Nina Ajmone Marsan | Associate Professor, Leiden University Medical Center, the Netherlands
Citation: EMJ Cardiol. 2023; DOI/10.33590/emjcardiol/10305570. https://doi.org/10.33590/emjcardiol/10305570.
How did you become a cardiologist specialising in non-invasive cardiac imaging, and specifically focusing on valvular heart disease and cardiomyopathies?
During my training in Cardiology, I quickly developed a passion for imaging, as it provides every cardiologist the tool to meticulously track the patient’s journey, from preventive measures and accurate diagnoses, to continuous monitoring and appropriate treatment. In every cardiovascular disease, imaging serves as the eyes to comprehend clinical pathophysiology, and plays a crucial role in effectively managing cardiovascular conditions. I further focused my interest and expertise particularly on valvular heart disease and cardiomyopathies; as recently as 20 years ago, not much was known about their pathophysiological mechanisms, and treatments were limited. As a result, there were significant opportunities for further research in these fields, which have indeed taken remarkable strides forward in the last decade.
You have authored over 500 international publications on non-invasive cardiovascular imaging. Could you briefly highlight any significant findings from your published work? Also, what do you believe to be the current gaps in literature?
Through my research in the field of non-invasive cardiovascular imaging, I have always striven to go beyond the mere technical aspects of the different imaging modalities. While optimising the performance of these imaging techniques is undeniably crucial, I believe that demonstrating their clinical value, in terms of their significant impact on patient management and outcomes, is essential. The publications of my research group have therefore focused on the role of cardiovascular imaging in improving diagnosis and risk stratification of various cardiovascular diseases, mainly highlighting how imaging can help the treating physicians in decision-making, particularly related to treatment options. In the field of cardiovascular imaging, as well as across various other fields of cardiology, current and future research should try to transition towards precision medicine. This transition should aim to identify the highly distinctive phenotype that sets apart each patient within a specific diagnosis, ultimately resulting in an individualised approach to both management and treatment. I believe this shift in paradigm to hold significant importance, not only for early diagnosis and the prevention of disease progression, but also notably for tailoring customised treatment strategies.
Are there any innovations on the horizon in the field of cardiovascular imaging that you think are particularly noteworthy?
In the field of cardiovascular imaging, as well as in other fields of cardiology and medicine in general, we are at the forefront of a new era defined by the integration of artificial intelligence (AI). I often refer to this phase as the “next industrial revolution,” which is characterised by the remarkable strides AI is making in redefining our practices. Personally, I embrace and actively drive technological advancements, including the integration of AI into our clinical practices. I believe that this integration will help us in achieving the personalised and precise medicine approach I mentioned earlier. It offers completely novel and exciting possibilities, specifically in cardiovascular imaging. However, it requires new, specialised skills, even from those already established as experts in the field, of which I admittedly still lack many. This requires an understanding of the entire spectrum of applications, identifying the boundaries for utilisation, and redefining the roles of imagers and physicians at large.
With the rapid advancements in technology, along with the increasing understanding of the genetic and molecular basis of valvular heart disease, how do you envision the future in terms of diagnosis and personalised treatment strategies for patients?
Several years ago, I started a new translational research endeavour, with the aim of unravelling the pathophysiological mechanisms behind degenerative valvular heart disease, from the genetic base (primarily inflammatory) that come into play. The overarching goal was to pinpoint the first signs of the disease to improve early diagnosis and, more importantly, to identify new potential targets for medical treatments, which we currently lack. I have learnt, and am still learning, a lot from this project, which has changed aspects of my daily clinical practice; for example, I now routinely inquire about family history in cases of valvular heart disease, and carry out screenings of family members. This project has changed and redirected my clinical research. Through the use of imaging, we are currently trying to visualise the pathophysiological processes of valvular heart disease more in detail, in order to monitor them for progression over time, and make well-timed therapeutic decisions.
At the European Society of Cardiology (ESC) Congress 2023, you were a speaker, and chaired several sessions. One in particular focused on ‘Novel approaches to patients with symptomatic tricuspid regurgitation’. What are some of the most promising imaging modalities or approaches for this specific valve disease?
Tricuspid regurgitation is currently the target of numerous new transcatheter treatments. Therefore, this valvular heart disease has gained renewed attention, and requires sophisticated imaging for the pre-procedural assessment and planning, for the intra-procedural guidance, and for follow-up analysis. The complex anatomy and function of the tricuspid valve apparatus, encompassing the right ventricle and the right atrium, should be properly assessed with a multi-modality approach, including 3D echocardiography (trans-thoracic, trans-oesophageal, intracardiac), computed tomography, and MRI. Dedicated software and specific protocols for the tricuspid valve have been developed for each of these imaging techniques, and they are the focus of current clinical research. Several highly intriguing simulation tools have also been developed for specific transcatheter procedures related to tricuspid regurgitation. Even for expert imagers, there is great excitement, and new challenges when dealing with patients suffering from tricuspid regurgitation. During the ESC Congress 2023, there were indeed several sessions and interesting discussions dedicated to this topic.
As a specialist involved in guiding percutaneous procedures for structural heart disease, what are your thoughts on the future integration of imaging modalities into these procedures?
The role of the interventional imager in transcatheter procedures for valvular heart disease has transformed into that of a multidisciplinary collaborator, seamlessly integrating diverse imaging techniques to enhance precision, safety, and the overall success of these complex cardiovascular interventions. During these sophisticated procedures, echocardiography, in addition to fluoroscopic guidance, offers real-time, anatomically accurate visualisation of the cardiac structure. Both CT and MRI contribute by delivering pre-procedural roadmaps, helping to anticipate challenges, and tailor the approach to the patient’s unique anatomy. The potential of integrating this complementary information in real-time is of crucial value, and has already been explored for fluoroscopy, 3D echocardiography, and CT, yielding very promising results. I expect significant advancements in the development of these applications in the near future. As technology continues to evolve, these integrative approaches will undoubtedly contribute to achieving unprecedented levels of procedural precision and patient outcomes.
What led you to become a board member for the European Association of Cardiovascular Imaging (EACVI)? As the past Chair of the EACVI Education Committee of EACVI, what initiatives have you undertaken to promote education and training in the field of cardiovascular imaging?
EACVI is currently the leading community for cardiovascular imaging, promoting the use of multi-modality imaging at the highest standard, across cardiology and relevant medical specialities. Being involved in the EACVI programmes, and particularly as active board member, has been therefore very important to me. I believe that it is through such an association that we can ultimately achieve the goal of spreading excellence in cardiovascular imaging at all levels. During my tenure as the Chair of the Education Committee 2020–2022, my primary focus was on developing educational programmes specifically tailored for “non-imagers”. These programmes were designed for general cardiologists and allied professionals, including anaesthesiologists and sonographers. Moreover, a unique dimension was introduced through the expansion of education to include patients themselves. The main objective was to create more awareness and provide the knowledge and competencies on the crucial role of imaging from diagnosis, management, and follow-up of patients to a broader community, uniting overall professionals dedicated to cardiovascular health. In parallel, I also promoted specific courses and training in advanced cardiovascular imaging. For example, I emphasised the importance of programmes for interventional imagers, a role I previously highlighted as a new and crucial presence within the field of percutaneous treatments for structural heart disease, demanding highly specialised skills.
Given your involvement in the supervision of PhD students, and leading a research team, which do you think are the most important leadership skills, and how did you develop them?
Supervising PhD students is by far the most enriching role for me. I believe it transcends academic instructions and mere leadership; it encompasses mentorship, knowledge cultivation, legacy creation, and global collaboration. As a mentor, guiding these talented colleagues extends beyond imparting technical expertise; it involves nurturing their growth as independent researchers, critical thinkers, and effective communicators. Mentorship also fosters a lasting legacy, as the impact of your guidance reverberates through your students’ contributions to academia and society. As they embark on their own research paths, they carry forward the insights, methodologies, and values instilled during their mentorship journey. Furthermore, supervising PhD students offers an opportunity to exchange ideas and expertise beyond national borders, leading to the development of an international network, and enriching the academic landscape.
