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Roman Phillips
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Clinical Cardiac Electrophysiology Techniques A...


Recent findings: Multiple recent studies provide supporting evidence for the transition to fluoroscopy-free techniques for both ablations and device implantation. The most frequently used alternative imaging approaches include intracardiac echocardiography, cardiac MRI guidance, and 3D electroanatomic mapping systems. Electroanatomic mapping and intracardiac echocardiography originally used to augment fluoroscopy imaging are now replacing the older imaging technique. The data supports that the future of electrophysiology can be fluoroscopy-free or very low fluoroscopy for the vast majority of cases. As provider and institution experience grows with these techniques, many EP labs may choose to completely forego the use of fluoroscopy. Trainees will benefit from early experience with these techniques.




Clinical Cardiac Electrophysiology Techniques a...



Clinical cardiac electrophysiology (EP) techniques, involving intracardiac recording and electrical stimulation, have been of major importance in elucidating the mechanisms of cardiac arrhythmias. They not only have led to improved interpretation of the surface electrocardiogram (ECG) but have evolved to play a major role in the therapy of tachycardias. This role has changed in recent years, with a decline in EP-guided therapy for ventricular tachyarrhythmias but an increase in diagnostic use prior to curative catheter ablation.


Mark E. Josephson (1943-2017) was an American cardiologist and writer, who was in the 1970s one of the American pioneers of the medical cardiology subspecialty of cardiac electrophysiology. His book titled Clinical Cardiac Electrophysiology: Techniques and Interpretations is widely acknowledged as the definitive treatment of the discipline. He served as Herman Dana Professor of Medicine at Harvard Medical School, director of the Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service[1] and the chief of cardiology at Harvard University's Beth Israel Deaconess Medical Center in Boston.[2]


After spending two years as a research associate with Anthony Damato at the Staten Island Public Health Service Hospital, he published articles on the electrophysiologic basis and anatomic location of AV nodal reentry and map-guided subendocardial resection to cure ventricular tachycardia, a procedure Time dubbed "the Pennsylvania Peel" in honor of the Penn cardiology department's surgical innovation.[4] Josephson's work helped to transform electrophysiology from a research field to a powerful clinical discipline for treating patients.[1]


Josephson has published over 400 original journal articles and 200 book chapters and reviews and is the author of the textbook of clinical cardiac electrophysiology, Clinical Cardiac Electrophysiology: Techniques and Interpretations.[4] First published in 1979, the book has run to six editions.[5]


Josephson worked closely over the years with European cardiac electrophysiology pioneer Hein Wellens, chief of cardiology emeritus at the University of Limburg in Maastricht, Netherlands. For over 30 years, they coached together at high-yield "How to Approach Complex Arrhythmias" course for cardiologists [6] and EP fellows.[7] In the 2000s, they initiated an advanced course "Intracardiac Unknowns" which was attended by most electrophysiology trainees in the USA for over 10 years.


The clinical cardiac electrophysiology fellowship offers an intensive, integrated training experience focused on fundamentals of the specialty as well as the newest technologies and procedures. Our fellowship provides unparalleled opportunities, including clinical electrophysiology, pacing and research.


The Advanced Cardiac Electrophysiology fellowship is a one-year training (beginning 2017 the fellowship will be a two-year fellowship per ACGME) program for fellows who have completed an accredited fellowship in Cardiovascular Disease and who wish to pursue further subspecialty training in cardiac electrophysiology.


The clinical cardiac electrophysiology laboratories at BWH and WRVA hospitals perform electrophysiology studies with catheter ablation, as well as cardiac rhythm management device (pacemaker and defibrillator) implants in over 3,000 patients annually. Our program has specific expertise in complex catheter ablation, including ablation of ventricular tachycardia and atrial fibrillation. We are also a referral center for patients needing advanced device management with laser lead extraction.


Fellows must have as a clinical prerequisite the equivalent of U.S. training in general cardiology, including exposure to cardiac catheterization, cardiac imaging techniques and inpatient management of cardiac patients.


Throughout the fellowship training program, regularly scheduled didactic sessions are held for trainees, providing focused instruction in a broad range of topics in basic and clinical cardiac electrophysiology, clinical pharmacology and fundamentals of clinical research.


Applications for the fellowship are accepted from the opening of ERAS through March from physicians who will have completed a three-year ACGME-accredited cardiovascular disease fellowship by the time the clinical cardiac electrophysiology program begins in July. All applicants must register and complete an application through the ERAS electronic residency application system. We will not accept applications by mail.


We interview approximately 8-10 candidates for the clinical cardiac electrophysiology program each year. Although we receive applications from many well-qualified candidates, it is not possible to interview all who apply. Every effort is made to notify applicants of their interview status in a timely manner in order to allow sufficient time for travel arrangements.


The Journal of Interventional Cardiac Electrophysiology is an international publication committed to showcasing comprehensive, multidisciplinary research in interventional techniques and therapies to manage cardiac arrhythmias. The Journal focuses on original research studies and scholarly scientific reviews encompassing basic, translational, observational, clinical trials, and epidemiology research. In addition, applied engineering studies related to diagnostic and therapeutic interventions in cardiac electrophysiology are encouraged. The Journal will examine advances in devices and ablation techniques in a structured and clinically relevant manner.


Gregory K. Feld, MD, is a board-certified cardiologist and cardiac electrophysiologist. His clinical and research interests include the mechanisms of cardiac arrhythmias and catheter ablation techniques for atrial arrhythmias, particularly atrial fibrillation.


He completed a fellowship in cardiovascular disease and a residency in internal medicine at the West Los Angeles VA Medical Center. Dr. Feld earned his medical degree from Geisel School of Medicine at Dartmouth. He is board certified in internal medicine, cardiovascular disease and clinical cardiac electrophysiology.


This historical paper on clinical electrophysiology covers several centuries. Although invasive clinical electrophysiology started in 1967, many early discoveries (e.g., origin of heartbeat, first ECG in humans in 1887) paved the road to this subspecialty. This paper moves from anatomical discoveries such as the AV node (1906) and sinus node (1910) to the first ablation. We move from Robert Adams (1791-1875) to Karl Aschoff (1866-1942), Wilhelm His Jr. (1863-1934) to Michel Haïsseguerre (1955- ), and from Karel Wenckebach (1864-1940) to Hein Wellens (1935-2020). Several ground-breaking discoveries are discussed. Also, the persons behind diagnoses we all know so well are highlighted, such as Mobitz, Wolff, Parkinson and White.


Many centuries later in Europe, Sanctorius Sanctorius (1561-1636) developed techniques for clinical measurements such as pulse rate [4, 5]. In 1717, Marcus Gerbezius (1658-1718) performed a very accurate pulse analysis and described symptoms of bradycardia, probably induced by a complete AV block. This observation was published after his death [6]. Some decades later, Giovanni Morgagni (1682-1771, a pupil of Antonio Valsalva) described the course of a patient with AV block in De sedibus et causis morborum per anatomen indagatis [6]. In the 19th century, anatomy and physiology expanded when more instruments were invented and made available. It became increasingly possible to do research not only in animals, but also in humans.


Invasive clinical EP is based on the heart catheter technique by Werner Forssmann [13]. EP began in 1967 in Amsterdam, when Dirk Durrer (1918-1984) and Hein Wellens (1935-2020) demonstrated in a patient with Wolff-Parkinson-White (WPW) syndrome that arrhythmias could be initiated and terminated by programmed electrical stimulation (PES). At the same time in France, Philippe Coumel (1935-2004) reported similar findings in a patient with an atrioventricular junctional tachycardia [24-26]. In the early 1960s, Durrer introduced the multi-terminal intramural needle electrode which gave insight into reentry/circus movement as a base for several tachycardias [8]. Wellens described the mechanism of the WPW syndrome [8]. EP was first used to induce ventricular tachycardias (VT) and elucidate WPW mechanisms. Later the effects of pharmacological therapies were studied, as well mechanism of sudden cardiac death [8].


The program is accredited by the ACGME and meets the requirements for subspecialty certification by the American Board of Internal Medicine in Clinical Cardiac Electrophysiology. Fellows are provided with outstanding clinical training in managing arrhythmias and syncope, electrophysiologic testing, radiofrequency ablation, and implantation of arrhythmia and resynchronization devices. They also engage in mentored research that prepares them for careers in academic cardiac electrophysiology. 041b061a72


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