10-Minute Interview: J. Philip Saul, MD

During my training at the Children's Hospital in Boston, there was a clear need for another pediatric electrophysiologist. I had a background in physics, which made me well suited for the field. In fact, at the time, I had been doing Electrical Engineering oriented research in the Medical Physics group at MIT. There was a case of a 5-month-old patient with multiple recurrent and life-threatening ventricular tachycardia (VT) of 3 varieties: a polymorphic right ventricular tachycardia, probably due to triggered automaticity, occasional torsades de pointes related to a form of long QT syndrome, and monomorphic VT originating in the LV purkinje system. The RV ventricular tachycardia was treated by surgical resection during attempted repair of complex congenital heart disease (biventricular outflow tract obstruction). Only 4.7 kg, he was the smallest patient to ever have an ICD implanted. During a two-week period in the pediatric cardiac ICU post-operatively, he had more than 600 VT episodes, less than 400 successful pace cardioversions, and 70 shocks delivered by the device. Eventually, we took him to the cath lab in the middle of the night and successfully ablated his LV fascicular tachycardia, and at the same time inducing AV block. However, he never had VT again and had his ICD eventually replaced by a dual chamber pacing system. Despite being arrhythmia-free, he had progressive deterioration of ventricular function, leading to a heart transplant at 11 months of age. Now, three and a half years later, he is doing very well. We are involved in a wide variety of studies, in part because of our participation in the NIH-funded Pediatric Heart Disease Research Network. These studies include a randomized trial of steroids for Kawasaki's disease and a cross-sectional study of Fontan patients from 6-17 years of age. Other studies are the NIH-funded Prospective Assessment after Pediatric Catheter Ablation (PAPCA), in which MUSC was the top recruiter, a dose-ranging randomized trial of amiodarone IV, and randomized trials of ramipril, carvedilol and milrinone. We are also active participants in multiple trials of catheter delivered Amplatzer occluder devices from AGA medical. My advice is to build a strong team spirit among all the faculty and staff involved in your program, and strive for absolute excellence and high service in all aspects of patient care. After achieving these factors, a program is destined to succeed. Decades is a long time, but at least in the next few years, I see continued development of 3-dimensional catheter based mapping systems that combine anatomic accuracy with reliable, local electrical signals obtainable in a single beat. Further, I am very much looking forward to the approval of cryoablation in the U.S. to allow for a safer ablation technique for the coronary arteries and AV node in small children. Clearly, continued miniaturization of the ICD technology will be a big plus for kids as well. Finally, accurate assessment of those at risk for sudden death for non-coronary diseases will be good for pediatric arrhythmia management as well.