Author + information
- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions∗ ()
- ↵∗Address correspondence to:
Dr. Spencer B. King III, Saint Joseph’s Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342.
Now that the economy of China is in a period of readjustment, and the Shanghai stock market has undergone a dramatic correction, one is tempted to think that everything including interventional cardiology would be impacted. It may be, but from my recent observations that is hardly the case. While I was in China for the Chinese Society of Cardiology meeting in Shanghai, I visited several hospitals and laboratories in Beijing, Shanghai, Wuhan, and Xi’an. What I observed was a booming enterprise. Hospitals from middle-sized to massive are performing 1,000 to 13,000 interventional procedures per year. Laboratories are modern, and some run almost 24/7. Teaching, or level-3 hospitals, are the recipients of very large patient volumes with some caring for 10,000 outpatient visits per day. These are major urban centers, and I am sure rural China is vastly different, but one is struck by the size of these endeavors. The purpose of my extended visit after the congress was to lecture and discuss clinical research methods and preparation of manuscripts to reflect the results. We talked about the principles of novelty, accuracy, and relevance of manuscripts. As usual, we stressed the preeminence of the planning and design and execution of the project over the preparation of the paper, but there were many questions about the structure, the conflicts of interest, how open to be about limitations, and what reviewers respond to favorably. Among my many visits to China, these discussions are becoming much more interactive. Many investigators are highly experienced and are becoming well published in leading interventional journals. One young colleague posed the question as to what interventional cardiology would be like in 5 years. I usually get these types of questions about spans of 10 to 15 years, but in China, things are moving so fast that 5 years is a long time. I do not have to go back to my first visit to China 28 years ago, when cath labs were hardly existent and bicycles were the only transportation for doctors to get to the hospital, to see the progress that has been made. Ten years ago, there was very little research in China. During this visit, I saw major contributions being made to large sponsored trials, but more importantly, to investigator-initiated studies to answer important questions. For example, much remains to be learned about antithrombotic therapy following percutaneous coronary intervention (PCI). The balance between controlling ischemic events and preventing excess bleeding is a highly nuanced problem that Chinese investigators have the capability to work out. One size does not fit all. Industry forges ahead with domestic companies now dominating the stent market. I am told that there is a growing interest in intellectual property rights now that China is becoming an innovator, not just an imitator. Various approaches including abluminal bioabsorbable polymers, increased endothelial cell–attracting luminal surfaces, and different release kinetics are being pursued by Chinese companies. I encountered interest in head-to-head comparison to the most popular second-generation stents. I encouraged these investigators to pursue clinical endpoints primarily rather than surrogate ones that have been used so extensively in the past. There is pre-clinical research ranging from valve bioengineering to genomic labs studying myriad diseases from hypertrophic cardiomyopathy to long-QT syndrome.
Five years for Chinese cardiology? I predict great things for several reasons. On the clinical side, the patient base is rapidly expanding (unfortunately). I heard a set of statistics that suggests a higher per capita myocardial infarction rate in China than in the United States, partly driven by the high smoking rate and other environmental risks (massive urbanization and air pollution). Cardiology training is moving at a rapid pace with enthusiasm among young interventionalists, many of whom are women. On the research side, I see increasing international collaboration with many engaging in research abroad. In Xi’an, I sat with cardiologists who had trained in Rotterdam, New York, Philadelphia, Rochester, and Palo Alto. It is rewarding discussing cases with colleagues. Chronic total occlusion (CTO) carries a special fascination here as it does elsewhere. A cadre of CTO operators recently conducted a live-case conference in Xi’an. Colleagues from Japan were invited, and tough cases were attempted by teams from Japan and from China. I found this type of collaboration very exciting, and the competition was reported to have produced many new ideas for both groups. Some important questions that might be pondered in China, as well as elsewhere, are:
• Which patients with stable coronary artery disease are appropriate candidates for PCI?
• Can someone prove that opening CTO extends life?
• How far can society go in percutaneous valve replacement, considering the magnitude of the problem?
• What should be done about a growing population of patients with advanced heart failure?
• Can the highly effective primary PCI programs in the cities be exported to small communities or rural areas, or are other approached needed?
Investigators in China are becoming equipped to address many of these issues, and we may all learn from them.
One final lesson I learned while in China is that, once again, noninvasive approaches are preferred. The discussions went long in Wuhan, and the rush to the airport to catch a flight to Xi’an was tight. Traffic was favorable, however, and we reached the departure curb with enough time. After exiting the Buick van (those seemed to be the standard limo), the driver tried to open the rear door to retrieve our luggage. Not only that door but all the doors remained locked with the keys in the ignition, the engine running, and our luggage still inside. A low-level of panic began to set in. I thought that a solution would be soon forthcoming, but no one seemed to have an answer. The traffic police said there was no one to open the car, and we should try a “surgical” approach by breaking out a window. The driver agreed, but the police refused to do it because surveillance cameras would capture the event, and they would be in serious trouble. Handing me a metal baton, they suggested I do it. A Buick van window is tougher than I thought, and the baton repeatedly bounced off. Where was Tiger Woods’ former wife with a five iron when we needed her? Finally, a man on a motorcycle appeared and swiftly cannulated the driver-side window and deftly directed the “guidewire” to release the door lock. Racing to the plane, I once again realized the value of interventional backup for failed surgical procedures. No randomized controlled trial was needed.
- American College of Cardiology Foundation