Charis Costopoulos | Consultant interventional cardiologist, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
Citation: EMJ Int Cardiol. 2026; https://doi.org/10.33590/emjintcardiol/4HT0LK85
Looking back on your career to date, what have been some of the defining moments that influenced your path towards interventional cardiology?
I think my time as an Academic Foundation Doctor during my second year was particularly influential. I had the opportunity to work very closely with Martin Bennett, Professor at the University of Cambridge, UK, and explore the mechanisms of atherosclerosis. Combined with my longstanding interest in physiology during my time at Cambridge, that experience brought everything together for me.
I realised that interventional cardiology encompasses both physiology and the mechanisms of disease, while also offering the opportunity to treat people directly and have an immediate impact on their health. Those were the main factors that attracted me to cardiology, and especially to interventional cardiology.
Given my current focus on structural cardiology, another defining experience was spending a year in Milan in 2012 as a fellow at one of the major Italian institutes under Antonio Colombo, Columbus Hospital, Milan, Italy, who is considered by many to be the godfather of interventional cardiology. That experience was certainly a major influence in pursuing a career in the field.
You have a particular interest in transcatheter aortic valve implantation (TAVI). How has the role of TAVI changed since you first began working in the field?
I think TAVI has been one of the interventions that has truly transformed cardiology over the last 15–20 years. Twenty-five years ago, older patients or patients who were not fit enough for surgery and had severe aortic stenosis really did not have many options. Treatment was largely limited to medical therapy, and it was often a slow and difficult process for patients.
I have seen the field evolve almost from its beginnings to what it is today. In the early 2010s, when TAVI was starting to expand, it was a challenging intervention. The delivery systems were much larger, around 22–24 French; the patients were often very sick, and the valve technology was still developing.
Today, the procedure has become far less invasive. Many patients undergo TAVI under conscious sedation or local anaesthesia, and, in some cases, it has become a same-day procedure. Patients can come in, have the intervention, and return home on the same day, while achieving outcomes that match those seen with surgical aortic valve replacement.
We now generally reserve surgery for younger patients, while many patients over 75 years of age, and even some younger individuals, can undergo TAVI with equivalent outcomes. In some cases, particularly in patients with a small annulus, results may even be superior.
The field continues to evolve, with companies developing valves that can be delivered through even smaller sheaths and devices designed for conditions such as aortic regurgitation. Over the next 5–10 years, I think we will see further significant advances, but even over the last decade alone, TAVI has fundamentally transformed the way we treat aortic stenosis.
What does the real-world success of TAVI teach us about how innovative cardiovascular technologies should be evaluated and adopted?
One of the next frontiers is refining and expanding transcatheter treatments in the mitral and tricuspid spaces. We already have technologies available, including edge-to-edge repair procedures and, more recently, transcatheter valve therapies, but these remain evolving fields because the anatomy treated with these devices is far more complex.
One of the key lessons from TAVI is that, even when there are challenges early on, if clinicians remain focused on patients’ best interests and continue working to help patients who otherwise have few treatment options, innovation progresses. Technology improves, evidence accumulates, and outcomes become better.
Looking ahead, advances such as AI may create even more opportunities. The most important principle is to keep patients at the centre of innovation, explore new ways of treating disease, and be willing to bring promising technologies into clinical practice while being guided by robust clinical results.
Structural heart interventions are expanding rapidly. Which developments excite you most, particularly in mitral and tricuspid valve therapies?
The mitral valve has always been challenging to treat. There remains a large group of patients with mitral regurgitation who either have prohibitive or very high surgical risk and therefore cannot undergo conventional surgery.
Alongside edge-to-edge repair procedures, transcatheter mitral valve replacement technologies are now emerging. The SAPIEN M3 valve (Edwards Lifesciences Corporation, Irvine, California, USA) has already shown considerable promise, and I will be very interested to see the long-term outcomes as more data become available.
The same is true in the tricuspid space. Surgeons have historically been reluctant to operate on the tricuspid valve, yet severe tricuspid regurgitation is common. Technologies such as the EVOQUE valve (Edwards Lifesciences Corporation, Irvine, California, USA) and emerging devices such as the Lux-Valve (Jenscare Scientific Co., Ltd., Zhejiang Province, China) are beginning to provide new treatment options.
Over the next 5–10 years, I believe some of the biggest developments in structural heart disease will occur in the mitral and tricuspid fields, particularly with the expansion of transcatheter valve replacement therapies.
As Clinical Lead for Non-Coronary Intervention at Royal Papworth Hospital, what emerging trends are you seeing in the treatment of structural heart disease?
We work within the financial constraints of the NHS, so therapies generally need to be supported by strong evidence and guided by National Institute for Health and Care Excellence (NICE) recommendations before they can be widely adopted.
At Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK, we have started our transcatheter journey in both the tricuspid and mitral spaces. Our early experiences with devices such as EVOQUE and SAPIEN M3 have been encouraging, although the number of treated patients remains relatively small.
As more evidence emerges and the technologies continue to demonstrate good outcomes, I expect these therapies to become increasingly integrated into routine clinical care. The situation is somewhat different from TAVI, because the mitral and tricuspid valves are more anatomically complex, but discussions around transcatheter valve replacement are becoming more common.
A few years ago, these technologies would rarely have been part of our multidisciplinary discussions. Today, when we review patients with our surgical colleagues, transcatheter options are increasingly considered alongside surgery, particularly for patients whose surgical risk is high. That is a clear sign of how quickly the field is evolving.
Your PhD focused on the role of biomechanical forces in coronary atherosclerosis. How has our understanding of coronary disease progressed since that work?
One of the great challenges in cardiology is understanding why some plaques rupture and cause myocardial infarction, while others do not. My PhD focused on the concept that plaque rupture results from an imbalance between biomechanical stresses within the plaque and the protective effects of the fibrous cap.
There has certainly been progress since then, but we are still some distance away from translating this knowledge fully into daily practice. We can now identify plaques that may be at higher risk using intravascular imaging techniques such as intravascular ultrasound and optical coherence tomography, but an important question remains: what should we do once we identify these plaques?
Should we implant a stent pre-emptively? Stenting carries its own risks, and we still do not have definitive evidence that treating these plaques improves outcomes. Large trials would be required to answer that question.
Looking ahead, technologies such as bioresorbable stents may offer an interesting solution. If we can improve our ability to identify genuinely high-risk plaques and treat them with devices that eventually dissolve and restore normal vessel physiology, that could be transformative. However, I think we are still some way from achieving that in routine clinical practice.
What qualities are most important for the next generation of interventional cardiologists to develop?
Different people will answer this differently, but for me, it is quite simple.
First and foremost, you must have the patient’s interests at heart. It is not about you; it is about the patient sitting in front of you. You should treat patients in the way that you would want yourself or your family members to be treated.
I also think it is important to have a strong ethical code. Interventional cardiology is a competitive field, but that does not mean we should step over people to achieve our goals. The same principle applies to any career.
Finally, there is no substitute for hard work. Stay committed, have a clear vision of where you want to be, and pursue it in the right way. In my experience, if you work hard, maintain high standards, and treat people with decency and respect, your work will be recognised.
Being a good team member is equally important. Respect the contributions of those around you and work collaboratively. Hard work and decency will usually take you a long way.
Cardiovascular medicine is becoming increasingly specialised. How can multidisciplinary collaboration help deliver the best outcomes for patients?
Every member of the team brings different strengths. As interventional cardiologists, we may focus on symptoms and procedural aspects, while specialist nurses often have a deeper understanding of patients’ social circumstances and the practical challenges they face before and after treatment.
No single clinician can see every aspect of a patient’s situation. Bringing together perspectives from nurses, surgeons, imaging specialists, and other HCPs allows us to form a much more complete picture.
When all these viewpoints are considered, discussions become richer, and decisions become better informed. It is through these multidisciplinary conversations that we can achieve the best outcomes for patients.
It is always concerning when one group makes decisions in isolation, because no one knows everything. It is not just about achieving a good anatomical result. For example, a procedure may look successful on imaging, but if a 90-year-old patient never returns to their baseline function, then we have not necessarily helped them. Equally, a younger patient may achieve an excellent immediate result, but we must also consider what treatment options remain available in 10 or 15 years.
Each member of the multidisciplinary team contributes a unique perspective, and when all of those perspectives are combined, we are much more likely to make decisions that truly serve the patient’s best interests.
What changes would you most like to see in cardiovascular care and research over the next 10 years?
I think cardiology will continue to change significantly, particularly through advances in medical therapy. We have already seen innovations such as monoclonal antibody therapies for cholesterol management, and I expect this type of treatment to expand into other areas of cardiovascular medicine.
At present, cardiology remains relatively reactive. We often treat patients once they develop symptoms or experience a cardiac event. I would like to see a much stronger emphasis on prevention.
I believe the incidence of coronary atherosclerosis will decrease over time, as preventative medicine improves. Public awareness of health continues to grow, smoking rates are falling, and therapies targeting obesity and weight management are becoming more effective and widely available.
At the same time, as people live longer, conditions associated with ageing, such as valvular heart disease, are likely to become more common. How we manage those conditions will depend on technological progress. There are already discussions around non-invasive approaches, such as ultrasound-based techniques designed to prevent the progression of calcific aortic stenosis.
Overall, I think prevention will be one of the defining themes of cardiovascular medicine over the coming decades. At the same time, structural intervention will continue to expand, and hopefully we will reach a point where we can prevent many diseases before they require invasive treatment. Of course, much of this remains speculative, but prevention will undoubtedly play a central role in the future of cardiovascular care.
