Interventional cardiology ‘at a pivot point’
SAN DIEGO — The field of interventional cardiology “has a very bright future,” Anthony N. DeMaria, MD, told the audience during the Hildner lecture at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.
Today, “interventional cardiology is at a pivot point. ... I see interventional cardiologists as standing their stronghold and expanding their role into multiple other areas,” DeMaria, the Jack and Judith White chair of cardiology at the University of California, San Diego, said here.
“It’s clear that interventional cardiology has absolutely revolutionized the treatment of acute coronary syndromes,” he said, referencing previous data showing benefits of PCI in this population.
However, recent studies have questioned the role of PCI in patients with stable CAD. Two such trials that have received intense scrutiny are COURAGE, which compared PCI vs. optimal medical therapy and showed no difference in survival, and ORBITA, which compared PCI vs. a sham procedure and showed no difference in exercise time. As discussion and vigorous research continues to surround intervention for stable CAD, DeMaria noted that neither trial was “perfect,” and there likely are other factors at play behind the results reported thus far.
“My message to you, as a noninvasive cardiologist, [is that], clearly, interventional cardiology will always have an important role in heart disease. It has been established as routine in ACS and I think it will be selectively applied in patients with chronic coronary disease and stable angina, and will be based on physiology. You will be well served to reinvestigate coronary physiology,” he said.
Looking ahead, structural heart disease is a continued important area of focus, according to DeMaria.
“Interventional cardiology has incredible opportunities in structural heart disease,” he told the audience.
The focus on valvular heart disease is important, as worldwide rates of undiagnosed valvular heart disease remain high. DeMaria referenced recent data from the OxVALVE population cohort study showing that 44% of individuals had mild valvular heart disease and 6.4% of asymptomatic, otherwise healthy individuals had significant moderate to severe valvular heart disease. “One in 20 people with moderate to severe valvular heart disease are often going untreated,” he said.
Transcatheter aortic valve replacement is well established in the intervention community and has since expanded to patients with intermediate and lower risk. DeMaria proposed that the future of TAVR surrounds resolving questions of durability, extending treatment to low risk patients with aortic stenosis and ultimately extending treatment to patients with asymptomatic aortic stenosis.
Beyond TAVR, the interventional cardiologist’s role in structural heart disease is broad and may encompass mitral and tricuspid valve replacement/repair, with annuloplasty, ventricular reshaping, chordal implantation, mitral prostheses and prosthetic valves; alternate minimally invasive approaches to treat mitral regurgitation; left atrial appendage occlusion; pulmonary balloon dilation for chronic thromboembolic pulmonary hypertension; and renal denervation, among others.
Interventions in congenital heart disease continue to focus on closure devices for atrial septal defect and patent foramen ovale, ventricular septal defect and patent ductus arteriosus; balloon dilation for pulmonic stenosis and pulmonary artery stenosis; dilation and stenting for coarctation of the aortic; and transcatheter valves, DeMaria said. PFO closure is of particular interest of late, with recent studies showing benefit. A variety of technologies continue to be developed and tested.
DeMaria also stressed the importance of imaging in structural intervention.
“As interventional procedures are being developed to treat structural heart disease, including for congenital, valvular, electrophysiologic and heart failure conditions, imaging is crucial in guiding these interventions,” DeMaria said.
Together, interventional cardiologists “can expand like crazy in structural heart disease,” he said. “You already have an excellent footprint. There are [many] technologies that can be applied to treat structural heart disease [and I anticipate that] they will increase dramatically.” – by Katie Kalvaitis
DeMaria AN. Hildner Lecture: A Pivotal Time for Interventional Cardiology. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; April 25-28, 2018; San Diego.
Disclosure: DeMaria reports he is editor of Structural Heart: The Journal of the Heart Team.