December 13, 2017 | Holger Thiele, MD
Education

Holger Thiele, MD, director of cardiology at Leipzig University Hospital in Leipzig, Germany, is the primary investigator for the both the IABP SHOCK II and CULPRIT-SHOCK trials. As an interventional cardiologist with extensive critical care experiences, his focus is on the management of cardiogenic shock. Below is an interview conducted by Ajar Kochar, MD, Fellow in Training (FIT) at Duke University in Durham, NC.

AK: Why did you choose to pursue cardiology and interventional cardiology?

HT: When I was first trained in medicine, I really enjoyed cardiology. I felt like interventional cardiology was a fast-moving field with so many new things in which you can directly help patients. I first started with percutaneous coronary intervention, and then structural heart interventions came around. They both caught my interest and again showed how fast-moving interventional cardiology is.

AK: Who were your mentors when you were training?

HT: My primary mentor was my former boss, Gerhard Schuler, MD, chief of cardiology at the University of Leipzig. He recently retired and I have taken over the role as his successor. Schuler was one of the pioneers of interventional cardiology in Germany, where he performed the first transcatheter aortic valve replacement (TAVR). What set him apart from others was that he was excellent at organizing many things at once. For example, the Heart Center at Leipzig is one of the largest in Germany, and probably Europe. Over 1,000 TAVRs are performed there per year. In addition to being organized, with respect to research, he always had big ideas. He motivated younger cardiologists to do research, and provided them with support to pursue their own ideas. After a while, the younger cardiologists such as myself could do work on their own. I was given a lot of support and liberty for my research interests.

AK: How did you become interested in cardiogenic shock?

HT: Where I trained in the intensive care unit, there were multiple cases of cardiogenic shock. My former boss believed that every patient needed an intra-aortic balloon pump (IABP). If we do not do an IABP, then we were not giving good care. However, I always questioned this idea and explained that there was no evidence behind using an IABP. Therefore, it was always my motivation to show the evidence behind IABP use; however, when I looked at the guidelines and evidence, I saw that it was not strong.

AK: The CULPRIT SHOCK trial is evaluating the role of complete versus infarct related artery revascularization in the setting of myocardial infarction (MI) related cardiogenic shock. Within the complete revascularization arm, the protocol recommends opening chronic total occlusions (CTOs). Can you talk us through the discussions behind this decision?

HT: We know that CTO is one of the strongest angiographic predictors for prognosis in cardiogenic shock. Therefore, we did not exclude patients with CTO, unlike in other studies such as PRAMI. We recommended that all CTOs be attempted. Currently, we do not know how much is possible in the immediate setting of cardiogenic shock.

AK: In the IABP SHOCK II trial, you showed that about 50 – 60 percent of patients with MI and cardiogenic shock will recover without any support. Can we predict which patients will recover and which patients may require additional support, perhaps through mechanical circulatory support (MCS)?

HT: We recently published a prognostication score that includes age, arterial lactate, admission glucose and admission creatinine, along with three levels of risk including low, intermediate and high. The score can help discriminate which patients have high mortality. Patients with an arterial lactate >5 (mmol/l) have a very high mortality (4).

AK: Are you using the score clinically?

HT: Not yet. It is a little harder to use clinically, as you often do not have the admission creatinine etc. However, we are working on a more simplified score that can be used in clinical practice and is an easily calculated score in the cath lab.

AK: What do you think are the most important unanswered questions in the cardiogenic shock realm and what do you see as the future of cardiogenic shock care?

HT: It is extremely important to figure out if MCS works, and we need a randomized clinical trial to show it.

AK: As this interview is tailored towards FITs, do you have any words of wisdom for fellows interested in caring for critically ill patients?

HT: Always look at the patient – how does he look? The personal impression is the most important one. Take really good care, and try to treat the patient by current guidelines. If a patient is very sick, consider transferring them to tertiary care center that is dedicated to cardiogenic shock care.