Tell us about your medical background and how you came to work in the field of electrophysiology. What interested you about this field?
My journey so far has zigzagged across 3 continents. I started out in India, where I received my basic medical education and initial training in medicine and cardiology. Soon thereafter I went on a scholarship to Oxford University, UK, where I completed my doctorate (D.Phil.) in clinical and translational electrophysiology. Subsequently, I moved to Boston and went on to complete my internal medicine residency, cardiology and cardiac electrophysiology fellowship at Massachusetts General Hospital, Harvard Medical School. Along the way, I also completed a research fellowship at the Framingham Heart Study and a Master of Science degree in clinical investigation from MIT-Harvard.
In regard to my interest in electrophysiology, this was primarily fostered during my early years of training. I had always been intrigued by complexities of the electrical circuitry of the heart, but it was my research years at Oxford and Framingham that solidified my interest in clinical electrophysiology. Over the years (more so by chance), I have managed to get a sound grounding and education in basic, epidemiological and clinical research in the field of electrophysiology. I really do enjoy taking care of patients, thinking about research and new approaches, and also working with my hands. The field of electrophysiology has provided me this “all-encompassing opportunity” to be a clinician, teacher, researcher, and an interventionalist.
Describe your position at Massachusetts General Hospital. Tell us about the Cardiac Resynchronization Therapy Program.
At MGH, I am the Director of the Cardiac Resynchronization Therapy Program. This is a multidisciplinary program caring for heart failure patients with implanted devices. I founded this program in late 2005, based on the contention that we were not doing enough for our patients with heart failure after implanting them with resynchronization therapy devices. These patients are, as you know, a frail group of ambulatory individuals with implanted devices who receive their care from a variety of subspecialists (i.e., electrophysiologists, heart failure and imaging specialists). At least in our institution at that time, there was no structured cross talk amongst the subspecialists involved and patients were presumably not getting what I would label as optimal integrated care. We all knew that a significant minority of patients receiving CRT devices were non-responders and that we could do more to recognize these patients; we were not proactively treating the correctable causes or using the valuable information from their device “diagnostics.” In fact, most of these patients would come to our attention only after they had already had a significant episode of heart failure exacerbation. So in order to provide better care, we brought together the different subspecialties under one roof in the form of a multidisciplinary clinic.
Through the CRT program, patients are seen by both heart failure and electrophysiology experts during the same visit. At their appointment, patients get their device interrogated and optimized with echocardiographic guidance. As part of an endeavor to gather objective clinical data during each visit, they have a 6-minute walk test and complete a QOL questionnaire. Even though our program is first and foremost a clinical service, nearly 70% of our patients are involved in one or more of our research protocols. The beauty of the program is that we have piggybacked our research component on to the service component in a rather seamless way, which enables prospective research without compromising or changing the clinical care provided to the patient. The data acquired and the lessons learned from our research are quickly brought back into clinical practice. So we are constantly learning and improving the way we deliver our therapy. We do 360 feedback surveys and use the information to help us evolve, morph, and further fine-tune our clinic flow and protocols.
This seems like a novel program and innovative way of doing things. Was it easy to set up?
Like all new endeavors, it had its challenges at the outset. However, being at Massachusetts General Hospital and working with forward-thinking colleagues, things fell into place quite quickly. I think the timing was right and the leadership at MGH felt it was the right thing to do. I must admit that there was some initial walking on eggshells while getting everyone equally enthused and trying to create the infrastructure and support staff. We now have 4 electrophysiologists, 3 heart failure specialists, 2 physician echocardiographers, 3 sonographers, 1 dedicated CRT nurse practitioner, 3 study coordinators, 4 research fellows and administrative support, amongst a host of other collaborative efforts with other divisions. The program is very streamlined, with staff rotating through the clinic on assigned days. The satisfaction of providing integrated, multidisciplinary care along with a productive research environment has kept everyone motivated and desirous of being involved. We’ve been following our patients prospectively and keeping an eye on our outcomes, and I am proud to say that we have reduced heart failure hospitalization and mortality by nearly two-fold in our patients receiving multidisciplinary care.
So what’s a typical day like for you? What are your areas of clinical interests?
That’s a tough question. No one day is similar to another during the course of the week. My time is distributed between seeing patients, doing procedures, teaching, brainstorming with my research fellows and colleagues, administrative tasks, and writing. As a part of my routine, I do end up traveling a lot too. In regard to my typical clinical day, if I’m not seeing patients in clinic I am usually doing procedures. I see patients both in a regular cardiac arrhythmia service clinic as well as in the CRT program clinic (on separate days). Although my research niche and passion lies in the field of CRT, I do a fair number of atrial fibrillation ablations. More recently, a lot of my attention has been focused on the intersection of atrial fibrillation and heart failure, as this is a very sick group of patients who need very specialized care. Interestingly, the most common cause of readmissions amongst the CRT population and other HF patients with devices is usually atrial fibrillation. Therefore, my interests have naturally progressed to this AF-HF arena.
What is one of the more memorable EP cases that you have come across?
I wish I could say there was one. Sometimes the most memorable ones are the ones you had complications with, as they continue to haunt you. Although as much as you would like to forget those one or two cases, I think they teach you lessons, which influence your practice forever. On a more pleasant note, I have had two recent very memorable cases. One was a 70-year-old gentleman with non-ischemic cardiomyopathy, persistent atrial fibrillation, NYHA class III-IV, end-stage renal disease on hemodialysis, and an LVEF of 17%, who after CRT improved his ejection fraction to 62%, making him eligible for renal transplant surgery. Post-renal transplant surgery, he became a dancing instructor at a senior center, and recently got married and started a new antique business. Another more recent patient was a 53-year-old restaurant owner who developed a tachy-induced cardiomyopathy with an LVEF of 16%, NYHA class III-IV, and an enlarged left atrium of 5.8 cm, and consequently lost his business. Post-AF ablation, the patient has stayed in normal sinus rhythm (without antiarrhythmics) with complete recovery of his ejection fraction. He was able to get back on his feet and get his business back in order, which I believe is now booming. Although there are many facets of the procedures that are memorable, somehow it’s the “human factor” that has its largest impact and makes it more meaningful.
What motivates you to continue your work in the EP lab? What aspects of your work do you find most rewarding?
Electrophysiology has this ability to provide immediate gratification. This could be either through a simple single chamber pacemaker or a complex device implant, a simple SVT ablation, or a more complex and involved atrial fibrillation ablation. The opportunity to be able to work with your hands and see immediate results is very rewarding. I think the ability to make a difference in a patient’s life on an instant basis after a procedure is both exhilarating and humbling at the same time. To be at the cutting edge of electrophysiology, I think it is imperative to be actively doing procedures, as this field is constantly evolving and changing. To be able to teach and discuss new and novel strategies, while also coming up with ideas to improve technology, I think it is important to be in the thick of things. Even though there are some parts of the procedure that one might be steadfast and resolute in practicing, I try to think of new approaches all the time. Then again, the opportunity to work with and teach fellows and EP lab staff is very satisfying and stimulating. I’m not sure I can put my finger on one particular thing, as there are several aspects of the EP lab and procedures that motivate me.
One of the other fulfilling aspects of my work is the interaction with the electrophysiology trainee fellows, residents, and research fellows. I take great pride in the achievements of the fellows working with me. I learn a lot from them on a daily basis, and I love seeing them excited by new ideas and working their way through an abstract and then a scholarly paper. Watching this whole process, and seeing them evolve from residents to fellows and then into attendings as they take off in their careers, is exceptionally rewarding. The satisfaction of having touched their life and maybe having inspired them in some remote way (at least I hope) keeps me motivated, and is certainly very rewarding.
Tell us about your research interests. Are you currently involved in any clinical trials?
Honestly, I could go on for hours, and this would no longer be a 10-minute interview! I think I may have already broken that time barrier. So my research interests as I mentioned have been in the arena of device therapy for heart failure and have evolved into the area of atrial fibrillation, especially where it transects with heart failure. I am very proud of our CRT program group and the physicians, nurses, and study coordinators who work with me in it. Between 8 physicians affiliated to the program, who are all principal investigators, we now have 19 different clinical research protocols underway. Many of these are investigator-initiated single-center studies, and some are international multi-center trials. We also have a coronary venous and lead location core-lab for several (currently 3) large multi-center studies with dedicated research fellows. Just to name a few, we are a part of the DIRECT, Echo-CRT study, MADIT-RIT study, IMPACT, PROMPT-MI, Enhance-CRT, Respond-CRT, Block-HF, etc. I have the honor of being the national principal investigator on two of these large international multi-center studies.
While participating in these trials, our home-grown investigative work has been directed at improving patient selection strategies, multimodality imaging, lead implantation techniques and follow-up protocols for patients receiving device therapy. Some of the more recent collaborative work we are involved with is in the arena of biomarkers as well as regenerative cell therapy.
What advancements do you think will be seen in cardiac electrophysiology in the next few years?
The field is moving so rapidly, that whatever I say probably will be outdated very soon. Much is happening on the molecular and regenerative cell therapy end of things. I think the progress here is slower, but the impact of this part of science will greatly influence our treatment strategy. On the device therapy front, I think it is the era of sensors and neuromodulation. Over the next few years, we will see a plethora of sensors, be it either left atrial pressure, PA pressure, or chemical sensors, much of this also spurring from advances in nanotechnology. There will be a host of improvements in battery technology, alternative energies (e.g., ultrasound, etc.), and methods of scavenging energy from motion, etc., that will change the field. There will also be advances in lead technology, whether they be transvenous, epicardial or endocardial. The era of neuromodulation is also descending upon us. At this juncture this is still a black box, and the therapies being developed, although provocative (i.e., spinal cord stimulation and vagal stimulation), will get refined and may influence the way we treat our patients. On the ablation front, the advances in technology are primarily geared toward achieving transmurality and durability of the ablation lesion set. Many alternative energies and catheter systems are evolving, so it’s a fun time to be involved in this area. I do feel that balloon-based technologies are here to stay and will continue to evolve. Over time these will make the procedures shorter and more reproducible amongst operators of variable experience. Robotics, remote navigation, and limited fluoroscopic approaches will continue to evolve, with continually increased adoption over the years.
Do you think recent trends toward healthcare reform will have an impact on the EP community?
That is certainly a loaded question. I will keep my answer brief. Yes, I think there will be significant changes in access to health care providers, reimbursement rates, and payment structures. Much more of what we do in electrophysiology will be driven by strategies that will evolve from comparative effectiveness research. Importantly, I think the adoption of new technology will not be driven by the latest advances, but in fact by data and the economics of outcomes. We are going to be held more accountable for our outcomes, whether it is for long-term survival after ICD implants, heart failure hospitalization in CRT recipients, or better AF control after ablations. While we will certainly have challenges, I think we should look at this as an opportunity to endeavor to do things better. The work environment within institutions must evolve to one of synergy, where we can all work together to enhance patient outcomes. It will be an interesting journey that we will need to embrace while we step out of our comfort zone and create new alignments and alliances.
What advice would you give to others in EP who are currently at the start of their medical career?
I would say, enjoy the ride. Be true to your self and those around you. It’s a great field, and the opportunities are many and diverse. It sometimes takes a while to find your niche and area of expertise. It’s a good thing to keep an open mind and be ready to evolve with the times, as you have to be incredibly lucky or well connected to find what you’re looking for at the very early stages of your career. When I say be an opportunist, I mean take advantage of the situation at hand. It may not be the one you were looking for at the outset, but if you do well at it, it will create additional opportunities for further good work. It’s also a great journey for friendships; there is enough work out there for everyone to do, and the more friends you make along the way, the more successful you will be. Balance is also important! I sometimes still find this difficult, but I think it’s important to set boundaries at the outset, so that you have enough time for family and others that are important in your life. Otherwise, the end result becomes meaningless.