The future of interventional cardiology

INTRODUCTION

The European Association of Percutaneous Cardiovascular Interventions (EAPCI) was founded back in 2006 from the former European Society of Cardiology (ESC) Working Group on Interventional Cardiology. Within the ESC, and as 1 of 7 different sub-specialties associations, EAPCI mission is specifically aimed at reducing the burden of cardiovascular disease through percutaneous cardiovascular interventions.

EAPCI empowers interventional cardiologists through a robust network of resources specifically designed to meet the demands of contemporary practice. In the following sections, we will outline the key benefits of EAPCI membership across several domains, including science, content, education, advocacy, and collaboration (figure 1). Each of these pillars contributes to a framework that not only keeps members at the cutting edge of interventional cardiology, but also fosters collaboration with national working groups and societies to move the field forward collectively.

Figure 1. Why join the European Association of Percutaneous Cardiovascular Interventions (EAPCI)?

By highlighting these core advantages, we hope we can underscore the true value of EAPCI membership in helping interventional cardiologists navigate the current fast-paced clinical environment and drive the future of interventional cardiology to improve daily clinical practice and scientific projects.

SCIENTIFIC ACTIVITIES CONDUCTED BY EAPCI

EAPCI scientific documents provide guidance for the clinical management of topics not covered in the ESC clinical practice guidelines complementing them by providing more in-depth information in specific areas that cannot be expanded upon in the guidelines.

EAPCI produces scientific documents and consensus statements specific to the domain of percutaneous cardiovascular interventions and in collaboration with other ESC associations, councils and working groups on topics overlapping among the different subspecialties and with affiliated countries (ie, the Society for Cardiovascular Angiography & Interventions, SCAI). A dedicated EAPCI website grants access to all EAPCI consensus documents and EAPCI position papers (2009-2024).1

The 2022-2024 EAPCI Scientific Documents Committee conducted extensive work developing new standard operating procedures that have, recently, been more widely adopted by the ESC Scientific Documents Committee. These new standard operating procedures guarantee that all EAPCI members can participate in the drafting of these documents. In addition, to guarantee inclusivity a balance between geographies and sex is guaranteed.

CONTENT CREATED BY EAPCI

The aim of the unique EAPCI Journal Club format is to provide a true valuable platform for disseminating recent clinical trials, fostering discussions on clinical implications, and guiding the integration of new data into clinical practice. The discussion of recent clinical trials addresses different aspects of cardiovascular interventions and pharmacotherapy, offering insights into cutting-edge therapeutic strategies and evolving standards of care.

The EAPCI Journal Club enables attendees to engage directly with principal investigators of the clinical trials and clarify clinical questions.

By promoting interaction among global experts, EAPCI webinars are tailored to the latest advances and best practices in cardiovascular interventions. The webinars serve as a link between research and clinical application. All content is available on demand on the EAPCI official website2 and the ESC365 platform for EAPCI members at any time.3

EDUCATIONAL RESOURCES BY EAPCI

EAPCI offers comprehensive educational resources to support professionals in interventional cardiology.

EAPCI Certification is an exam designed to assess knowledge and skills in percutaneous cardiovascular interventions. Earning this certification is a significant accomplishment for professionals, as it verifies a high level of competence and dedication in interventional cardiology. For nurses and health care support specialists, achieving such a certification provides career advancement opportunities, enhances confidence in clinical practice, and solidifies their role in a multidisciplinary care team.

EAPCI online courses are another key offering providing structured, modular learning opportunities for participants to explore specific topics at their own pace. These courses include interactive elements, such as case studies and assessments, reinforcing knowledge and promoting practical understanding. For nurses and health care support specialists, online courses focus on essential areas such as perioperative care, device management, and complication prevention, providing them with essential, job-specific skills to improve patient outcomes.

Altogether, EAPCI Certification, EAPCI webinars, and EAPCI online courses foster a supportive and enriching learning environment empowering nurses and health care support specialists to expand their knowledge, achieve certifications, and deliver high-quality, patient-centered cardiovascular care.

In addition, EAPCI is further expanding its educational offers through an agreement signed between the ESC and Europa Group. EAPCI official courses are EuroPCR, the EAPCI PCR Fellows Course, and PCR London Valves. The official textbook is the PCR-EAPCI Textbook4 and EuroIntervention5 is EAPCI official journal.

Advocacy provided by EAPCI

In terms of advocacy, the key objectives of EACPI are to understand and overcome barriers preventing patients from receiving the appropriate diagnostics and treatment, and evaluate and improve patient experience during interventional procedures.

To achieve the first goal, the ATLAS in Interventional Cardiology has been developed as the landmark project, allowing comparisons across different contemporary interventional cardiology practices in multiple ESC countries and the use of this information when negotiating reimbursement policies with national regulatory bodies. Data collection started in 2016 and the first report was published in 20206 mainly on human resources, infrastructure and procedural volumes.

To achieve the second goal, the Patient Experience in the Catheterization Laboratory (PATCATH) tool,7 patient information videos8 and Valve for Life initiative9 have been launched in collaboration with the EACPI Patient Engagement Committee. The PATCATH tool has been developed to try to understand and improve the patients’ experience while undergoing interventional cardiology procedures and is now fully available in 10 different languages. In addition, 5 patient information videos on percutaneous cardiovascular interventions have been produced to help patients understand these procedures, which remain available for use by EAPCI members in English, French, German, Italian, and Spanish. The use of PATCATH demonstrated that patient understanding of common cardiovascular procedures may be suboptimal.7,10 In turn, patients who were shown a dedicated video animation prior to the procedure tended to have more positive informational experience.11

Finally, the Valve for Life initiative launched in 2015 aims to improve transcatheter aortic and atrioventricular valve interventions across Europe to raise awareness, facilitate access to transcatheter heart valve interventions and, last but not least, reduce age and gender discrimination regarding access to health care.9 Recently, a survey has been distributed to all national societies to identify current gaps in structural valve procedires to identify the countries and topics that should be addressed in the next edition.

EACPI INITIATIVES FOR THE YOUNG

Identificating and addressing the needs of the young community is one of the key EAPCI goals. Currently, almost 50% of all EAPCI members are younger than 40 years and 25% are in training.

The EAPCI Young Committee has identified networking, education and mentoring as the priorities for 2024-2026. The networking opportunities for young EAPCI members include the possibility to participate in joint sessions during national society congresses, expand collaboration with other ESC associations, working groups, and affiliated countries.

In terms of education, young EAPCI members have access to online educational resources, including a step-by-step video library created for early career interventional cardiologists.

Two programs are dedicated to young members:

1. The 12-month EAPCI Online Coaching Program that promotes the personal development of young interventional cardiologists with practical, research and personal development tips in a one-to-one mentor-mentee relationship. The upcoming coaching program includes further development of the existing mentorship program and will include more mentors among the EACPI members on interventional skills and career development (“leadership accelerator”) and create mentorship for very early career colleagues and even students with young mentors (“young to young”).
2. The Education and Training Grant program provides an opportunity for clinical training in the interventional cardiology field in a country from ESC National Cardiac Societies other than their own. The goal of this grant is to help young candidates attain clinical competence with hands on activities and acquire experience on high-quality cardiological clinical practice to contribute to improving academic and clinical standards upon return to their own country. The number of grants has increased in the last term.

To underline the valuable contribution of young members, EACPI introduced a 50% reduced membership fee of €75/year for people younger than 40 years.

EAPCI-EMPOWERED COLLABORATION

ESC National Cardiac Societies are the founders and principal constituent bodies of the ESC. Currently, there are 58 national cardiac societies.12 As institutional members they pay a membership fee and vote to help shape the future of cardiology and drive ESC activities. They are also instrumental in ESC research, dissemination of clinical practice guidelines and a wide range of other activities.

The presidents, or their official representatives, make up the EAPCI National Cardiac Societies Committee whose aim is to promote interactions across countries and help understand the diverse needs of different geographical areas to foster collaboration. For example, in collaboration with the German Interventional Working Group (AGIK) EAPCI became a cooperation partner in a 2-day Complete Higher Risk Indicated Percutaneous Coronary Intervention course held in Berlin in 2024 called AGIK CHIP International. Many joint sessions have recently been held at various national society congresses, including the Romanian Society of Cardiology, APIC (Associação Portuguesa de Intervenção Cardiovascular), and GISE (Società Italiana di Cardiologia Interventistica).

With EAPCI global scope collaborative relationships with many ESC Affiliated Cardiac Societies,13 for the first time, an EAPCI International Committee was established for 2024-2026 whose plan is to build bridges and promote global collaborations through joint sessions in congresses and courses, creating scientific documents and preparing webinars together.

An agreement has already been reached with the Society for Cardiovascular Angiography & Interventions (SCAI) with a joint session at the SCAI meeting in 2024 and 2 scientific documents with collaboration between SCAI and EAPCI are already being drafted. A joint session between EAPCI and the Latin American Society of Interventional Cardiology (SOLACI) was held in Buenos Aires (Argentina) in 2024 demonstrating the importance of global collaboration and education to achieve common goals. More collaborative events and scientific projects are in the pipeline with other affiliated countries.

THEN, WHY JOIN EAPCI?

EAPCI serves as a vital platform for interventional cardiologists to address the challenges of a rapidly evolving medical landscape. By offering access to cutting-edge scientific content, innovative educational opportunities, and robust collaborative networks, EAPCI provides its members with tools to stay at the forefront of interventional cardiology. From contributing to the development of groundbreaking scientific documents and consensus statements to leveraging platforms such as the Journal Club and ESC365 for continuous learning, EAPCI ensures its members are prepared to deliver optimal patient care. Additionally, advocacy initiatives such as the ATLAS project and Valve for Life underline EAPCI commitment to improving access to cardiovascular interventions across Europe and beyond. In addition, it provides an ideal platform for early career doctors and those in training to have access to educational offers, a one-to-one coaching program, fellowship grants providing access to an international network to become the future leaders of tomorrow. The EAPCI membership not only fosters professional growth but also strengthens global collaboration, making it an essential step for those wishing to lead and innovate in the field of interventional cardiology. Join EAPCI and become a member by scanning the QR code (figure 2) to access these benefits and help shape the future of our specialty.

Figure 2. EAPCI membership QR code.

FUNDING

None declared.

CONFLICTS OF INTEREST

E. Rafflenbeul is chair of the EAPCI Educational Content, Courses and Webinars Committee (2024-2026). M. Iannaccone is chair of the EAPCI Young Committee (2024-2026). A. Gasecka is co-chair of the EAPCI Young Committee (2024-2026). N. Ryan is chair of the EAPCI Online and Communication Committee (2024—2026). A. Chieffo is EAPCI president (2024-2026).

REFERENCES

INTRODUCTION

Preventive percutaneous coronary intervention (PCI) refers to the treatment of high-risk plaque before the occurrence of any adverse events. Typically, the decision to perform preventive treatment is made when the expected event rate of the underlying condition outweighs the potential short- and long-term complications of the procedure. This approach is also applicable to the treatment of coronary disease. In recent years, advances in understanding atherosclerotic plaque progression and identifying high-risk plaques, along with technological progress in coronary devices, have shifted the balance between the risks of the underlying condition and those of percutaneous treatment.

THE CONCEPT OF VULNERABLE PLAQUE

The understanding of high-risk coronary plaques, also known as vulnerable plaques, has evolved over the years. Initially, a vulnerable plaque was often considered an angiographically nonsignificant stenosis that was prone to rupture and cause acute coronary syndrome.1 The PROSPECT study was the first landmark trial to focus on the natural history of vulnerable plaques, assessed using intravascular ultrasound with virtual histology.2 This trial was the first to define specific criteria for plaque vulnerability, notably thin-cap fibroatheroma (TCFA). TCFA is characterized by a lipid-rich plaque with a necrotic core, separated from the vessel lumen by a thin fibrotic cap. The trial also identified 2 other quantitative criteria: a plaque burden > 70% and a minimum lumen area (MLA) < 4.0 mm². Despite its major contributions, the study had limitations: a) the resolution of intravascular ultrasound with virtual histology was not sufficient to detect the cap thickness ≤ 0.65 µm (cutoff value for true TCFA), and b) the trial could not exclude the absence of ischemia in lesions that led to events.

THIN-CAP FIBROATHEROMA

The use of more sophisticated imaging modalities, such as optical coherence tomography (OCT), which has a resolution of 10 to 20 µm and is therefore able to detect TCFA, has paved the way for the true detection of vulnerable plaque. Indeed, the COMBINE OCT-FFR trial,3 a natural history study that compared the outcomes of nonischemic lesions, categorized as TCFA or non-TCFA based on OCT assessment, showed for the first time that even in the absence of ischemia, the presence of an OCT-assessed TCFA was associated with a 4-fold higher event rate compared with lesions without TCFA. This trial provided evidence that the morphological features of a lesion might be more important than ischemia in predicting future adverse events, opening the door to the potential treatment of nonischemic lesions.

Interestingly, our group has also shown that TCFA, rather than any lipidic plaque, is associated with future adverse events, while lipidic plaques with a thick cap have a benign outcome comparable to that of fibrotic plaques. This finding suggests that only about a third of all lipidic plaques and less than a quarter of all plaques might benefit from pre-emptive treatment.4 Other studies, such as CLIMA5 and PECTUS,6 have corroborated the role of TCFA in predicting future adverse events. Similarly, Kubo et al.7 have also shown that the presence of TCFA is associated with a high rate of future adverse events.

VULNERABLE PLAQUE NEW CONCEPTS

Recent studies have demonstrated that, contrary to previous beliefs, vulnerable plaques that lead to future adverse events typically have a large plaque volume and show a significant degree of luminal stenosis. COMBINE OCT-FFR and the FORZA trial8 both independently found that an MLA cutoff of 2.5 mm² was a better predictor of future adverse events than the previously considered 4.0 mm².

In addition to MLA, other plaque features are associated with vulnerability. A recent post hoc analysis from the COMBINE OCT-FFR study9 showed that, beyond MLA, other signs of plaque destabilization adjacent to TCFA, such as old plaque ruptures or healed plaques, are associated with a significantly increased rate of adverse events. When vulnerability features coexist, the event rate can progressively increase. For example, while TCFA alone was associated with a 20% future adverse event rate, a combination of TCFA with MLA < 2.5 mm² adjacent to a healed plaque was associated with an event rate of 50%.

These findings are important as they introduce a new way of thinking about vulnerable plaques. The concept has shifted from a simple yes/no binary to a variable and progressive model. In this model, the vulnerability of a plaque increases based on the number of high-risk features present, with the most vulnerable plaques being those with more than 3 risk factors.

The notion that a plaque that ruptures without causing an acute event will heal and stabilize has also been challenged. “Healed” plaques often do not represent stable plaques but are prone to new ruptures in adjacent locations, making them one of the strongest predictors of vulnerability. Araki et al.10 have very nicely shown that multiple repeat plaque ruptures and healings are the true mechanisms behind atherosclerosis progression.

It is understandable that growth in the volume of intraluminal plaque parallels ischemia progression, as plaque progression will eventually lead to ischemic lesions. However, it is important to recognize that, based on this rupture and healing model of plaque progression, any future destabilization (rupture and/or healing) of a plaque with vulnerable features—whether angiographically borderline or already significant but not yet ischemic—could result in either an acute coronary syndrome or rapid progression (from one day to the next) of luminal stenosis, leading to ischemia and likely stable or unstable angina.

Based in this rationale, revascularization based on OCT imaging, which has the potential to detect these plaques, becomes an appealing strategy, rather than relying solely on ischemia-guided intervention. The FORZA trial was the first to show a benefit for imaging-guided PCI vs ischemia-guided PCI. However, the trial used only quantitative OCT criteria rather than a combination of quantitative and qualitative OCT vulnerability criteria. As explained above, the benefit of OCT guidance lies in its ability to identify lesions with a high degree of vulnerability that do not yet cause symptoms, thereby paving the way for preventive PCI.

IMPROVED PCI OUTCOMES

Improvements in stent technology, PCI techniques, and intravascular imaging guidance have led to very low complication rates with PCI, especially in nonseverely stenosed lesions. The PREVENT trial,11 which compared a medical therapy vs PCI in lesions with a diameter stenosis of ≥ 50% but which were otherwise nonischemic, showed very low event rate in the PCI arm (< 1%). This suggests that PCI can currently provide lower event rates than medical therapy for these high-risk vulnerable lesions.

IMPROVING THE CURRENT REVASCULARIZATION STRATEGY BY INTEGRATING A PREVENTIVE VULNERABLE PLAQUE INTERVENTION

Interestingly, while at first glance, an approach similar to that of the PREVENT trial might seem to open the door to stenting all intermediate lesions, the reality is different. The ability of OCT to detect truly vulnerable features has significantly limited the number of lesions that might benefit from preventive PCI. In patients without ischemia but with a lesion that has a diameter stenosis of more than 50%, the prevalence of vulnerable lesions according to OCT criteria may range between 10% and 20% compared with > 90% in the PREVENT trial.

On the other hand, large trials like ISCHEMIA12 and FAME 2,13 have shown that approximately 20% of patients with ischemic lesions are unresponsive to medical treatment and require PCI to control angina symptoms. Interestingly, this 20% corresponds to the percentage of truly ischemic lesions, defined as having a fractional flow reserve (FFR) of < 0.75.14 Therefore, it can be deduced that there is still a role for ischemia detection and revascularization of these lesions with true ischemia (FFR < 0.75), regardless of the presence of vulnerability features. Meanwhile, the role of preventive PCI could be reserved for plaques with highly vulnerable features that show at least an intermediate degree of stenosis but are otherwise nonischemic.

If such a combined decision-making strategy is correctly applied, the number of lesions that may benefit from PCI treatment could be similar to or even lower than those identified through the current ischemia-driven revascularization strategy alone. Indeed, with this new combined strategy, the only lesions requiring PCI would be those with true ischemia (FFR ≤ 0.75), which represent about 20% of lesions, and those with high-risk vulnerable plaque, which represent another 10% to 20% of all lesions. This compares with the 40% of lesions that currently undergo PCI based on an ischemia-driven revascularization strategy (FFR ≤ 0.80).

This combined FFR- and OCT-guided treatment strategy in patients with multivessel disease (lesions with angiographic stenosis > 50%) presenting with stable or acute coronary syndromes is now being tested in the COMBINE-INETREVENE trial (NCT05333068), a global randomized controlled trial. This new strategy involves reserving PCI to lesions with an FFR of ≤ 0.75, as well to to all lesions with an FFR > 0.75 that show vulnerable features such as TCFA, ruptured plaque, or plaque erosions with significant lumen reduction (MLA < 2.5 mm²).

Another trial implementing a purely preventive percutaneous treatment is the VULNERABLE trial (NCT05599061), an ongoing multicenter study in Spain that tests a similar concept but focuses solely on nonischemic, ST-segment elevation myocardial infarction nonculprit lesions with high-risk vulnerable features. We believe that the results of these trials, as well as new imaging technologies that could lead to automatic detection of vulnerable plaques, combined imaging and hemodynamic assessment modalities, and improved intracoronary treatment devices (whether implantable or not), will provide new insights into the role of preventive PCI.

FUNDING

There was no funding for this manuscript.

CONFLICTS OF INTEREST

E. Kedhi has received institutional research grants from Medtronic and Abbott and is a proctor for Abbott.

REFERENCES

The management of symptomatic coronary artery disease in older adults presents a conundrum. Depending on their residual life expectancy, treatment is focused more on quality of life and symptomatic relief than on the improvement of long-term prognosis. Consequently, coronary artery bypass grafting (CABG) often is not an option, not only because of an increased and sometimes prohibitive risk but also because of the slow or even incomplete recovery after major surgery in older adults. On the other hand, medical treatment alone is of limited efficacy and may result in polypharmacy, with associated problems of adherence and drug interaction. Thus, percutaneous coronary intervention (PCI) may remain the only reasonable option. Nevertheless, PCI in older adults is often technically challenging and carries a substantially increased risk compared with PCI in younger patients.1 The extent and location of coronary artery disease appear to be even more important in older adults than in younger patients. Specifically, the risk of PCI in older patients is increased by more than twofold, if it involves the left main coronary artery as compared with PCI in other territories.1

Thus, guidance on left main PCI in older adults is particularly needed. There is, however, a paucity of data to aid treatment decisions in this setting. Older age groups are scarcely represented in the randomized trials that inform current guidelines.2 As a first approach to this problem, it may be important to learn how the outcomes of left main PCI in older adults differ from those in the younger age groups included in pivotal trials.

The study by Gallo et al.,3 recently published in REC: Interventional Cardiology, is an important first step in this direction. This retrospective, single-center observational study investigated all older adult (≥ 75 years) patients undergoing left main PCI at the Cardiology Service of the Hospital Universitario Reina Sofía (Córdoba, Spain) between 2017 and 2021. Gallo et al. identified 140 patients with a median age of 80 years and a median SYNTAX score of 21, similar to those in published randomized studies. Highlighting the clinical relevance of the issue, these patients represented as much as 32% of their left main PCI cohort.

With a median follow-up of 19 months (interquartile range, 5-35 months), Gallo et al. found substantial differences in outcomes for their left main PCI cohort of older adults compared with published outcomes in pivotal randomized trials comparing left main PCI with CABG (figure 1). In these trials, patients had to be eligible for CABG and were approximately 14 years younger.4 As shown by a recent individual patient data meta-analysis, outcomes in the pivotal trials were driven by nonfatal cardiac events rather than mortality.4 In the current cohort of Gallo et al., however, only 2.1% had a spontaneous nonfatal myocardial infarction during the 2-year follow-up and reintervention was indicated in only 4.3%, whereas 2-year mortality was 27.1%.3

Figure 1. Two-year outcomes of left main percutaneous coronary intervention (PCI) in older adults in the study by Gallo et al.3 compared with younger patients included in randomized studies comparing PCI with coronary artery bypass grafting.4 Percentages were derived from numbers of events divided by total number of patients for older adults and from Kaplan-Meier estimates for younger patients. The incidence of noncardiovascular death in younger patients was imputed based on the reported proportion of 44% for noncardiovascular death at 5 years. MI, myocardial infarction.

 

The younger patients in the randomized trials had a substantially better prognosis with a 2-year mortality of only 4.5%. In these patients, outcomes were dominated by spontaneous myocardial infarction and reintervention, with 2-year incidences of 3.0% and 9.6%, respectively.4 According to the individual patient data meta-analysis, CABG substantially reduced these latter events—to 1.6% and 3.4%, respectively—but did not significantly improve survival.

In this context, the results of the study by Gallo et al. are important. They show that the contribution of those events where CABG clearly outperforms PCI (ie, spontaneous myocardial infarction and reintervention) is less relevant in older adults than in the younger patients of the randomized trials.

In the population of older adults in the study by Gallo et al., deaths that could be clearly attributed to noncardiac causes were more frequent than in younger patients. The incidence of noncardiac death was 7.1% at the 2-year follow-up after left main PCI in older adults, while it ranged around 2% in the younger patients of randomized studies on left main PCI (figure 1). This indicates a higher number of deaths not amenable to any cardiovascular treatment in older patients compared with younger patients.

Although higher in absolute numbers, the proportion of deaths that could be attributed unequivocally to noncardiac causes was lower in older adults than in younger patients (figure 1). This finding is, however, difficult to interpret. In line with common practice, deaths of unknown cause were counted as cardiac deaths. Thus, we do not know how many of these deaths were from true cardiac causes, let alone what proportion of deaths were due to treatment failure of left main PCI.

Despite these uncertainties, the study by Gallo et al. shows that in older adults with left main PCI, the causes of death not related to myocardial revascularization were more frequent than in younger patients undergoing left main PCI.

Mortality was driven less by calendar age and more by frailty. Gallo et al. stratified their cohort into nonfrail and frail groups, as defined by a frailty score of 3 or higher. As many as 57% of the frail patients had died at the 3-year follow-up compared with 23% of the nonfrail patients (P = .001) (for 2-year mortality, see figure 1). After inverse probability of treatment weighting with a number of variables including age, this difference in all-cause mortality remained substantial and statistically significant (23 % vs 44%; P = .046). Thus, frailty, but not age or SYNTAX score, was a significant independent predictor of mortality (multivariable hazard ratio = 2.4; 95% confidence interval, 1.2-5.0; P = .018).These findings are in line with a recently published study on PCI in older adults that identified frailty, but not calendar age, as a strong predictor of mortality.5

The high mortality of older adults with left main coronary disease despite PCI poses the question of futility, particularly in frail patients. While PCI may indeed be futile in terms of prolonging life, it may still alleviate symptoms. In this regard, it is important to note that PCI in the study by Gallo et al. could be accomplished without complications in 94% of the patients (92% of frail patients and 97% of nonfrail patients), and 91% of the patients left the hospital alive, even though 50% of them had presented with acute myocardial infarction. Thus, there is no prohibitive complication rate that justifies withholding left main PCI in older adults as an attempt to improve symptoms. Moreover, the randomized After Eighty study found that myocardial revascularization reduced the risk of myocardial infarction and urgent revascularization in older patients with acute coronary syndromes.6 Thus, PCI in older adults, particularly for the left main, may offer more than just relief from angina or angina equivalents. The low incidences of spontaneous myocardial infarction and reintervention found by Gallo et al. after left main PCI may thus reflect the positive effects of the procedure. However, in the absence of a control group such interpretation remains speculative. Moreover, the number of patients in this retrospective observational study is limited. Together, with the single-center design of the study, this weakens the generalisability of the current findings.

Nevertheless, 3 important messages of the study by Gallo et al. prevail: a) left main PCI in older adults is a reasonable option with a fair procedural success rate; b) the clinical course after left main PCI differs substantially from that in younger patients with death being far more common than nonfatal cardiovascular events; c) frailty is more relevant to prognosis than calendar age, being a central determinant of mortality after left main PCI. Further studies are needed to determine how best to integrate these findings into individualized treatment decisions in older adults presenting with symptomatic left main disease.

FUNDING

None.

CONFLICTS OF INTEREST

F.-J. Neumann has received consultancy honoraria from Novartis and Meril, speaker honoraria from Boston, Amgen, Daiichi-Sankyo and Meril and reports speaker honoraria paid to his institution from BMS/Pfizer as well as research grants paid to his institution from Boston and Abbott.

REFERENCES

In 1998, in response to a comment on the limited durability of an aortic valvuloplasty performed during the last Madrid Interventional Cardiology (MIC) course, Alain Cribier insightfully stated: “We’ll mount a stent on the valvuloplasty balloon, attach the leaflets, and problem solved.” Four years and countless hours of work later, both at his hospital in Rouen, France, and at the animal experimentation center in Lyon, France, the recently deceased Alain Cribier (1945-2024) achieved a groundbreaking milestone.1 On April 16, 2002, he performed the world’s first surgery-free transcatheter aortic valve implantation (TAVI), prolonging the patient’s life and revolutionizing heart valve surgery. This innovation dramatically improved the quality of life of a high percentage of patients with severe aortic stenosis who were ineligible for conventional heart surgery. Since then, more than a million patients have benefited from his technological innovation.

After this pivotal first case of TAVI,1 isolated procedures were performed in selected patients in the following years, with few technical variations, and all via antegrade access. While interventional cardiologists were enthusiastic and had high expectations, critics predicted apocalyptic disasters due to alleged complications, such as vascular complications, valve instability and migration, coronary occlusion, strokes, annular and aortic rupture, paravalvular regurgitation, and concerns about the durability of the valve. In 2006, the first clinical trials (REVIVAL2 in the United States and REVIVE3 in Europe) changed the procedure strategy. The adoption of retrograde access, facilitated by the versatility of a flexible carrier catheter, considerably simplified the technique and contributed to its widespread adoption.

After a stay in Vancouver, Canada to acquire theoretical and practical training in the technique, and with Cribier’s assistance, a team of interventional cardiologists from Hospital Gregorio Marañón, Madrid, Spain successfully implanted the first 2 aortic valves via transfemoral access in Spain on April 23, 2007 (figure 1). Throughout 2007, the team contributed to the REVIVE trial, successfully treating 10 patients with transfemoral TAVI, with no perioperative mortality or major complications. This success, with contributions from other European centers, paved the way for the approval of this technology for clinical use.

Figure 1. First transcatheter aortic valve implantation performed in Spain, on April 23^rd, 2007. In the photograph, from left to right, Dr. Alain Cribier, Dr. Eulogio García, and Dr. Javier Ortal.

 

After standardizing and defining the complications associated with the procedure,4 the randomized PARTNER clinical trials were conducted in inoperable patients and high-risk surgical patients.5,6 These trials confirmed the safety and efficacy of TAVI, establishing it as the treatment of choice for high-risk patients.7 Eventually TAVI became the preferred treatment for all patients with aortic stenosis older than 75 years.8-10

In this exciting journey, we contributed a few technical improvements, demonstrating the safety of direct implantation without prior valvuloplasty11 and improving the management of vascular access via contralateral access.12 The gradual simplification of TAVI led to its classification as a “minimally invasive procedure”. It is now available in all cath labs, with more than 1 million valves implanted in all 5 continents.13

Alain Cribier was technically elegant and efficient; meticulous, systematic, and generous in his teaching. His perseverance in the management of aortic stenosis drove him to seek a definitive solution. Bernard Guiraud-Chaumeil, former president of the French health assessment department, highlighted Cribier’s exceptional contribution to the management of valvular heart disease, stating: “Revolutionary advances in medicine must be accessible to patients as soon as possible.” Cribier’s dedication, perseverance, and ingenuity changed the history of severe aortic stenosis; his legacy will not only save thousands of lives but will also improve the clinical practice of present and future generations of interventional cardiologists.

FUNDING

None declared.

CONFLICTS OF INTEREST

None declared.

REFERENCES