Martyn Thomas, clinical director of Cardiology and Cardiothoracic Services, St Thomas’ Hospital, London, UK, is an enthusiast of transcatheter aortic intervention. In this interview, he told Cardiovascular News why he believes TAVI will be the dominant technology for aortic stenosis within the next 10 years. He also spoke about how he “stumbled” into a medical career, new technologies such as bioresorbable stents, and his passions for travelling, a glass of Burgundy and Crystal Palace Football Club.
How did you come to choose medicine as a career, and what drew you to interventional cardiology?
I rather stumbled into a medical career! I was able to pass exams at school and this rather pushed you in this direction. There is no medical history in my family. In addition I wanted to get as far from home as possible to discover the “bright lights” having been brought up in a small town in South Wales. So London was an obvious option. Medicine seemed like quite fun with programmes such as “Doctor in the House” being on UK television at the time. I had no idea it would be such hard work. So once more I cannot pretend to having had some sort of “calling”; it sort of happened!
Who are the people who have influenced you the most?
This is a tricky one. I have always been influenced by people who are balanced, honest and fair. I would prefer not to name names. I think individuals who have taught me over the years know who they are. To some extent I would say my parents influenced me the most. They taught me the importance of honesty and humility. It is very easy to take your eye off the ball when you are working in the rarefied atmosphere of interventional cardiology. When individuals “go off the rails” in my particular speciality, it is because they lose sight of these ideals and concentrate more on their own self importance than the best outcome for the patient.
Which innovations in medicine shaped your career?
This is pretty easy! I have always been attracted to interesting, but usually rather difficult, procedures. I was lucky to have been in the vanguard of intra-coronary brachytherapy. This was a technology that was ultimately destined to fail but was hugely useful during its time. I remember receiving a letter from a particularly young woman (with multiple restenoses in left main stents) following a coronary artery bypass graft at an early age. She travelled a long way to have brachytherapy done by me, which ultimately failed. However, she sent me an amazing letter thanking me for keeping her going long enough to be ready to receive a drug-eluting stent, which eventually cured her problem. She had the ultimate insight into the usefulness of a new technology. Following this, the SYNTAX trial re-introduced the concept of a multidisciplinary team. It turned out that I had some skills in forming such teams and now that we have transcatheter aortic valve implantation (TAVI), these skills have proven very useful (and great fun!).
What is your view of the results obtained with TAVI so far? Where do you see this technique going?
TAVI is an extraordinary technology. I think current results have established it as a treatment for patients who have been turned down by a surgeon for open surgical aortic valve replacement. However, this is only within the setting of a “Heart Team” meeting. In my mind there is no doubt that some patients are too sick and frail to receive TAVI and, despite the poor outcomes of medical therapy, sadly some patients should not receive TAVI. The ongoing challenge for TAVI in a high-risk surgical patient population is who should receive surgery and who should receive TAVI? This is a process which is ongoing. The PARTNER US randomised trial shows that surgery is still an excellent option so I am not convinced we have found the ideal TAVI patient yet. Having said that, I am convinced TAVI will be the dominant technology for aortic stenosis within the next 10 years.
PCR London Valves is in its second year. As chairman of the symposium, what do you hope to achieve?
I have a very simple aim for the meeting. I really would just like to deliver a high quality educational meeting. London is a fantastic venue, which I hope will attract people from around the world. Our true desire for the meeting is to make it really multidisciplinary. I would love to see interventional cardiologists, cardiac surgeons, imaging specialists and nurses all present and sharing their experience and learning from each other in the TAVI field.
King’s College Hospital was the first hospital in the UK to offer a 24/7 primary angioplasty service in 2003. What has the impact of this implementation been?
I was clinical director at King’s College Hospital before moving as director to St Thomas’ Hospital, which has been my role for the last three and a half years. While at King’s, we introduced the first 24/7 primary PCI rota for STEMI. This was an amazing commitment of the department and subsequently this form of therapy became the gold standard therapy for STEMI. This willingness to introduce change is a love of the speciality I work in and I have been lucky enough to work in institutions that have been able to listen and adopt these changes at an early stage. Both King’s College Hospital and St Thomas’ have now embraced TAVI and are leading UK centres.
One of your main research interests is the assessment and development of new interventional devices. What are you working on at the moment?
My current interest is TAVI. The trials and registries I am interested in involve the establishment of TAVI as an accepted treatment for aortic stenosis and also to investigate the best way of doing TAVI, ie. trials of devices to prevent stroke during TAVI and trials of the requirement to treat coronary artery disease prior to TAVI.
Which developing techniques and technologies are you watching closely for the future? Are bioresorbable stents the way forward?
It is pretty difficult to get too excited about the stent world at the moment. The technology has advanced so much that future improvements will be very difficult to prove. Fully bioresorbable stents are of course the ideal. However, I am not sure the companies will be prepared to spend the billions of dollars it will require in R&D to develop them. In addition, will the clinical community be prepared to pay premium prices for what will be a theoretical benefit? I am not convinced the clinical trials will ever be done to “prove” that these stents are better than drug-eluting stents as the patient numbers for such a trial will be enormous.
In the TAVI world, it will be exciting times over the coming years. A number of new devices will come into the clinical domain in the relatively near future. It will be interesting to see whether balloon expandable or self expanding technologies win the day. I am not so convinced that repositionability and retrievability are so important, but we will see. In addition it is probable that new technologies will appear to prevent stroke, reduce paravalvular leak and debulk calcium from the native valve.
What still fascinates you about interventional cardiology?
The real joy of interventional cardiology is the pace of change. In my lifetime I have been lucky enough to witness the breakthrough of truly “disruptive” technologies. Bare metal stents, drug-eluting stents and now TAVI have truly revolutionised the way patients can be treated by interventional means.
Could you name one moment in the history of cardiology that you found overwhelming?
I think the first time I saw an aortic valve replaced with a beating heart and the patient talking, I was totally blown away. The patient had extremely poor lung function so we were doing the case under regional and not general anaesthesia. The patient was very chatty and did not lose consciousness during the rapid pacing and as the valve was deployed. He was talking to me as we replaced the valve… amazing!
What are some of your proudest achievements?
I think my best achievement is having been able to create two fantastic TAVI teams during my work both at King’s College Hospital and now at St Thomas’ Hospital. A Cardiovascular Department is made up of a team of people, not a number of individuals. When I watch the team working so professionally and calmly during difficult TAVI cases it makes me very proud. Visitors to our department always comment on the teamwork. This makes me feel that at least I have achieved something.
What are your interests outside of medicine?
I am a bit of a sporting nut! I have been a season ticket holder with Crystal Palace Football Club for 15 years. I have travelled all over the world watching the English football team. In addition I love to watch test match cricket. I have been as far as the MCG in Melbourne to watch England vs. Australia. I used to play a lot of sports when I was younger and at one stage got to a golf handicap of four. Nowadays I do not have time to play so I just watch all types of sport. The Olympics in London in 2012 will be unbelievable.
My job has allowed me to travel all over the world but I also like to travel for enjoyment. During a recent trip to Singapore, my partner and I visited Vietnam and Cambodia. Finally I love to spend an evening eating good food with nice company and I love French Burgundy. Last year, I visited Montrachet and Meursault in France to taste the best Burgundys in the world. Fantastic!
Current and past positions
2007–present Clinical director of Cardiology and Cardiothoracic Services, Department of Cardiology, St Thomas’ Hospital, London, UK
2003–2006 Clinical director of Cardiology and Cardiothoracic Services Department of Cardiology, Kings College Hospital, London
1982–1983 House physician in General Medicine, Whipps Cross Hospital, Leytonstone, London
1983–1983 House surgeon in Urology, St Bartholomew’s Hospital, London
1983–1983 House surgeon in General Surgery, St Bartholomew’s Hospital, London
1983–1984 Senior house officer in Accident and Emergency, King George Hospital, Ilford,
UK SHO Medical Rotation, St Mary’s Hospital, Portsmouth, UK
1984 Senior house officer, Dept Medicine for the Elderly, St Mary’s Hospital, Portsmouth
1984–1985 Senior house officer in Medicine and Cardiology, St Mary’s Hospital, Portsmouth
1985–1985 Senior house officer in Medicine and Respiratory Medicine, St Mary’s Hospital, Portsmouth
Medical Registrar Rotation, St Mary’s Hospital, London
1985–1986 Registrar in General Medicine and Neurology, St Mary’s Hospital, London
1986–1987 Registrar to the Medical Unit, St Mary’s Hospital, London
Registrar Rotation in Medicine/Cardiology, Hastings/King’s College Hospital
1987–1988 Registrar in Cardiology/Gastroenterology/Endocrinology, St Helen’s Hospital, Hastings, UK
1988–1989 Cardiology registrar, King’s College Hospital, London
1989–1992 British Heart Foundation Research Fellow, Department of Cardiology, King’s College Hospital, London
2004–2008 President, British Cardiovascular Intervention Society (BCIS)