Cath Lab Spotlight

Doing It All and Always Learning: Dr. Sievert’s Unique Cath Lab in Germany

Sameer Gafoor, MD, talks with Horst Sievert, MD, FESC, FACC, FSCAI, Professor of Medicine, Internal Medicine, Cardiology and Vascular Medicine of the CardioVascular Center Frankfurt, Sankt Katharinen; Head of Department of Cardiology and Vascular Medicine, Sankt Katharinen Hospital, Frankfurt, Germany.
Sameer Gafoor, MD, talks with Horst Sievert, MD, FESC, FACC, FSCAI, Professor of Medicine, Internal Medicine, Cardiology and Vascular Medicine of the CardioVascular Center Frankfurt, Sankt Katharinen; Head of Department of Cardiology and Vascular Medicine, Sankt Katharinen Hospital, Frankfurt, Germany.

Interventional cardiologist Dr. Horst Sievert has performed over 50,000 interventions, treating coronary, structural heart, and peripheral artery disease. He is the founder of several international conferences focusing on endovascular and structural heart treatments. An American fellow at Dr. Sievert’s lab, Dr. Sameer Gafoor, was kind enough to ask Dr. Sievert about his work, philosophy and experience.

Dr. Gafoor: Dr. Sievert, you perform a wide variety of procedures at your facility, from percutaneous coronary intervention to peripheral artery disease intervention, to structural heart disease treatment, and more. Can you tell us about your lab?

Dr. Sievert: Our center, CardioVascular Center (CVC) Frankfurt, is privately owned. We have two cath labs in the Sankt Katharinen Hospital and three at other hospitals with whom we have contracts, so we are at a total of four hospitals in the area of Frankfurt. We do all kinds of interventions, including endovascular, peripheral, carotid, structural, coronary and bowel, and the total volume is about 2,500 interventions/year. We have two and a half full-time interventionalists and nowadays, two very good fellows from abroad working with us. 

Dr. Gafoor: You were the first to close the left atrial appendage (LAA) percutaneously in 2001. 

Now that more than ten years have passed, can you share more about where we stand now with LAA closure?

Dr. Sievert: In our lab, LAA closure has been a routine procedure since 2003, and worldwide, it is now approved in most countries with the exception of the U.S. In our view, it is an alternative to anticoagulation, not only for patients who are contraindicated, but also for patients who just don’t want to take it. I think it has a lot of advantages for regular patients, but also for patients who receive a drug-eluting stent, transcatheter aortic valve implantation (TAVI), or other procedures where there is a conflict between different needs for medications, such as requiring antiplatelet therapy and Coumadin at the same time. For all these patients, it is an especially valuable alternative. 

Dr. Gafoor: Tell us about the conferences and workshops on LAA closure you are organizing.

Dr. Sievert:  We are organizing several conferences dealing with LAA closure. One is the Congenital & Structural Interventions (CSI) Congress (http://www.csi-congress.org) held in June with around 1,000 attendees, and then from November 22-23, we are holding a CSI Focus conference, where we focus just for one or two days just on LAA closure (http://www.csi-congress.org/laa-workshop.php). This LAA workshop happens in Frankfurt every year and attracts about 250 people from around the world. Ninety percent of attendees are from abroad. We also have a LAA closure workshop in Asia (which recently took place in Hong Kong, on May 4, 2013).

Dr. Gafoor: How is the LAA workshop structured?

Dr. Sievert:  It takes place over two days. During the first day, we provide information about why LAA closure should be done, talk about the different devices available, discuss clinical trial results and so on, and the second day focuses on between 6-10 live cases, where attendees can learn, step by step, how to do the procedure. LAA closure is a very valuable procedure, but it is not a straightforward procedure like percutaneous coronary intervention (PCI), so there is a learning curve. For that reason, teaching courses are extremely important. 

Dr. Gafoor: What are your thoughts on where we stand with renal denervation and long-term outcomes?

Dr. Sievert: Renal denervation has probably been one of the most important developments in interventional cardiology over the past few years, because it will impact a huge percentage of the population. We now have three-year results from the initial trial, which show that the treatment is active until that time. The success rate is in the 70-80% range. We can treat patients who are otherwise resistant to medical treatment. We know that blood pressure reduction is one of the most important measures in reducing cardiovascular mortality. I think it will really change how we treat our patients.

Dr. Gafoor: Can you tell us about your renal denervation conference? 

Dr. Sievert: We have set up a conference in Frankfurt every spring. The last one was in early March, with more than 500 attendees from around the world. We focus on all kinds of renal denervation techniques. The next conference will be held in September 2013, in Taiwan. It is structured like our LAA workshops, with one day of didactics and one day of 6-10 cases. This way people can learn the science as well as see how it is done again and again. People say that this is the best way to learn a new technique and we get positive comments from all over the world. More information on our TREND renal denervation conference is at http://www.csi-congress.org/trend-workshop. 

Dr. Gafoor: People are often surprised by what you are able to do in your lab, especially people coming from the United States. For example, TAVI, abdominal aortic aneurysms, MitraClip (Abbott), and other complex procedures are sometimes done with only local sedation.

Dr. Sievert: We always try to make procedures as simple as possible, and that is not only because it is more convenient for us. It also means less risk to the patient. So when we started, for example, aortic valve implantation, we used general anesthesia, then we switched to deep sedation, then we switched to mild sedation, and now we do it only under local anesthesia. It is the same way with all the other procedures, such as the MitraClip. We started with general anesthesia and now we do it without any sedation. People may say that makes the procedure unsafe, but in my opinion, this actually makes the procedure safer. These are really sick patients, where any anesthesia, any deep sedation, actually increases risk. We only give local anesthesia, so there is no conscious sedation. 

The only exception is patients who may have trouble swallowing the transesophageal echocardiography (TEE) probe. We give something short-acting like propofol, which is over after 5 minutes. Then, when the TEE probe has been placed, then patients can tolerate it very well. I am always making jokes at conferences about this; when I give lectures in the United States, I say, “Well, these are German people, who are much more resistant than Americans.” Of course, it’s not really true; we have successfully treated a number of Americans at our lab in the same fashion. Patients need something to swallow the TEE probe and thereafter there is actually no sedation necessary, and they can tolerate it very well. 

Dr. Gafoor: You have installed new imaging in your cath lab. One is an echo fluoro overlay system called EchoNavigator (Philips) and one is a fluoroscopic CT system called DynaCT (Siemens). How do you integrate this imaging in your practice, especially with structural and peripheral interventions?

Dr. Sievert: EchoNavigator allows us to mark certain spots on the structures in TEE images. Then these marked spots will appear on the fluoro screen, which allows us to see structures which otherwise only will be seen on the echo images. It helps us when we navigate with catheters through the heart, because we use these dots as markers showing us where to go. For example, if we want to go into the LAA, the appendage cannot be seen on a fluoro screen, but we can mark dots for transseptal puncture as well as the pulmonary ridge and left circumflex on the fluoro screen, which helps us to navigate the catheter into the LAA. 

DynaCT is a technique that simulates a kind of CT scan on the cath table. We are just looking at how it can help with LAA closure. It is also in use for positioning aortic valves during valve implantation, and there may be other indications like thoracic aneurysms, especially when you think about complicated procedures with side arms and branch endografts. 

Dr. Gafoor: There has been a great deal of discussion about the importance of a heart team, multi-disciplinary approach, particularly because of TAVI. You are also working in a hospital without an institutional cardiac surgery system. How do you work with surgeons and other specialties to address the complex patient care that you provide?

Dr. Sievert: Well, when we need somebody, then they come in. They bring their own nurses, we have a pump installed, we have cardiac anesthesia and so on, so actually we are extremely well-prepared for any emergency situation which may occur in TAVI, although I must say we have never had a situation where we had to convert the patient to surgery. If it happens, however, then we are very well prepared. It is the same for other specialties. If we need a vascular surgeon, then a vascular surgeon comes in. When we need imaging people, they come in. It actually works very well.

Regarding the heart team discussion in general, discussion with the surgeon is not a new thing. Since the invention of PCI in the late 1970’s, we have had discussions with surgeons first about every patient, and then over the years, this discussion, let’s say, flattened to some degree, because everybody, both interventionalists and surgeons, had more experience. We did not have to discuss every single patient any more. Now, with TAVI, there seems to be a need for that kind of discussion, but it also seems to disappear, because everybody now knows who is a good candidate for surgery and who is a good candidate for TAVI. So yes, there is a place, but I think there is a little bit too much discussion about this.

Dr. Gafoor: What are some of the philosophical/clinical approaches to work in your lab that are not typical in the U.S.? You spent some time working in the U.S. as well, so you have a unique perspective on both the U.S. and European approaches to interventional cardiology and healthcare.

Dr. Sievert: The main difference between the European/German healthcare system and the U.S. healthcare system is that everybody in Germany has access to not only standard care, but advanced care. There is no large population without insurance. The percentage of uninsured in Germany is about 0.5%. Another difference important for our field, interventional cardiology, is that in Europe, we have access to new devices. It takes about 5-15 years until the devices approved here are available in the U.S. Devices in the U.S. can actually be approved at a time when no one in Europe is using them any more. For example, the Helix Occluder from Gore, a patent foramen ovale (PFO)/atrial septal defect (ASD) closure device, was approved in the U.S. two years ago, and it is not in use any more in Europe. One could argue that it is even unethical to withhold known proven treatments that can save lives from patients — for example, TAVR, which was approved here before it was in the U.S. Many patients died because the government took a long time to get on board. The same can be said for renal denervation. This is probably the most important difference in our field. 

In addition, regulatory issues are quite different. We are not as restricted regarding which procedures we can do and which trials. Finally, there is a difference in procedural volume per physician, not only in interventional cardiology but also in cardiac surgery. The average volume for an interventionalist here in Europe is certainly much higher than in the U.S. 

Dr. Gafoor: Can you tell us about a recent complication or mistake that you have learned from?

Dr. Sievert:  The most impressive and bad case we had in the last two weeks was an acute stroke which arrived in the hospital about 50 minutes after onset of symptoms, but then for some logistic reasons which were completely our internal problem, this patient arrived on the table about 3 hours after the event. We opened the occluded middle cerebral artery, but because of the time delay, the patient did not recover and finally died from secondary complications due to the stroke. It was probably the ugliest complication we had within the last few weeks. We learned that we needed to work on our internal logistics and improve our systems.

Dr. Gafoor: You give speeches across the world and put on different conferences. What drives you to do so and what currently interests you most in your work?

Dr. Sievert:  For me, having a mixture of different things to do is the most interesting thing. It’s not that I am only keen to give talks, nor am I only keen to do coronary interventions and so forth. The mixture is important for me, along with the desire to do whatever I do as perfectly as I can. There have been periods in my life where I did not give one single talk for ten years. Then I started to give talks, and I thought, okay, I can do this, and I can do it reasonably well, so I should do this as perfectly as possible. It is the same for all other procedures. I started, somehow, I realized I can do it reasonably well, so I tried to make it as perfect as possible. But I could also do many other things. I could also start selling potatoes, and if I were to do this, I would do it as perfectly as possible, and I am sure I would enjoy it very much.

Whatever I do, I learned from other people, not always during formal training, but sometimes just from watching or speaking to someone. We have to teach younger people and colleagues, and try to make them as perfect as possible. This will help everybody: the community, the patients, and our specialty. It is important to broaden knowledge to make progress in medicine and in life in general.

Cath Lab Digest: What do you think about the development of the interventionalist as we move into the future?

Dr. Sievert:  I think the borders between our different specialties are obsolete. TAVI and the MitraClip are good examples. These are procedures that require a combination of different skill sets. A huge part of my learning curve with the MitraClip has been coming to understand mitral valve morphology, which is not really taught in the cardiology field. Surgeons tend to handle mitral valve repair. It took me a considerable amount of time to understand the morphology and pathology of the mitral valve, and I learned a great deal from our surgeons. We frequently did all these procedures, TAVI as well as MitraClip, together, and I have now trained two surgeons. I think every specialty can learn all of these procedures. It’s not that interventionalists should just do TAVI and surgeons should only do aortic valve replacement. I think both, certainly surgeons, can do TAVI as well. 

Dr. Gafoor:You first started putting on the Congenital and Structural Interventions (CSI) Congress in 1996 as a cardiologist. How has CSI Congress changed from 1996 to 2013?

Dr. Sievert:  CSI Congress began as a teaching course on ASD closure, because it was a brand-new procedure at that time. When I started the conference, I had basically no experience with ASD closure. I think we had done 5 or 10 cases, but we had done among the first cases in the world, so I thought, let’s start an educational program. Over the years, other procedures became part of CSI and now it is a course about all kinds of structural, congenital and valvular interventions. Now we have more than 1,000 attendees with anywhere from 20-30 live cases. If you want to see the best debate the best over what is the best, come to the course. It is doing something as well as you can. That is basically the philosophy behind the course. 

Dr. Sievert: Sameer, what do you think the main difference is between the U.S. and Germany?

Dr. Gafoor: In Germany, there are fewer divisions or boundaries defining what it means to be an interventionalist, cardiac surgeon, vascular surgeon, or even radiologist. In Germany, I am learning much more about many different things. For example, by doing endovascular procedures, I have come to understand some of the complications after TAVI and how to treat them. By learning about ASD and PFO closure, I have learned techniques and knowledge I can apply to stenting of subclavians or renal arteries, or vice versa. This fellowship combines cerebrovascular, peripheral and structural heart disease treatment, and offers techniques and philosophies that cross borders between each disease state. Patients do not come in marked as “coronary” or “structural” or “peripheral” patients. I believe we as physicians should have some understanding of all of these diseases and treatments. For me, coming to understand the disease process and some of the therapies has been very eye-opening. 

I do think that there are only certain people, like Dr. Sievert, who can work in all three of these areas in an outstanding fashion. Dr. Sievert has been kind of hiding himself for about 10-15 years in a small hospital, working by himself at the table in a hospital without institutional cardiac surgery, all the while perfecting these very minute things that make a complex procedure very simple. The first time I came here, I saw him doing PCI and structural procedures without a second person to assist. He used local sedation for some very complex cases with great success. I don’t think every patient qualifies, but it is important to know how to make that happen when it’s required. 

Cath Lab Digest: Dr. Sievert, it is interesting that you are at the table on your own.

Dr. Gafoor: Since Dr. Sievert has worked at another institution in the U.S., he knows what it is like to work at a table in the U.S. versus a table in Germany.

Dr. Sievert:  This is a question of efficiency. The center here is actually my own investment, so from the first day (and actually at my prior institution it was similar), I tried to work as efficiently as possible. What I learned is that the greater the number of people involved in something, let’s say in a cath lab, the more complicated it will be. We do almost all procedures with just one physician on the table, and two nurse-techs, one in the room and one outside. In the U.S., but also elsewhere, you can have up to 5 or 6 people in the room. This does not make it easier, but actually makes it more complicated, because then nobody knows what the other person is doing. There is a lot of talk and need for information exchange, which is just eliminated if you reduce the number of people. 

Dr. Gafoor: If you have more people in the room, more people can contribute and understand, but there is also room for miscommunication and diffusion of responsibility. I have seen both positives and negatives to having a lot of people in the room, both as a spectator and also as a person at the table. It’s something every physician must figure out on her or his own. But it is always good to know that, if for any reason I am working alone or have to figure out how to do two things at once, I can look back to this year where I watched Dr. Sievert do everything at once. The simple fact is that everyone says something can’t be done until someone does it. That’s how we ended up in this field, anyway — a guy thought it was possible to insert a catheter into a heart when no one else thought it was possible. That ability to think outside the box and to think of a more efficient way to do the same thing — that’s something I wanted to learn this year. 

Dr. Sievert: I want to say that there are many positive things about working in the U.S. I really enjoyed working there. One example is that although the volume per doctor is lower in the U.S. than in Germany, the skills and the knowledge of the U.S. physician is much higher than one would expect, and that is because of the opportunities to learn from each other and communicate, a result of the many clinical conferences, cath lab conferences, mortality conferences, and so on. Education is much better developed in the U.S. than in Europe, at least in Germany. There are many things that are just better in the U.S. than in Germany. In one U.S. hospital where I worked, when there was an interesting case, everybody could see it. The experience of one single doctor was spread out to 60 other doctors. In Germany, we also have these types of conferences, but it is not as developed as in the U.S. 

Cath Lab Digest: Dr. Gafoor, how did you end up in Frankfurt?

Dr. Gafoor: I finished my interventional cardiology fellowship, and I knew I wanted to do more work in structural and peripheral vascular disease. I wrote to every single person I could think of in the U.S. that was doing structural work to see if they had any fellowships available. There were only a few fellowships, some of which were filled internally and some for many years in the future. 

So I asked some of my mentors, who said, “Why don’t you think about Europe?” I wrote to just about every person I could think of in Europe. Some didn’t reply, and some replied and said that I would have to bring my own funding for multiple years. Eventually, Dr. Sievert, after a few emails, said, “Well, I’m running a very small hospital and I’m not so sure that it would be the right place.” I tell him even now that was his chance to say no and he lost it. 

I wrote back and said, “No, absolutely it would be the right place. Can I come for a year?” He replied, “Why don’t you come for a week?” because he thought that I would be gone after three days. I came for a week and saw some amazing things. In one day, Dr. Sievert did 3 carotids, 5 peripherals, 3 advanced coronaries, 3 renal denervations, and 3 paravalvular leaks. In the same week, he also had a TAVR case and also a fully percutaneous thoracic aneurysm endograft procedure. It was amazing and I knew I had to be here.

The first issue was funding. He asked me if I was rich, and I said no, but I can get by with less. He allowed me to write some grants to establish a fellowship program, and through that we got some funding for the year. The second thing was that I needed to get a German medical license. That required me to have an understanding of German, meaning I would have to take a proficiency test (B2 level, which required a high school level understanding of speaking, writing, reading, and listening; soon they plan to raise it to C1). I took some time off after my interventional fellowship, learned German, passed the proficiency test, and showed up roughly a year after my first initial visit to Germany. I’m not the only one, either — Dr. Simon Lam from Hong Kong had the same idea about the same time I did, and did the same background work. We joke that we came from different corners of the world to meet in Frankfurt. 

However, I have to admit that it was pretty stressful. There were many times when I doubted this could work and others said the same. For example, funding came through only in May of my interventional fellowship year, when my other classmates already had jobs lined up; I was that guy that was “going to work in Europe.” Yet it just seemed to work out in the end. The first week that I came here made all the tough times of the last year fade away. I have to thank my mentors for the advice and support, and most of all my family, for allowing me to pursue this wild adventure. I also have to thank Dr. Sievert and the rest of the faculty and staff for taking a chance and allowing me to be part of the CVC family. I get to work with a world-class interventionalist who is an excellent teacher, mentor, and friend. He and the team consistently push me to be better — clinically, procedurally, and scientifically. I tell Dr. Sievert if someone told me all the obstacles at the beginning, I probably never would have done it, but I thought, oh well, I’ve gone so far already. Why not take this next step? 

Dr. Sievert:  He made it because of his persistence. I am sure you will hear more about and from him in the future, because there are so few people in the world who are persistent in that way. 

Dr. Gafoor: How much money do I owe you again?

Access information about the Congenital and Structural Interventions (CSI) Congress. 

Learn more about the next LAA Workshop on November 22-23 in Frankfurt.

The next Renal Denervation Workshop is September 14 in Taiwan, with another one in Frankfurt in early 2014.

Dr. Sameer Gafoor can be contacted at sameergafoor@gmail.com. Dr. Horst Sievert can be contacted at horstsievertmd@aol.com.

A Selection of Dr. Sievert’s 2013 Publications 

Hemmann K, Sirotina M, De Rosa S, Ehrlich JR, Fox H, Weber J, Moritz A, Zeiher AM, Hofmann I, Schächinger V, Doss M, Sievert H, Fichtlscherer S, Lehmann R. The STS score is the strongest predictor of long-term survival following transcatheter aortic valve implantation, whereas access route (transapical versus transfemoral) has no predictive value beyond the periprocedural phase. Interact Cardiovasc Thorac Surg. 2013 May 3. [Epub ahead of print]

Wunderlich N, Wilson N, Sievert H. A novel approach to treat residual peridevice leakage after left-atrial appendage closure. Catheter Cardiovasc Interv. 2013 Apr 29. doi: 10.1002/ccd.23014. [Epub ahead of print]

Machaalany J, Bilodeau L, Hoffmann R, Sack S, Sievert H, Kautzner J, Hehrlein C, Serruys P, Sénéchal M, Douglas P, Bertrand OF. Treatment of functional mitral valve regurgitation with the permanent percutaneous transvenous mitral annuloplasty system: Results of the multicenter international Percutaneous Transvenous Mitral Annuloplasty System to Reduce Mitral Valve Regurgitation in Patients with Heart Failure trial. Am Heart J. 2013 May;165(5):761-9. doi: 10.1016/j.ahj.2013.01.010. Epub 2013 Feb 14.

Mahfoud F, Lüscher TF, Andersson B, Baumgartner I, Cifkova R, Dimario C, Doevendans P, Fagard R, Fajadet J, Komajda M, Lefèvre T, Lotan C, Sievert H, Volpe M, Widimsky P, Wijns W, Williams B, Windecker S, Witkowski A, Zeller T, Böhm M. Expert consensus document from the European Society of Cardiology on catheter-based renal denervation. Eur Heart J. 2013 Apr 25. [Epub ahead of print]

Wunderlich N, Franke J, Sievert H. A novel technique to remove a right atrial thrombotic mass attached to a patent foramen ovale (PFO) closure device. Catheter Cardiovasc Interv. 2013 Apr 24. doi: 10.1002/ccd.24972. [Epub ahead of print]

Ledwoch J, Franke J, Gerckens U, Kuck KH, Linke A, Nickenig G, Krülls-Münch J, Vöhringer M, Hambrecht R, Erbel R, Richardt G, Horack M, Zahn R, Senges J, Sievert H; on behalf of the German Transcatheter Aortic Valve Interventions Registry Investigators. Incidence and predictors of permanent pacemaker implantation following transcatheter aortic valve implantation: Analysis from the german transcatheter aortic valve interventions registry. Catheter Cardiovasc Interv. 2013 Mar 8. doi: 10.1002/ccd.24915. [Epub ahead of print]