Ulrich Sigwart, emeritus chairman of Cardiology, University of Geneva, Switzerland, is one of the pioneers in coronary angioplasty, having performed his first case in 1978. He told Cardiovascular News about this first experience, his most memorable cases, and why he considers himself a “nomad”.
Can you describe your journey into medicine and cardiology?
As a boy, I dreamed of being a veterinary surgeon. A number of people discouraged me to do so, mainly because of the somewhat commercial aspects of the profession. It was in fact my elder sister who convinced me that human medicine would be a good choice. I have never regretted this decision. About the choice of going into cardiology, I was already interested in the heart during medical school. During the clinical years of medical school, I was absolutely fascinated by practical aspects such as the auscultation course and, very soon, I started dreaming of becoming a cardiologist. The combination of basic sciences, physics and the purely human aspects of cardiology made me choose that subject. This is why, after the obligatory basic education, I immediately engaged in cardiology while I was in the United States.
Who has influenced you the most in your career?
The people who have influenced me a great deal were my teachers at medical school and the young colleagues who I trained with. Alain Reid was my first contact in Houston; he taught me the basics of cardiology. Later, in Zürich, it was Willy Rutishauser with his rigorous approach to sciences who left a profound mark on me. In London, I learned a lot from my colleagues in pathology and cardiac surgery; undoubtedly they also influenced me a lot.
How has interventional cardiology evolved since you began your career?
I got into cardiology at a fascinating moment, namely when interventional cardiology became airborne. Charles Dotter in the USA did his first cases in peripheral arterial disease; Porstman in Berlin started attacking congenital heart disease; and then Andreas Grüntzig in Zurich topped it all off by threading balloons into the coronary tree. It all resembled a revolution. That was the moment when limiting ourselves to prescribing digitalis and diuretics was over. I jumped on the wagon right away and, shortly after Grüntzig had done his first case, I followed in his footsteps.
Which innovation in the cardiovascular field shaped your career the most?
Undoubtedly balloon angioplasty influenced me most. It was in 1977 when Willy Rutishauser, at the Computers in Cardiology meeting in Holland, told me about the first balloon angioplasty done in Zürich. I was overwhelmed with the idea of being able to do something of that sort and went to Zürich to meet Grüntzig (who I knew from my former years in Zürich). We had lunch (Peter Rentrop was there as well), and I left with three balloons and two guiding catheters to start angioplasty on my own. My then superior, Professor Ulrich Gleichmann was very supportive in allowing this unorthodox procedure to happen at his institution. Our surgical standby relied on a military helicopter to liaise with the Medizinische Hochschule Hannover, in case of trouble.
You were one of the first cardiologists to perform a coronary angioplasty. Can you describe the first procedure you performed?
The first angioplasty at the Gollwitzer-Meier-Institute was not only a memorable but also a breathtaking experience. It was done on a relatively young lady who came with severe, unstable angina due to a very tight proximal left anterior descending artery lesion. It took me a fairly long time to get the non-steerable balloon through the lesion, and I will never forget the moment when the balloon deflated and the distal pressure came up. That was early in 1978! After the first seven cases were performed at the Gollwitzer-Meier-Institute, I moved to Lausanne where in-house coronary surgery was available at the University Hospital. The first cases there in 1979 reminded me vividly of the exciting times before. I felt that movable guidewires would be mandatory and was so happy when John Simpson came to Lausanne to show us a workable system. He and I had a great time together. The movable guidewire helped us to get to most lesions we were aiming at.
The principle problem with balloon angioplasty was the unpredictable outcome once the balloon started to deflate. Also the restenosis rate of some 30 to 40% remained a huge obstacle. It was obvious to me that one had to use mechanical devices to support arteries after balloon angioplasty, but it was only in 1986, after having performed quite a number of animal experiments, that we started putting stents into human coronary arteries. This has changed our life substantially.
One of your papers reports on the 22-year follow-up of the first patient treated with coronary stenting. What were the outcomes of this case?
The first patient who received a “coronary” stent was in fact a patient with bypass graft stenosis. He survived a number of years without recurrence. The patient who has changed the field was a lady with two-vessel disease, whose left anterior descending artery was occluded after balloon angioplasty and was bailed out by the insertion of a stent. It was this patient who fundamentally changed coronary angioplasty. She is still alive and is doing well. Jean-Jacques Goy has put an additional stent into that patient’s circumflex artery a number of years ago.
Interventional cardiologists now perform lower limb interventions and also renal angioplasty. How do you see the future, with interventional radiologists and vascular surgeons sharing the endovascular field?
This is an interesting and, unfortunately, a highly political issue. My approach to this question has always been simple: the one who does it well should do procedures like this. I have the impression that endoluminal techniques could be done either by surgeons, interventional cardiologists or interventional radiologists. I put my first stents into femoral and iliac arteries before doing so in the coronaries.
(By the way, I have just seen the patient in whom I stented the superficial femoral artery from top to bottom in March 1986; he is still well, although he had further atherectomy done inside the stent and, after a dozen years, had a saphenous vein bypass.) As to renal and carotid angioplasty, I feel that cardiologists in general have the greatest experience in doing these procedures but this may vary from institution to institution. As I said, it is the person who does it well who should do it.
Will it be possible to develop the ideal coronary stent in the future?
Every stent is a foreign body, and foreign bodies in arteries are always less than ideal. On the other hand, I have seen an enormous progress in the stenting technology over the last 25 years and even “vanishing” stents have become possible. The ideal drug to be used for the inhibition of hyperplasia has yet to be defined, and I am quite sure that stents can be made much more flexible and biologically friendly. I am not so sure that the ideal stent exists. Every patient is different and the stent of choice must be adapted to the patient’s needs.
What are the benefits of alcohol septal ablation for hypertrophic obstructive cardiomyopathy?
Alcohol ablation for septal hypertrophy has become fairly routine. I am not saying that it is better than surgery but it is probably not much worse. On the other hand, myectomy is a hugely invasive, open heart procedure for such cases. I have seen a number of patients leaving not even 24 hours after alcohol ablation with a quite significant reduction and even suppression of symptoms. This is why one should not compare the two procedures without taking into account the differences in morbidity and discomfort.
What is the most interesting paper you have come across recently?
I have recently seen a very interesting paper presented by Bon-Kwon Koo, a physician from Korea. He describes a computer tomographic method to determine the haemodynamic repercussions of coronary artery stenoses. The method could potentially be the equivalent to the measurement of the fractional flow reserve by invasive methods. I find this absolutely fascinating as it would allow determining, without “instrumenting” the heart, the need for intervention in individual lesions.
The paper may be too optimistic, but I will be most interested in hearing more about this method.
Tell us about one of your most memorable clinical cases.
The most memorable clinical cases were certainly the first patient who ever received a stent in an emergency situation and the patient who, for the first time, had a non-surgical ablation of her interventricular septum in hypertrophic, obstructive cardiomyopathy. Fortunately both patients are still alive and well. I am so grateful for that. On the other hand, I will always remember a man who came in the early 80s with a rather trivial looking, tight stenosis in his circumflex coronary artery. His brother, a surgeon, travelled all across the Atlantic to witness the angioplasty procedure, which was quite easy to do. In stupor and disbelief I watched the artery close again under my eyes with no chance of obtaining a decent result. Bypass surgery was the only solution in this case, which made me contemplate other ways of stabilising dissections.
How have the professional experiences in the USA, Switzerland, Germany, and the UK, shaped your career?
I have worked in the United States, in Switzerland, Germany and the UK and also in other parts of the world. To define the experience in all these countries would require at least an entire evening of talking. A few remarks, however, may be appropriate.
I think it was a good decision that I started my clinical career in the United States, where I was given responsibility very early during my apprenticeship. I was allowed to do arterial cutdowns for coronary angiography after a very brief introduction. This helped me a lot in becoming proficient. I am still impressed by the sheer power and organisation of the American system, which may, on the other hand, leave lesser room for true inventions.
When I arrived in Switzerland, the focus shifted to much more basic science, the more clinical parts were the privilege of the more senior staff. That was a character building experience. I am sure it has not too much to do with a country-specific approach but rather with the particular institution.
Switzerland is spoiled: there are no waiting lists, every one can choose their doctor and will get the medication they need. In general, the health system is quite elaborate, but – as in all countries around the world – too expensive for its citizens.
In Germany, I happened to be very much on my own again and had extensive responsibilities in setting up an invasive and later an interventional programme.
The health system is sound, less luxurious than Switzerland, and quite thoroughly organised.
When it comes to the UK it was the friendly and supportive atmosphere that struck me most. At the National Heart, and then at the Royal Brompton Hospital, Tony Rickards and I formed a great team with no animosity and a great deal of mutual support. The other colleagues – surgeons, radiologists, paediatric cardiologists, etc – were always there to discuss problems and potential solutions and I felt greatly encouraged in pursuing my path. The academic atmosphere shines through into most aspects of medicine and gives it a unique and particular halo. The system is lean, but over-administrated in my mind, and would do better with less bureaucracy.
I have spent a fantastic life as a “nomad” crossing frontiers all the time, and I must admit that I learned enormously during all those movements.
What are your current areas of research?
I retired from my academic career in October 2006, which was a turning point regarding proper research. I am still actively involved in cardiology but I am more interested in observing what the younger cardiologists are doing. I still give lectures, help people in different countries doing interventions and am involved in a number of projects regarding technology. On the other hand, proper, structured research is no longer my thing.
What advice would you give to young cardiologists?
The advice I would give to young cardiologists is the advice I would give to every young person: Do what you are fascinated about. Doing medicine for financial gain is bound to fail in the end. Doing cardiology because it is great fun and to help patients is most satisfactory. This is what they should aim for.
Outside of medicine, what other interests do you have?
Medicine has been my life from the end of high school. This is why it is difficult to leave it behind. That is also why I carry on seeing patients and doing interventions. On the other hand, I have a number of activities outside medicine that I find fascinating. I have been interested in flying for all my life, in skiing in wintertime and spending time with my family.
When you become a grandfather it is most rewarding to spend time with the youngsters either biking or hiking or doing sports together. I have the great fortune of being married to an overwhelmingly stimulating wife, who encouraged me to do all kinds of interesting tasks, for more than 40 years. We have set up a charity called Jonasfoundation for children in difficult situations, who are being taught music and arts in a number of different countries. My wife and I sing together in a choir in the mountains, and when things are too quiet I take my trumpet out of its case!
Emeritus chairman of Cardiology, University of Geneva, Geneva, Switzerland
July 1967 Medical degree, University of Münster
1967–1968 Internship, Medicine, Surgery, Gyn & Obstetrics, Community Hospital Lörrach
October 1967 Dr med, University of Freiburg (magna cum laude)
1968–1971 Residency, Boston VA Hospital, Framingham Union Hospital
1971–1972 Fellowship, Cardiology, Baylor College of Medicine, Houston, USA
1972–1973 Training, Cardiology, University Hospital, Zürich
October 1978 Dr med habil, University of Düsseldorf
February 1985 Professor Dr med habil, University of Düsseldorf
2002–2006 Chief of Cardiology, University of Geneva
1989–2001 Director, Dept of Invasive Cardiology, Royal Brompton Hospital, London
1979–1989 Medecin associé, then ajoint, University Hospital, Lausanne
1973–1979 Chief of Cath Lab, Gollwitzer Meier Institute, Bad Oeynhausen
- Royal Brompton Hospital, London
- The Heart Hospital, London
- Harley Street Clinic, London
- Humana Wellington Hospital, London
- Cromwell Hospital, London
- Clinique de Genolier, Genolier, Switzerland
- Clinique La Source, Lausanne, Switzerland
- Centre Cardiothoracique de Monaco
- Professor and chair of Cardiology Emeritus, University of Geneva
- Professor of Medicine, University of Düsseldorf
- Associate professor of Cardiology, University of Lausanne (until 1989)
- Recognised teacher, Imperial College of Medicine, London
- CIRSE Award Winner 1987
- ESC Grüntzig Award 1996
- Doctor honoris causa, University of Lausanne 1999
- King Faisal International Prize for Medicine 2004
- European Academy of Science Prize 2006
- ACC Maseri-Florio Award 2007