George Van Hare (The Louis Larrick Ward professor of Pediatrics and director, Division of Pediatric Cardiology, Washington University School of Medicine, St Louis, USA), has worked towards advancing paediatric electrophysiology, as a recognised specialty, in the paediatric cardiology world and the electrophysiology world. He considers that working as a paediatric electrophysiologist is a “rewarding” experience, because it has allowed him to diagnose and cure at a very early stage. He talks to Cardiac Rhythm News about his most memorable clinical case, the challenges of working with children and advises physicians wanting to specialise in this field. As current Scientific Sessions Programme chair and first vice president of the Heart Rhythm Society (HRS) he speaks about the highlights of this year’s meeting.
When did you decide you wanted a career –in medicine?
I remember when I was 12 or so, being deeply impressed by my uncle, Jim Van Hare, who is a primary care physician in Michigan, USA. However, like many kids in the 60s, I also wanted to be an astronaut. I figured I wanted to join the Air Force to become a pilot, go to engineering school and join the space programme. But I was 6 foot 3 by the age of 15 and realised I might end up being too tall to get into flight training, and so I decided to be a physician instead. I would still like to be an astronaut though.
Why did you choose to specialise in paediatric electrophysiology?
I believe electrophysiology is clearly the best specialty in paediatric cardiology. While my echo/imaging colleagues get to make diagnoses, they do not get to fix things. My interventional colleagues help plenty of kids through devices, dilations, and stents, but only rarely have the thrill of making a diagnosis in the lab. Electrophysiologists get to do both: to diagnose and to cure. We get to diagnose and cure in children, who have their entire life ahead of them. It would be hard to find a more spiritually rewarding specialty.
Who were your mentors and what influence did they have on your career?
I have been incredibly fortunate to have had a lot of really great mentors. First and foremost, it was Jerry Liebman, in Cleveland, USA, who inspired me as a fourth year medical student to pursue paediatric cardiology. As a fellow at University of California at San Francisco (UCSF), I worked closely with Abe Rudolph, one of the early founders of paediatric cardiology, and who pioneered infant heart catheterisation. While a fellow, it was Paul Stanger who taught me the most about clinical paediatric cardiology. He noticed that I was the only fellow who enjoyed arguing with him about ECGs, and recognised that I had some potential in the arrhythmia field. Paul arranged for me to do a fellowship in adult electrophysiology at UCSF with Mel Scheinman, followed by a few months in Houston with Tim Garson. Mel has always been my ideal role model-a masterly clinician, a total gentleman, and respected by everyone. My time with Mel started me on my career which has been characterised by continued close associations with adult electrophysiology programmes, and this included my time in Cleveland in the 90s where I got to work with and learn from folks like Al Waldo, from whom I learned so much about arrhythmia mechanisms, and Mark Carlson, who actually taught me how to put in transvenous ICDs.
What have your proudest moments been?
Being president of the Pediatric and Congenital Electrophysiology Society in 2006-08 as well as entering the Presidential track at the Heart Rhythm Society. However, my son Mark was married last autumn to Kelly Stout, an editor at The New Yorker. David Remnick, her boss and editor-in-chief, told me I did a good job with my son. That was pretty neat.
Could you tell us about one of your most memorable clinical cases?
My memorable cases have usually involved children in deep trouble due to an arrhythmia, in whom we have been able to successfully treat them with a full return to health. Several years ago we took care of an infant who presented in cardiogenic shock due to cardiomyopathy caused by incessant atrial tachycardia from the right atrial appendage. The baby was so sick that we crashed onto extracorporeal membrane oxygenation (ECMO) and then the arrhythmia was not adequately suppressed using amiodarone. We were able to perform a 3D map and a successful catheter ablation (using cryoenergy) in this 6kg infant while on ECMO. He was ultimately successfully decannulated and discharged in normal sinus rhythm after full recovery of his ventricular function.
What are your current areas of research?
These days, as a cardiology division director and Heart Centre co-director, I am not actively involved in research as a principal investigator, but work hard to support the efforts of my colleagues. Much of the best clinical research in paediatric electrophysiology is multicentre, and our programme is involved with multiple other programmes investigating various issues, and is leading several projects.
What are the biggest challenges of working –with children?
One challenge is the issue simply of size-our patients can range from 2kg – 200kg. This requires versatility. We deal with the fascinating variety of congenital heart disease, and so you really need to know your way around these structurally abnormal hearts. Finally, children come (mostly) with parents, and one thing I learned from my days in adult electrophysiology is that parents ask a lot more questions about a procedure you are proposing for their child, than they would if they were considering the procedure for themselves.
Please name three research priorities in paediatric cardiology?
First, we need to better understand the ways how the decisions we as paediatric cardiologists make in the care of children can influence their status negatively as adults. Most of our congenital heart patients now grow up and become adults, often with chronic problems which could potentially have been avoided. The best example I can cite, as an electrophysiologist, is the problem of ventricular tachycardia in adult survivors of surgery for Tetralogy of Fallot, related to scars on the right ventricle and chronic pulmonary insufficiency. Second, we are concerned about our use of fluoroscopy and other radiology procedures in children. Radiation exposure is arguably a bigger deal in children than in adults, due to their longer expected longevity. We have some tools now for minimising radiation exposure, but these can be improved. Thirdly, the genetic revolution in inherited arrhythmias continues and learning how to approach the (so far) asymptomatic child with a disease-causing mutation is an ongoing conundrum.
You have co-authored the “2015 SPCTPD/ACC/AAP/AHA Training guidelines for pediatric cardiology fellowship programs”; could you tell us the key messages from –these guidelines?
The main message is that paediatric electrophysiology is a distinct clinical specialty with a body of skills and knowledge that are distinct from those in both paediatric cardiology and adult electrophysiology. However, training programmes are encouraged to use their local adult electrophysiology training programmes as a resource for training paediatric electrophysiology physicians.
You have dedicated a good part of your career to teaching and training; could you describe your greatest achievement in this area?
I have been very interested in finding ways to advance our specialty, as a recognised specialty, within both the paediatric cardiology world and the larger electrophysiology world. What defines a specialty is a testable body of knowledge, and three important elements are training guidelines, specialty certification, and accreditation/credentialing. Training is covered above. I am actually proudest of my role as paediatric chair for the Physician Electrophysiology Examination given by the International Board of Heart Rhythm Examiners (IBHRE). Because the American Board of Pediatrics has no plans for offering “third tier” certifications-such as for paediatric electrophysiology-we needed another approach if we were to provide a test; so we were able to partner with IBHRE in creating a modular examination with a common core knowledge element and additional advanced adult electrophysiology and paediatric modules. Most practising paediatric electrophysiology physicians in the USA have now taken and passed this examination. It is available worldwide and is an important element, furthermore, in becoming recognised as a Fellow of the Heart Rhythm Society.
As the Scientific Sessions Programme chair and first vice president of HRS; could you tell us what the highlights of this year’s meeting are?
The keynote address will be great. Salman Kahn, founder of the Kahn Academy, will be speaking. We chose Sal Kahn because of his focus on novel methods for providing education. He is a great fit for our annual scientific sessions, given the strong focus of our society on professional education. We, as arrhythmia specialists, are involved in education every day. While we certainly are training medical students, residents and fellows, and learning ourselves, I would argue that our most important role is in making sure that our patients have access to excellent educational resources concerning their arrhythmia diagnosis and treatment. Educated patients (and their families) are the best partners in managing their conditions.
What advice would you give to physicians wanting to specialise in paediatric electrophysiology?
I have several pieces of advice. First, start early learning the science and physiology behind the specialty. It is a completely different body of knowledge than the rest of paediatric cardiology. Second, spend as much time as possible with your hands on catheters, in the electrophysiology lab of course, but the cath lab as well. This will pay dividends over the long term. Finally, develop a strong relationship with an excellent adult programme. Paediatric electrophysiology programmes tend to be small and therefore opportunities for mentorship are often limited. Many paediatric electrophysiology physicians, including myself, have been extensively mentored by adult colleagues. It seems that most advances in paediatric electrophysiology start in adults and then migrate to children; therefore, your connection will help you be on the leading edge. Finally, it is just more fun working as part of a group!
Outside of medicine, what other hobbies or interests do you have?
These days, my outside interests are mainly musical. My wife and I are faithful supporters of the St Louis Symphony, which is great, a real gem in our town. I started singing in a church choir about 15 years ago, and I love the eclectic mix of musical styles, from 15th century to modern choral music and gospel. I am a pretty good acoustic guitar player, having played since college, and I focus on fingerstyle blues, although I get to do some bluegrass with friends from my choir from time to time. Lately, have taken up banjo, although I am not allowed to practice at home, at least when my wife is around.
2015- Chair, Scientific Sessions Pogramme and first vice president of the Heart Rhythm Society
2015- Finance Committee, Heart Rhythm Society
2008- Director, Division of Pediatric Cardiology, Washington University School of Medicine, St Louis, USA
2008- The Louis Larrick Ward Professor of Pediatrics, Washington University School of Medicine, St Louis, USA
Honours and awards
2006 Fellow of the Heart Rhythm Society (FHRS)
1999 Fellow of the American Academy of Pediatrics (FAAP)
1991 Fellow of the American College of Cardiology (FACC)
1988 Postdoctoral Award for Excellence in Teaching, Department of Pediatrics, UCSF
2011- Section Editor (Pediatric Electrophysiology) Journal of Innovations in Cardiac Rhythm Management
2005- Congenital Heart Disease
2003- Heart Rhythm
2002- Turkish Journal of Arrhythmia, Pacing and Electrophysiology
Professional Societies and organisations
2008- Midwestern Pediatric Cardiology Society
2008- Cardiac Bioelectricity and Arrhythmia Center, WUSTL
2002- International Society for Computerized Electrocardiology
2001- International Society for Adult Congenital Cardiac Disease
1997- Cardiac Electrophysiology Society
1992- Heart Rhythm Society
1990- Council on Cardiovascular Disease in the Young, American Heart Association
1989- Pediatric and Congenital Electrophysiology Society
1986- American College of Cardiology