Morton Kern is chief of cardiology at the Long Beach Veterans Administration Hospital, Long Beach, USA, and is also associate chief of Cardiology at University of California, Irvine, Orange California, USA. He is the co-chair of the Society for Cardiovascular Angiography and Interventions’ annual meeting (SCAI; 8–11 May 2013, Orlando, Florida). He talked to Cardiovascular News about his career and his achievements
Why did you decide to become a doctor and, in particular, why did you decide to specialise in interventional cardiology?
My father was a general medical practitioner and my mother is a retired bacteriologist. My father was always bringing home science projects, magazines, instruments, and plastic models of human organs from drug company give-aways. My interests in science grew from observing my father’s work.
My path into cardiology (and later interventional cardiology) began in my third year at Mt Sinai Medical School. Dr Richard Gorlin, who was our new chief of Medicine, inspired me. Although I wanted to stay in New York for my fellowship training, he pointed me to the Brigham and Women’s Hospital in Boston where invasive cardiology became the focus and love of my professional life. In 1982, after returning from John Simpson’s first interventional cardiology meeting, I knew interventional cardiology was for me. I could see we would be treating coronary artery disease in ways much like the surgeons but with more delicate, subtle, and hopefully equally effective means.
Who were your mentors and what influence did they have on your career?
I have had many mentors but three stand out. The late Dr Richard Gorlin was a marvellous teacher, fount of wisdom, gentleman, and superb physician.
Dr William Grossman, who was the chief of the Cardiac Cath Lab at the Brigham and Women’s Hospital in 1979, also played a major role in my professional life. It was because of Bill’s encouragement that my journey into invasive haemodynamics and coronary physiology has been so rewarding and stimulating.
Finally, as a cardiology fellow, I worked with Dr William Barry, who joined the Brigham and Women’s cath lab group with Bill Grossman in 1977. Bill Barry was the true “triple-threat” cardiologist. He was a consummate clinician and academician, a dedicated and thoughtful teacher, and an insightful and world class researcher. He was one of the first to demonstrate the role of calcium on myocardial cell contraction.
In your view, what has been the most important development in interventional cardiology during your career?
It is too hard to name just one so I will give you my top four; the moveable guidewire balloon catheter system, the stent, the development of fraction flow reserve (FFR) and transcatheter aortic valve implantation (TAVI).
The development of the moveable percutaneous transluminal coronary angioplasty (PCTA) guidewire catheter by John Simpson was a practice changing event. PTCA catheters subsequently evolved from the over-the-wire to monorail systems. While seemingly insignificant, this development made PTCA significantly safer, easier and widely available to operators worldwide.
The biggest development in interventional cardiology to me is the stent. Stent development over the last 20 years now permits us to implant drug-eluting stents and bioresorbable stents routinely—dreams come true for the interventional pioneers.
Through my totally biased eyes, I believe FFR development by Drs Nico Pijls and Bernard DeBruyne is among the most important and least appreciated achievements in interventional cardiology. Until recently, FFR has always taken a back seat to the therapeutic devices. But after 15 years of studies (FAME I, II studies, DEFER, and others), FFR objectively provides the lesion significant and promotes a correct first decision and is associated with better outcomes compared to angiographic guidance alone.
Lastly, TAVI and other structural heart disease innovations will herald another revolution in the field. I look forward to seeing the TAVI methodology become as common place as stenting one of these days.
Of the research you have been involved in, which piece of research are you most proud of and why?
I am most proud of the work with the Doppler tipped angioplasty guidewire to measure coronary flow reserve across coronary stenoses in the cath lab in the awake patient. Beginning in 1987, using the coronary Doppler guidewire, we challenged the current concepts of coronary blood flow, coronary reserve and atherosclerotic obstructions. One particular study that opened my eyes was the measurement of coronary blood flow velocity before and after balloon angioplasty and again after stenting. Coupling intravascular ultrasound at each step of the flow measurements demonstrated that although balloon angioplasty produced acceptable angiographic images, the lumen was still partially occluded and blood flow remained impaired. Stenting produced a marked increase in the lumen dimensions and nearly normalised coronary blood flow and reserve in about 80% of patients. Another new finding was that 20% of patients still had impaired coronary reserve despite having a widely patent artery, indicating underlying microvascular disease was present. This study helped us understand the mechanisms of stenting and its effect on coronary flow improvement. It explained in part, the disconnection between the balloon angioplasty angiographic image and the clinical behaviour in the post PTCA period.
What are your current research interests?
I am interested and actively studying FFR and coronary flow reserve to better understand pressure and flow discordance across stenosis. We are also involved in the study of vulnerable plaques using new techniques such as near-infra red spectroscopic catheter based imaging (NIRS) and optical coherence tomography (OCT) imaging.
You are co-chair of the programme committee of SCAI annual meeting (8–11 May 2013, Orlando, Florida). What are the key themes of the meeting?
Interact, innovate, upgrade and understand (quality). With these themes, this year’s SCAI meeting, co-chaired by myself and Dr Ken Rosenfeld from Boston, is slated to be the best and most exciting of our annual scientific sessions. Bringing these themes to the attendees has required the development of four speciality tracks—coronary, the peripheral vascular, the structural heart track and the newest addition, the quality track—devoted to what we believe are the most important aspects of the interventionalists’ educational needs. Commencing with the best and brightest stars in each of these tracks, the faculty will be presenting mini symposia, complications and their solutions, methods to establish new structural programmes and how to be a quality champion for your practice, lab, hospital, state, and society.
One of the talks at SCAI is on maximising PCI outcomes through lesion assessment. In your view, how can PCI outcomes be maximised through lesion assessment?
Lesion assessment is needed when an operator is uncertain about the significance of an angiographic percutaneous coronary intervention (PCI) target lesion. Is this lesion responsible for producing ischemia and the patient’s clinical syndrome? Uncertainty occurs when there is discordance among the symptoms, ischaemia testing, and angiogram—principally in stable angina patients. In the acute coronary syndrome, the target lesions generally do not need a physiologic assessment. Lesion assessment is best made by measuring FFR, accurately, quickly, and objectively identifying whether a lesion is associated with ischaemia.
Anatomic lesion assessment by IVUS or OCT will not always accurately reflect the physiology and should be used only to assess the morphologic aspects of the PCI procedure.
Better PCI outcomes using physiologic lesion assessment are well demonstrated by the FAME I, FAME II studies and most recently, the Mayo Clinic FFR outcomes study as well as many other single centre studies. Lesion assessment by FFR is critical to optimally practiced PCI. To those operators eschewing the technique, I can only say, given the current state of the art (read data), “retool or retire”.
What has been your most memorable case and why?
My most memorable, challenging, and emotional case involved having to treat one of our closest family friend’s father, Ted. While he and his wife were driving to his granddaughter’s Bat Mitvah [Jewish coming age of ceremony for women], he had chest pains. Ted was 78 years old, had a prior coronary artery bypass graft (CABG), diabetes, hypertension, prior myocardial infarctions, and survived colon cancer. I told Ted and his wife to go to the nearest emergency room, but he refused and kept driving. He wanted me to take care of him; he had faith in me; the family had faith in me. I was praying that I would be able get him to the ceremony. The pressure to make this happen was building fast. In the emergency room, his chest pain and ST changes were relieved by nitroglycerin (NTG) but only transiently. With the entire extended family in attendance, I explained the need for PCI or possibly CABG with the potential complications of myocardial infarction, stroke, and death.
For him, however, the possibility of missing the ceremony was worse than any complication I just described. In the lab I found a thrombotic saphenous vein graft with a lesion at the junction of a very large and diseased marginal. I had to contend with the given needs of the situation, the family’s expectations, and—as luck would have it—every step of this “routine” procedure being a struggle (difficulty with guide seating and support; challenging guidewire placement across the anastomotic lesion and a struggle to get a balloon catheter beyond the tortuous segment to the blockage). After an hour of work, I had to settle for a good balloon angioplasty result, as a stent was out of the question. I finished in a full sweat, physically and emotionally exhausted, avoiding a catastrophe and all the while thinking he should have gone to surgery.
The silver lining to the story; He was pain free, no enzymes, or other problems. He left the hospital the next day and attended the ceremony the following day. With all the hugs and tears that day, I will never forget Ted and his “routine PTCA”.
How do you think social media sites, such as Twitter, could be used to further education in interventional cardiology?
I have repeatedly experimented with emailing several of my colleagues to help me find solutions to all sorts of questions from the management of the non-culprit vessel in ST elevation myocardial infarction to how should we code and be reimbursed for FFR. I believe this early model of “social media” communication will expand to the medical world at large for both general and specific groups wishing immediate and relevant communications on issues of medical care, technical approaches, quality assurance, regulatory issues, and perhaps medical legal aspects of practice.
In addition, I have been participating with a medical video internet site, vumedi.com. It provides access to a wide spectrum of interventional cardiology cases for review, discussion, questions, and opinions on how to do better.
Outside of medicine, what are you hobbies and interests?
I like golf, poker, skiing, and reading Patrick O’Brien’s stories of the British Navy. Regarding Poker, I play with my fellows and one thing I know is that I am glad I still make a living in medicine because I sure can’t playing poker!
My most memorable ski trip was to Jackson Hole, WY in 1980 with Dr Bill Barry and a group of attendings and fellows after a San Francisco American College of Cardiology meeting. It was on this trip that I really experienced skiing deep powder, really deep powder. After spending most of the morning buried in the snow after each fall, we finally learned how to float on the powder. The thrill of deep snow has never left me.
2009: Chief, Division of Cardiology, Long Beach Veterans Admin Medical Center, Long Beach, California, USA
2006: Associate chief, Division of Cardiology, director Clinical Affairs, University California, Irvine, Orange, USA
2006: Professor of Medicine, University of California Irvine, Orange, USA
1979-1981: Fellow, Cardiovascular Division, Brigham and Women’s Hospital, Boston, USA
1977-1979: Resident, Internal Medicine, Mt Sinai Hospital, New York, USA
1976-1977: Intern, Internal Medicine, Mt Sinai Hospital, New York, USA
1976: MD, Mt Sinai Hospital, New York, USA
2006: Fellow, Society of Invasive Cardiology Professionals
2000: Fellow, American Heart Association (AHA)
1989: Fellow, Council on Clinical Cardiology (AHA)
1987: Member, St. Louis Cardiac Club (AHA)
1986: Fellow, Society for Cardiac Angiography
1984: Fellow, American College of Cardiology
1982: Member, San Antonio Cardiology Society
1977: Member, American Medical Association
1976: Member, American College of Physicians
2012: Elite Reviewer, Catheterization and Cardiovascular Intervention
2009: Simon Dack Award, Outstanding Scholarship from the Journal of the American College of Cardiology
2008: Southern California ‘Super’ Doctors (Cardiology), Orange County Magazine