Angelo Auricchio, director, Clinical Electrophysiology Unit, Fondazione Cardiocentro Ticino, Lugano, Switzerland; professor of Cardiology, University Magdeburg, Magdeburg, Germany, and president of the European Heart Rhythm Association, reviews the highlights of his impressive career with Cardiac Rhythm News.
Why did you choose medicine as a career and in particular, why did you choose to specialise in electrophysiology?
I was fascinated with mechanics and electricity when I was a teenager, and cardiology involves both of these. In my view, the heart and the circulatory system is a wonderful piece of machinery that is driven by an electrical system that is both uncomplicated and powerful.
In terms of your career, who or what has been your greatest inspiration?
I had the good fortune to have four great mentors: Aldo Iacono, chief of cardiology at the University of Naples, who educated me on clinical cardiology and cardiac physiology; Pasquale Vitale at the University of Naples, who taught me about cardiac electrophysiology; Helmut Klein, at Hannover Medical School in Germany, who was my mentor in clinical electrophysiology; and finally Bernd Heublein, also at Hannover Medical School in Germany, who was my mentor in invasive cardiology and cardiac mechanics. Professor Vitale was a visionary person and maintained a constant interest in technology. He passed on his enthusiasm, perseverance, dedication to the work and passion for clinical research to me.
However, the colleague who inspired me the most was probably Morton Mower, visiting associate professor of Medicine, The Johns Hopkins University School of Medicine, Baltimore and professor of Physiology and Biophysics, Howard University School of Medicine, Washington, USA. He visited me in Rome in the summer of 1992 and on that occasion, told me about one of his most recent ideas-left ventricular pacing for improving cardiac mechanics.
In your view, what have been the most important developments during your career and why?
There have been several breakthrough developments in clinical electrophysiology: radiofrequency catheter ablation, which has revolutionised our approach to both atrial and ventricular arrhythmias; implantable cardioverter defibrillators, which are now established as one of the mainstays of treatment for the primary and secondary prevention of sudden cardiac arrest; device-based monitoring and electrical treatment of heart failure, which have both significantly challenged our physiopathological understanding of a disease that was previously thought to be an exclusively haemodynamic and/or neurohumoral disorder (ie, heart failure) and have had a profound influence in the appreciation of haemodynamic alteration produced by more traditional pacing; and finally, the evolution of our understanding in channelopathies and related electrical disorders has also been an important development. These developments and several other diagnostic procedures and treatment strategies have contributed immensely to the development of electrophysiology as a main subspecialty in cardiology and to the establishment of electrophysiology as a profession.
What do you consider to be your career milestones and why?
The publication of the long-term results of patients included in the Pacing for Congestive Heart Failure Study (PATH-CHF) in the Journal of the American College of Cardiology in 2002 (39:2026–33) is my career milestone. This study showed that pacing in patients with advanced heart failure improves functional class and improves quality of life. Importantly, it was one of the first studies to indicate that non-pharmacological therapy may possibly reverse ventricular remodelling and affect long-term outcomes.
The PATH-CHF study was designed in the early 1990s and its aim was to obtain as much data as possible about the physiopathology of pacing in heart failure patients. It has allowed us to design novel monitoring features (eg, automatic analysis of heart rate variability), which nearly all cardiac resynchronisation therapies (CRT) now have.
Moreover, the PATH-CHF study demonstrated for the first time (Circulation 1999; 99:2993–3001) that patients with different QRS duration may have different outcomes; we showed that patients with QRS duration ≥150ms were those patients in whom CRT significantly increases exercise capacity and left ventricular ejection fraction, and improves quality of life which may translate into greater survival and lower hospitalisation rate. This notion anticipated the outcome of more than 10 years of clinical research in CRT. Recently, the REVERSE, MADIT-CRT and RAFT studies very consistently showed that patients with QRS duration ≥150ms have the lowest mortality and morbidity after CRT compared with patients with narrower QRS duration.
What other work in your career are you most proud of?
The work I enjoyed most was the design and development of novel leads for pacing the left ventricle and related delivery catheters. The “over-the-wire pacing lead” idea was unique (Am J Cardiol 1999; 83:136D–142D). It was a nice example of knowledge from one speciality transferring to another. Over-the-wire technology was regularly used in invasive cardiology (eg, percutaneous transluminal coronary angioplasty) and prior to the development of the idea, pacing leads were only stylet-driven.
Additionally, at the time, the vast majority of electrophysiologists could only access the coronary sinus when they tried enter into coronary venous circulation. However, I identified the importance of developing a venous map by using balloon-occlusive angiography to precisely assess coronary vein anatomy, understood the need to use proper guidewires to reach specific targets within the coronary veins, and recognised the value of having thin and stable guidewires that are easy to push over a guidewire. Also, I saw that it was necessary to have a collection of pre-shaped delivery catheters to match different anatomies of coronary sinus.
As president of the European Heart Rhythm Association, what in your view are the benefits of becoming a member in terms of career and education?
Since its constitution in 2007, the European Heart Rhythm Association (EHRA) has continually developed its membership subscription as well as the portfolio of educational activities and scientific initiatives at the disposal of EHRA members. EHRA now has about 1,400 paying members who enjoy several benefits. As an EHRA member, one can be appointed by the president to take an active role in each of our committees. This includes being the chair or co-chair of a committee. EHRA members also receive a bimonthly newsletter free-of-charge, which has information on the association’s activities, provides updates about key deadlines.
Also, members receive a significantly discounted subscription rate to EP Europace (the official journal of EHRA and of the European Society of Cardiology Working Group on Cellular Cardiac Electrophysiology), discounted registration to EHRA’s biannual meeting, and a discounted rate for EHRA educational courses and webinars (which take place on a regular basis and provide participants with updated scientific content).
Finally, EHRA members enjoy a facilitated access to the EHRA Fellowship Training Program, which helps fund junior colleagues to spend one or two years in some of the best European electrophysiological laboratories.
As president, one of your goals is to provide more uniform access to the best therapy for arrhythmic disorders across Europe. Why is this so important and what steps have you taken so far to achieve this goal?
EHRA nowadays represents 54 national working groups, which collectively take care of a population of more than 900 million citizens. The significant heterogeneity in care we observe among the 54 ESC member countries represents an opportunity to improve quality and quantity of care in all geographies, which will result in better quality and quantity of life for our arrhythmic patients.
These goals may be achieved:
- By advertising and by supporting implementation of clinical practice guidelines to which EHRA contributes as one of the constituent bodies of the European Society of Cardiology
- By promoting the certification of electrophysiologists and allied professionals who operate in Europe in the field of electrophysiology
- By investigating the reasons for the disparity in treatment using among other resources, the EHRA White Book
- By taking actions in those geographies in which infrastructures for diagnosis and treatment of cardiac arrhythmias are either missing or under developed
- By providing junior, talented physicians who want to start their career in electrophysiology with training grants
In general, what are the main goals of EHRA for 2012 and beyond?
We are aiming to make EHRA a reliable partner for similar large international arrhythmia societies and an increasingly powerful interlocutor for national regulatory authorities, industry partners and commissions operating at the European Parliament. Europe deserves a unified, well-organised arrhythmia association, appropriate to the prestige of European achievements in our field.
You were the lead investigator of the PERMIT-CARE study, which was recently presented at the annual meeting of ESC. What did this study find and what are its implications?
The results of the PERMIT-CARE survey demonstrated that significant functional mitral regurgitation (FMR) is a possible cause for clinical non-response to CRT and that FMR reduction with MitraClip treatment is feasible, safe, and leads to substantial improvement in NYHA functional class and reverse ventricular remodelling. Although the MitraClip procedure in this advanced heart failure population carries some peri- and postoperative morbidity and mortality risk, it is worth noting that nearly all patients were considered not eligible for mitral valve surgery due to a very high estimated mortality risk.
PERMIT-CARE is an hypothesis generating study. If PERMIT-CARE results are confirmed by a properly-designed prospective randomised controlled study, the implication of both PERMIT-CARE and the new study is quite substantial. Indeed, for the first time since introduction of CRT as a therapy of heart failure, we have identified a treatable mechanism of failure of CRT. Moreover, it opens to a new way of thinking in the management of heart failure patients, ie. the use of hybrid therapies (combination of electrical and mechanical therapies) in selected group of heart failure patients.
Which paper have you seen recently that you found interesting?
It is very difficult to make a good choice, the reason being is that there is plenty of excellent and intriguing work I have seen published in different aspects of basic, translational and clinical electrophysiology. I prefer to stay focused on the research field I am most involved with (ie. pacing for heart failure). In a relatively short period, David Kass’s group at Johns Hopkins has revealed profound basic cellular and molecular changes in dyssynchronous heart failure, many of which appear to be characteristic of this form of heart failure and are not observed in synchronous heart failure; moreover, his group has shown how CRT can substantially target these changes and reverse them.
There are several implication of Kass’s work. One of the most immediate implications are is that it lets us speculate that responders to CRT have a molecular signature that could prove to be an important adjunct to the visible wall-motion changes and/or electrical activation sequence upon which we have solely focused up to now. Future studies testing this possibility are needed.
Outside of work and EHRA, what are your hobbies?
I enjoy photography, sailing and music very much.
Professional appointments (selected)
2006–present Director, Clinical Electrophysiology Unit, Fondazione Cardiocentro Ticino, Lugano, Switzerland
1994–2005 Director, Cardiac Catheterization Laboratory, University Hospital Magdeburg, Germany
1991–1994 Attending Physician, Division of Cardiac Surgery, University Hospital Rome, Italy
06/07 1994 Visiting physician, Ziekenhuis Aalst, Belgium
1988–1991 Attending physician, Division of Cardiology, University Hospital, Hannover, Germany
1986–1988 Attending physician, Division of Cardiology, University Hospital, Naples, Italy
Teaching appointments (selected)
2006–present Part-time professor, Division of Cardiology, University of L’Aquila, Italy
2000–present Part-time professor, Cardiology, University of Varese, Italy
1995–present Lecture and seminars for medical students, lectures and seminars for nurses
2005–present Mentor to medical students, Division of Cardiology, University of L’Aquila, Italy
1991–2005 Mentor to medical students, University Hospital, Magdeburg, Germany
1991–1994 Dottorato di Ricerca in Fisiopatologia Cardiovascolare, University of Rome Tor Vergata, Rome, Italy
1985–1989 Specialisation in Cardiology, Federico II, University of Naples, Italy
1979–1985 Medical School, Federico II, University of Naples, Italy
2005 Fritz Acker Award, Deutsche Gesellschaft für Kardiologie
1991 Young Investigator Award. North American Society of Pacing and Electrophysiology
Main research areas
- Clinical electrophysiology: mapping techniques in dilated cardiomyopathies, non-pharmacological therapy of arrhythmias
- Heart failure: non-pharmacological therapies for heart failure
- European Society of Cardiology
- European Heart Rhythm Association (President)
- Fellow of the European Society of Cardiology