Updated from the print edition In this month’s interview, we speak with Dr. Acevedo, an electrophysiologist with Munroe Heart in Ocala, Florida. Tell us about your medical background and how you came to work in the field of electrophysiology. What interested you about this field? As an internal medicine resident in Pittsburgh, I treated a clinic patient who had one of the early implantable defibrillators (ICD). The ICD had been implanted in the early 1990s after he survived cardiac arrest. The patient had subsequently received appropriate ICD therapy for ventricular fibrillation. Knowing (even as an intern) the lethality of this arrhythmia, I could not help but be fascinated with the technology that had allowed this gentleman to survive such typically devastating events. Later in my career as a cardiology fellow, I also had the opportunity to witness key advancements in our field of cardiac electrophysiology, including cardiac resynchronization therapy, the evolution of mapping systems that allowed us to better describe, among other things, complex reentrant arrhythmias such as atypical atrial flutters, and the advent of ablation as an alternative to treating atrial fibrillation. For these reasons, after completing my cardiology fellowship I trained in cardiac electrophysiology at the University of Louisville in Kentucky. I could not have chosen a better career that allows the opportunity for direct patient contact, precision in surgical equipment/catheter manipulation, and deductive reasoning. Describe your role as an electrophysiologist with Munroe Heart. What is a typical day like for you? Munroe Heart was an established cardiovascular program in central Florida with many years of experience and a great reputation, although lacking a cardiac electrophysiology program. I was presented with the opportunity to establish an ablation-focused program with a cardiac electrophysiology laboratory specifically designed for complex ablations. During these complex ablations, multiple imaging modalities may be required. For this reason a spacious room was designed; it has an enclosed shielded area where electrogram analysis takes place and has a single large screen (Philips EP cockpit) that can accept different imaging modalities. The information can be displayed according to the type of arrhythmia being treated. What is one of the more unusual EP cases that you have ever worked on? I will share with you a recent case that was not the most unusual or challenging, but one that illustrates the application of deductive reasoning in our field. We were doing an electrophysiology study on a woman with very frequent palpitations. A narrow complex tachycardia had been captured during one of the episodes of palpitations. In the electrophysiology laboratory, an arrhythmia was induced and found to be reentrant with early activation close to the AV node. It could easily be induced with either ventricular or atrial pacing. The timing between ventricular and atrial retrograde activation was slightly longer than that seen during AVNRT. Parahisian pacing was mechanically difficult to achieve; therefore, classic techniques such as pacing when the His was refractory and IV adenosine were required to confirm the diagnosis. The septal track was mapped during SVT and was extremely close to the AV node; therefore, it was cryoablated. This case, although common, illustrates the progress in the way we approach a tachycardia to understand its mechanism and the different techniques that we have available to us to ablate it. By switching to cryoablation in this particular case, we were able to get extremely close to the AV node without causing heart block, although we did extend the PR interval by 80 msec. What aspects of your work do you find most rewarding? What motivates you to continue your work in the EP lab? I think one of the most rewarding aspects in evaluating patients with palpitations is being able to validate a symptom as being arrhythmia related in those patients that remain undiagnosed. Patients may present to the ER or to their physician’s office having non-specific complaints that are often dismissed as panic attacks or anxiety, when indeed they are experiencing an arrhythmia. In the majority of cases, a careful history can help distinguish those that require EP testing. On multiple occasions we have taken patients to the electrophysiology laboratory without documentation of an arrhythmia and based on a careful history, will find an arrhythmia. We can then perform an ablation and not only validate their complaints, but also implement curative therapy. Tell us about your research interests. Are you currently involved in any research initiatives or clinical trials? Over the past several years I have worked very hard on cutting down fluoroscopy time. Over the past three years we have been very successful at achieving this goal. We currently perform more than half of all our ablations without any fluoroscopy exposure, and have cut down this exposure during atrial fibrillation ablations to less than 10 minutes. We are currently compiling this data to prove that this can be done safely in a community setting. Aside from the obvious benefit of avoiding radiation exposure, an added bonus to us in the EP lab is less back strain since no lead is required during fluoroscopy cases. What advancements do you hope to see in the field of cardiac electrophysiology in the next few years? I would like to see advancements such as extending the mapping system capabilities to device implants, thereby minimizing or avoiding fluoroscopy altogether. What advice would you give to others in EP who are currently at the start of their career? Like my teacher, Dr. Igor Singer, wrote in his textbook Interventional Electrophysiology, potential complications are better “anticipated rather than reacted to.”1 This is critical while performing procedures, but can also be applied to the evaluation of indications for surgery/procedures, to a medical practice and/or business decisions. Has anyone in particular been helpful to you in your growth as an electrophysiologist? I have had many great teachers throughout my career, but I must say that journal and book authors transcend the confines of a classroom or hospital ward. I was very fortunate to train under such an author, Dr. Igor Singer, who wrote several textbooks in our field and probably the first ‘how to’ guide on performing catheter ablations. He gave me the opportunity to be the last EP fellow to train under him at the University of Louisville, delaying his move into private practice until I finished my training. Is there anything else you'd like to add? Most importantly, I must extend my utmost appreciation to all my patients. They have trusted me to do everything in my power to alleviate their suffering or assist them in living longer lives.
- Singer I. Interventional Electrophysiology, Second Edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2001.
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