10-Minute Interview: George Van Hare, MD

How did you choose to work in the field of electrophysiology? Describe your medical background and what led you to working in pediatric EP.

I went into pediatric cardiology after a short career in general pediatrics in a medically underserved area (inner city Cleveland), paying back the National Health Service Corps. During my fellowship in San Francisco, Dr. Paul Stanger noticed that I was the only fellow who was willing to argue with him over ECG interpretations, and so he knew I had inherited the EP gene and encouraged me to extend my training. I trained initially in adult EP (with Dr. Mel Scheinman and his group at UCSF) and subsequently in pediatric EP in Houston with Dr. Tim Garson and his group. I then returned to San Francisco to start the pediatric EP program from scratch in 1989. In 1998, I returned to the Bay Area to establish the joint pediatric arrhythmia service at UCSF and Stanford, under the auspices of UCSF-Stanford Health Care, which was a clinical merger between the two medical schools in 1997. The merger did not survive, but my partners and I have been able to maintain and build our joint program. I work with several very talented pediatric electrophysiologists: Dr. Kathryn Collins, based at UCSF; Dr. Anne Dubin, at LPCH; and Dr. Kishor Avasarala, who is based at Children's Hospital Oakland and works with us at UCSF.

Tell us about your role as Director of the Pediatric Cardiology Fellowship Training Program and of the Pediatric Arrhythmia Center at UCSF and Stanford. What is a typical work day like for you? What are some of the daily challenges you encounter?

The principal challenge I experience, over and above the expected challenges of doing invasive procedures in children at low risk, have to do with the political relationships between the two medical centers where we work. UCSF and Stanford are both magnificent academic medical centers with extremely strong pediatric cardiology programs, and they certainly compete with each other in many aspects of clinical care in northern California. In truth, the leadership at both UCSF and Stanford have been extraordinarily supportive of the concept of combining forces in pediatric EP, as they recognize that results are very dependent on volume, and that a large program gives us the opportunity of having a critical mass of patients to support a critical mass of faculty. This in turn allows us to do clinical research and train advanced pediatric EP fellows. Still, we do not fit the usual model of a program based at a single center competing with programs based at other centers, so I spend a fair amount of my time explaining our motives and aspirations to various people in positions of authority at both institutions.

Your program is recognized as one of the largest pediatric arrhythmia programs in the United States. Approximately how many procedures does the EP lab perform each week?

Between UCSF and Stanford, we do about 350 cases (EP, ablation, device implant) per year, which comes to an average of 6-7 procedures a week. In addition, it seems like we are always working on a pacemaker case late on Fridays a common experience in this business!

What are the most common pediatric EP procedures performed at UCSF and Stanford?

We do about 50-60 devices a year, and the rest are EP studies (with or without ablation). We have a good mix of bread-and-butter SVT and more complex cases, including postop congenital cases. We have focused on using cryoablation for AV node reentry in children, as well as for anteroseptal pathways and ablations in the cardiac veins. In addition to all that, we do the occasional tilt table test, implantable loop recorder, drug challenge, etc.

What was the most interesting and/or memorable case you have ever been involved with?

They are too numerous to count! My most memorable case was actually my first RF ablation, in 1989, on a 10-month-old with incessant junctional tachycardia. I didn't have a clear idea at the time that the world was about to change for all of us. It seems that pediatric EP has been an amazing roller-coaster ride, with the introduction of amazing technology at frequent intervals and the excitement of figuring out how to use this amazing technology in small hearts and novel anatomy.

I see that you've participated in international work with the Pediatric Arrhythmia Program in Moscow. Can you describe the work you did there?

I've had the opportunity to work with a number of great people around the world. Our effort in Moscow came out of an existing relationship with Heart to Heart (www.heart-2-heart.org) in Oakland, California, an organization that sends teams of pediatric cardiologists and surgeons to St. Petersburg and Samara to do surgery. After her visit to California, Maria Shkolnikova, a prominent pediatric cardiologist in Moscow, invited us to visit with the support of Heart to Heart. We spent an amazing week, doing procedures with their team, taking advantage of their overwhelming hospitality, and seeing Moscow. A high point was seeing Red Square at night under a blanket of snow. We now have an ongoing relationship with them, and are doing some collaborative clinical research.

Tell us about the Prospective Assessment after Pediatric Cardiac Ablation (PAPCA) study. Is this complete? In addition, is your hospital involved in any other clinical research trials in pediatric electrophysiology?

PAPCA is complete, we are just writing the last papers. It was a 5-year multicenter study based at 43 North American pediatric EP centers. It is really the first time the pediatric EP community has done something on this scale, and we have published a number of papers. One valuable resource that came out of the PAPCA study is that we now have very clear benchmarks for expected results of radiofrequency procedures in children, to which new centers and new cardiologists can refer when evaluating their own results. We are involved in a number of other clinical projects. All of our clinical research is performed jointly at UCSF and Stanford, and we are often also able to include patients from affiliated centers such as Children's Hospital Oakland and Children's Hospital Central California in Madera. Notable current projects involve AV node reentry in children, cryoablation for AVNRT, and the evaluation of resynchronization therapy in single ventricle and tetralogy of Fallot patients.

Please describe the program you helped develop at Lucile Packard Children's Hospital (LPCH) to diagnose and treat fetal cardiac arrhythmias.

Fetal cardiology is strong at both LPCH and UCSF, and we consult when arrhythmias are identified in fetuses. These programs are directed by Dr. Lisa Hornberger at UCSF and Dr. Norman Silverman at LPCH.

What is your best piece of advice for others in the field of pediatric medicine?

Find ways to collaborate with other centers in clinical research. It can be very difficult to figure out what the best practices should be in our small subspecialty, given that most centers have only one pediatric electrophysiologist and limited clinical volume. The Pediatric and Congenital Electrophysiology Society (www.pediatricepsociety.org) is an international organization that promotes and organizes this kind of multicenter clinical pediatric arrhythmia research.

What advances do you hope to see in pediatric electrophysiology in the coming year?

I hope that we can sort out some of the issues surrounding the use of cryoablation for AV node reentry in children. Because of the risk of AV block associated with RF ablation for posterior AV node modification, I think that most people in the field would prefer to use cryoablation. However, in many centers, including ours, the risk of recurrence after an initially successful procedure is higher than with RF. We are clearly in the middle of a learning curve, and I expect that soon we will better understand how to do this procedure with a recurrence risk that is acceptably low in children.