Antonio Raviele (Venice, Italy), cofounder of the VeniceArrhythmias congress, implanted the first intravenous defibrillator lead in Italy. He spoke to Cardiac Rhythm News about this experience, his current research, his projects dedicated to enhance awareness on cardiac arrhythmias and the highlights of VeniceArrhythmias 2013
Why did you choose a career in medicine and, in particular, why did you choose to specialise in cardiology and electrophysiology?
I remember an episode that occurred when I was 13. I was with my father and one of his friends, who asked me “What do you want to do when you grow up?” I was not prepared to answer, so I clammed up! To get me out of an awkward situation, my father said: “He does not know yet, but I would like him to become a cardiologist”. This somehow influenced my decision later in life. Apart from this anecdote, the main reason that drove me into medicine was the scientific and human aspect of this profession. Then, I specialised in cardiology and electrophysiology when I started to work in hospitals. I was attracted by the speculative and intellectual nature of these subjects that require continuous reasoning to find the right solution.
Who were your career mentors and what advice did they impart to you?
I had a great mentor, Professor Eligio Piccolo. After graduation, he spent three years in Mexico City, Mexico, at the Instituto Nacional de Cardiologia where Enrique Cabrera and Demetrio Sodi Pallares passed onto him their passion for deductive electrocardiography. Professor Piccolo thought me to be open-minded, intellectually honest and to be ready to share my personal knowledge and experience with other people. I remember one sentence he used to repeat: “Make sure that your door is always half-open and allow everybody to enter and ask you”. This teaching has been always with me.
Of the research you have been involved in, what do you consider to be your greatest achievement and why?
I think that my best achievement is the research in the field of unexplained syncope and the introduction in clinical practice of nitroglycerin test for the diagnosis of the neuro-mediated origin of a loss of consciousness. The possibility to assess the cause of syncope with a relatively simple and easily accessible test has avoided many other more costly investigations that usually have a limited diagnostic yield. Moreover, the discovery of a benign condition as responsible for fainting may have a reassurance effect on the patients, often leading to a strong reduction or even to the lack of syncopal recurrences during the follow-up. Finally, the diagnosis of vaso-vagal syncope helps to prevent the unnecessary implant of pacemakers or implantable cardioverter defibrillators (ICDs) in patients with syncope of unknown origin.
How has electrophysiology evolved since you began your career?
When I started to work in hospitals, electrophysiology was a recently-born subspecialty of cardiology and only had a diagnostic value. In this category, electrophysiologists were allowed to establish the presence and the type of an arrhythmia but were not allowed to make decisions on treatment. Things have changed progressively over time and electrophysiology has become a predominantly therapeutic branch. Nowadays, you can eliminate the substrate of many supraventricular and ventricular tachyarrhythmias with ablation procedures, prevent sudden death with implantation of pacemakers and ICDs and improve heart failure and prolong life with cardiac resynchronisation therapy. Not to mention the current possibility of remote monitoring of diseases and devices.
What has been your most memorable case and why?
Some years ago, I was on night duty and the emergency room sent a patient with an acute pulmonary oedema that was advanced. The patient had the death-rattle on his throat and was almost unconscious. After two hours of intensive care, the patient unexpectedly recovered and then fell asleep. The following morning I returned to the coronary care unit and saw the patient seated on his bed and shaving. I smiled at him and asked “How are you?” Surprisingly, he looked at me and replied “Who are you? I have never seen you before!” This is the good thing of our profession: you can save a life without the person saved even being aware of it.
You implanted the first transvenous defibrillator in Italy, in 1988. Could you tell us more about this experience?
It was an exciting experience and a great progress at that time. Before, you had to implant the device through the abdomen and insert the patches on the pericardium with a thoracotomy. The new approach eliminated the need for surgery and greatly contributed to a widespread diffusion of the ICD. I remember the shouts of joy from the members of the implanting team when the defibrillation test was successful. The great idea of Michel Mirowski had finally become real.
What are your current research interests?
Nowadays, my main research interest is the clinical outcome of transcatheter ablation of atrial fibrillation, especially, the investigation towards the need to continue oral anticoagulation after an apparently successful ablation. Current guidelines (HRS-EHRA-ECAS and VeniceChart International Consensus documents) recommend not to interrupt oral anticoagulation even in the absence of arrhythmic recurrences in patients with CHADS2 score or CHA2DS2-VASc score ≥1. I think that this recommendation is very strict and may put many patients at an unwarranted risk of major haemorrhages associated with the use of warfarin or new oral anticoagulants, as some evidence coming from retrospective non-randomised studies suggest. However, we need large prospective randomised studies to demonstrate the correctness of this assumption.
As a reviewer of various renowned journals, which research paper published, in the last year, do you consider the most interesting?
In my opinion, the paper of Dr Sanjiv Narayan and colleagues published last year in the Journal of the American College of Cardiology (2012; 60:628-36) is extremely innovative and relevant from both a speculative and practical point of view. The paper describes the possibility to use a special software (Focal Impulse and Rotor Mapping–FIRM) to map and ablate localised sources (electrical rotors and focal impulses) considered to be the prevalent sustaining mechanisms for human atrial fibrillation. The elimination of these patient-specific sources was associated, according to the authors, with a high acute and long-term success rate (86% and 82.4%, respectively). This new ablation strategy seems to be particularly useful in improving the ablation outcome in patients with persistent atrial fibrillation. However, future studies from different centres must confirm these very promising initial data.
What are the main research priorities in electrophysiology?
A better understanding of the mechanisms underlying atrial fibrillation in different clinical conditions, the development of techniques and technologies to render ablation of atrial fibrillation easier, safer and more effective, a better identification of patients at high risk of sudden death who really need ICD implantation, and the discovery of the reasons why some patients do not respond to cardiac resynchronisation therapy.
You were highly involved in the HeArtBeats (HAB) Venice Short Film Festival in 2011. Could you tell us more about this initiative and its relationship with the awareness of cardiac arrhythmias?
Movies are emotions and these, like cardiac arrhythmias, accelerate heartbeats making the heart pounding, hence the link between cinema and cardiac arrhythmias and the idea of organising the first edition of HeArt Beats (HAB) Venice Short Film Festival during the VeniceArrhythmias 2011 meeting. The Festival had an eminent jury chaired by the great cinema maestro Francis Ford Coppola and it was composed of authoritative personalities from the movie scene and in the field of arrhythmology, such as Krzystof Zanussi, Florian Henckel, Douglas Zipes and John Camm. The great success of the HAB Festival acted as a sounding board for VeniceArrhythmias and helped to attract the attention of mass media on cardiac arrhythmias, hence to increase the awareness of the general population on this medical problem.
As the president of Alliance to Fight Atrial Fibrillation (ALFA), could you tell us what has been the biggest contribution of this charity to the field of cardiac arrhythmias?
-The awareness of the clinical relevance of atrial fibrillation, especially as far as regards the risk of ictus, is still limited among politicians, public health managers, and even physicians; hence the need for educational campaigns to allow an early diagnosis and an appropriate treatment of this very common arrhythmia. Charities may be very useful generating awareness and may also stimulate health expenditure decision-makers to allocate more financial resources for the management of atrial fibrillation. This is the main reason that Andrea Natale, Sakis Themistoclakis and I decided to create the Alliance to Fight Atrial Fibrillation (ALFA) in 2010. In the same year, ALFA conducted STOP AF, the first Italian awareness campaign on atrial fibrillation. Our association aims at providing, besides information, proper support and access to medical care for patients affected by atrial fibrillation.
–Could you tell us what the highlights of VeniceArrhythmias are for this year?
-The highlights of VeniceArrhythmias 2013 will be: indications and practical aspects of the use of new oral anticoagulants; detection, prognosis and interventions for silent atrial fibrillation; value of transcatheter ablation of atrial fibrillation in different clinical settings; surgical ablation of lone atrial fibrillation; left atrial appendage: new insights and interventions; new technologies and techniques for catheter ablation; syncope 2013 update; hot topics and controversies in arrhythmias and sports; role of cardiac imaging in electrophysiology; early repolarisation and arrhythmias: myth or reality?; novel pacing strategies; clinical lead management issues and optimisation of cardiac resynchronisation therapy.
–How do you see electrophysiology developing in the future?
-I believe that the future will provide us with implantable devices capable of monitoring different vital parameters and diseases, wireless and biological pacemakers, implantable drug delivery systems, genetic therapy, new atrial and ventricular selective antiarrhythmic drugs and innovative software for mapping and ablating the patient-specific substrate in atrial fibrillation.
–The economic crisis is affecting many countries, particularly in Europe. How do you think this will affect healthcare innovation in the field of cardiac arrhythmias?
-This is surely a problem. In Italy, for example, the Italian Agency for Drugs (AIFA) recently approved (after more than three years since the publication of the RELY trial and with many restrictions) the reimbursement of the new oral anticoagulant dabigatran for the prevention of thromboembolism in patients with atrial fibrillation. The late approval happened only because dabigatran is significantly more expensive than warfarin-without taking into account the net clinical benefit and the cost-effectiveness of the new drug. This scenario also applies to the introduction of innovative electromedical devices. In my opinion, scientific societies, recognised leaders in the field of electrophysiology and patient organisations should join their forces and put adequate pressure on politicians, institutional agencies and health expenditure decision-makers to allow the approval and the adequate reimbursement of innovative healthcare products.
–Outside of medicine, what are your interests and hobbies?
-My favourite hobbies are reading books, travelling, football and photography. I like reading books by Paulo Coelho and visiting exotic countries. I am a big supporter of Milan Football Club and especially I love photography.
Present and past appointments
2010 President of the Alliance to Fight Atrial Fibrillation (ALFA);
1989 President of the International Congress VeniceArrhythmias
2008–2012 Chief Cardiovascular Department Arrhythmia Center & Center for Atrial Fibrillation, Dell’Angelo Hospital, Venice Mestre
2000–2008 Chief Cardiovascular Department Arrhythmia Center & Center for Atrial Fibrillation, Umberto I Hospital, Venice Mestre
1995–2008 Chief of Cardiology Division, Umberto I Hospital, Venice Mestre
1988–1995 Head of Cardiac pacing and electrophysiology Laboratories, Umberto I Hospital, Venice Mestre
1980–1988 Head of Cardiac pacing and electrophysiology Laboratories, Mirano Hospital, Mirano, Venice
1974–1980 Fellow of Cardiology Division, Mirano Hospital, Mirano, Venice
1971–1974 Fellow of Internal Medicine Division, Mirano Hospital, Mirano, Venice
1971 Degree in Medicine and Surgery
1974 Specialisation in Cardiology
Membership to task forces and scientific societies
- Member of the task-force on “Syncope” of the European Society of Cardiology (2001, 2004, 2010)
- Chairman of the task-force for the guidelines for management of atrial fibrillation of the Italian Association on Arrhythmology and Cardiac Pacing (2010)
- Co-chairman of the VeniceChart International Consensus Document on Atrial Fibrillation Ablation (2007)
- Co-chairman of the VeniceChart International Consensus Document on Ventricular Tachycardia / Fibrillation Ablation (2009)
- Co-chairman of the VeniceChart International Consensus Document on Atrial Fibrillation Ablation. 2011 Update (2011)
- Chairman of the EHRA position Paper on Management of patients with palpitations
- Co-chairman of the EHRA Scientific Documents Committee
- Fellow of the European Society of Cardiology (ESC)
- Fellow of the Heart Rhythm Society (HRS)
Member of the Editorial Board of Giornale Italiano di Cardiologia, Giornale Italiano di Aritmologia e Cardiiostimolazione, Journal of Cardiovascular Medicine, Revista Latina de Cardiologia, Cardiology Journal, Europace, Journal of Cardiovascular Electrophysiology, Journal of Interventional Cardiac Electrophysiology, Journal of atrial fibrillation, Scientific World Journal, Arrhythmia and Electrophysiology review.