EP Perspectives

Sailing in the Lab

Geoffrey Rubin, MD

Columbia University Medical Center; New York, New York

Geoffrey Rubin, MD

Columbia University Medical Center; New York, New York

As the son of an electrophysiologist who was also an avid sailor, I grew up hearing stories of not only resuscitations, but also of the open sea. My father taught me how to properly treat a typical counterclockwise atrial flutter and also how to rig a sail.

Most mornings during my first year of fellowship, I’d run along the Hudson River before going to the hospital: no headphones — just my thoughts and the vista of the boats. It’s not a bad way to start the day, by internalizing the peaceful serenity of the sea and then heading to the lab. 

After a year of pre-lab jogs, the superficial and deep connections between sailing and our electrical calling have become clear.

It’s been said that interventional cardiologists cruise channels while electrophysiologists navigate the ocean. The beginning of fellowship is frequently uncomfortable, confronting the unknown sea. In the laboratory, we develop foreign skills previously unpracticed in our medical training. Using a scalpel, finding a vein after a cutdown, advancing wires, connecting tubing and conducting cables, interrogating and navigating the stimulator console. 

Generally, in both sailing and EP, the hard work precedes the easy walk. The tough vigor of tacking occurs before the comfortable broad reach straight to port. Similarly, the slow, detailed, and careful electroanatomical mapping is required before the satisfying rush of ablation. 

The cerebral challenge of navigating the water mirrors the thinking involved in making a diagnosis in the lab. To paraphrase the seminal electrophysiologist Dr. Mark Josephson, “Don’t be an ablationist, be an electrophysiologist.”1 In other words, don’t be a boater, be a sailor.

Even the mundane specifics of the two activities echo each other. Before the sail and before the procedure:

  • You open the cabin. And you prep the operative field.
  • You wash the boat. And you scrub in.
  • You adjust the main sail, rig the jib, bring the sheets neatly into the cockpit. You position your catheters, hook up the saline drip, and tidy up the lines on the table.
  • You choke the engine, clear the spiders from the deck, and test the radio. You flush the ablator, rid the tubing of bubbles, and test thresholds.

You’re then ready to sail, just as you’re ready to start the case.

On a less concrete level, both endeavors involve the initiation of a journey, occasionally with an unknown destination. On the boat, it’s the sailor and the sea, a predominantly personal fulfillment. In the lab, it’s the physician and the patient. The ultimate objective is a successfully treated arrhythmia — a more scientific pursuit than sailing, although certainly involving a small modicum of self-satisfaction.

The fluoroscopic angled images of the heart — RAO and LAO — are views of the cardiac silhouette from both sides of the boat, the operating table’s windward and leeward. 

The peaceful beating of the heart as the ablator turns septal or lateral invokes the rhythmic thumps of the bow wake as the boat heads to the starboard or port side.

The endocardial crevices, ridges, and pouches seen on the 3D map are the crags and channel markers of the topographic map.

The basic planning of the sailboat’s course is akin to the fundamental EP study. The programmed stimulation reveals an A-H jump, induces tachycardia, and plots the path towards a slow pathway ablation.

And in both fields, the fun finally comes after the work.

On the water, the engine is cut off. All that remains is the gush of the boat’s wake and the sound of sailing. 

In the lab, after creating a complete electroanatomical map, the ideal signal is discovered. The rhythmic noise and comforting hum of ablation is activated.

Then comes the WHOMP of the sail as the boat catches the wind. 

And the termination of tachycardia beeps as the arrhythmia breaks to sinus rhythm.

At the end, the sails come down. The sheaths come out. 

The satisfaction of both beautiful acts is felt by all those involved.

Whether I’m in the EP lab or on a sailboat, I’m reminded of my roots. The world is a little more harmonious when viewed through the lens of cardiac electrophysiology. 

References
  1. Josephson ME. Electrophysiology at a crossroads. Heart Rhythm. 2007;4:658-661.
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