This transcript has been edited for clarity.
E. Magnus Ohman, MD: Hello. I'm Magnus Ohman. Welcome to another edition of Life and Times of Leading Cardiologists. We're very fortunate today to have one of the leading lights in the world on cardiogenic shock. Dr Holger Thiele is a professor at the Heart Center in Leipzig and has done more in this field on shock than many people have. Welcome to the program.
Holger Thiele, MD: Thank you very much.
Ohman: Did you start your career knowing that you were going to specialize in cardiogenic shock? How did you come to cardiogenic shock?
A Recommendation With Little Evidence
Thiele: It was more by chance. When I was working at the ICU at Heart Center Leipzig, I had many discussions with my former boss. He was always fully convinced that we needed to use the intra-aortic balloon pump. I remember one time when there was a patient with nearly normal blood pressure, but he had elevated lactate. I did not put in an intra-aortic balloon pump in this patient when I started working in the cath lab.
Ohman: Were you in training at this time?
Thiele: Yes, I was in training. He said, "You always have to put in an intra-aortic balloon pump because it's a class I indication." I said, "Oh, okay." When I looked it up, I saw that there was not much evidence behind it, and thought, okay, maybe we have to do a randomized trial.
Ohman: This started with an argument with a superior?
Thiele: It made me think about the evidence behind it, and that's the reason we started doing it.
Ohman: Wow. Now, you said that you started your training in Leipzig; is that correct?
Thiele: No. I first started in Berlin in a small general hospital and did internal medicine, but then I moved to Leipzig in 1997.
Ohman: This is Berlin before the wall came down?
Thiele: Yes. I was born and grew up in West Berlin, and I saw the wall come down, which was 29 years ago. It was on the ninth of November in 1989. I went to medical school at this time, but with the wall coming down, we decided not to go to school.
Ohman: You went out to celebrate.
Thiele: Yes, we went out to celebrate. We were standing on the wall to see the people come from East Berlin to West Berlin.
Ohman: Fascinating. Tell us about the emotion behind this, because it's hard for anybody who hasn't lived through the Cold War to really understand these implications.
Thiele: I grew up in the American sector of West Berlin.
Ohman: That's why your English is so good.
Thiele: Oh, I'm not sure about that. It was the American sector, so this was the southern part of West Berlin. When we went out for a run in the evening, we were always running along the wall because there were lights.
Ohman: Was it safe?
Thiele: It was fully safe, yes, on the western part. On the other side of the wall, it was not safe.
Ohman: But you never ventured on the other side?
Thiele: No. It was possible for us to go there, but you always had to do it in advance—apply 1 week before. We had some relatives on the other side, so that's why, three times a year, we went over to the other side.
Ohman: Your family was a split family from the east and the west side?
Thiele: It was a cousin of my mother living there.
Ohman: It must be very unusual to have that sort of breakdown in a family—I guess this was common at that stage. Growing up in this environment, do you think it made any difference to how you saw the world at a later stage in life?
Thiele: I don't think so. I was 19 when the wall came down, so the world was a little bigger after this. I started cycling. I bought a map of the southern part of Berlin and I started cycling every road to learn the new environment because I had never seen it before.
Ohman: You got to know your city again, yes.
Thiele: Not the city—the countryside, because that's a place we never had been before.
Ohman: That's fascinating. And you then got to see your cousins more frequently.
Thiele: Sure, yes.
Ohman: Now, from that background, you went to medical school. Why did you pick cardiology?
Thiele: It was more by chance, to be honest.
Ohman: Things happen in Holger's life by chance.
Thiele: Yes, it happened by chance. In Berlin, I started more general internal medicine, and at this time, there were not enough jobs.
Ohman: Because it was so small?
Thiele: Because it was small and everybody wanted to stay in Berlin. It was attractive to be there and there were many doctors unemployed at this time.
Ohman: That is so hard for us to understand. Unemployed doctors. Amazing.
Thiele: At this time, I had many colleagues who were trying to apply for a job. They had maybe written 200 or 300 applications to get a job. I was a bit luckier to get one, but that's why I came to Leipzig. I'd been 1 month unemployed and then I started working in Leipzig at the Heart Center.
Ohman: Wow. So did cardiology come as part of that? What got you interested in cardiology? I know you're very athletic, so did you see the beauty in cardiology because of the physiology? Or was it just an interesting topic?
Thiele: I found it very interesting because it's not only prescribing drugs but doing interventional things. That's why I found it very attractive.
Ohman: Okay. Now you're in Leipzig doing your training. Did you have a mentor along the way besides the professor you argued with?
Thiele: Really, it was Gerhard Schuler. He was my mentor. He always supported me and he sent me abroad to other places to learn cardiac MRI. I was in Leeds in the UK for nearly half a year to be trained in cardiac MRI. I also went back once again to the Heart Center in Berlin to learn cardiac MRI. I was a research fellow during this time, so I did cardiac MRI.
Ohman: You did cardiac MRI recently. How was it to go to Leeds? From Berlin to Leipzig—are there similarities with Leeds? Leeds is in the middle of the country in the UK.
Thiele: Yes. It's in the northern part of England, so there's a Yorkshire accent that's relatively hard to understand. Leeds is nearly as big as Leipzig; it's roughly 500,000 people living there. It was very similar. It was a nice time to be there.
Ohman: When you learned this MRI, were you thinking that you would apply this to cardiology in any specific way or was it more about the imaging part that got you excited?
Thiele: It was the imaging part. When I started doing cardiac MRI—this was the very early stage of cardiac MRI—it was extremely difficult also to get an ECG during this time because we had no vector ECG, which is standard today. Sometimes it took us half an hour to get an appropriate ECG just for triggering the MRI, but we started doing it. Later, I used it for randomized trials as a surrogate endpoint to assess infarct size and myocardial salvage. [I took what I learned and incorporated] it into clinical practice and clinical trials.
Ohman: As you were doing this research in MRI, were you already looking at doing interventional cardiology or did that come later?
Thiele: It was at the same time, roughly. I was already starting training in interventional cardiology and I was doing cardiac MRI at the same time.
Ohman: Wow, that was very unusual. There are only a few people who do that combination.
Thiele: I would not call myself an imager, although I have been trained in cardiac MRI and in imaging. I am more an interventional cardiologist.
Ohman: What was your first research project in this field?
Thiele: Comparison of different sequences in MRI.
Ohman: Oh, so very technical.
Thiele: Very technical. These sequences—maybe you know them—steady-state free precession, which is the standard today. Previously, we were using gradient echo and then steady state. Free precession came up, so we just made comparisons—signal-to-noise ratios. Those were some of my first publications.
Ohman: That's fascinating. And then, of course, you went off and did other things. You're now back in Leipzig, you finished your training, and you had to get your first job. Was it as hard as getting the training with 200 applicants or was it a little bit easier now?
Living in a UNESCO Heritage Site
Thiele: It was much easier for me to get it when I started working in Leipzig. I've been, all together, nearly 16 years in Lübeck, starting from a research fellow and then as a full interventional cardiologist. In 2013, I became professor of cardiology and the chief of cardiology at the University of Lübeck.
Ohman: Lübeck is—most of our audience will probably not know where that is in Germany. I think everybody knows Berlin, but where is Lübeck?
Thiele: Lübeck is in the northern part of Germany. It's at the Baltic Sea and is relatively famous. The old town of Lübeck is a UNESCO World Heritage site, so many people—tourists, at least—go there.
Ohman: Now you are the professor, which is a fairly important part in Germany. You call it "higher professor"—is that correct?
Thiele: Full professor.
Ohman: Full professor, yes. And now you're running your own department.
Thiele: At Lübeck, I was running my own department. I moved back to Leipzig and became the successor of my former professor, who was my mentor. Leipzig is attractive because it's a very big heart center in Europe.
Ohman: One of the biggest, I believe.
Thiele: It's one of the biggest, yes.
Ohman: When you were in Lübeck, I recall you telling me that when you were on call—it's a small city—you were actually bicycling to do the primary PCI. I have to ask you, did it delay time to treatment in any way?
Thiele: No, I don't think so.
Ohman: How long did you have to cycle?
Thiele: When I was on call in Leipzig, I did it. For me, it took maybe 20 or 25 minutes from my home.
Ohman: That's the average commute in the US, so you would have been within the boundaries. How did you feel when you arrived? Were you short of breath or were you so fit that it didn't really make an impact on you?
Thiele: I don't think it made a big impact. I was fit because I'd been cycling every day. I still do it every day. Usually, I do at least 1 hour or maybe 2 hours a day on the bike. I think I'm fit enough to do a cath on a STEMI afterwards.
Ohman: You're one of few cardiologists that I'm aware of who actually do this, but how did you get to this level of fitness? You've done marathons as well?
Ohman: You must have started training as a young person.
Thiele: Yes. When I was very young, I started playing soccer, but I always have been interested in running. I think I did my first marathon when I was 17 and then I started doing triathlons. I also did at least one Ironman. Not in Hawaii, but—
Ohman: Yes, one Ironman—that's very impressive. It's good that you didn't have to swim to the cath lab because that probably would have been a little bit harder for you. Are you keeping this up now or have you [stopped running] marathons?
Thiele: For time issues, I'm not able to do triathlons or marathons anymore, but I still try to keep my fitness.
The Lure of Cardiogenic Shock
Ohman: Let's go back to cardiogenic shock. You did the first balloon pump trial and then you really stayed with this. What is it about cardiogenic shock that got your interest? From the first trial that you proved your professor wrong, which is always a good start—I've been in the same boat—but what has kept your interest in this?
Thiele: I think the most important thing, still, is very high mortality. After we built up our network for cardiogenic shock in Germany, it was much easier to do the next trials because we had the network and we also knew how to do randomization in these patients. Randomization is difficult because usually these patients can't give informed consent. With the ethical committees, now we know how to do it and we are able to do these large-scale, randomized trials on cardiogenic shock.
Ohman: Have you done three or four trials in cardiogenic shock now?
Thiele: We did some small trials—before we did the big IABP-SHOCK II trial—with active assist devices. We did one in comparison with the TandemHeart, IABP versus TandemHeart, which was a small, randomized trial on 40 patients. Afterward, we started with IABP-SHOCK II, which was the big trial with 600 patients.
Ohman: Then you followed that with CULPRIT-SHOCK.
Thiele: CULPRIT-SHOCK, yes.
Ohman: There have always been intriguing results.
Thiele: Yes, we were lucky to publish CULPRIT-SHOCK twice in the New England Journal, including the 1-year results.
Ohman: That is quite a feat. I hear that you're also a high-risk skier. Does that go with the high mortality of cardiogenic shock? Do you ski a lot?
Thiele: I do ski a lot, but I don't think I'm a high-risk skier. We also do off-piste, but I always try to keep the risk under control.
Ohman: Just like shock. You're keeping the risk under control. Now that you got married and have a baby—
Thiele: This will maybe also influence the risk I'm taking.
Ohman: Hopefully, you'll continue working with cardiogenic shock. What's next for you? You've done some really pivotal trials in the field. Where does your career go next?
Thiele: We are already [preparing] for the next big trial, which will be called ECLS SHOCK. It will be VA ECMO versus standard of care in patients with cardiogenic shock. Approximately 420 patients will be randomized. We currently are applying to get approval by the ethical committee. I'm hoping we'll get it in the next weeks and then we'll start with the next trial. I think the next major questions to be answered will be when, how, and which assist device or mechanical circulatory support device we will really need.
Ohman: You have trainees working with you. What advice do you give them as far as how to shape their career or how to do what you did? This is quite unique. You've taken the field to a new level.
Thiele: I always try to tell them that they should stick with one topic. I started with several different topics, so—
Ohman: Like MRI, yes.
Thiele: MRI, endocarditis, also stable coronary artery disease. Usually it's better just to follow one line, just do one topic, and you will be even more successful. I still do some MRI, but if you are the head of a department, you always have to motivate the people. I always try to tell them not to do too many different things.
Ohman: Are you still cycling?
Ohman: So that hasn't changed.
Thiele: That hasn't changed.
Ohman: Well, Holger, this has been terrific. I really appreciate you taking the time to visit with us today.
Thiele: Thank you very much for the invitation.
Ohman: Thank you, the audience, for participating. It's an interesting story from Germany about a very fit cardiologist. Thank you.
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Cite this: Life and Times of Leading Cardiologists: Holger Thiele - Medscape - Feb 14, 2019.