Tell us about your medical background and how you came to work in the field of electrophysiology. What interested you about this field?
After graduating from Medical School at Trinity College Dublin, Ireland, I completed Internal Medicine and Cardiology training in Dublin and London, followed by a period of clinical research at the National Institutes of Health in Bethesda, Maryland. I had become interested in Cardiology as a medical student and pursued this career, initially under the mentorship of Dr. Gerard Gearty at The Royal City of Dublin Hospital. It was only during the completion of my later training at VCU Medical Center in Richmond, where I did fellowships both in Interventional Cardiology and Electrophysiology (EP), that I decided on a career in EP. Thus, before I settled on EP, I had a long exposure to all areas of General Cardiology, Interventional Cardiology and research. In the end, EP won out simply because of incredible variety and challenges I saw in this field of medicine. That decision was made 17 years ago, and I still enjoy EP today for the exact same reasons. As a cardiac electrophysiologist, on any given day one functions both as an internist and a surgeon, one cares for the most benign to immediately life-threatening illnesses, and one can challenge one’s cognitive and technical skills continually.
Describe your role at CJW Medical Center-The Levinson Heart Hospital. What is a typical day like for you?
I suspect that I am like many electrophysiologists, especially those in private practice, who have a dual role between hospital and office. As an interventional electrophysiologist, I am hospital based and every day begins with hospital rounds. To manage the competing time demands of hospital and office, I have found it best to schedule all-day hospital procedure days. On office days I round, do shorter procedures as needed, and then spend a full day in the office. The advantage of this schedule is that on hospital days I can focus on the work in the EP lab all day. On hospital days, between procedures, there is usually significant clinical activity with consults and admissions/discharges. Despite a busy day I find it is essential to maintain my old Irish habit of having a mid-morning and late afternoon “tea break” for 5 to 10 minutes.
What is one of the more memorable EP cases that you have worked on?
Many of our cases and patients have been memorable for various reasons. I could simply start with yesterday’s atypical left atrial flutter, which was successfully and fairly quickly ablated — this is an arrhythmia we would have had great difficulty with several years ago. Tremendous satisfaction comes at that moment when everything — in terms of the team, the technology and preparation — works to get the patient an excellent result. The “first” case is always memorable, and the field of EP has given us many opportunities for “firsts” in the last 17 years. We presented our first case of ablating an atrial tachycardia from the aortic root at the HRS meeting some years ago, just when that phenomenon was being recognized. To be the first in the country to do something is exciting for the lab; for instance, a few years ago we were the first EP lab in the US to implant Boston Scientific’s COGNIS® CRT-D device.
Sometimes the memorable cases are those with complications. I, like all electrophysiologists, have had complications over the years. If we have a complication, I always look to see what could have been done differently and implement change if needed.
Finally, for a clinical electrophysiologist, memorable cases are not always in the lab or even that dramatic. Recently diagnosing adrenal insufficiency in one of our former atrial fibrillation ablation patients who was feeling terrible, despite minimal arrhythmia recurrence and a negative work-up, was very rewarding. After treatment the patient came back feeling great and very thankful — that is what we work for.
What aspects of your job are most challenging?
In many ways I find that the main challenges are not the tough cases in the lab, although they certainly occur. I suspect the challenges I encounter are the same for many practicing electrophysiologists. I would categorize them on time scales. Examples include day-to-day challenges in running busy schedules, and simple resilience issues like getting through a busy night of general cardiology call and then having a busy EP schedule. Then there are month-to-month issues such as providing enough office time for new and follow-up patients versus the time to do hospital procedures, maintaining support staff and other infrastructure both at the office and hospital. There are also the long-term challenges of maintaining and growing a quality EP practice. I find that I have to be a strong advocate for EP within my own cardiovascular group and within the hospital organization, usually trying to convince whoever needs to be convinced at the time that EP is the most important field in medicine and needs to be supported!
Most importantly, the challenge of balancing a demanding career with personal and family life affects us all. In recent years I have taken to running as my main hobby and just participated, with some 40,000 others, in Richmond’s Monument Avenue 10K.
What clinical research are you currently involved in?
I have been involved in clinical research throughout my career, particularly in the earlier years when I authored or co-authored approximately 60 papers across a range of cardiology topics. The challenge in private practice has been to maintain and incorporate worthwhile clinical research into daily practice. I have always been interested in the hemodynamics of pacing, cardiomyopathy and heart failure. We recently participated in the SMART-AV study, which looked at how best to program the AV delay in CRT devices. We are currently involved in the MultiSENSE Trial, looking at the utility of device diagnostics in CHF management. Like all large EP centers, our atrial fibrillation ablation program continues to expand. We are part of a limited multi-center trial on the Convergent Maze procedure sponsored by nContact, and will shortly begin the PREVAIL trial of the Watchman left atrial appendage occlusion device.
What advancements do you hope to see in the field of cardiac electrophysiology in the next decade?
I would like to see Cardiac Electrophysiology become a larger sub-specialty within Cardiology and Internal Medicine. Cardiac electrophysiologists should be the “go-to” referral person for a range of common symptoms, such as syncope and arrhythmia issues. Cardiac electrophysiology should expand its role in the prevention of sudden death, and we must do something to prevent the burden of atrial fibrillation. In terms of device therapy, I think that we still do not know how to pace the heart optimally in many situations, and there are major problems with multiple chronic transvenous leads. I am hoping for a paradigm shift in this area. In the field of ablation, progress seems rapid in some ways, but I believe we still cannot “see” what we are doing. We need new ways of visualizing cardiac tissue to identify the arrhythmia substrate, and we need to clearly see the effects of ablation, including transmurality and continuity of lesions. Hopefully we will see innovation in this area in the next decade.
Is there anything else you'd like to add?
I would simply like to thank the doctors who have inspired and guided me over the years, the patients who have and continue to put their trust in me, my colleagues at Virginia Cardiovascular Specialists who practice with me, and the many excellent people who help me in my work, including the staff of the EP labs and nursing units at CJW Medical Center, my office staff, and the industry support personnel in Richmond. Finally, none of us could pursue this career without the support of family, and for this I am truly grateful to my wife and sons.