10-Minute Interview: Mo al-Ahdab, MD and Sambit Mondal, MD

Mo al-Ahdab, MD, FAAP Why did you choose to work in the field of pediatric electrophysiology? Describe your medical background. My passion for the field started in medical school, during the time I was learning how to read electrocardiograms. During my residency training in pediatrics at the University of Illinois at Chicago, I was exposed to some patients with arrhythmia issues that were medically treated. When Dr. Mark Ovadia joined the program and started to perform EPS and ablations on these patients, I was amazed how a life of a patient can change from one where they were taking one or two anti-arrhythmics to being drug-free and symptom-free after their procedure. During my cardiology fellowship, I knew this was what I wanted to do. I was fortunate to spend the next two years in the world of EP. In my first year at the University of Michigan, I had the pleasure of working with Dr. Macdonald Dick and Dr. Peter Fischback in Ann Arbor. They cemented my interest in electrophysiology and provided invaluable mentoring and guidance during my early career. Afterwards, I pursued more training at Children s Hospital in Boston, where I further expanded my knowledge and experience by working closely with great faculty and seeing more complicated cases. Describe your role as pediatric electrophysiologist at Cypress Heart and Via Christi Regional Medical Center. What is a typical day like? My role is very unique. There is a definite need for my specialty in the state of Kansas, as no other person with this background is practicing in the state. Most cases used to be sent out of town to be treated. Most pediatric EPs establish their practice at a children s hospital. I found a great potential here in Wichita to build such a practice and to develop many aspects of it. My group is very supportive they share my vision to become a good resource of care for patients in need. At Cypress Heart, I established a practice that includes general pediatric cardiology care and specialized electrophysiology care. I have two full-day clinics, two half-day clinics and two days for procedures. I cover three major hospitals and two smaller ones here in Wichita. My group also pulls patients from the whole state of Kansas, as we have 13 outreach clinics. Since day one, I have worked with the EP lab leadership at Via Christi to build their confidence and experience in performing pediatric EP cases. They are wonderful and passionate about EP. I have opted not to perform any invasive procedures in the very young patients, since we do not yet have the setup and backup needed to handle its complexity. I have teamed up with my partner, Dr. Sambit Mondal, in performing adult and pediatric cases. In addition, I was blessed with hiring a smart and dedicated pediatric nurse practitioner, Jenny Ecord, who has been a great asset to my practice. My practice has grown much faster than I initially expected. My goal is to continue to provide excellent medical care no less than any established academic practice. Name one of the most unusual pediatric EP cases you have ever worked on. There are many. One that stands out in my mind involved a baby who was born with severe Ebstein s anomaly and severe heart failure, and required ECMO support in the cardiac ICU. He developed incessant SVT that was not controlled with anti-arrhythmics. He was taken to the EP lab on ECMO and all the ICU support, and had an EP study and radiofrequency catheter ablation. He had a right-sided accessory pathway mediated tachycardia. He underwent successful RF ablation of the accessory pathways. I learned plenty of things from that case: the pathology, the process, the difficulties and the results. What aspects of your work do you find most rewarding? What aspects are most challenging? The fact that I always learn something new every week is what I love about my specialty. I picked up early on in cardiology training that no matter how much you have seen or read about before, there is always something new that you have not seen before and you will learn how to approach it correctly. I think one major challenge here in Wichita is that we do not have an established pediatric cardiovascular surgical program, so we refer all our surgical cases out to surrounding centers. This adds to the inconvenience and anxiety levels of parents of children with congenital heart defects who require surgical repair or interventional procedures. Are you currently involved in any pediatric EP-related research? Yes. We are actively participating as a contributing center in a registry that investigates the safety of sports participation for individuals with an implantable cardioverter-defibrillator (ICD). This study is based at Yale University. Some of these young patients with ICDs do participate in vigorous activities despite the guidelines to refrain from doing so. The risk is unknown on a large scale. What advancements do you hope to see in the field of pediatric electrophysiology in the next five years? What specific areas of EP and/or patient care need more attention? I would like to see more affordable comprehensive genetic testing available for diagnosis of congenital arrhythmias, a better profile of cryoablation technology with similar cost to RF catheters, Stereotaxis being used in more pediatric EP cases, as well as a better understanding and successful ablation results of complicated atrial tachyarrhythmias in adults with congenital heart defects. The pediatric EP market is obviously much smaller in comparison to adult EP. Having said that, I would like to see companies pay more attention to our needs. One specific area that is growing quickly is the management of arrhythmias in adults with congenital heart defects. What advice can you offer to others who want to a build a successful pediatric EP program? Stay tuned, and always be prepared and detailed. Find a good mentor who is willing to support you and do not hesitate to seek his input, advice and help. Be patient and persistent. Always be available and nurturing. The change on a mother s face from anxiety to pleasure after a successful procedure on her child is really priceless. What is the best advice you have received so far in your medical career? Be humble to the fact there is always someone else that knows more and that sometimes you have to say I do not know, but I will find the answer. Has anyone in particular been helpful to you during your medical career? I was blessed with the company of many great teachers at different stages of my career. One stands out very as close and dear to my heart: Dr. Rene Arcilla, who was the chief of cardiology at The Heart Institute for Children in Chicago during my cardiology fellowship training. He exemplified to me the meaning of a great leader of an energetic group in a humble, passionate and fatherly fashion. Is there anything else you d like to add? I want to thank you for your time and hope to be able to deliver beyond the standard of care to my patients here in Wichita. Sambit Mondal, MD Why did you choose to work in the field of electrophysiology? Describe your medical background. I completed my cardiology and then cardiac electrophysiology fellowship at the University of Miami. My interest in electrophysiology was borne out of exposure to the field during the initial years in cardiology. Dr. Castellanos and Dr. Myerburg were major inspirations. It is amazing to see the transition of understanding of a bunch of squiggles on the 25 mm/sec EKG paper speed at various levels of training to the finality of electrophysiology. Electrophysiology allows a unique opportunity to fuse technical skills, knowledge, and intellectual thirst in pursuit of arrhythmias. Describe your role as an electrophysiologist at Cypress Heart and Via Christi Regional Medical Center. I am currently serving in Wichita as an electrophysiologist for the community as a part of a private group of cardiologists at Cypress Heart. The electrophysiology work is done at Via Christi Medical Center, which has two electrophysiology labs. The lab is accessible to other electrophysiologists in the area and serves as a state-of-the-art lab wherein complex ablations and device implants can be handled. The consults for electrophysiology are evenly split between cardiologists within the group and those outside the group who don t have an electrophysiologist of their own. A large section of consults are also directly from primary care physician, with typical consults ranging from syncope to tachycardia to heart failure requiring device therapy. What is a typical day like for you? The days in the week are split between clinic and lab days. One day a week is devoted to clinic where both new consults as well as follow-up patients are seen. A parallel device clinic is run along with the clinic days. The rest of the days are kept for cases in the EP lab, which typically start at 8 am. Most of the cases are EP studies and ablations, with about 40-50% of the cases being that for atrial fibrillation (AF). In the last year, an increasing amount of time was spent performing atrial fibrillation cases. What is one of the most unusual cases you have been involved with? We had one case of a middle-aged woman with recurrent symptomatic palpitations with documented atrial tachycardia and incessant short runs of atrial fibrillation. During the EP study, she was noted to have clear left-sided atrial tachycardia. In the setting of atrial fibrillation, we proceeded to isolate each pulmonary vein and subsequent to isolation of each pulmonary vein, we were able to prevent any inducible, sustained atrial fibrillation; however, the atrial tachycardia was still inducible with minimal stimulation. The local activation time map of the tachycardia using the EnSite NavX electroanatomical mapping system was done and was noted to be using the macro-reentry around the right-sided pulmonary veins. Tachycardia could be entrained from the proximal coronary sinus, roof of the left atrium, although it was not possible to do so from the posterior wall, as there was capture issues from the scarred posterior wall. A roof line and a mitral isthmus line from the right and left inferior pulmonary veins was done, which did not terminate the tachycardia, although it did shorten the cycle length of the tachycardia. It was difficult to entrain the tachycardia, as pacing from the posterior wall of the left atrium was not possible even with maximum outputs. CFAE (complex fractionated atrial electrograms) maps of the posterior wall noted a line of double potentials along the middle of the posterior wall flanked at the two ends with complex fractionated electrograms. These were considered to be the turnaround points of the tachycardia, and ablation at these sites led to termination of the tachycardia and noninducibility, even with isuprel infusion and concomitant aggressive atrial stimulation protocols. Short bursts of energy with constant proximal esophageal temperature monitoring was done during ablations on the posterior wall of the left atrium. This case, although not a very unusual one, was certainly challenging. What aspects of your work do you find most rewarding? What aspects are most challenging? Electrophysiology is one of the branches of medicine wherein a potential cure for issues around tachycardia can be achieved. It has been very rewarding to see patients with crippling symptoms be completely rid of their symptoms post ablation. A heartfelt thank you at the end of the day is what is most rewarding. Challenges in the EP lab include when tachycardias do not terminate despite ablating at the proposed targets. A need to reassess the case after one has been at it for a few hours can be quite challenging. Keeping the patient care a priority always helps to keep oneself on track to reach the ultimate goal. Are you currently involved in any EP-related research? Yes, we are involved with both device-related and ablation-related research. What advancements do you hope to see in the field of cardiac EP in the next five years? The field of electrophysiology is the fastest-growing field of cardiology. Technology has played a big role in the progress of this field. Atrial fibrillation and ventricular arrhythmias continue to be challenges; I hope we have a better hold on chronic atrial fibrillation and the prevention of proarrhythmic effects of ablations in the left atrium in the near future. Some of the other areas I would like to see advancements in include the invention of 4D mapping (taking into account real-time movement of the heart), further development of remote mapping systems and ablation technology from Stereotaxis and Hansen Medical, and better ablation technologies to cut down procedure time. There also needs to be some enthusiasm infused back into device research, especially in the areas of predictors of inappropriate shocks, proarrhythmic effects of device therapy, and maximal outcomes from biventricular pacemakers. Genomics of arrhythmias and tailoring drug sensitivities to the individual is currently a subject of great interest that hopefully will bear fruit in the future. What specific areas of EP and/or patient care need more attention? The prevention of atrial arrhythmias post AF ablation is a priority. The proarrhythmic effects of ablation need to be studied; this is closely linked to the mechanism of arrhythmia. The recognition of differences in mechanism between acute and chronic atrial fibrillation and in patients with low ejection fractions also needs to be addressed. What aspects do you think are important when building a successful EP program? A successful EP program in private practice is dependent on a multitude of factors, the most important of which is referral source. This includes keeping good professional relationships with physicians, actively engaging in education for physicians on issues involving arrhythmias, and providing strong follow-up care. It is also essential that a good EP lab maintain high-quality work and partake in the progress of the field of clinical EP. Another key factor in building a robust EP program is to support both economics and logistics from the hospital. In the last few years, there has been increasing recognition for hospitals around the country for the most rapidly growing area of cardiology: electrophysiology. Has anyone in particular been helpful to you during your medical career? My entire family and closest friends have been of rock-solid support to me during my entire medical career.