Practical Electrophysiology, Second Edition: Interview with Todd J. Cohen, MD

What prompted you to write the second edition of Practical Electrophysiology?

The first edition of Practical Electrophysiology served a need in the electrophysiology community. This book provided an essential reference for ancillary personnel, cardiology fellows, and cardiologists, as well as a beginning book for electrophysiology fellows. This book was published approximately three years ago. Within that period of time, there have been significant advances in electrophysiology and its technology. The field has advanced with respect to implantable devices and the techniques used for catheter ablation. All of this needed to be updated. In addition, healthcare professionals and electrophysiology staff members require a background in basic and advanced cardiac life support; there was no short and easy review reference for these techniques as they relate to electrophysiology. Therefore, a chapter has been added to the book with respect to cardiopulmonary resuscitation, the essential drugs, and the important algorithms needed in this regard. In addition, my earlier edition did not have any significant mention as it relates to lead extraction, a technique that is becoming more and more common. Thus, a lead extraction chapter has been added to this edition as well. Finally, the initial book garnered significant positive feedback from the electrophysiology community. One of the things that was missing, however, was testing to assess the reader’s knowledge of the information contained in this book. I have subsequently added a series of three quizzes in order to test one’s proficiency.

Is this book still considered an “EP 101” guide for beginners? Who will get the most out of reading this book?

As time has advanced, with this second edition, the scope of the book has continued to advance as well. The first book can certainly be considered an “EP 101” guide. However, I would consider the second edition an “EP 101 Plus” guide for beginners as well as those with intermediate healthcare backgrounds. The individuals who would gain the most from this book would be electrophysiology staff, both new and old. It is a very good review, even for those who are experienced in the EP lab. It updates all the latest guidelines with respect to implantable devices, including atrial fibrillation ablation. In addition, it is a very useful guide for those who are learning cardiology and rotating in the electrophysiology field. I have used this for fellows on the rotation and have received positive feedback. In addition, it is a useful introduction for those who are studying electrophysiology. In fact, it may be a useful review of the most recent guidelines for those who are considering certification and/or re-certification in electrophysiology. The book is very visual and offers many electrograms and images. The vendors and field engineers that sell and service the interventional products and implantable devices will find this book to be very useful as well. The latest techniques are discussed and photographic images of the most recent devices, catheters, imaging/navigation tools are displayed. The book not only talks about interventional devices and products, but also includes pharmacology and even mentions a newer investigational drug known as dronedarone that is coming down the pike. This is an amiodarone-like drug with the potential for less side effects that might be useful in treating atrial fibrillation.

Tell us more about the new chapter on basic and advanced cardiac life support. Why was it important to add this information in?

This important chapter was written by Douglas Beinborn, MA, RN, who works in the electrophysiology laboratory at the Mayo Clinic. In the electrophysiology laboratory we perform catheter ablations and device implants of all types. Occasionally patients may experience a complication such as myocardial perforation (cardiac tamponade) and/or cardiac arrest. Understanding and effectively implementing basic and advanced cardiac life support is critical to effectively treating and restoring myocardial and cerebral circulation and achieving a good outcome. Basic and advanced cardiac life support is essential for all licensed members of the EP staff (including physicians). The current guidelines have evolved over the years to include more quality chest compressions during cardiopulmonary resuscitation (with less frequent ventilation). In addition, there have been changes in the drugs that have been recommended (i.e., a change from epinephrine to vasopressin). Beinborn updates this information in a very simple and meaningful way as it relates to electrophysiology. A table of the important medications, route of administration, and frequency of delivery is included (see table excerpted from book chapter in Figure 1). Essential algorithms obtained from the American Heart Association’s latest guidelines are reproduced; these demonstrate the treatment of such conditions as bradycardia, tachycardia, and pulseless electrical activity. It is important to note that each and every licensed personnel is required in our EP laboratory to maintain active certifications in both basic and advanced cardiac life support. These certifications last only two years, and the re-certification process should be considered at least six months before certificate expiration. This new chapter will help review the latest guidelines and help one prepare for certification and/or re-certification in both basic and advanced cardiac life support. Another new chapter is about lead extraction. What can you tell us about this? Lead extraction is gaining more attention. Especially in light of the Sprint Fidelis lead recall (one of the largest lead recalls of all time), questions have been raised about removing all potentially defective leads. Recently, the Heart Rhythm Society posted on their website the results of a Mayo Clinic study, which demonstrated that abandoning old defective leads may be prudent without subjecting the patient to the risks of extraction. This study by Dr. Michael Glikson and colleagues investigated the Mayo Clinic ICD database in order to identify 101 abandoned leads over almost a 10-year period. They concluded that it may be appropriate in many instances to abandon leads rather than perform more risky lead extractions. This is highlighted in the book’s new lead extraction chapter (see book excerpt in Figure 2). In general, awareness of the indications for lead extraction and conservative management is prudent in the current era of high quality, low cost medical care.

The last chapter discusses future advancements in electrophysiology. How is robotic catheter navigation changing EP?

Robotics is here to stay. Electrophysiologists do not want to wear lead, and they want to remove themselves from the potential long-lasting effects of radiation. The very complicated electrophysiology procedures such as ventricular tachycardia and atrial fibrillation ablation are long and tedious procedures, which in the past required lots of lead and lots of radiation exposure. Electrophysiologists want to sit in a more comfortable environment, without wearing lead shielding, and remotely be able to manipulate the ablation catheter in order to perform complex ablations. Companies such as Stereotaxis and Hansen Medical have pioneered the implementation of robotics for remote navigation of EP catheters. These companies have demonstrated the feasibility of robotics and remote catheter navigation. The problem, however, relates to the size, complexity, and cost of the currently approved systems. Catheter Robotics, Inc. has developed a less complicated system that utilizes standard catheters and sheaths along with its low-profile robot. It is simple, lightweight, easy to manipulate, and compatible with any electrophysiology laboratory without additional construction or space. The Catheter Robotics system (which is close to beginning their FDA clinical trial) has the potential for a more affordable remote navigation system, which would make robotics more readily available.

What other new features will people find in this book?

All the devices and catheters have been updated in the book. Simple tables exist that clearly identify the new indications for the various procedures, including catheter ablation and device implantation (Figure 3). The essential documents and current EP lab inventory are included. There are updated patient care forms, which help demonstrate effective ways to perform preoperative, operative, and post operative care, including ACT levels, weight-based isoproterenol administration, and dofetilide administration. Test questions have been added to help assess the reader’s proficiency in different areas and potentially help certify/re-certify them for a variety of examinations/degrees (see example in Figure 4). In addition, the Appendix section and information about the materials currently used in modern EP labs have been updated. There is now an algorithm for treating dofetilide, and information on the investigational drug dronedarone, which is awaiting U.S. FDA approval, is also mentioned. Essentially, the book has been entirely reviewed and rewritten where necessary. It has been updated for 2009 and beyond. Hopefully, the readers will find these new features very helpful in understanding and/or reviewing electrophysiology.

What do you find most intriguing about current research in electrophysiology?

Personally I am excited about robotics. Having helped develop the robotic system used in the Catheter Robotics remote navigation system, I believe that a lower cost, simpler system using standard catheters has a huge appeal to the electrophysiology community. I am also excited about research that could lead to improved implantable device and lead performance. I am investigating a number of new advances in the area of implantable cardiac monitors and electronic medical records. I believe that latter will be very important in our current economic climate under the Obama administration. I think improvements in pharmacology might help to re-invigorate drugs as a weapon against arrhythmias. I am intrigued about research as it relates to biologics and other investigational drugs. The ability to deliver stem cells and other biologics into certain diseased areas of the myocardium and potentially improve conduction in the AV node and/or areas of myocardial scarring, fibrosis, and/or old infarction is also intriguing.

How have you incorporated the Practical Electrophysiology book into your practice?

When the book was first published, I utilized it during the cardiology fellows’ electrophysiology rotation. During the one-month rotation, I had them read the book and focus on the clinical EP chapters that relate to the basic mechanisms of arrhythmias, pharmacology, electrophysiology studies, catheter ablation, the specific arrhythmias, implantable devices, and the conditions of syncope and congestive heart failure. I had them focus in on the indications for the various procedures, which are clearly indicated in tabular form. In addition, I had them utilize the electrograms included in the book in order to better understand what we actually do during a clinical electrophysiology study and catheter ablation. I also gave the book to all of my EP staff members and made sure they read it. This helped enhance the general understanding of electrophysiology in our EP labs. The book has been given to or used by most of the new EP staff members when they enter my lab. In addition, house-staff who have chosen to participate in research in our area have used the book as a primer before delving deeper into EP research. In addition, I have given this book to students and house-staff during their electrophysiology rotation, and they have used this book as their core curricula. I have also given it to the general cardiologists and their staff members. They have been very appreciative of this easy reference book, especially because of its clear access to the latest EP and device guidelines. It has been particularly useful in the cardiology practices to reinforce the ejection fraction cut-offs for primary and secondary prevention implantable defibrillators. It also is useful at summarizing the criteria of those who can benefit from cardiac resynchronization devices. Overall, the book sits in my office. I often use it (together with its many pictures) to explain a particular condition, device, or procedure to my patients and their families. At times, I have allowed patients and their families to read selected sections in order to understand their condition.

What other projects are you currently working on?

I am currently working on a book entitled A Patient’s Guide to Heart Rhythm Problems. The book is hopefully going to be published by the Johns Hopkins University Press in 2010. This book is geared towards the public, and has already received the endorsement of the Sudden Cardiac Arrest Association. The latter association is a very important, not-for-profit patient advocacy group for those who have arrhythmias and may be at risk for sudden cardiac arrest. I have recently been invited to serve on their medical advisory board, and have accepted their invitation. I am also very interested in philanthropy in other areas, and am trying to help with a number of projects. I serve on the board of trustees of the Nassau County Art Museum and help with the museum’s projects, including the Art and Exhibition Committee. Other philanthropy projects relate to my son's school, The Summit School, Queens, as well as the Port Washington Special Education Parent Teachers Association. I have been successful with my inventions related to new methods of CPR, novel sensor detection in implantable pacemakers and defibrillators, and LV access tools. More recently, I have been helping Catheter Robotics Inc. move my robotics invention forward into its clinical trial, with the hope of gaining FDA approval. I am also working on a number of improvements in implantable devices, and a novel electronic medical record system, which makes critical heart information available anytime, anywhere.

Is there anything else you would like to add?

I am very appreciative of the support I have received from my CEO, Mr. John Collins. He is a can-do individual with a keen mind towards finance and healthcare. He is a very practical and sensible man who has encouraged me to continue my creative venues, including the second edition of Practical Electrophysiology and my upcoming book, A Patient’s Guide to Heart Rhythm Problems. I would also like to thank the support that I have garnered from my wonderful wife, Jill Cohen, and my children, Brittany and Justin. Having a loving and supportive family is very important in being able to complete projects such as the second edition of Practical Electrophysiology, as well as my other upcoming layperson EP book. In addition, I would also like to thank my family for allowing me to have the time “to sow my creative oats” with my various inventions including the robotic system, various catheters, and pacemaker/defibrillator innovations that I have helped to develop. Finally, I would like to thank HMP Communications for their support and encouragement as I have worked with EP Lab Digest, The Journal for Invasive Cardiology, as well as my published books.

For more information, please visit: www.practicalep.com