Clinical Innovators: Advancing Noninvasive Cardiac Imaging An Interview with Anthony DeMaria, MD | Interview by Katlyn Nemani, MD
CardioSource WorldNews | Anthony DeMaria, MD, MACC, is the Judith and Jack White Chair in Cardiology and founding director of the Sulpizio Cardiovascular Center at University of California-San Diego. He regularly participates in trials involving non-invasive methods to diagnose and treat heart disease. Dr. DeMaria has received numerous awards and is listed in The Best Doctors in America. He served as a member of the Subspecialty Board on Cardiovascular Disease for the American Board of Internal Medicine from 1991 to 1997. He is a past editor-in-chief of the JACC and of Echocardiography. Dr. DeMaria received his medical degree from the New Jersey College of Medicine, completed his internal medicine residency at the U.S. Public Health Service Hospital in Staten Island, and his fellowship in cardiology at the University of California, Davis. He is a leading expert in echocardiography and noninvasive cardiac imaging.
When did you first become interested in becoming a cardiologist?
I first became interested in being a cardiologist while serving in the United States Public Health Service (PHS). The Staten Island PHS Hospital housed an innovative CardioPulmonary Program directed by Tony Damato, MD, who led the team that first described the recording of the His Bundle electrogram in humans. Dr. Damato attracted many very bright, young, inquisitive physicians to the program which was leading the way in the development of clinical electrophysiology. I had my first opportunity to do research at that time, and it stimulated me to seek a career in cardiology.
You entered the field when recording heart motion by ultrasound was a new technique. What kind of changes have you seen in cardiac imaging over the course of your career?
As a first-year Cardiology Fellow at the University of California, Davis, I was assigned to work on a technology to assess cardiac motion by fluoroscopy called radarkymography. It led me to attend a session on echocardiography which convinced me that this was a much superior method to assess cardiac function. I convinced my chief, Dean Mason, MD, FACC, to let me go to Indiana University to learn the technique from Harvey Feigenbaum, MD, FACC. At the time only “ice pick” m-mode echocardiograms could be obtained, and Dr. Feigenbaum had just made the giant leap of performing strip chart recordings rather than Polaroid pictures from an oscilloscope. The initial strip chart recorders were huge, relatively immobile, and required photographic developers. However, they enabled echo scans of the entire heart from apex to base over a number of cardiac cycles. Subsequently two-dimensional echographs were developed which provided excellent anatomic orientation and opened up imaging from windows other than the parasternal area. Doppler recordings were soon added which provided assessment of blood flow in addition to anatomy, and added an important hemodynamic and physiologic information. This enabled echo to provide the same information as cardiac catheterization for many conditions. Innovation continued in the development of 3D echo and the acquisition of Doppler recordings from tissue and the measurement of strain. Contrast agents were developed to enhance cardiac images and opacify myocardial perfusion. Miniaturization of instrumentation made it possible to image from the esophagus and most recently to image with small handheld devices that can fit in the pocket.
Thus, during my career cardiac ultrasound has gone from a technique with a limited ability to record only anatomy using large cumbersome instruments to a technology that provides comprehensive recordings of cardiac anatomy and physiology that can be widely applied not only in the noninvasive cardiology laboratory, but widely in clinics and hospitals.
You recently published an article in Lancet about ixCell-DCM, the largest cell therapy done in patients with heart failure so far. Can you tell us about this therapy and the outcomes you found?
I was recently privileged to be part of an investigative team that evaluated a unique stem cell preparation to improve the clinical outcome in patients with ischemic cardiomyopathy. Ixmyeolcel-T is a multicellular therapy produced from the patient’s own bone marrow that contains a variety of mononuclear cells including mesenchymal stem cells and M2 macrophages that can potentially aid the repair of and reduce the inflammation of ischemic cardiomyopathy. My interest in this research was stimulated by the fact that there were no good therapies available for patients with end-stage heart failure due to irreversibly damaged myocardium. We conducted a multicenter, randomized, prospective, blinded clinical trial in patients with advanced heart failure. We found a statistically significant benefit in the primary endpoint of a composite of all cause death, hospitalization and unplanned clinic visits for heart failure decompensation compared to controls. Although the mechanism of benefit remains uncertain, I believe that this largest randomized trial of cell therapy for heart failure supports the potential benefit of cell therapy for this very ill patient population that has few therapeutic options.
You are a key player in San Diego’s successful “Be There” campaign to address cardiac risk factors. What is unique about this campaign?
Be There, the Project to Make San Diego a Heart Attack and Stroke Free Zone, is one of the projects that I am involved with that I am proudest of. Physicians from virtually all the major medical systems in San Diego have come together to collaborate to reduce heart attacks and strokes in our county. I have the honor of serving as Executive Committee chair of this group. We aim to energize physicians to aggressively pursue evidence based risk reduction measures for their patients, and to activate patients to adhere to medications and a healthy lifestyle. To energize physicians, we meet monthly at a “University of Best Practices” to share the most effective protocols to reduce cardiovascular risk. To accomplish the latter goal, we appeal to patients to alter behavior so that they can survive to “be there” as an important presence in the lives of loved ones. We have succeeded in obtaining a grant from the Innovations Center of Medicare and Medicaid Innovation and are enrolling 4,000 individuals to receive intensive risk reduction measures including a bundle of medications, health care coaches, and for many participants, wireless blood pressure monitoring. We are attempting to establish a boilerplate for a community effort to decrease heart attacks that can be utilized throughout the United States.
What is the focus of your current research?
My current research is divided into several different areas. My longstanding (career long) interest in cardiac imaging, particularly echocardiography, continues. I am involved in several projects assessing the ability of contrast ultrasound to assess coronary disease, ischemic memory using targeted microbubble markers, and intracavitary flow dynamics. We have just completed some work on the long term follow up of echo markers of diastolic dysfunction, and are linking these descriptors to ultimate outcome such as heart failure and atrial fibrillation. I have also become interested in population health, and am involved with the Be There project to reduce heart attacks and strokes. I am pursuing several studies evaluating the use of cell therapy for cardiac disease, and am collaborating with a bioengineer to label stem cells and track their location and survival in the myocardium after injection. We still do not have a good method to identify and track stem cells after they are injected into humans, and this ability would be fundamental to understanding the mechanism and best application of this therapy clinically.
You have written about the importance of a willingness to take risks and fail as being necessary for medical innovation—characteristics that are not inherent in many physicians. What needs to happen to foster the innovative process in future physicians?
In studying the characteristics of several very successful medical innovators who had converted discoveries into clinical practice, it became apparent that their initial attempts at innovation often had not been successful. Physicians, as a group, are very high achievers who are accustomed to performing at a very high level and being very successful. They are particularly averse to the concept of possibly failing. However, failure need not be the end of a process, and in fact may lead to an understanding of what is necessary for success. In addition, the lack of immediate acceptance of an innovation may not mean the innovation is wrong, but may mean that it has not been properly understood. So, accepting the risk of failure and persistence in achieving the ultimate goal are critical for successful innovation. Great innovative successes typically require an individual to undertake a substantial risk of failure.
As you look back on your career, what have been some of the most rewarding milestones?
As I look back on my career, there are a number of milestones that stand out. Very early in my career I was fortunate enough to be selected as a finalist for the Young Investigators Competition of the ACC. Although I did not win, just being a finalist encouraged me that I could be a productive researcher and provide useful new information. When my laboratory first injected contrast microbubbles into the coronary arteries of canines and visualized myocardial opacification, this opened up the field of myocardial contrast echo as a method to examine myocardial perfusion. When I was first appointed as Chief of Cardiology, it was an important milestone in that I became responsible for individuals and programs other than myself and my own. In fact, I am most proud of the individuals whose training I have contributed to and who have gone on to be great contributors to the profession themselves. Of course, having the honor of serving as the president of the ACC and America Society of Echocardiography have been extraordinary experiences and have given me the opportunity to give back to the profession. Perhaps the crowning milestone was being selected as editor-in-chief of JACC. Being entrusted to evaluate the research of others was an awesome and sacred responsibility, and the opportunity to insure that the best new information was presented to readers provided another great opportunity to contribute to the profession.
Katlyn Nemani, MD, is a physician at New York University
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