Sumeet S. Chugh, MD is the Associate Director of the Heart Institute, Section Chief of Clinical Electrophysiology, and Pauline and Harold Price Chair in Cardiac Electrophysiology Research at Cedars-Sinai Medical Center in Los Angeles, California. He is also Professor of Medicine at David Geffen School of Medicine at UCLA. Tell us about your medical background and how you came to work in the field of electrophysiology (EP). I had trained as a medical student in India and was just finishing up medical school when I came to Tufts New England Medical Center in Boston. That was almost 21 years ago. I spent two years doing research as well as a year of internship at Tufts, then moved to Minneapolis, where I trained at Hennepin County Medical Center for the rest of my residency. I did my cardiology fellowship at the University of Minnesota, and my two years of cardiac electrophysiology training were at the Mayo Clinic in Rochester, Minnesota. My first faculty job was at the Oregon Health & Science University (OHSU) as an electrophysiologist. I spent about nine years at OHSU, and in the process became section chief of electrophysiology. Recently I found this exciting new opportunity at Cedars-Sinai Medical Center, which I joined in November 2008. These days I divide my time between clinical electrophysiology, research on mechanisms of cardiac arrest and the fellowship training program in clinical cardiac electrophysiology. Describe your new positions at the Cedars-Sinai Heart Institute. What is a typical day like for you? There is something really wonderful that happened at Cedars in 2007. The institution invested heavily in a large umbrella organization for all of heart care, known as the Heart Institute, and named Eduardo Marbán, MD, PhD as director. The Heart Institute includes all cardiologists and cardiothoracic surgeons of the entire clinical and research infrastructure at Cedars. For me, wearing two hats, the day can be quite full, which is putting it simply. In my capacity as section chief of electrophysiology, I am responsible for the running of clinical electrophysiology and training of fellows in the program. There are about 15 clinical electrophysiologists who practice at Cedars; three of them are on the full-time academic faculty, and about 12 are private electrophysiologists, many of them who also have very strong academic leanings. On the other hand, our research programs investigating mechanisms of cardiac arrest as well as atrial fibrillation are active and growing. So a typical week is split between seeing patients who have heart rhythm issues, doing procedures on them (including ablations and device implants), administration and taking care of the research program, which is currently funded by the National Heart, Lung, and Blood Institute. Tell us about one of the more unique cases you have ever been involved with. These days I think the excitement for electrophysiology is in the left atrium. The majority of complex cases that we are doing at Cedars are focused in the left atrium. There have been many unique cases, so it is difficult to choose one, but the cases I find most challenging are patients who have adult congenital heart disease. When they were very young they each had some kind of surgical procedure to correct the abnormality, but as they became adults they’ve come back with various kinds of arrhythmias. Patients who have had the Fontan procedure are particularly challenging, and it takes a lot of effort to try and localize the circuit for usually what are re-entrant atrial arrhythmias. These are the cases that I find particularly exciting and challenging to work on. Tell us about your research in sudden cardiac arrest. Are you currently involved in any new research? In my role as associate director of the Heart Institute for Genomic Cardiology, the major focus of this particular role is to advance science that connects questions in clinical cardiology to findings from the human genome project. For us, a major focus in this regard has been identifying novel mechanisms of sudden cardiac arrest. For the last 15 years we have been focusing on the overall goal of preventing sudden cardiac arrest. But before we even approach that goal, we have to first determine who is at risk. Today the major existing criterion for implanting a defibrillator is having a severely reduced ejection fraction, and it can be a very useful tool. However, from the work we have done on the Oregon Sudden Unexpected Death Study, less than a third of patients who will experience cardiac arrest will actually have an ejection fraction of this kind. So the question is, how do you improve the ability to predict risk, and how do you extend beyond the ejection fraction? Our research group focuses on novel risk stratification methods that will enable us to extend beyond the ejection fraction. There are some really interesting things that we have been involved in. Our most recent findings, published in February 2009, relate to how the prolonged QT interval may be a risk stratification tool that extends beyond the ejection fraction. In addition, the more recent work that we have done involves how you can look for heart spots on the human genome that can either predict who is more resistant to cardiac arrest or can actually predict who is more likely to get cardiac arrest. These are findings that have been accepted for presentation at this year’s Heart Rhythm Society meeting, which is where we will be presenting information about a novel heart spot on the human genome that seems to be very closely connected to sudden cardiac arrest. What is misunderstood about sudden cardiac arrest? I think we have made a lot of strides in being better at resuscitation for cardiac arrest. For example, we now have the automated external defibrillator that more recently has become a useful tool for reviving patients with out-of-hospital cardiac arrest. However, there are really enormous gaps in our knowledge regarding mechanisms of sudden cardiac arrest, so if we are going to be able to prevent this devastating condition, we need a better idea of what the mechanisms are. For instance, if you look at the most common findings in patients with sudden cardiac arrest, at least 80 percent of them will have coronary disease. However, if you take 100 patients with coronary disease, only 10 or 15 of them will ever suffer a sudden cardiac arrest. So even within this large group of patients with coronary disease, we are very limited in identifying the patient who is at highest risk and who will benefit the most. Today we are implanting at least 15 defibrillators to save one life. I believe we need a step-wise approach, and the first step will be in trying to understand who is the best person to get a defibrillator so that we can get the biggest bang for our buck, especially with an economy and a healthcare system that is currently in dire straits. It’s not a matter of implanting more or implanting fewer ICDs — it’s about implanting ICDs in the patients who need them the most. The implantable defibrillator is a very useful tool available to us now, so we need to hone in on ways that will maximize the bang for the buck for the ICD. The second step is to try to understand some novel pathways that create rhythm disturbances. We traditionally have used the substrate and trigger hypothesis where we say there may be an inherent problem in the heart akin to having a “loaded gun”, but that has to be combined with a trigger factor for the rhythm disorder to occur. Our mission today is to expand our knowledge of the kinds of “loaded guns” that are out there, and the different kinds of triggers. We also have to open our horizons to accept and understand genetic tendency, meaning, if one parent has a cardiac arrest, your risk of cardiac arrest doubles, and if both parents have cardiac arrest, your risk increases ninefold. Try to name any other condition known to man that has a 95 percent instantaneous death rate — there aren’t any except for sudden cardiac arrest. Today, even in the United States, on average only five people out of a hundred will make it back home alive after a cardiac arrest. So you can imagine the potential there is for making a dent in mortality by preventing cardiac arrest, or even making some strides in it. Tell us about your involvement with the Clinical Research & Training Committee of the Heart Rhythm Society. This is a very special involvement for me. The future of cardiac electrophysiology lies in the hearts and minds of the young people who choose to work in this field. The HRS Clinical Research & Training Committee is composed of a group of very dedicated individuals who are heavily invested in teaching, most of whom are program directors of electrophysiology programs, who advise and provide oversight to the approximately 100 clinical electrophysiology training programs in the U.S. today. For better or worse, I’ve been asked to take the role of heading this committee for another two years, and I am honored. One of the recent things we are working on that will be in print within the next few months is we are trying to understand altering trends in the field of clinical electrophysiology and how this will affect the future trainee in this specialty. We’ve completed a program director survey that went out to all 100 program directors, and we have received some very interesting responses that we will compile as results in a manuscript, which I think the electrophysiology community will find quite useful. Tell us about your work with the World Health Organization’s Global Burden of Disease Study. What advancements do you hope to bring about or see in the next decade? This was one of the roles that I was initially reluctant to take on because of the time commitment, but now I am really getting very interested in it. I was asked to chair one of the Global Burden of Disease panels for the World Health Organization (WHO). Every ten years or so, the World Health Organization does a Global Burden of Disease assessment for every disease known to man — it can range from HIV to coronary disease. Yet they had never before assessed the global burden of arrhythmias. Our panel will assess the global burden of arrhythmias, and the first task that we are tackling is atrial fibrillation. We are realizing that while the prevalence of atrial fibrillation around the world is rising, the information related to atrial fibrillation is available in only a small part of the world — basically only in Europe and North America. The WHO divides the world into 21 regions, and in the vast majority of these regions, there is very little information even on the epidemiology of atrial fibrillation. Therefore, what I’d love to see in the very near future is more work done on trying to understand the burden of atrial fibrillation, even the basic issues, so we can move on to providing a large part of the world with more information on even just how to prevent stroke from atrial fibrillation. On a similar note, I would also love to see the start of a large prospective, randomized trial of atrial fibrillation ablation versus drugs. Such a study has long been in the planning stages and many of us are hoping that it starts soon so that we can all learn from it. Finally, I’m hoping that as time goes on and as we chip away at the process of risk assessment for sudden cardiac arrest, that we can develop some kind of risk score for sudden cardiac arrest, much in the way that we have developed for coronary artery disease. What aspects of your work do you find most rewarding or challenging? I’ve been blessed to be in a situation day to day where I can go between helping people with heart rhythm problems and then looking at it from the other side of how can I prevent it from happening. There are challenges in juggling clinical care and research, because both can be very demanding, but it is also very rewarding to have this ability to work in both areas. Is there anything you’d like to add? Due to the legacy of pioneers such as Dr. C. Thomas Peter, Dr. Peng-Sheng Chen, and others, the Cedars EP lab has long enjoyed a strong ability to care for patients as well as conduct research. I have the good fortune of having joined Cedars along with two wonderful colleagues on the full-time faculty, both of whom are stellar clinical electrophysiologists. Dr. X. Wang, who is the Director of the Cardiac Electrophysiology Laboratory at Cedars, is a clinical electrophysiology maestro. He was part of the group that performed the first radiofrequency ablation procedure for an accessory pathway in Oklahoma City, and was a co-author on the report subsequently published in the New England Journal of Medicine in the early 1990s. Electrograms talk to him, and we all learn from him. We were also very fortunate to recruit Dr. Michael Shehata, Director of our Device Clinic and Associate Program Director for the fellowship program, who is a dedicated teacher and gifted with a unique ability at both radiofrequency ablation procedures and devices. In addition, the Cedars EP lab has the good fortune of having long been the home of several very talented clinical electrophysiologists, including Drs. Jeffrey Goodman, Charles Swerdlow and Eli Gang, to name a few. There have been recent expansions to the infrastructure, and others are planned for the near future. We are approaching the next decade on a positive note and hope to provide stellar clinical care to our patients while continuing to advance teaching and research in clinical cardiac electrophysiology.