Ulrich Sigwart

Can you describe your journey into medicine and cardiology?

As a boy, I dreamed of being a veterinary surgeon. A number of people discouraged me to do so, mainly because of the somewhat commercial aspects of the profession. It was in fact my elder sister who convinced me that human medicine would be a good choice. I have never regretted this decision. About the choice of going into cardiology, I was already interested in the heart during medical school. During the clinical years of medical school, I was absolutely fascinated by practical aspects such as the auscultation course and, very soon, I started dreaming of becoming a cardiologist. The combination of basic sciences, physics and the purely human aspects of cardiology made me choose that subject. This is why, after the obligatory basic education, I immediately engaged in cardiology while I was in the United States.

Who has influenced you the most in your career?

The people who have influenced me a great deal were my teachers at medical school and the young colleagues who I trained with. Alain Reid was my first contact in Houston; he taught me the basics of cardiology. Later, in Zürich, it was Willy Rutishauser with his rigorous approach to sciences who left a profound mark on me. In London, I learned a lot from my colleagues in pathology and cardiac surgery; undoubtedly they also influenced me a lot.

How has interventional cardiology evolved since you began your career?

I got into cardiology at a fascinating moment, namely when interventional cardiology became airborne. Charles Dotter in the USA did his first cases in peripheral arterial disease; Porstman in Berlin started attacking congenital heart disease; and then Andreas Grüntzig in Zurich topped it all off by threading balloons into the coronary tree. It all resembled a revolution. That was the moment when limiting ourselves to prescribing digitalis and diuretics was over. I jumped on the wagon right away and, shortly after Grüntzig had done his first case, I followed in his footsteps. 

Which innovation in the cardiovascular field shaped your career the most?

Undoubtedly balloon angioplasty influenced me most. It was in 1977 when Willy Rutishauser, at the Computers in Cardiology meeting in Holland, told me about the first balloon angioplasty done in Zürich. I was overwhelmed with the idea of being able to do something of that sort and went to Zürich to meet Grüntzig (who I knew from my former years in Zürich). We had lunch (Peter Rentrop was there as well), and I left with three balloons and two guiding catheters to start angioplasty on my own. My then superior, Professor Ulrich Gleichmann was very supportive in allowing this unorthodox procedure to happen at his institution. Our surgical standby relied on a military helicopter to liaise with the Medizinische Hochschule Hannover, in case of trouble.

You were one of the first cardiologists to perform a coronary angioplasty. Can you describe the first procedure you performed?

The first angioplasty at the Gollwitzer-Meier-Institute was not only a memorable but also a breathtaking experience. It was done on a relatively young lady who came with severe, unstable angina due to a very tight proximal left anterior descending artery lesion. It took me a fairly long time to get the non-steerable balloon through the lesion, and I will never forget the moment when the balloon deflated and the distal pressure came up. That was early in 1978! After the first seven cases were performed at the Gollwitzer-Meier-Institute, I moved to Lausanne where in-house coronary surgery was available at the University Hospital. The first cases there in 1979 reminded me vividly of the exciting times before. I felt that movable guidewires would be mandatory and was so happy when John Simpson came to Lausanne to show us a workable system. He and I had a great time together. The movable guidewire helped us to get to most lesions we were aiming at.

The principle problem with balloon angioplasty was the unpredictable outcome once the balloon started to deflate. Also the restenosis rate of some 30 to 40% remained a huge obstacle. It was obvious to me that one had to use mechanical devices to support arteries after balloon angioplasty, but it was only in 1986, after having performed quite a number of animal experiments, that we started putting stents into human coronary arteries. This has changed our life substantially.

One of your papers reports on the 22-year follow-up of the first patient treated with coronary stenting. What were the outcomes of this case?

The first patient who received a “coronary” stent was in fact a patient with bypass graft stenosis. He survived a number of years without recurrence. The patient who has changed the field was a lady with two-vessel disease, whose left anterior descending artery was occluded after balloon angioplasty and was bailed out by the insertion of a stent. It was this patient who fundamentally changed coronary angioplasty. She is still alive and is doing well. Jean-Jacques Goy has put an additional stent into that patient’s circumflex artery a number of years ago.

Interventional cardiologists now perform lower limb interventions and also renal angioplasty. How do you see the future, with interventional radiologists and vascular surgeons sharing the endovascular field?

This is an interesting and, unfortunately, a highly political issue. My approach to this question has always been simple: the one who does it well should do procedures like this. I have the impression that endoluminal techniques could be done either by surgeons, interventional cardiologists or interventional radiologists. I put my first stents into femoral and iliac arteries before doing so in the coronaries.

(By the way, I have just seen the patient in whom I stented the superficial femoral artery from top to bottom in March 1986; he is still well, although he had further atherectomy done inside the stent and, after a dozen years, had a saphenous vein bypass.) As to renal and carotid angioplasty, I feel that cardiologists in general have the greatest experience in doing these procedures but this may vary from institution to institution. As I said, it is the person who does it well who should do it.

Will it be possible to develop the ideal coronary stent in the future?

Every stent is a foreign body, and foreign bodies in arteries are always less than ideal. On the other hand, I have seen an enormous progress in the stenting technology over the last 25 years and even “vanishing” stents have become possible. The ideal drug to be used for the inhibition of hyperplasia has yet to be defined, and I am quite sure that stents can be made much more flexible and biologically friendly. I am not so sure that the ideal stent exists. Every patient is different and the stent of choice must be adapted to the patient’s needs.

What are the benefits of alcohol septal ablation for hypertrophic obstructive cardiomyopathy?

Alcohol ablation for septal hypertrophy has become fairly routine. I am not saying that it is better than surgery but it is probably not much worse. On the other hand, myectomy is a hugely invasive, open heart procedure for such cases. I have seen a number of patients leaving not even 24 hours after alcohol ablation with a quite significant reduction and even suppression of symptoms. This is why one should not compare the two procedures without taking into account the differences in morbidity and discomfort.

What is the most interesting paper you have come across recently?

I have recently seen a very interesting paper presented by Bon-Kwon Koo, a physician from Korea. He describes a computer tomographic method to determine the haemodynamic repercussions of coronary artery stenoses. The method could potentially be the equivalent to the measurement of the fractional flow reserve by invasive methods. I find this absolutely fascinating as it would allow determining, without “instrumenting” the heart, the need for intervention in individual lesions.

The paper may be too optimistic, but I will be most interested in hearing more about this method.

Tell us about one of your most memorable clinical cases.

The most memorable clinical cases were certainly the first patient who ever received a stent in an emergency situation and the patient who, for the first time, had a non-surgical ablation of her interventricular septum in hypertrophic, obstructive cardiomyopathy. Fortunately both patients are still alive and well. I am so grateful for that. On the other hand, I will always remember a man who came in the early 80s with a rather trivial looking, tight stenosis in his circumflex coronary artery. His brother, a surgeon, travelled all across the Atlantic to witness the angioplasty procedure, which was quite easy to do. In stupor and disbelief I watched the artery close again under my eyes with no chance of obtaining a decent result. Bypass surgery was the only solution in this case, which made me contemplate other ways of stabilising dissections.