Clinical Innovators: Pioneering Angioplasty Technology, and Beyond An Interview with Richard Heuser, MD | Interview by Katlyn Nemani, MD

CardioSource WorldNews | Richard Heuser, MD, FACC, is an internationally-recognized cardiologist, inventor, educator and author, and is one of the early pioneers of the angioplasty procedure. Dr. Heuser has served as principal investigator to research the safety and/or effectiveness of more than 100 medical devices and more than 70 pharmaceutical products. This year he was named 2016 Physician of the Year at the 2016 Healthcare Leadership Awards, and received a top cardiovascular innovation award for his role in developing the Punctual Guidewire technology. Dr. Heuser received his medical degree from the University of Wisconsin School of Medicine, and completed his residency and cardiology fellowship at Johns Hopkins Hospital. He currently serves as chief of cardiology at St. Luke’s Medical Center and as professor of medicine at the University of Arizona College of Medicine.

When did you first develop an interest in interventional cardiology?

In 1977, I was a junior resident at Johns Hopkins Hospital. At the time, the young Chief of Cardiology, Myron Weisfeldt, had already built on the legacy of Hopkins cardiology to make it a world leader in cardiovascular research. At the time this was occurring, we were getting early reports of the performance of balloon procedures to treat blocked arteries. Although this intrigued me, I was really interested in the field of cardiology research for a clinical career in academic medicine.   

You began training in the field during the early days of balloon angioplasty over 30 years ago. What are some of the most remarkable advances in technology you have seen over the years?

I left Johns Hopkins in 1982 and moved to the Southwest. Although I continued to write papers, it was much more satisfying career-wise to develop new treatments separate from an academic center. We were fortunate in the early 1980s to come upon the idea of treating cardiogenic shock with angioplasty and were the first to present our results at international meetings along with separate groups from Michigan and New York. At the same time, we developed a procedure to treat acute mitral regurgitation and pulmonary edema with multi-vessel angioplasty. Although this occurred in the mid-1980s, it was the first catheter treatment for mitral valve regurgitation ever described. I was fortunate to replace the co-inventor of the coronary stent, Richard Schatz at the Arizona Heart Institute, where we developed one of the world’s largest experiences in coronary and peripheral stenting. At the same time, working in concert with Ted Diethrich, we developed the first covered coronary stent that is now in every cath lab worldwide that performs angioplasty. In Phoenix, we also were honored to be asked to be founding members of the CTO (Chronic Total Occlusion) Club from work that we pioneered to treat these complicated patients. Over the last several decades, we have become very involved in treating critical limb ischemia and have recently developed dedicated CTO devices for coronary and peripheral CTOs.

A textbook published last year, Renal Denervation, reviewed this procedure for treating resistant hypertension. Could you tell us about this technology and where things currently stand?

Unfortunately, renal denervation, which showed promise in registry trials, is still at an investigational stage. After the SYMPLICITY HTN3 study was released, most of the innovators in this technique realized that they had to actually look at human anatomy. Once they looked at the neuro-anatomy, they realized that the periarterial approach may not be the ideal situation in treating patients with resistant hypertension. However, I still think this approach may be effective in some patients.   

We started an approach that was different with our company, Verve Medical. In fact, the majority of the afferent nerves which are responsible for overall sympathetic tone are primarily located in the collection system in the kidney. Naively, we felt we needed to evaluate the pathophysiology in humans rather than base all our clinical treatment on animal studies. This turned out to be prescient. In the patients that we treated prior to nephrectomy, we found that we hit all of the nerves intended and unlike any of the other renal denervation treatments, we obtained an immediate blood pressure drop. Our current studies are concentrating on the worst patients with hypertension—those with chronic kidney disease—where we can make a huge impact. With 1.3 billion people worldwide with hypertension, any of the approaches that are being looked at need to be further vetted, because the reality is that many patients with hypertension never take the medications, reach goal, or have sufficient improvement to reduce long term cardiovascular morbidity.

This year you won a Cardiovascular Research Technologies Cardiovascular Innovation Award for your development of the new Punctual Guidewire technology. Can you tell us about this new technology?

Over 13 million access procedures are performed in the United States per year. Radial procedures are accelerating in application in the United States, and pedal procedures are being performed in patients with severe peripheral vascular disease. We feel that our smaller 24 gauge needle, which allows very quick and safe access to arteries and veins, may be a significant move forward in something that is fairly basic in interventional work, but from a patient standpoint has really not evolved very much over the decades. We are receiving a lot of interest with this new access approach.

You have written about room for improvement in stroke care with IV tPA offering such a narrow treatment window. What is the role of interventional cardiologists in improving care?

In the early 1980s, we treated MIs with IV tPA with a success rate of 40-50%. Very quickly, we put together a group of interventional programs around the world to treat these patients on a 24/7 call schedule. We were involved with improvement in these treatments resulting in success rates far in excess of 90% with these patients using catheter techniques. I feel the health care system has neglected stroke patients and has seemed to use any excuse not to treat patients when they come in with strokes. The average neuroradiologist treats about 8 patients per year for stroke. Many interventional cardiologists may treat 8 MIs per weekend. Endovascular stroke intervention, although different, has many similarities to acute MI care and I believe this national tragedy can be reversed through involvement with interventional cardiologists. Technology has evolved and with interventional cardiologists participating, it will get even better.   

You have called attention to the fact that the prevalence of chronic total occlusions (CTOs) is as high as 50% in angiographic series and that patients can be helped with recanalization, yet only 10-20% of CTOs are currently attempted. What are the barriers to treatment?

We have been training physicians to treat CTOs for the last 30 years. Still, very few patients with CTOs are currently even approached for recanalization. At our center (being radial first), many of these patients can have the procedure done radially, and in many cases, discharged the same day. I think the barriers have been put up by some of us in the field where the only way to do these procedures is through a 3-4 hour process. We have been involved with developing technology to improve our results. We developed the first hydrophilic coronary wire in the early 1990s, and most recently developed the CrossLock catheter which helps with coronary as well as peripheral CTO recanalization. The bottom line is that physicians who are doing a large number of angioplasties should spend time with experienced operators and start treating these CTO patients. The procedures can be done with success rates exceeding 90%, if you use common sense and a step wise approach to these complicated patients.

What are the most exciting treatment advances you see on the horizon for the coming decade?

I believe that we are just seeing the beginning of a revolution in lipid treatments to perhaps arrest or even reverse coronary artery disease, particularly with the new PCSK9 inhibitors. Stay tuned–this will continue to evolve. On the peripheral side, Jim Joye and I have been working on a different approach to treat very complicated peripheral vascular disease with the performance of a percutaneous-based bypass procedure called PQ Bypass. This may revolutionize the care of peripheral vascular patients.

Read the full October issue of CardioSource WorldNews at ACC.org/CSWN

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: CardioSource WorldNews, Angioplasty, Leadership, Research


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