Daniel Gelfman
Indianapolis, IN

In 2024, the world of interventional cardiology lost one of its greatest innovators: Alain Cribier, MD (1945–2024). Called the father of “structural heart disease” treatment and described as “larger than life, he was a Renaissance man, fluent in English and French, knowledgeable in philosophy and art, but keen to be a physician rather than a concert pianist. His interest in using catheters in the treatment of heart disease led him to work with Jeremy Swan and William Ganz at the Cedar Sinai Medical Center.¹ They are likely known to every physician for the development of the Swan-Ganz pulmonary artery catheter.

One of the most difficult tasks one faces in the practice of medicine is telling patients and their families that there is nothing more that can be done, and that death is very near. While we know that death will come for all of us, it happened much earlier in life, especially with heart disease, in the past. Aortic stenosis or obstruction is a disease that medication alone cannot treat. When the aortic valve becomes too obstructed and the patient becomes symptomatic, the valve must be replaced, or the patient will die. Those symptoms include exertional chest pain, shortness of breath due to heart failure, and passing out due to insufficient blood reaching the brain because the heart can’t deliver enough through the obstructed aortic valve. Most commonly the aortic valve can become obstructed for three reasons: the valve developed incorrectly and was not formed properly at birth; as a consequence of rheumatic heart disease, a late effect from a streptococcal throat infection that wasn’t treated; or calcification from age.

In 1952, Dr. Hufnagel implanted the first prosthetic aortic heart valve at Georgetown University. Once this became a reality, aortic stenosis could be treated. But open-heart surgery means that the patient undergoes general anesthetic and is placed on a heart-lung bypass machine that maintains circulation to the body during the time of the lengthy operation. So, in order to have a valve replaced in the past, one needed to be strong enough to go on that machine while having their chest and aorta opened and their native valve removed and replaced. This is the definition of a “big” operation. For some time, surgeons would not even attempt this if a person was over the age of 75. Even if one could get the heart restarted after surgery, there was still a risk of complications such as kidney failure, embolization, stroke, and infection. Many patients had the above “difficult” conversation and were turned down for aortic valve replacement. Today, these complications are much less, and low-risk aortic valve surgery is felt to be under 2 or 3%. As an aside, years ago, I spoke with an older individual who told me of his experience when he had his aortic valve replaced around 1960 by Dr. Hufnagel at Georgetown University. It had been on a Friday, and he went in aware that none of the patients from Monday through Thursday that week had survived.

Dr. Cribier had the idea that if one could open up the obstructed aortic valve using catheters, many of those inoperable patients could be treated. By the 1980s, the risk of aortic valve replacement surgery was <5%, but only if done on relatively healthy individuals. He first tried to crack open the aortic valve using a catheter with a very tough balloon in 1984. Remember that coronary angioplasty was just starting at that time. Almost all the equipment he needed to do this with he and others had to invent. Yet fixing the obstructed valve this way made the use of general anesthetic, cutting open the chest and aorta, and the bypass machine unnecessary. Unfortunately, aortic valve balloon valvuloplasty worked, but didn’t last. The valve would close up in a few months. Also, there is something else that is very unique to catheter intervention on the aortic valve: this procedure is being done on a beating heart. That means that when the valve is inflated to open it, there is no blood coming out of the heart or flowing in the body. I remember watching this procedure once when I was a cardiology fellow, and I remember thinking this procedure took real nerve for the interventional cardiologist to perform.

Fortunately, Dr Cribier did not give up. While many people helped him develop a tissue prosthetic aortic valve that could be placed inside a patient’s calcified obstructed aortic valve, others thought this was impossible, too dangerous, and too difficult. When one puts a prosthetic valve inside the heart using catheters, it has to have a casing or stent that is tall enough to hold it in place and so that it does not leak around the outside of the valve, as it is not sutured in place as with open heart surgery. Just above the aortic valve, both the right and left coronary arteries come off the aorta. If one were to obstruct one of these, the patient would have a major myocardial infarction or “heart attack”. If the obstructed artery was the left coronary artery, the patient would likely die in minutes. If the occlusion involved the right coronary artery, they would have a major myocardial infarction but could possibly survive. Just below the aortic valve sits the interventricular septum and the mitral valve. Damage to the intraventricular septum could damage the cardiac conducting system and result in complete heart block, causing the ventricles to stop pumping blood to the body. This can be treated with a pacemaker, not ideal but very compatible with life. Placing the valve too low and disrupting the mitral valve would likely necessitate open heart surgery for repair, something these early patients would not have likely survived. Yet this unbelievable goal was finally achieved in 2002 in Rouen, France, when Dr. Cribier led a team to successfully perform the percutaneous transcatheter implantation of an aortic valve for aortic stenosis in a fifty-seven-year-old man who was dying of inoperable aortic stenosis.^2,3 By 2019, a variation of this procedure, now called TAVI or transcutaneous aortic valve implantation, was performed more frequently than SAVR or surgical aortic valve replacement.

What is equally as impressive as his accomplishment above was his spirit. Reading the accounts of his students and colleagues gives one a better picture of the kind of person he was. Many of these individuals are scientists who published their accounts and thus we are lucky to have many documented quotes.

Martin Leon, MD (New York-Presbyterian/Columbia University Irving Medical Center, New York), said the following:

Alain Cribier was arguably the “father” of modern-era structural heart disease, he was a caring physician, a humble humanitarian, a creative iconoclast, and an intuitive transcatheter operator—vital character and professional attributes which led to the remarkable discovery of TAVI. His two most endearing qualities were passion and perseverance, which drove his pursuit of an unimaginable vision: the successful transcatheter treatment of critical aortic stenosis in an awake patient on a beating heart. Most important to me, he was a dear and loyal friend, and I shall miss him desperately.¹

In speaking of his perseverance for transcatheter aortic valve implantation, Dr. Cribier once stated, “When you decide to innovate in medicine, you have a number of people against you. The biggest lesson is to make sure you are right, then persevere and try to jump all obstacles in your way. Never be discouraged.” He added, “I just had to continue and prove that what I had in mind would be useful for patients. I never thought about giving up, but I confess it was a lot of work, and I had many sleepless nights. But twenty years later, what a reward!”⁴

One cannot say more than the following written tribute by Vasilis C. Babaliaros, MD, Professor of Medicine of Interventional Cardiology at Emory University, about his mentor, Dr. Cribier:

At a time when I was looking for meaning in my work, I serendipitously met my hero who showed me how to properly struggle for a greater good. And like the heroes in Greek mythology whose reward after death was immortality, Alain lives on in all of us, every time a TAVR valve is implanted or a new doctor dares to dream of a better way.⁵

References

1. Wood S. Alain Cribier’s Death Mourned, His Legacy Celebrated Around the World. TCTMD.com. February 19, 2024. Accessed March 8, 2025. https://www.tctmd.com/news/alain-cribiers-death-mourned-his-legacy-celebrated-around-world
2. Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous Transcatheter Implantation of an Aortic Valve Prosthesis for Calcific Aortic Stenosis. Circulation. 2002;106(24):3006-8.
3. Cribier A. The development of transcatheter aortic valve replacement (TAVR). Glob Cardiol Sci Pract. 2016(4):e201632. doi:10.21542/gcsp.2016.32
4. Feature | TAVR: Clearing Hurdles to Become an Established Treatment. American College of Cardiology. Accessed March 8, 2025. https://www.acc.org/Latest-in-Cardiology/Articles/2022/03/12/01/42/Feature-TAVR-Clearing-Hurdles-to-Become-an-Established-Treatment-acc-2022.
5. Babaliaros VC, Nercolini DC, Agatiello C, Amor R. Dr Alain Cribier—The Man, the Myth, the Legend—January 25, 1945, to February 16, 2024. J Soc Cardiovasc Angiogr Interv. 2024;3(4). doi:10.1016/j.jscai.2024.101860.