Tell us about your medical background and how you came to work in the field of electrophysiology. What interested you about this field?
I completed my undergraduate studies and bachelor’s degree at Johns Hopkins University. I was fortunate to complete my undergraduate curriculum in three years, and therefore, entered medical school early in my home state at Louisiana State University (LSU) in New Orleans. I completed an internal medicine training program at LSU. Adult cardiovascular medicine training was performed at Ochsner Clinic Foundation in New Orleans. I was fortunate to spend the last seven months of my cardiology training working alongside adult and pediatric electrophysiologists at Ochsner. This provided me with a strong foundation prior to entering a formal electrophysiology training program at the University of Maryland under the tutelage of Drs. Stephen Shorofsky, Timm Dickfeld, Magdi Saba, Robert Hood, Robert Peters, and Anastasios Saliaris. After that, I left for Fort Lauderdale, Florida, to help contribute to an electrophysiology program at Holy Cross Hospital, and have been enjoying it ever since.
While in general cardiology, the broad scope of procedures and management decisions that electrophysiologists perform captivated my interest. Electrophysiology is a blend of minor surgery, internal medicine, and good old-fashioned tinkering, or as we say, “electro-fiddling.” To be a sound electrophysiologist, you have to have good “hands” as well as a sharp mind. Dr. Shorofsky would constantly force me to think my way through each case. He shunned rote memorization — it has no place in his electrophysiology lab — one had to understand the basics of arrhythmia and device mechanisms, and demonstrate this knowledge on a daily basis. Most importantly, he imparted a healthy respect for the unknown. There is no shame in stopping a procedure when you just don’t understand what is going on and revisiting the case another day.
Describe your position as Medical Director of the Holy Cross Hospital EP laboratory. What is a typical day like for you?
Holy Cross Hospital has a rich history when it comes to electrophysiology. Our EP labs first opened in the early 1990s under the directorship of Dr. Richard Luceri. In approximately 2003, Drs. Philip Zilo and Ahmed Osman assumed the role as co-medical directors. In 2011, I assumed the EP medical director role at Holy Cross Hospital, and we have accomplished a lot. When I stepped into this role, we were still performing procedures in a makeshift lab because our old EP labs required a facelift. We literally redesigned two old EP labs from the ground up. I was heavily involved in the design elements, as well as in the planning and construction of the labs. The biggest challenge, and what I considered my foremost responsibility, was to ensure that these labs were inviting and friendly for other electrophysiologists in the community to bring their patients. Now that the labs are complete, we are focusing our efforts on strengthening our EPS staff and instituting effective nursing management, which will allow for “on-time” and faster room turnaround times. There is a formula for building a successful EP laboratory, and it involves having the right equipment, effective and well-trained EPS staff, an engaged hospital administration, and a motivated EPS director. We are achieving our goals.
For me, a typical day is always a balance between procedures, seeing patients in the hospital, seeing office patients, and handling my administrative responsibilities. I’ve found the easiest way for me to manage that is to separate my procedural days from my office days, so I can devote myself fully on those designated procedure days. During downtime between procedures, I can handle administrative tasks and maximize my efficiency.
Tell us about building the new state-of-the-art EP lab at Holy Cross Hospital. What new technologies does the lab include, and what are the benefits of this new technology?
The renovated electrophysiology lab officially reopened in March 2011. The lab features a Philips Allura Xper FD10 fluoroscopy system and EP cockpit. One of my main interests was to reduce radiation exposure to not only the patient but also the staff and physician, so it was important to have the right fluoroscopy equipment in the lab. The Philips product allows me to utilize low frames per second while maintaining image quality. I have also been thrilled with being able to organize all of our third-party vendor equipment on an equipment rack, and in effect, organizing the clutter that is typical of many EP labs.
I am most excited about the rotational angiography that is part of the Philips fluoroscopy equipment. In our lab we’re starting to get involved with research protocols utilizing some of this technology, evaluating how we can use it to advance our ablation work, particularly in the arena of atrial fibrillation ablation. We’re trying to find new ways to use the technology that is available in EP to speed up our work, reduce radiation exposure, and improve patient outcomes. Practically, I don’t think it would be a stretch of the imagination to see rotational angiography replace pre-procedural CT scans prior to an atrial fibrillation ablation. The benefit to the patient would be less radiation exposure. The trick is to work a new technology into one’s workflow process in an efficient manner which is not disruptive.
At the end of the day, there are many excellent electrophysiology labs across the country that rightfully can claim themselves as “state-of-the-art” facilities. With the right mix of technology, a genuine drive to contribute to the academic research arena, and motivated medical leadership, it is my sincere hope that the Holy Cross Hospital EP laboratory will be considered one of those “state-of-the-art” facilities.
What challenges did you encounter during this process?
In building an “integrated” electrophysiology lab, we routed all the third-party pieces of equipment that go into an electrophysiology lab through a Philips-based platform. The main challenge was making sure that all of the equipment — the 3D mapping equipment, intracardiac echocardiography, stimulator and recording machines, and ablation equipment — fully integrated with our Philips display monitors without glitches. I would be fibbing if I said there were no glitches, but I am pleased with the level of support that industry provided in getting the job done.
Tell us about your research interests, including your work with the ALERTS and ASSESS-AF trials.
Holy Cross Hospital recently restructured the Jim Moran Heart and Vascular Research Institute, which receives support from JM Family Enterprises, Inc. It is through this institute that I am able to participate in the research process. We were the first in South Florida to participate in the ALERTS trial, a clinical device investigational trial of the AngelMed Guardian System. The trial is designed to test the device’s ability to detect the early onset of an acute MI in at-risk patients, which can alert the patient through an audible and vibratory signal to either see the doctor or go to the emergency room. We were able to bring this technology to Fort Lauderdale because we had a research infrastructure as part of our institution. Once we demonstrated we could adequately enroll patients and collect data in an appropriate and diligent manner, this led to other opportunities.
Another trial we are involved with is the ASSESS-AF trial, which is a national trial run by Dr. Andrea Natale and Dr. James Edgerton, looking at implantable loop recorders for the monitoring of atrial fibrillation burden pre- and post-AF ablation.
We were recently notified that we will receive funding to engage in a randomized comparison of rotational angiography/electroanatomical mapping fusion versus CT/electroanatomical mapping fusion to guide atrial fibrillation ablation. This is an exciting opportunity for our laboratory, as it provides us an opportunity to collaborate with Dr. Michael Orlov in Boston and Dr. Pierre Jais in Bordeaux, France, recognized leaders in electrophysiology.
Discuss your development of a “Best Practice” algorithm for the implantation of ICDs. What does this entail?
In light of the recent news media reports about overutilization of ICD therapy, we took it upon ourselves to evaluate how we as an institution are performing when it comes to identifying patients who meet the criteria for an ICD. We devised a simple one-page checklist that would substantiate the clinical criteria that a patient meets prior to receiving an ICD. I am proud of the proactive role Holy Cross Hospital is taking in “getting with the guidelines,” and I am honored to play a role in a worthwhile endeavor.
Tell us about your participation with medical relief efforts during Hurricane Katrina. What was that experience like?
Hurricane Katrina happened in the first year of my cardiology fellowship. When Hurricane Katrina struck, it wiped out LSU’s Charity Hospital, it completely took out Tulane Hospital, and actually Ochsner Hospital was one of the few hospitals that remained open during the entirety of the hurricane. My wife and I had evacuated New Orleans, and we were able to get back into New Orleans the day after Katrina on a military medical caravan. We went to the hospital and stayed there for a week straight, camping out in the hospital and providing relief to patients currently there, trying to Helivac them out. The first week was total anarchy — there were random acts of violence, sniper fire, and pervasive lawlessness. However, the city of New Orleans persevered and got through this difficult time. My wife and I gained a renewed respect for the resiliency of the human spirit in the face of adversity.
What advancements do you hope to see in the field of cardiac EP?
There has been some exciting growth in the management of atrial fibrillation. Just five years ago I remember hearing lectures that we shouldn’t consider an AF ablation unless the patient is symptomatic and they’ve failed two antiarrhythmic drugs. Now I see people consider AF ablation when they’re symptomatic and have failed one antiarrhythmic drug, or even consider AF ablation as first-line therapy in patients who have documented AF-induced cardiomyopathy. So you can see that AF ablation as a treatment strategy is maturing. In the AF ablation arena, I am excited about technologies that allow us to reduce patient radiation exposure, achieve better catheter contact, and allow us to “see” what we are ablating.
We also need to improve on our ability to detect normal EF patients at risk for sudden cardiac death as well as refine the ability to determine who is at risk for SCD in those patients with an EF less than 35%. That is another key area where improvements have been lacking, but there is new data coming out on how we can better identify those patients who are at risk for sudden cardiac death and need defibrillator therapy. I don’t know if technologies such as T-wave alternans testing, MRI-based post-MI scar volume detection, or other methods will help us achieve these goals, but I am excited about our fellow electrophysiologists who are leading the way in these arenas and look forward to their research.
What advice would you give to others in EP who are currently at the start of their career?
The advice that was given to me remains true, that the keys to success are being available, being affable, and having ability, exactly in that order. As Dr. Shorofsky always taught me, there is no shame in stopping a case when you just don’t know what is going on. Stop, “dial-a-friend” about the case, and revisit it another day. Incorporating these elements early into one’s career will go a long way to help cement a good reputation and a solid base for a prosperous and fruitful career.