Nicolas van Mieghem (professor of interventional cardiology, department of cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands) shares his thoughts on a wide range of topics with Cardiovascular News, including mechanical circulatory support and artificial intelligence, the durability of transcatheter aortic valve replacement, and his future hopes for the potential of transcatheter mitral valve replacement.
Why did you decide to become a doctor, and why did you choose to specialise in interventional cardiology?
Even as a child I wanted to do something significant and to help people. I enjoy the feeling of being able to help someone or do something important for them. I also wanted to enter a profession that would channel my energy—I was always a busy child. Originally, I thought about becoming a cardiac surgeon. But in 1999, the then head of cardiac surgery in the medical school at the University of Leuven told me that the future was in interventional cardiology rather than cardiac surgery, and that valves would soon be replaced with catheters. So I decided to become a cardiologist. In 2002, I saw the first-in-human case report of transcatheter aortic valve implantation (TAVI) in Circulation by Alain Cribier. I knew that day that that was what I wanted to do.
Who were your mentors at the beginning of your career?
My father was a general cardiologist. He was a hardworking man in private practice, an excellent clinician who also tried to contribute to multicentre research, and was a high-enroller in trials. We have similar character traits and he taught me what to do, and what not to do. I also identified with an excellent intensive care specialist and somewhat bizarre personality, Dr Manu Malbrain. Another big influence came later in my career when I trained at Lenox Hill Hospital in New York. The great Gary Roubin left a mark on me as an interventional cardiologist. I feel blessed to have performed procedures with him, and to become part of the Andreas Gruentzig legacy. In addition, in my early tenure here in Rotterdam I was impressed and fascinated by the overwhelming work energy and interventional cardiology IQ of Professor Patrick Serruys.
What has been the most important development in interventional cardiology during your career?
Transcatheter aortic valve implantation. I stepped into the TAVI space around the time it really started to take off. I feel honoured to have played an active part in shaping this amazing technology into an everyday procedure that has such an impact on patients’ lives.
What has been the greatest disappointment—an advance that you hoped would change practice, but which failed to do so?
So far transcatheter mitral valve replacement has lagged behind. It seems that the mitral valve is a totally different and not-so-easy-to-tame animal.
What are your current research interests?
I’m still passionate about cerebral embolic protection during TAVI and the search for improved large bore closure devices. I work actively in expanding TAVI indications, most notably TAVI as a means to further unload the left ventricle in heart failure patients with moderate aortic stenosis (the TAVR UNLOAD trial). I am heavily involved in the development and dispersion of mechanical circulatory support (MCS) devices. Finally, I am involved with transcatheter mitral and tricuspid repair techniques. In terms of imaging and preprocedural planning, an important research line focuses on computed tomography (CT)-derived 3D modelling and printing.
What do you consider to be your biggest contribution to the field of interventional cardiology?
I believe I contributed significantly to the field by making TAVI safer, faster, and even less invasive. I am convinced however, that the best is yet to come from my end.
What was the most important paper published in the past year?
I think both the PARTNER 3 and the Evolut Low Risk trials were essential because they cemented the position of TAVI in the treatment of severe aortic stenosis across the entire operative risk spectrum. Now, we need to add more granularity to the TAVI literature to see how far this technology can go in terms of durability and less straightforward patient anatomies (such as, bicuspid aortic stenosis) and indications (for example, asymptomatic severe aortic stenosis).
What are the key unanswered questions that future research should prioritise?
How does TAVI durability compare with surgical aortic valve replacement (SAVR) durability? I am convinced that TAVI will end up at least as durable as SAVR, but we need proof.
You were deputy chair of the SURTAVI trial: what do you believe are the factors that should be taken into consideration when deciding between TAVI and surgery, as TAVI moves into treatment of low-risk populations?
A detailed analysis of an individual patient’s anatomy should determine TAVI eligibility. If the TAVI procedure is considered low risk, the patient should be treated with TAVI. Age and frailty should no longer be the driver for strategy selection.
What factors should be considered when deciding whether to use mechanical circulatory support in shock or percutaneous coronary intervention (PCI)?
Left ventricular (LV) function and coronary lesion complexity should drive the decision to proceed with mechanical support. Another important aspect is access site management. Preprocedural planning should guide the decision whenever possible. Furthermore, I believe MCS should only be used by experienced operators. There is no point in positioning MCS as a mainstream technique. By default, MCS should be considered advanced care to be used in selected centres by selected operators.
What role will artificial intelligence play in the future development of interventional cardiology techniques?
I think artificial intelligence is an intriguing concept that may help to make interventional cardiology a safer place—both in everyday practice by helping to select the proper technology and techniques for the individual patient, and in the development of new techniques. Computer learning may seem relatively abstract to many of us but it is coming.
What do you think the next breakthrough innovation in interventional cardiology will be?
I would say transcatheter mitral valve replacement. We are not there yet, but I do hope we find a reliable technology that also fits into clinical practice within the next five years. In the coronary space, I could envision a medical therapy that results in significant coronary plaque regression or maybe decalcification of aortic leaflets. That would be a huge breakthrough.
Is there any value in this online age of attending conferences?
For non-academic physicians who are in busy practices, yes. For academics it is counterproductive. A physical presence at congresses is crucial for networking and brainstorming, developing and designing future research, and for refining ideas and concepts that help to improve interventional cardiology practice. But, maybe there are too many congresses, and too many journals. We may need to trim down to make progress.
What is the added value of social media?
Social media is a double-edged sword. On one hand, it brings the world closer, as well as each of us to one another. On the other hand, it trivialises, it is uncensored and it is not peer reviewed—it comes with fake news, misinformation, and one-sided stories.
What advice would you give to someone who was starting out in cardiovascular medicine?
Pursue a career for the right reasons or find something else. A cardiologist should be dedicated to the job and genuinely care for patients. If you want a business model, you need to do something else. Every day I realise that what I do for each individual patients means so much for that person. That is not trivial. It makes me feel humble and proud at the same time.
What was your childhood dream job?
Olympic athlete. A long time ago, I was member of the national swim team of Belgium. I dreamt of competing at the Atlanta ‘96 Olympics. But I soon realised that medicine would be a perfect fit for me.
What are your hobbies and interests outside of medicine?
My passion is medicine; however, I also love sport. My mantra is: mens sana in corpore sano (a healthy mind in a healthy body). I work out on a regular basis: in the gym, on my racing bike, or in the swimming pool. I am a fan of American sports (NBA and NFL) and, like all Belgians, I love to watch the big cycling events—the Classic cycle races, the Tour de France, the Giro d’Italia, the Vuelta a España. I also like music; I grew up with ‘80s music, and am a big Oasis fan. And, I watch my share of Netflix and movies, particularly anything with Al Pacino or Robert De Niro.
- Clinical director of interventional cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Full professor of interventional cardiology, Erasmus University Medical Center
- TEACH course coordinator, Erasmus University Medical Center
- Co-director of Joint Interventional Meeting (JIM)
- European Society of Cardiology (ESC)
- American College of Cardiology (ACC)
- European Association of Percutaneous Coronary Intervention (EAPCI)
- Committee to define the core curriculum for percutaneous cardiovascular interventions on behalf of the EAPCI
- Steering committee SURTAVI trial
- Advisory board ANCORA LV restoration therapies
- Advisory board TriCinch tricuspid therapies
- Rotterdam TAVI Expert Meeting course director
- Lead investigator ENVISAGE TAVI AF Trial and TAVR UNLOAD trial
- Steering committee member RESPOND Edge trial
- BIVOLUT X co-principle investigator
- Principal investigator MARVEL and MASH trials on novel large bore closure devices
- Principal investigator POLESTAR trial on early discharge protocol with ACURATE TAVR
Lead investigator on focused research lines
- Cerebral embolic protection in TAVI
- Access site management and new large bore closure devices
- Percutaneous mechanical circulatory support
- Advanced transcatheter structural mitral and tricuspid Interventions
- CT derived procedure simulation and modelling
- Strategies to treat coronary calcifications