Mirvat Alasnag is the Gulf region’s first female interventional cardiologist. Currently the director of the Catheterization Laboratory at King Fahd Armed Forces Hospital (Jeddah, Saudi Arabia), she serves on a number of councils including the American College of Cardiology (ACC) Interventional Leadership, Society for Cardiovascular Angiography & Interventions (SCAI) Board of Trustees, and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Women’s Steering Committee. She talks to Cardiovascular News about her career in medicine and the challenges for women in the interventional cardiology field.
This profile features in issue 63 of Cardiovascular News.
Why did you choose to become a doctor and why, in particular, did you choose to specialise in interventional cardiology?
Early on in my life my father struggled with heart disease. We are a very close-knit family and lived through his surgeries and hospitalisations. I quickly realised how fascinating medicine and cardiology can be by offering a lifeline to someone. When I started my cardiology fellowship, my intent was to focus on imaging. As soon as I started my cath lab rotation I found myself seduced by the instant gratification of opening closed vessels. I could not imagine myself specialising in anything else. But, I understood the intimate relationship between imaging and interventions.
Who have been your career mentors?
I was fortunate to have many mentors who have encouraged and supported me. The chief resident in my early training years was an incredible anchor and support as I was ploughing through residency and personal loss. She was also an important source of inspiration. Later in my career I had many cardiologists both on social media, and during my career, guide and encourage me. Each had his or her own impact. To name a few: Khaled Al-Shaibi, Waqar Ahmed, Mamas Mamas, Roxana Mehran, Ted Shreiber, Marie Claude Morice.
What has been the most important development in interventional cardiology during your career?
Imaging has taken huge leaps in the last decade facilitating novel procedures particularly in the structural arena. As imaging technologies and acquisition protocols became more streamlined the procedures have expanded to a higher risk population and included more complex interventions. Imaging is an important tool to predict complications and strategise the safest approach.
What has been the biggest disappointment? Something you hoped would change practice but did not?
Sadly, we still do not seek quality of life in the therapies we offer. Much of our discussions revolve around hard endpoints like death, myocardial infarction (MI) and stroke. However, quality of life matters to patients and this becomes increasingly important with advanced age—a population often excluded from research. The definition of quality of life is subjective and this makes it difficult to capture. The only way to understand it is to have patients be a part of the conversation early on.
What are your current research interests?
I am very interested in generating local research. We need to understand the landscape of regional practices and identify areas for improvement. We need to learn about the population we treat and their response to therapies, and create predictive models for our region. In this respect, Khalid AlHabib at King Saud University (Riyadh, Saudi Arabia) has been a pioneer.
What are the key unanswered questions around the field that future research should prioritise?
Artificial intelligence (AI) has certainly shown promise in smaller scale studies. I am very interested in evaluating its performance in the evaluation of the functional significance of stenoses—fractional flow reserve (FFR), instant flow reserve (iFR) non-hyperemic indices. I am also interested to see if it has a role in the as the assessment of plaque morphology obtained through intracoronary imaging—intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The CLARITY trial examined the role of machine learning and AI in the evaluation of plaque determined by cardiac computed tomography (CCT) and compared it to results reported by expert readers.
What do you foresee is the next practice-changing step forward in cardiovascular imaging?
I believe artificial intelligence is the next big thing in this space. It will permit population studies and adoption of algorithms that are time efficient, precise, and reproducible. Although this is still a developing technology, I believe once the evidence is generated, it will soar. Its utility will largely aid in prevention programmes, but I could see it streamline cost efficiency.
What has been the most important paper published in the past year?
There have been several, but I would say the ISCHEMIA trial for chronic coronary syndromes and the COAPT trial for percutaneous repair of the mitral valve have been practice changing or reaffirming. The selection of patients is central to better outcomes.
What are the current challenges facing women seeking to enter the interventional cardiology field, and how would these be best overcome?
The difficulties facing women are multi-layered. There are the expectations set by society to have an older man perform delicate procedures. Historically, men have directed centres and been the principal investigators of landmark trials. Most women were hidden in the shadows. This has posed a challenge for women in the field of interventional cardiology to assume leadership positions, whether as researchers, administrators, mentors or operators. It is not uncommon for staff to listen to the men in the cath lab. It becomes a daily struggle for women to assert themselves in this field in particular.
Have you found the switch to digital learning during the pandemic a positive or a negative development?
Digital learning permitted us to travel the world several times in the same day. Suddenly, the world felt connected like a small village and the science became more accessible to everyone. However, we lost the human interaction. Digital meetings also snatched opportunities for mentees and trainees to interact and engage with their mentors and experts. Traditionally, in-person meetings allowed side meetings for trainees, investigator meetings, and hands-on training. A lot of those smaller round table meetings were lost.
What value does social media add to practice and how important has it been in your career?
Social media has been a force that propelled my career forward. I met virtual mentors and collaborators. I found like-minded colleagues to discuss techniques, cases and research projects. Today, I enlist collaborators and faculty for scientific webinars and meetings from social media. I am able to understand their train of thought, areas of expertise, and reach out to them unofficially to gauge their availability and interests. There are of course drawbacks to social media. The most important is that these are public platforms that are not regulated. Patient privacy and operator critique can take unpleasant turns.
Looking back over your career, what has been your most memorable case?
It was an older woman who came with critical left main disease and pulmonary oedema. I had to go, as a young petite woman with little experience, and explain to her family (tall men, many of whom were older than me) that I would need to put in a mechanical circulatory device and stent her left main artery. I will never forget how difficult it was to impress them and gain their trust. But, it was that case that taught me to be self-confident. It paid off and I learned how to assert myself when discussing complicated management plans. She did well and was my patient for many years later.
What can interventional cardiology do to better attract young physicians into the field?
Training in interventional cardiology generally focuses on two key areas: skill and judgement development. As the cath lab volume drops globally, integrating simulation and research in the core training can overcome the issue of volume. More importantly, it is important to instil in trainees the principle of lifelong learning. This is integral as the field is always evolving with new data, and new and more refined devices and techniques. As for the judgement, I find this is an area that requires meticulous effort. Trainees need to attend mortality and morbidity rounds, heart team meetings and assume leadership roles in order to exercise judgment. Judgment is critical—not only in decision making but in the basic communication with patients, families and colleagues. At some point during their training, candidates should be given the opportunity to be the primary communicator with the families and to lead care team discussions. This is how empathy and wisdom grow, both integral to a field that deals with life and death situations on a daily basis.
Outside of medicine, what are your hobbies and interests?
Before the pandemic, I enjoyed travel and exploring new cultures, cuisines, and visiting historic sites. I now enjoy some quiet time with a good book or some uninterrupted family time with the kids. They are a wonderful source of energy and fun.