Olaf Wendler (lead for Cardiothoracic Surgery, King’s Health Partners, and chair of the Heart and Vascular Institute of the Cleveland Clinic London, UK) performed the first transcatheter aortic valve implantation (TAVI) procedure in the UK. He is a course co-director of PCR London Valves and is a keen proponent of the heart team. He talks to Cardiovascular News about the future of TAVI and the potential impact of Brexit on EU nationals, such as himself, working for the NHS.
Why did you decide to become a doctor and why, in particular, did you decide to go into cardiothoracic surgery?
I was fascinated by the opportunities to cure, often young patients, with very complex health issues.
Who have been your career mentors?
I started my medical training with Professor Hans Borst (Medical School Hannover, Hannover, Germany), an eminent leader of cardiac surgery in Germany at the time and a pioneer in aortic surgery. Being a man with strong ethical values, he was an outstanding teacher and role model far beyond the operating theatre and an important advisor throughout my entire medical training.
When Professor Fred Mohr (Heart Center Leipzig, Leipzig, Germany) asked me to join his team to build the Heart Center Leipzig, no one could have predicted that it would be one of the world’s leading organisations for cardiovascular care 20 years later. Professor Mohr demonstrated to me that nothing in cardiac surgery is impossible and also showed a strong link with innovators enables new technology for the benefit of patient care.
Professor Jochen Schaefers (University Homburg-Saar, Saarland, Germany) is an extremely skilful cardiovascular surgeon, who polished my surgical skills and personally pushed me to surgical limits. His structured approach to diagnosis and treatment has helped me throughout my career to develop a particular quality of surgical care.
What has been the most important development in cardiothoracic surgery during your career?
I was lucky enough that I was able to become directly involved in the development of TAVI technology and procedures.
What has been the biggest disappointment? Something you hoped would change practice but did not?
In 2015, I was the first to implant a spacer-balloon into a human. The patient had ischaemic mitral regurgitation and left heart failure; after the procedure, his heart failure symptoms greatly improved as did his left ventricular function. The improvements meant he was then able to be considered as “low risk” for mitral valve surgery, and he is now living a normal life.
Despite this excellent experience with the device, this spacer technology has not been further developed—the original sponsor did not provide further funding for commercial reasons. However, I strongly believe that this technology could greatly benefit patients with left heart failure in the future and it would be a wasted opportunity from my point of view not to proceed further.
You performed the first transapical TAVI procedure in the UK in 2007. How has TAVI changed since then?
TAVI is nowadays a routine treatment for elderly patients with severe aortic stenosis. While vascular access was initially a major issue due to the size of devices, these days, most procedures are done percutaneously and under conscious sedation. This reduction in procedural trauma, technical experience and patient selection has resulted in a continuous improvement of outcomes.
Do you think TAVI has the potential to mirror PCI (for coronary artery disease) and become the default strategy for aortic stenosis (irrespective of a patient’s risk profile)?
TAVI is already the default strategy in patients with severe aortic stenosis and who are at high surgical risk. However, so far, all trials have been performed in elderly patients—mainly above 80 years of age. Before we consider using TAVI in younger patients, we should have a better understanding about the durability of transcatheter heart valves. There is no doubt that, particularly in patients who suffer from impaired mobility, TAVI provides advantages with respect to their time of recovery.
In the USA, the Centers for Medicare & Medicaid Services are in the process of reviewing their national coverage determination for TAVI. Specifically, they are looking at centre and operator volume requirements. What is your view about volume requirements?
There is a lot of evidence from other cardiac treatments that there is a strong relationship between activities and outcomes. However, often it is not differentiated between individual and institutional activities. As a co-author of the latest European guidelines on the management of valvular heart disease, I have addressed this issue when we defined heart centres and heart teams. We focussed less on procedural numbers, as they are so variant between European countries, but defined clinical infrastructure, governance and working relationships. Key from our point of view is that cardiac surgery is on-site and involved in the interventional treatment of heart valve disease.
In both Europe and the USA, there is a strong emphasis on the need for a multidisciplinary heart team in structural heart interventions. Why is a cardiothoracic surgeon an important part of such a team?
Cardiothoracic surgeons have a tremendous experience with treatment of all kinds of valvular heart disease, not only aortic stenosis. They are also in the best position to determine the surgical risk of patients and to identify the most appropriate surgical technique in individual patients.
I strongly believe that if surgeons are aware of the outcomes of interventional techniques, if interventional cardiologists are aware of the outcomes of surgical techniques, and if they work as a functional team, this team is best placed to identify the most suitable treatment option for patients on an individualised basis.
You are the principal investigator of a CE mark trial of a transcatheter mitral valve implantation (TMVI) device. When do you think we will see the first “TMVI” device come onto the market?
I had, as did many of my colleagues, expected a much faster progress with TMVI when it started. All current TMVI devices face the limitation that they can only be used in patients with a suitable anatomy. Therefore, recruitment of patients is challenging and it has become obvious that the optimal technology still needs to be developed. At the moment, I think that it will take at least another four years until the first one-year results of a TMVI US FDA or CE mark trial will be available.
You are a course co-director of PCR London Valves. What big developments in transcatheter heart valve therapies do you think the course will be discussing over the next few years?
We will certainly see more information on the outcome of TAVI in lower risk patients with aortic stenosis. I also expect more data on transcatheter mitral and tricuspid valve repair devices such as edge-to-edge technology and valvuloplasty. We will also see more development of TMVI technology. However, how much this will change our view on this technology already this year remains to be seen.
Why is it valuable for physicians to become involved in helping to develop conferences such as PCR London Valves?
Clinically active physicians know the day to day challenges cardiologists and surgeons face. Their experience enables them to create relevant educational sessions, so that clinically interesting questions can be discussed. Physicians are also crucial to facilitate discussions with the industry, which is particularly helpful when it comes to device development.
Given that a substantial number of people, such as yourself, working for the NHS are EU nationals, are you concerned about the potential impact of Brexit on the NHS workforce?
From my point of view, I struggle to understand why during this age of globalisation—with all the resultant benefits for scientists—some countries fall back into nationalistic ideas that may isolate them in the future.
However, I am personally not particularly concerned about myself in this respect. Given the large number of highly qualified European Union (EU) medical staff working in the NHS, the UK Government has already taken precautions to support EU nationals working in the NHS and to address future changes.
What was your most memorable case?
One of my most memorable cases was the patient in whom I implanted the spacer into the mitral valve. Not only because he is a man the same age as me with a lovely character, but also because he was turned down for all established therapies and I could offer him something new and innovative—which finally worked out and turned his life back to normal.
Outside of medicine, what are your hobbies and interests?
I love sailing with my family, particularly in the Caribbean, and we enjoy hiking, mountain biking and skiing in the Alps when we visit our family barn in Austria.
- 2018–present: Chair of the Heart and Vascular Institute Cleveland Clinic London, London, UK
- 2016–present: Lead for Cardiothoracic Surgery, King’s Health Partners, London, UK
- 2004–present: Professor and consultant of Cardiac Surgery, King’s College Hospital, London, UK
- 1994–1997: Senior registrar, Department of Cardiac Surgery, Heart Centre Leipzig, Germany
- 1992–1994: Registrar, Department of Cardiology, Siloah Hannover Medical School, Hannover, Germany
- 1990–1992: House Officer Registrar, Department of Thoracic and Cardiovascular Surgery, Surgical Centre, Hannover Medical School, Hannover, Germany
Professional memberships and societies
- Fellow of the Royal College of Surgeons of England
- Society of Cardiothoracic Surgeons of Britain and Ireland (Member of the Adult Cardiac Subcommittee 2014–2017)
- The Society of Thoracic Surgeons
- European Association for Cardiothoracic Surgery
- European Society for Cardiology (Nucleus member of the ESC working group on heart valve disease)
- German Society for Thoracic and Cardiovascular Surgery (Board Member 2003–2004)
- German Society for Cardiology
- Member of the Faculty University of the Saarland/Germany
- 2015: Performed the world’s first implantation of a spacer into a patient with heart failure and functional mitral regurgitation
- 2011: Performed the first transapical mitral valve implantation in a failing bioprosthesis in the UK, and performed the world’s first transapical TAVI procedure without predilatation in the native aortic valve
- 2007: Performed the first transapical TAVI in the UK
- 2006: Performed the world’s first surgical closure of an acute ventricular septal defect using an occluder device and started a pilot trial to evaluate this new technique