2000s: Structural heart disease

The history of interventional therapeutic cardiology can be regarded as a set of overlapping eras initiated by a flurry of innovation, followed by rapid diffusion of new technologies and procedures. Such eras include the development of balloon angioplasty, the treatment of acute myocardial infarction, the advent of coronary stents, particularly drug-eluting stents, and more recently the development of procedures designed to treat macro-cardiac structures. Going to work in the heart, cardiologists took their knowledge and enthusiasm for balloon technology and applied it to aortic and mitral valve disease. While success in the aortic position was limited, percutaneous balloon mitral valvuloplasty rapidly became standard of care for carefully selected patients with rheumatic mitral stenosis. The development of transcutaneous heart valve technology for the treatment of calcific aortic stenosis resulted in a permanent transformation of the treatment of cardiac patients. Despite initial continued significant resistance, transcutaneous aortic valve replacement (TAVR) is now commonplace and the preferred treatment for many patient subsets. The development of TAVR followed the familiar timeline: An innovation initially regarded not feasible and perhaps not safe ("crazy") became fully developed through innovation funded by medical device companies, validated in prospective studies, and applied worldwide. Now, rather than being considered bizarre or inappropriate, we wonder "why didn't we think of that?" Perhaps the answer lies in ex arca or out-of-the-box thinking when approaching patient problems. Innovation in structural heart interventions continues rapidly, and now encompasses all four heart valves, with the development of procedures using off-the-shelf technology, as well as innovative novel valve designs. Pioneers, who often do not know what lays over the horizon, industry partners, skilled operators, and clinical researchers are all necessary to make this ecosystem work. The future is bright, and we expect patients with structural heart disease to look forward to more minimally invasive and hybrid technologies brought to bear to their problems.