EP Lab Digest speaks with Benedict Glover, MD, MB BCh BAO, MRCP from Queens University, Kingston, in Ontario, Canada, where he is chief of the heart rhythm service, assistant professor and head of the cardiac electrophysiology fellowship program (Royal College of Physicians and Surgeons of Canada Accreditation), as well as the chair of the Canadian Heart Rhythm Society's annual meeting planning committee. In this interview, he discusses his current projects and ongoing work in the EP field.
Tell us about your medical background. What interested you about EP?
I originate from Ireland, and trained in undergraduate and early postgraduate medicine in Queen’s University Belfast. Following graduation from medical school, I underwent further training in medicine where I gained my membership of the Royal College of Physicians of London in the UK. It was during this time that I first gained an interest in cardiology, due largely to the combination of invasive procedures, patient contact, and potential for research and development. In gaining experience in coronary angiography and echocardiography, I completed my thesis looking at the optimal waveform for the internal cardioversion of atrial fibrillation. This really initiated my interest in cardiac electrophysiology. I found it exciting at the time to position catheters within the coronary sinus and examine different shock vectors, and soon realized that we had (and still have) a lot to learn about the mechanisms of common clinical arrhythmias. The perpetual need to gain a better understanding and essentially improve patient care was one of the most important features of cardiac electrophysiology and has maintained my interest in this field. I am still excited by what I continue to learn in the electrophysiology laboratory. During my fellowship in Toronto, I was truly inspired by leaders in cardiac electrophysiology, including Dr. Paul Dorian, Dr. Kumaraswamy Nanthakumar, and Dr. Eugene Downar. To this day, they continue to act as friends and mentors, and for that I am eternally grateful.
What is typical day or week like for you?
It’s very busy. I am sure that anyone reading this will understand the complexities of trying to combine a busy clinical job with research and administration. I have an excellent team of physicians who excel in this field, and that makes it much easier. My week is largely divided between clinical work (I’m predominantly in the electrophysiology laboratory for 2 days, device lab generally one day every two weeks, and clinic half day per week), and the remainder is spent doing teaching, administration, and research. My research studies are focused on two particular areas. One is the development of novel mapping and ablation technologies, and the other is risk factor modification in the management of atrial fibrillation. We also conduct several other trials, but I try to remain focused on my interests. One of the more enjoyable parts to my week is interacting with trainees. I find that a keen trainee is a pleasure to teach, and their questions also test me and maintain my academic interest.
Kingston Health Sciences Centre (KHSC) recently hosted a two-day international EP course to train on the technologies and methods in place there for complex cardiac cases. What can you tell us about this first-of-its-kind cardiac program?
This was particularly exciting, and was co-organized between myself and my colleague and friend Dr. Adrian Baranchuk. He is an incredible educator — I’ve learned so much from him — and it is a pleasure to work with him on a daily basis. This course involved very experienced electrophysiologists from Argentina coming to visit. During this time, we presented live mapping cases using the EnSite Precision Cardiac Mapping System (Abbott), allowed the attendees to use the simulator for training, and discussed some interesting complex cases that we had previously performed. This was an exciting experience for all involved; it gave us an opportunity to demonstrate the potentials of the EnSite Precision Cardiac Mapping System and allow our visiting colleagues to interact with us in a relaxed environment. This program, which took much time and energy to develop, demonstrated a very positive effect of educational collaboration between industry and academic institutions. We will be hosting this program three more times over the next year, and welcome more electrophysiologists with an interest in complex mapping to attend.
How did the book, Clinical Handbook of Cardiac Electrophysiology, written with Pedro Brugada, come about?
I felt that there was a need for a book for electrophysiology trainees and allied health professionals to explain all of the important concepts for each arrhythmia. Professor Pedro Brugada is not only one of the top cardiac electrophysiologists in the world, but he is also a true gentleman. He was a huge help in writing this book, and I am very grateful for his knowledge and expertise. Before writing this book, I wrote down all of the questions and important points that I felt a fellow should know but that are not always easily accessible. The book describes the mechanisms, ablation strategies, anatomy, and troubleshooting for each of the common arrhythmias. Each chapter also has a different contributing author with expertise in imaging and cardiac anatomy, which I find particularly helpful.
This book features updated information about contemporary mapping systems and non-invasive multi-electrode mapping. Why was it important to include this? What should physicians keep in mind when choosing a specific mapping system?
Cardiac electrophysiology has evolved significantly over the last two decades, from the interpretation of electrograms and the use of fluoroscopy for the localization of catheters, to the widespread use of three-dimensional electroanatomic mapping. Given that there are now several mapping systems that employ differing technologies, I felt that it was very important to describe each of these systems in detail, showing how they compare and often complement one another. I also feel that non-invasive high-resolution mapping is an interesting development that may help guide our ablation strategies. There continues to be big developments in the use of new invasive and non-invasive mapping technologies in cardiac electrophysiology, and I believe that this book provides a detailed perspective of these. The future of catheter localization for all cardiac ablations in the future will rely on three-dimensional mapping rather than fluoroscopy. In my opinion, the most important features of a mapping system are accuracy with no map shift and an open platform.
Another interesting aspect of the book is the inclusion of difficult case descriptions, as well as a lengthy section on how to perform PVI. In your opinion, what are the most unique features of the book?
There are several books that provide the reader with the concepts of electrophysiology; however, what is unique about this book is that we also describe specific features of troubleshooting for catheter ablation of each individual arrhythmia. I decided to devote a lot of time describing how to perform a PVI or, more correctly, catheter ablation for atrial fibrillation, as this is probably the most commonly performed procedure in cardiac electrophysiology. There are many variations to what I describe, but I hope that this provides a skeleton to work from.
This book is now on the recommended reading list for the IBHRE exam. Who is this book best geared toward?
This book should be considered a “one-stop shop” for technologists, arrhythmia nurses, fellows and residents in training, cardiologists, physicians with an interest in arrhythmia management, industry representatives, and basic scientists. We wanted to provide the reader with an adequate knowledge of and hopefully a good understanding of clinical electrophysiology. I really think that everyone who reads this will gain some knowledge and a better understanding of this field.
What aspects of EP are you most interested in or passionate about? What are your current research interests?
My main interests in cardiac electrophysiology include novel technologies for mapping and ablation, lifestyle modification in patients with atrial fibrillation, and the epidemiology of atrial arrhythmias. Most of my research falls within these fields, and is mainly translational in nature. There are so many aspects of cardiac electrophysiology that lend themselves to research, and that is one of the most intriguing features of this subspecialty. If we can advance these fields, we can significantly alter the way in which we treat our patients.
You were instrumental in building the complex ablation program at KHSC, which was the first center in North America to use the EnSite Precision Cardiac Mapping System to treat cardiac patients. What are your goals for the program?
The goals of our program are to provide our patients with world-class innovation and care. I believe that by embracing new methods and technological advances, we can try to improve clinical outcomes. We have been instrumental in embracing new techniques and technology for these purposes, and I am always interested in looking at novel technologies. We have gained vast experience on the use of new technologies, and there is a lot that is on the way to the clinical arena.
You post frequently on Twitter. What do you find important or beneficial about the use of social media in healthcare?
I find that social media — Twitter in particular — is an excellent forum to share interesting cases as well as gather thoughts and opinions from colleagues around the world. It also provides me with an opportunity to globally interact with other physicians and gain a better and more current view of their practice. Although traditional peer-reviewed journals are still fundamental for the advancement of education, the emerging role of social media is also extremely important. I feel that in mainstream cardiac electrophysiology, there is a significant amount of self-regulation and moderation due to the participation of very experienced and highly respected physicians.
What advancements in the management of atrial fibrillation and ventricular arrhythmia do you think we’ll see in the near future?
That’s a very intriguing question. I would answer this by saying that the way we deliver care, from detection, early management, invasive ablation technology and techniques, and monitoring, will change radically in the next 2-3 years. With regards to atrial fibrillation, alternative outpatient management strategies that reduce the need for emergency room visits, pre-ablation imaging to stratify patients to different techniques (or no procedure), and a better understanding of mechanisms in order to alter strategies, are the obvious issues which need to be addressed. In ventricular tachycardia, we need to examine whether procedures should be performed at an earlier stage, as well as examine optimal mapping techniques and ablation strategies. Significant developments in mapping and ablation tools are required specifically for ventricular tachycardia rather than using technologies extrapolated from atrial fibrillation ablation. The good news is that I see us accomplishing this and more.
What’s next for you?
We have established a very collaborative environment across Canada, and I am now in the process of creating a group of invasive electrophysiologists who are interested in collaborative research and innovation. I would love to expand this to include international physicians who have an interest in invasive arrhythmia research. I have a very keen interest in innovation, and am working on developing novel catheters that I am confident will play a significant role in the future of cardiac electrophysiology. I also have a strong belief and commitment in developing zero fluoroscopy procedures, which I believe are the future in our field.
Is there anything else you’d like to add?
I think it is important that we try to encourage trainees, females in particular, to consider a career in cardiac electrophysiology. Electrophysiology is a very attractive subspecialty for many reasons, but the most important is that we haven’t yet found all the answers. I am very happy that I have chosen this career, as it keeps me continually intrigued. I hope that trainees reading this will find some inspiration from this article, which may encourage them along this path.
In addition, as chair of the annual Canadian Heart Rhythm Society (CHRS) meeting, which takes place September 14-15 in Ottawa, Ontario, that we can attract more international attendees. The conference features a lot of discussion on catheter ablation for the management of atrial and ventricular arrhythmias as well as complex device management. Details are on the CHRS webpage.
Disclosure: The author has no conflicts of interest to report regarding the content herein.