology and imaging, is essential for successful patient care. I believe this compartmentalisation into academic divisions in the field of vascular medicine really has to come to an end and cross training is the answer. These turf wars serve no one’s purpose, other than the certain individuals who are just interested in their territorial ascension.
What advice do you give young interventional cardiologists?
There are two dicta. First, always think about the patients’ needs. Their needs may not conform to your capabilities, and it is either up to improve your capabilities with new learning, or help develop the capabilities for the field with new research. Second, never cut corners. Being 90% right means that in 10 out of 100 patients you got it wrong. You have got to be systematic in your approach, and every individual, at a given point, has every possibility, in terms of diagnosis and complications. You cannot count on the patient to take care of you (for oversights); you have to take care of the patient.
What are your interests outside of medicine?
I do love skiing, though I do not get to do it as much as I used to. I still try to get about 10 to 15 days of skiing in a year. I like the steeps, hate cruising. I am lucky enough to be able to play tennis on a regular basis in the summer. While I am not very competitive, in the sense that I do not play to win, I do like good technique, and I do love running around the court on a hot day, and jumping into the pool. Politics are certainly a fascination of mine. I have had the good fortune to be involved with certain campaigns and politicians since my youth. I have had the good fortune to befriend some of the New York leaders, and participate and observe how decisions are made in the political system. Combining that with my interest in history, an election keeps my mind very engaged and active.
Education and training
1970–1974 MD, University of Pennsylvania School of Medicine, Philadelphia
1974–1975 Intern (Medicine), Presbyterian-University of Pennsylvania Medical Center, Philadelphia
1975–1977 Resident (Medicine), Presbyterian-University of Pennsylvania Medical Center
1978–1980 Cardiology Fellow, Presbyterian-University of Pennsylvania
1975–1980 Assistant instructor in Medicine, University of Pennsylvania, Philadelphia
1980–1981 Instructor (Medicine), Cornell University Medical College, New York
1981–1987 Assistant professor (Medicine), Cornell University Medical College
1987 Associate professor, Clinical Medicine, Cornell University Medical College
1993–1996 Clinical associate professor of Medicine, New York University School of Medicine, New York
1996–2004 Clinical Professor of Medicine, New York University School of Medicine, New York
2004–present Professor of Medicine, Columbia University Medical Center, New York
Hospital positions (selected)
1988–2004 Senior attending, Lenox Hill Hospital
2004–2010 Director, Center for Interventional Vascular Therapy (CIVT), NYPH/Columbia University Medical Center
2004–Present Director, Catheterization Lab, NYPH/Columbia University Medical Center
2010–2011 Director, Interventional Services, New York Presbyterian/Columbia, and New York Presbyterian/Weill Cornell Medical Center
2011–Present Chair, Executive Committee for Clinical Practice Development, NYPH/Columbia University Medical Center