10-Minute Interview: Jeffrey Neuhauser, DO, FACC

Interview by Jodie Elrod

Interview by Jodie Elrod

Tell us about your medical background and how you came to work in the field of electrophysiology. What interested you about this field?

I served a three-year fellowship in cardiovascular diseases at Albert Einstein Medical Center in Philadelphia from 1991–1994. I originally intended to become an interventional cardiologist. During my third year, I was involved in over 300 interventional procedures. However, during the 1990s, there was still a fairly high incidence of post-intervention coronary artery restenosis. Because of this, as well as the fact that there was no data that coronary interventions actually impacted survival (except in the case of acute myocardial infarction), I began to wonder what I was actually accomplishing and how much my efforts were really helping people. At the same time, I became extremely interested in the field of cardiovascular electrophysiology — it was just so different than the world of interventional cardiology. I saw EP as a specialty that was very early in its development, with tremendous potential for growth. Since I was a bit insecure with my knowledge of arrhythmias and didn’t really understand the complexities of implantable devices, I saw the study of EP as a personal challenge. Also, the notion that one could “cure” an arrhythmia by ablation was particularly appealing. It was at that point that I decided to pursue an additional fellowship in EP. I was very fortunate to have been offered a position at the University of Oklahoma Health Sciences Center. I trained at OU for two years under Drs. Warren (Sonny) Jackman, Dwight Reynolds, and Ralph Lazzara. During the mid 1990s, OU was an incredible place to train in EP. We received referrals not only from all over the U.S., but from around the world. I participated in ablation procedures on patients from China, Russia, Kuwait, the Czech Republic, and Saudi Arabia. Most of these patients had previously unsuccessful ablations and had recurrences of their arrhythmias. This provided a phenomenal opportunity for me to study the ablations that were performed by some of the world’s most prominent electrophysiologists of that time. On numerous occasions, I was able to learn why these procedures were unsuccessful or why the patients had recurrence of their arrhythmias. In addition, I was seeing a high volume of very unusual arrhythmias that most centers only rarely see. This helped to greatly advance my knowledge and skill set as an electrophysiologist. At OU, there were frequent visitors to the clinical and basic EP labs. Some of these people were prominent physicians and scientists who would share some of their ideas regarding arrhythmias and ablation. On one memorable occasion, Dr. Anton Becker spent several days sectioning a human heart and teaching us the anatomy of the posteroseptal atrium. To this day, I still remember how we analyzed the anatomic relationships of the coronary sinus and septal isthmus. It was a very personal anatomy lesson that I will never forget.

Describe your role at Baptist Health. What is a typical day like for you?

I am an attending physician in cardiology and electrophysiology at Baptist Health. I am part of a single-specialty private practice that consists of 14 cardiologists. I am the only full-time dedicated electrophysiologist at Baptist Memorial Medical Center in North Little Rock, Arkansas. I don’t know if there is any such thing as a “typical” day for me. However, my week is structured such that Mondays, Wednesdays, and Fridays are procedure days, and Tuesdays and Thursdays are clinic days. Yesterday, we had two atrial flutter ablations and a pacemaker implant. Today we had clinic. Tomorrow, we have a VT ablation and two pacemaker implants. The EP lab in North Little Rock has a dedicated staff that includes one CCRN and two RTs, and our clinic is staffed by one RN and one LPN. We perform a diversity of procedures, including diagnostic EP studies, TEE, cardioversion, catheter ablation (including atrial fibrillation ablation), and pacemaker, defibrillator, and CRT device implants, as well as remote device monitoring, Holter monitoring, event recording, echo, and stress testing. Lead extractions are done in the OR in conjunction with a cardiothoracic team.

What is one of the more memorable ablation cases that you have come across?

Over the years there have been so many memorable cases that it’s hard to pick just one. We recently had a patient referred for an AF ablation. During the initial evaluation, we learned that the patient had an ASD repair as an adolescent. I immediately became suspicious that the culprit arrhythmia may not have been atrial fibrillation. Once the ECGs were obtained, it was clear that the patient had some type of atrial tachycardia and not AF. The procedure was performed using 3D mapping. I was expecting a macroreentrant atrial tachycardia around the area of the ASD repair; however, 3D mapping revealed that the area of reentry was along the free wall of the right atrium, more consistent with the site of the atriotomy scar. Ablation along that location terminated the tachycardia. So far, at one-year follow-up, the patient has not had recurrent tachycardia.

I had another interesting case of a previously healthy 34-year-old male who had near syncope and a documented wide QRS complex tachycardia. He apparently had frequent episodes of tachycardia associated with symptoms of light-headedness and near syncope. He was originally referred to another EP and had a thorough evaluation, which included an echo, cardiac catheterization, cardiac MRI, and an EP study. Structurally, he had a completely normal heart. Unfortunately, during the EP study he had only occasional PVCs but no inducible tachycardia. He was started on medical therapy, but continued to have symptomatic tachycardia. Because we had 3D mapping available in our lab, he was referred to us. During the baseline EP study, he had PVCs and a few short runs of NSVT, but no inducible sustained arrhythmia. There was no evidence of an accessory pathway or dual AV nodal physiology. The NSVT appeared to match the ECG of the clinical tachycardia. The ECG was consistent with an RVOT VT. We were able to use 3D mapping to locate the area of earliest activation within the RVOT. Pace mapping at that location yielded an exact 12 out of 12 ECG match with the clinical PVCs and NSVT. It was perhaps one of the most perfect pace maps I had ever obtained. Ablation was performed during sinus rhythm at that location. Because the patient had such infrequent arrhythmia during the procedure, it was difficult to be certain if the arrhythmia was successfully ablated. However, as of nine-month follow-up, the patient is still arrhythmia free, including a recent exercise treadmill test with no evidence of exercise-induced VT.

There is one other case that comes to mind. A male patient in his 50s had undergone pulmonary vein isolation for AF by another EP. He had recurrent AF after about six months, and presented for a second opinion. A review of the ECG suggested that the recurrent arrhythmia may have been a pulmonary vein tachycardia. He agreed to undergo a second ablation procedure. I went into the case thinking that the patient would probably require complete repeat pulmonary vein isolation. However, after 3D mapping was performed, it was evident that there was a small area of breakthrough posterolaterally along the base of the left superior pulmonary vein. A very discrete single ablation at that location along the antrum not only terminated tachycardia, but rendered the patient completely noninducible, even with high-dose isoproterenol. It was one of those cases that was impressive because we were able to find one discreet location for the arrhythmia and perform a successful ablation on a recurrent arrhythmia with essentially one application of RF energy.

What aspects of your work do you find most rewarding? What motivates you to continue your work in the EP lab?

To me, the ability to cure arrhythmias with ablation and improve quality of life with both ablation and devices is the most rewarding. I really feel that we make a substantial difference in people’s lives. This, more than anything else, motivates me to go to work every day.

Tell us about your research interests. Are you currently involved in any clinical trials?

My particular interests include AF ablation, selective and alternative site pacing, and congestive heart failure. We have previously participated in multiple clinical trials involving ICDs and resynchronization devices. We are currently involved with collecting data assessing the efficacy of Medtronic’s Lead Integrity Alert (LIA) software in detecting issues from other manufacturers’ leads.

What are some of the ways you see the EP field changing?

I think the field of EP will continue to evolve in a number of ways. There will continue to be improvements in device technology that will allow for improvements in patient and hemodynamic monitoring, as well as the continued development of subcutaneous devices. Remote monitoring, which has already dramatically changed the way we follow patients, will continue to improve. There will be substantial evolution in implantable loop recorders. In regards to ablation, I think we will also continue to further our understanding of AF, and begin to employ hybrid approaches to ablation. There will be alternative energy sources and methods for delivery of energy. We’ve already seen some of this come to fruition with the cryoballoon. With the advent of left atrial appendage occlusion devices, we will have the opportunity to reduce one of the major complications of AF in higher risk patients that may not be suitable for chronic anticoagulation.

What advice would you give to others in EP who are currently at the start of their career?

EP is a very difficult, challenging, and rapidly evolving field. You can learn from everyone. Focus on three aspects: knowledge base, lab skills, and developing clinical judgment. Regardless of whether you’re just out of your training or if you have some practice experience, when selecting a new position, be very careful to thoroughly assess the opportunity presented. Look very carefully at the practice, the hospital, and the medical community. There are practices that think they have enough to support an EP, but really don’t understand what developing an EP practice actually involves. While visiting the practice and the hospitals involved, try to talk to as many people as possible. When interviewing, if one or more of the physicians speaks critically or negatively about their competitors, walk away from that job and don’t look back. More than anything else, trust your instincts and do what feels right.

When starting a new position, be very selective with the patients you accept to perform procedures on, and if you have any reservations about the patient being high risk for complications, don’t be afraid to decline and manage them more conservatively. I’ve seen instances in which EPs that were new to a practice be referred a backlog of high-risk patients who were very far along in their disease process and probably should have had intervention long before. These are exactly the type of patients who are likely to have bad outcomes from procedures. Whether you are just out of your fellowship or you’ve been out for 20 years, your number one priority in a new practice setting is to keep yourself pristine for at least the first year. Your colleagues and the medical community will be a lot more forgiving of adverse outcomes after you have established a reputation for good work, but this takes time. Perception is everything! I’ve seen good physicians fail because they were referred too many high-risk cases that resulted in too many complications.

Be careful with the way you manage atrial fibrillation. With the explosion of ablation, it can be tempting to get aggressive. One should very carefully select patients for AF ablation. Remember, AF is basically a non-lethal arrhythmia. It can be hard to defend oneself if the patient has had a complication from AF ablation that has left them more debilitated than they were prior to the procedure. Furthermore, it is tragic to have someone die from an ablation of a non-lethal arrhythmia. Also, antiarrhythmic drugs have significant toxicities, and there is no definitive evidence that patients in normal sinus rhythm live longer. The cure should not be worse than the disease. So, when it comes to managing AF, use good judgment! I can’t stress that enough!

Has anyone in particular been helpful to you in your growth as an electrophysiologist?

Throughout my training and career, I have tried to learn from everyone. There have been many people that have been responsible for making me the physician that I am today. In regards to EP, Drs. Reynolds, Karen Beckman, and James McClelland were invaluable in teaching me the academic and clinical aspects of EP. They not only helped me develop my lab skills, but also my clinical judgment. Dr. Mauricio Arruda taught me a tremendous amount about catheter manipulation for ablation. During my training, I reached a point where I was not certain about my direction. Dr. C. A. Sivaram provided me with absolutely invaluable counsel and helped guide me through a very difficult time. One of the most important EP relationships that I have formed in practice has been with Dr. Joseph Bissett at the University of Arkansas Medical School. We spent a great deal of time together developing a safe and highly effective technique for performing transseptal punctures. Throughout my years in Little Rock, Dr. Bissett has been a tremendous friend and colleague.

What medical textbooks or online EP resources have you utilized that you can recommend?

My continuing education comes from numerous sources. I try to attend the Heart Rhythm Society’s annual scientific sessions and read journals including PACE, JCE, JACC, and the New England Journal of Medicine. In regards to textbooks, I prefer those written by Drs. Zipes and Jalife, as well as by Dr. Braunwald and Dr. Josephson. I also use the CardioSource and Medscape websites.

Is there anything else you’d like to add?

I consider myself extremely fortunate to have trained in an environment that was so highly academically stimulating and to have been able to meet and learn from some of the most brilliant minds in the world of EP. I am thankful for the opportunity to have an ever-challenging job where I can make a difference in people’s lives and have the chance to make my little corner of the world a brighter place.

To see another recent 10-Minute Interview, please visit: http://eplabdigest.com/articles/10-Minute-Interview-Kevin-R-Campbell-MD-FACC