Interview With Todd J. Cohen, MD

What is currently happening in the field of electrophysiology and what are the problems?

Electrophysiology is the most rapidly growing field in cardiology. It is a very exciting time to be in electrophysiology. In particular, we are seeing an expansion in the applications and indications of implantable devices, as well as a broadening of the applicability of radiofrequency catheter ablation. There are two areas of electrophysiology of particular interest. The first is implantable devices and its expansion in patients with congestive heart failure. This excludes not only the possible application of prophylactic implantable defibrillators to these patients, but resynchronization technology. Resynchronization is a technique in which one places pacing wires into the coronary sinus vein as well as in the right ventricle in order to pace the right and left ventricles simultaneously, thus permitting a narrowing of the QRS complex and a more synchronized cardiac conduction pattern. Initial trials have shown that this technique is useful in improving cardiac output and symptomatic improvements in patients with congestive heart failure. There are three U.S. manufacturers working on products to help with resynchronization, which include its application in stand-alone pacemaker systems as well as systems with backup implantable defibrillators. (ESWT), for treating proximal plantar fasciitis. (See News and Trends, December 2000) The second area of interest in electrophysiology is the broadening of radiofrequency catheter ablative techniques to atrial fibrillation. Atrial fibrillation is the most common benign cardiac arrhythmia. Its incidence increases with age. Electrophysiologists are trying to look for focal causes of atrial fibrillation and target these causes for eradication and cure. Thus, a lot of the recent focus has been on finding new techniques and methods that will eradicate atrial fibrillation.

How did you become interested in electrophysiology?

My story is a little unusual in the sense that I got started in electrophysiology at a very early age. At the end of my freshman year in college, I had the good fortune to work with Victor Parsonnet, MD, a well-known pacemaker surgeon at Newark Beth Israel Medical Center. In fact, I spent two summers working with him. The first summer he was involved in the founding of NASPE, the North American Society of Pacing and Electrophysiology. I worked on a number of projects with Dr. Parsonnet over those two summers. The first summer, my task was to tackle lead fracture which was a problem in 1978. They threw me into a room and said Eliminate the problem of lead fracture by eliminating the lead. I therefore worked on a radiofrequency transmitter receiver pacing system in which we eliminated the lead. We actually developed a pacing system, encapsulated it and tested it in vitro. The project culminated in implantation into a dog showing not only its feasibility but its success. I entered a research competition at Newark Beth Israel when I was still a college freshman and was a finalist in the competition. I returned to work again with Dr. Parsonnet the following summer to work on a project comparing dual chamber to single chamber pacemakers. During that summer, I started coming up with my own ideas, some of which were influenced by the fact that I met a medical student who had one of these pacemakers and would get short of breath when he went skiing. This student would bring a programmer with him and would program up the rate of the pacemaker. At the same time that the companies were working on the application of the sensors and two pacemakers to make them more physiologic and increase their rate proportionally, I was coming up with similar ideas while in college. My ideas on rate responsive pacemakers were disclosed to Johns Hopkins University where I was a student. They were shown to all the different pacing manufacturers who were probably working on similar things at the time. However, when the institution s secrecy agreement expired, one of the manufacturers did apply for a patent for the product. I have been fortunate in my career to meet and work with very extraordinary individuals who have greatly influenced my work. One of those individuals was Morton Mower, MD, who was one of the inventors of the implantable defibrillator. I happened to have been in medical school at the Johns Hopkins University School of Medicine where the implantable defibrillator was first implanted and I knew Michel Morowski, MD, who was the co-inventor of the implantable defibrillator. My interest in devices led me to the idea that sensors that applied to pacemakers would also apply to implantable defibrillators. I communicated these ideas to Dr. Mower, who encouraged me to further investigate. Thus, during my residency, I conducted a number of studies very similar to the trials that I did in animals with pacing techniques for bradyarrhythmias and applied them to tachyarrhythmias. By doing this, we demonstrated that sensors can be useful in distinguishing between malignant and benign arrhythmias. For many years throughout my residency and cardiology fellowship, as well as during my clinical practice, I performed a number of animal studies and human trials which demonstrated the feasibility of sensor technology in implantable devices, particularly as applied to implantable defibrillators. I have been fortunate to be able to get a number of patents in this area and I have licensed the patents to most of the U.S. companies that manufacture these devices. I have also had the good fortune to work with Melvin Scheinman, MD, who is like a father to me. I am not the only one who thinks that highly of him; many of his students and Fellows deeply admire and appreciate him as well. There was a ceremony held at this year s ACC to honor Dr. Scheinman together with Douglas D. Zipes, MD. Dr. Scheinman is one of the people who is credited with inventing the catheter ablation technique. In 1981, he performed the first direct current catheter ablation with Rolando Gonzales, MD, a Chilean physician. I spent two years working with him and Jerry Griffin, MD, learning radiofrequency catheter ablation techniques and implantable devices. Jerry is another person who has greatly impacted what I do today. Without these individuals support, encouragement and expertise, I would not be where I am today.

Tell us about your work in the area of resynchronization.

The first animal study ever performed on resynchronization by ventricular pacing was performed by Dr. Morton Mower, back in 1986 or 1987. I was one of the co-investigators on this study. We were using one of the animals for one of the sensor studies related to arrhythmia discrimination. Dr. Mower paced the right ventricle and left ventricle of a dog and demonstrated, by narrowing the QRS complex, that he could increase the cardiac output of the dog. This was the first animal trial on resynchronization and it really paved the way for everything that is coming down the pike now.

Twelve years later, are these products now being used in humans or are they still being tested?

They are still being tested, but one is very close to being released. From the data of the preliminary trials that are being released, I anticipate that within the next six months, we will see resynchronization products on the market in the United States.

You grew up in New Jersey, and attended college in Baltimore; why the West coast for your cardiology fellowship?

I was interested in this electrophysiology before there were implantable defibrillators or catheter ablation. My cardiology fellowship was completed at Stanford University Medical Center. I spent two years training in electrophysiology under Dr. Melvin Scheinman at University of California in San Francisco (UCSF). One of those years was devoted to research in the field. Part of the reason why I chose Stanford was because of its tradition in electrophysiology with Roger Winkle, MD and Charles Sweed, MD. Unfortunately, when I finally was accepted to the fellowship program, both Roger and Chuck had left Stanford and I worked with Bing Liem, DO, who was running the EP program there. Bing was a very supportive individual who basically allowed me to pursue my own ideas. Naturally, it is very unusual for somebody to say to a cardiology fellow, Look, you have your own ideas, run with them but that s exactly what he did. During my residency when I did animal studies, I had the idea that pressure sensors inside the heart could distinguish supraventricular from ventricular tachycardia. I wanted to do the study in humans, which is what I did at Stanford. I applied for a patent around that time and we did human trials, published a paper on it in Circulation, which was just one of many papers that were published on this topic. Dr. Bing Liem, along with the other wonderful people I have mentioned, was supportive and collaborative, not someone who was restrictive in his guidance. LG: Tell us about radiofrequency catheter ablation (RFCA). TC: When I went to the University of California in San Francisco, catheter ablation was being changed from direct current energy in which the catheter was attached to an implantable defibrillator and there was an explosion inside the heart, the barotrauma. The results were somewhat mixed with occasional adverse outcomes. In 1990, when I was at UCSF, companies were just perfecting the technique of RFCA. We had good tools for the first time where we could steer catheters inside the heart attached to controllable radiofrequency energy. We were part of one of the first U.S. trials and first publications on RFCA in patients with Wolff Parkinson White syndrome. We used this technique on almost every arrhythmia. I was fortunate to be part of many of the first series on RFCA applied to various cardiac arrhythmias. We published the first series on RFCA for treatment of bundle branch reentrant tachycardia, ventricular tachycardia, idiopathic ventricular tachycardia, supraventricular tachycardia of every type. It really was a tremendously exciting time.

Where did you grow up? What kinds of hobbies or sports did you pursue?

I grew up in northern New Jersey. I initially lived in Linden, then we moved to Short Hills, New Jersey. Linden was a rather tough area to grow up in, so moving to the Millburn/Short Hills area was a bit of a shock for me because it was such a pleasant place to live people were so nice there. My interests in childhood were clearly in the science and mathematics areas. As a junior in high school, I received a National Science Foundation scholarship to spend a summer at the University of Iowa. There I worked with Dr. James Curtis, a PhD who ran the speech pathology and audiology department. I spent the summer working on the development of differences in sound and phonation related to a talking computer. Dr. Curtis was another important encouraging individual person in my life. Over the summers, my father and I played golf. I was young to start golf at the time, 13 or 14, which of course is not very young today. My folks would drop me off at the golf course and they would go to the swim club. I would spend the whole day playing golf and eventually became a fairly decent player. When I was 14, I was county golf champion and when I was a sophomore at Linden High School, I was number one on the golf team for a while. Linden, however, was not a very good golf high school. When I moved to Millburn High School, which was a more affluent area where golf was popular, I wasn't quite as good a player as others, so I switched to tennis. The tennis team at Millburn was one of the best in the state. We had a student on the team named Fritz Buehning who was an excellent player. He skipped his senior year, got a full scholarship to UCLA, played number one singles there, and turned professional competing with the likes of John McEnroe.

It makes sense that you would choose those two sports if you had a strong interest in physics.

Absolutely.

Tell us about your education at Johns Hopkins University.

At Johns Hopkins, I was initially a biophysics major, but ended up getting a degree in natural sciences. I worked closely there with my mentor and advisor, Michael Beer, PhD, developing arginine-specific labeling for different proteins sort of a precursor to the coding of DNA using electron microscopy. He used to come by the lab when I was working and say, Todd, how are you doing? Are you having fun? That was his attitude. He wasn't grilling me or socratic in nature; he would go up to the different people working in the laboratory and ask, Are you having fun? He would have conferences or gather people together for wine and cheese. It was a very enjoyable setting. I knew I was destined to work in research. but I also enjoyed the clinical aspects of science and medicine. It seemed logical to me that my future career would combine both of these disciplines.

Your wife has a career in the cardiology field, doesn't she?

She is a nurse, but her main job these days is taking care of our children. During my internship at New York Hospital, she was a neurology critical care nurse and eventually became a cardiac critical care nurse in the CCU at Johns Hopkins University. When we moved out to California, my wife worked not only in the CCU at Palo Alto VA hospital, but eventually switched over to cardiac rehabilitation and worked at the San Francisco Heart Institute where she ran their inpatient cardiac rehabilitation program and she did quite a good job of it!

How did you decide to move back to the East coast and settle in New York?

If it were up to me, I probably would have stayed in the Bay area. But really, my wife and I were committed to moving back to the northeast to be near our families in northern New Jersey. I had the opportunity to build an electrophysiology program at North Shore University Hospital and Health System. In 1992, this 1,000-bed institution had no electrophysiology department. After the EP program was up and running, I began implanting devices as a cardiologist/electrophysiologist and started the ablation program. I brought a terrific individual on board with me, Mr. Booker Pulling (the chief technicians from Dr. Scheinman's lab), to perform the ablations at North Shore. Despite limited equipment initially, we lined up a couple of cases and Booker and I got things going at North Shore. The program flourished and grew. By the time I left, there were three electrophysiologists on staff. I was then wooed over to Winthrop University Hospital, which was one of North Shore s competitors in the same area. I did not have to move from my town. Winthrop's EP department enjoyed a lot of support and encouragement from the hospital administration. Winthrop also has a fantastic new chief, Vellore Padmanabhan, MD, who was a very encouraging, supportive individual. I had worked with Vellore at North Shore for four years. He has helped promote and develop our program considerably over the past year. Winthrop is a very down-to-earth hospital with great nursing care and terrific cardiac surgery. According to newly released statistics, Winthrop has the best open heart mortality rates in the state of New York. I think you cannot accomplish your goals all by yourself, so I have surrounded myself with a very good EP team: great nurses and support staff, from transporter to secretary, to nurses, technicians, PhDs all who help us deliver great care to our patients as well as enable us to be successful in the research arena.

What are some of your current goals?

My most recent goal has been to devote some time to philanthropy. I am helping raise money for our hospital and our new electrophysiology center of excellence. I am also assisting the American Heart Association in Long Island in some of the charitable aspects of raising money. I also serve on the committee for the AHA golf classic. LG: Tell us about the CPR device you invented. TC: I was the co-inventor of a device called the CardioPump (at least in Europe and most of the rest of the world). It has also been licensed to a company in the United States called CPRx. Again, everything in life tends to be fortuitous and anecdotal, but I happen to have been a cardiology fellow with Dr. Keith Lurie, who is now at the University of Minnesota. He wrote a silly letter published in the Journal of the American Medical Association (JAMA) called "CPR: The P Stands for Plumber's Helper". This was based on an anecdotal case of an individual who was not trained in CPR who grabbed a toilet plunger when someone was in cardiac arrest, plunged the chest, and succeeded in resuscitating the individual. Dr. Lurie s letter got a lot of laughs and spawned a good number of cartoons, but I thought there was something real there. Thus, I began performing a number of animal trials and conceived the device based on the concept that standard CPR is active compression of the chest with passive relaxation. Perhaps by actively compressing and decompressing the chest (by sucking up on the chest), one might be able to take advantage of the thoracic pump model of CPR and improve the cardiac output, resuscitation and outcome.

Describe the history of the CardioPump s development.

A number of animal trials and some early human trials were conducted. Very soon after, the device was licensed to a Danish company called Ambu International. The company built prototypes of the device which we tested in humans. Low and behold, compared to the standard CPR technique, it showed improvement in cardiac output and circulatory flow. We published the results in JAMA. When I left San Francisco for North Shore University Hospital, one of the first human trials, if not the first, was a randomized study which compared the CardioPump as a first line of therapy to standard CPR. In this trial, we showed that the CardioPump had significantly better improvement in resuscitation compared to standard CPR. The results of this trial were published in the New England Journal of Medicine. A number of other trials were performed both in and out of the hospital. The long and short of it is that now there is a huge body of evidence with a multitude of worldwide trials that have shown this technique is certainly not worse than standard CPR and in many of the trials, it is significantly better than standard CPR. One of the more recent trials by Dr. Plaisance, which was published in Circulation and I believe also in the New England Journal of Medicine, demonstrated in a randomized trial in Paris that this device not only improves resuscitation out of the hospital (as compared to standard CPR), but has also demonstrated an improvement in survival and neurologic outcome at twelve months. The CardioPump is now approved throughout the world.

What about the CardioPump's acceptance in the United States?

The latest manual on advanced cardiac life support lists this as a Class 2 B indication, which is an accepted alternative to standard CPR when the operator is appropriately trained in the technique. Thus, the CardioPump has a higher rating than commonly used drugs such as epinephrine and lidocaine which have received a Class Indeterminate rating. The CardioPump is approved worldwide, but the Danish company was not actively seeking FDA approval in the United States. I anticipate that with all of the clinical trials being conducted and the publicity the CardioPump has received, it will be approved in the U.S. in the near future. LG: What would you like cardiologists to know about electrophysiology? TC: Cardiologists know a lot about electrophysiology. Electrophysiology has gained greater exposure and its indications have expanded to treat patients and improve their lives. Cardiologists awareness is what is helping electrophysiology to grow at a rate of 25% annually.

If you could change the medical environment somehow, what would that change be?

Certainly, the problem of managed care has been a difficult one for physicians. As a physician, you want to do what is best for the patient. Now I have to be on the phone every day with people from the managed care end. For example, I may be scrubbing for a procedure and have to be on the phone trying to justify another day for the patient in the hospital when, in my opinion, this is good medical practice. I think of managed care more as meddling care. With managed care, they are meddling with the good practices of the vast majority of physicians. I want to get my patients in and out of the hospital as quickly as anybody. I think it is wrong for managed care to turn down or make it difficult to keep sick patients in the hospital, when in my judgment, they need an extra day or two of hospitalization; I think such decisions should be at the discretion of the physician and not require approval from a third party over the phone. The managed care problem is something all physicians are confronting today.

Would you encourage someone today with an interest in science to become a physician?

I would discuss the pros and cons about the field of medicine it certainly is not an entirely rosy picture. I work a very long week, which unfortunately takes away from family time and requires a huge commitment to my job. It really is not for the weak of heart; it is for someone who is devoted to the field and committed to the idea of helping patients. That goes for everything I do. I don t need be involved in research, writing or editing, but I am, and it takes a lot of time and devotion. But the medical field is very important to me, so if I have free time, instead of going to a movie, I choose to write a paper or work on a research project or stay later at the hospital. Needless to say, I don t see very many movies! Working in the medical field is a personal choice and an enormous professional commitment.

What is your schedule like on a typical day?

On a typical day, I leave for the hospital at around 7:15 or 7:30 in the morning, arriving there at about 8:00 am to start a procedure. In our lab, we perform about fifteen procedures a day, not all of them invasive. We will average anywhere from six to eleven interventional procedures performed in a single EP lab, which includes device implants. Because I have a single lab, we are probably pushing through two lab s worth of procedures in a day. It requires quite a commitment from the staff and physicians to handle that many procedures in a day while maintaining good patient care; there is no time to dilly dally. If there is any time, we try to make rounds on our patients. We are fortunate to have a large support staff, including physician assistants, who help with the rounds and make sure that the patients receive appropriate pre- and post-operative care. I make sure that I spend the appropriate amount of time as well with my patients prior to their procedure, which is absolutely critical when performing interventions. I return home typically around 8:30 pm. My days are like that probably four out of five days a week. On one of the days during the week, I see an average of thirty to fifty patients. This clinical office day is in the middle of the week to break up my days in the lab.

Do you still have time to pursue tennis and golf?

I really don t fit in much time for tennis or golf. I did get in an enjoyable round of golf at one of the Disney courses called Osprey. As a busy physician/scientist, most of my free time is devoted to my family and kids; I would much rather be with my son and daughter than spend five or six hours playing a round of golf. With the late hours I work during the week, my children are pretty much heading off to bed when I get home, so we don t get much time to talk. I use the weekends to reconnect with them and spend time with them. I do try to get home early one day a week in order to have dinner with my family. All in all, the hours are not easy on my family, but I have a very understanding wife and two great kids.

I want to thank you for spending time to share your insights and experiences in the field.

Thank you.