Jeremy Ruskin (Boston, USA), professor of medicine Harvard Medical School and director emeritus of the Cardiac Arrhythmia Service and Clinical Electrophysiology Laboratory at Mass General Hospital (MGH), has mentored and trained over 120 clinical and research fellows over the past 38 years with the EP Fellowship Program at MGH. Ruskin’s passion for academia and education expands with more than 450 original scientific publications and 22 years of service to the global cardiac electrophysiology (EP) community as director of the AF Symposium. In this interview, he shares his experience founding and running one of the first subspecialty services in the USA, gives his views about current research and advances in the field and provides highlights of next year’s AF Symposium.
When did you decide you wanted a career in medicine and why did you choose to specialise in cardiac EP?
I knew from an early age that I was interested in a career in medicine since I grew up in a medical family in which not only my father but several aunts, uncles and cousins were or are physicians. They were all accomplished, dedicated professionals whom I admired tremendously and who took great pleasure in practicing medicine. My maternal aunt was a prominent obstetrician-gynaecologist in South Africa who delivered all the family and friends of my generation (except, to her frustration, her own three children). My father trained in cardiology with Paul Wood at Hammersmith Hospital during the London Blitz then returned to South Africa as one of the very few specialists in the country. Because of the brutal system of Apartheid and my mother’s political activism, we left South Africa in 1952 and moved to New York where my father was from. Watching my father give up a thriving practice and national reputation in his early 40s to restart his professional life in the USA made a deep impression on me, as did his passion for medicine and his deep commitment and attachment to his patients.
My decision to specialise in cardiac EP was total serendipity. Towards the end of my medical residency, I had the opportunity to become a fellow in Anthony Damato’s Lab in Staten Island, USA. While I had not planned on this path, I leaped at the opportunity and it turned out to be the most important decision of my professional life. Once involved in the early days of cardiac EP, I was consumed by the excitement and challenge of participating in ground-breaking research in a fledgling field where everything we studied was new and uncharted.
Who were your mentors and what influence did they have on your career?
My most important mentors were my parents who, in addition to core values, taught me to aspire to analytic thinking and intellectual honesty. From my patients I have learned more medicine and more about courage and grace in the face of adversity than from any other source. Other mentors who were critically important to my life in medicine include my chief during medical residency at the Beth Israel Hospital in Boston, Howard Hiatt, who built a new world-class academic department by recruiting the brightest young people he could find and ran interference for them to ensure that they had the freedom to grow and be productive. I absorbed and applied this model to building the arrhythmia service at MGH starting in 1978. Tony Damato was responsible for providing me and many others the opportunity to train and pursue an academic career in the newly emerging field of clinical cardiac EP. He was without doubt the single most important person in determining the course of my professional career. Damato was an incisive thinker and data-driven clinical investigator whose intellectual rigor and honesty had a major impact on me at an early stage of my training. He also became a friend and someone whom I think about often with tremendous gratitude. Edgar Haber, who was chief of cardiology at MGH when I arrived as a clinical fellow in 1975 and a world-class basic scientist, gave me the opportunity and freedom to start to build the first dedicated subspecialty service in cardiac arrhythmias in New England, USA.
Of the research you have seen in the past year, which did you find the most interesting and why?
I am intrigued by the basic and translational science related to the role of inflammation and fibrosis in driving the development of atrial myopathy and the substrate for atrial fibrillation (AF). The impact of obesity and epicardial adipose tissue in the process of atrial remodelling seems clear and may offer a therapeutic window. A closely related area of inquiry is addressing the question of whether pharmacologic approaches to reversing some types of fibrosis may be possible with implications for potentially modifying AF substrates. Another area of innovative research is the emerging field of neurocardiology. Basic, translational and clinical work on the complex functional interconnections and interdependence of the nervous system and cardiovascular system is opening up a new frontier in the study of arrhythmia mechanisms as well as that of other cardiovascular conditions. As the complex relationships of these neural control systems to normal and abnormal cardiovascular function are delineated, it seems likely that new therapeutic options for the management of arrhythmias, as well as other cardiovascular conditions including hypertension and heart failure, will emerge. The progress in this area also provides hope that a better understanding of autonomic regulation and dysregulation may lead to more precise identification of patients at high risk for sudden cardiac death and offer new therapeutic windows into this vexing problem. The rapidly expanding field of arrhythmia genetics, owing in part to remarkable advances in technology and informatics that now permit rapid whole genome sequencing in large numbers of subjects at manageable cost, also holds great promise in terms of potential insights into underlying mechanisms and, hopefully, new therapeutic options.
One of your major research interests is the mechanism and management of atrial fibrillation including innovative technologies for catheter ablation; could you give us your views regarding rotor ablation?
This remains an area of considerable controversy. Improvements in outcomes of ablation for persistent and long-standing persistent AF are most likely to come from a better understanding of underlying mechanisms. The rotor and focal source hypotheses are important attempts to use mechanism-guided approaches to AF ablation based on comparatively low resolution mapping systems that are limited to one surface of the atrium. The inability to achieve rapid, high density direct contact mapping of the endocardial and epicardial surfaces during AF requires the use of algorithms that employ a range of assumptions and substantial interpolation to create maps that are used to guide ablation therapy. While these approaches hold promise for better outcomes than pulmonary vein isolation (PVI) alone and PVI plus empirical linear and complex fractionated atrial electrogram (CFAE) ablation, we still need better validation in large multicentre clinical trials and have a long way to go in terms of a more definitive understanding of AF mechanisms.
How close are we to developing an effective antiarrhythmic drug?
On this question, I take a glass-half-full position. I believe that we have several effective antiarrhythmic drugs. How many of us could get through a single day in the clinic without access to currently available antiarrhythmic drugs? It is true that all antiarrhythmic drugs are limited by less than perfect efficacy and significant risks in terms of potential pro-arrhythmic effects, side effects and, in some cases, organ toxicity. History has taught us that the use of ion channel blockers is inevitably a double edged sword in which the balance can shift from protection to harm depending on a number of dynamic factors and that careful patient selection, dose selection and monitoring when appropriate are the best strategies for optimising the therapeutic advantages and limiting the risks of these agents. Given the multiplicity of factors that contribute to arrhythmogenesis, as well as their dynamic and often unpredictable behaviour, it seems unrealistic to expect that we will ever have a completely effective and safe antiarrhythmic drug. That said, tremendous numbers of our patients depend heavily on and benefit greatly from currently available antiarrhythmic drugs. A large majority of patients with symptomatic AF are likely to continue to be managed with antiarrhythmic drugs alone for the foreseeable future. The combination of devices or ablation with concomitant antiarrhythmic therapy, while not the first choice, should be regarded not as a failure, but as an indispensable part of our therapeutic armamentarium. We certainly could use additional antiarrhythmic drugs to expand treatment options for our patients, but the odds are high that they will continue to be limited by less than perfect safety and effectiveness. Drugs that ultimately reduce susceptibility to arrhythmias by modifying arrhythmia substrates by anti-fibrotic or other mechanisms are greatly needed but not likely to replace the need for membrane active antiarrhythmic drugs.
As the founder and director emeritus of the MGH Cardiac Arrhythmia Service and Clinical Electrophysiology Laboratory; could you tell us what the key aspects of running a successful service as such are?
I think that the key aspects of building a successful and innovative service involved:
1) Setting the highest standards for quality and safety in the EP lab.
2) On the clinical service, establishing a first-class experimental and clinical research programme grounded in physiology and directed at important questions (initially mechanisms of sudden cardiac death and later AF).
3) Establishing a world-class training programme that prepared trainees to become outstanding clinicians, investigators and academic leaders, and fostering the growth of young faculty members by insuring that they had adequate support and mentorship.
4) Working with colleagues who share the same values and vision is also extremely important. I had the good fortune to recruit Hasan Garan as my first fellow after working hard to convince him that the fledgling field of EP had a future. Within a year, we were partners and close friends. Hasan’s genius contributed immeasurably to the growth and development of the service as did that of Brian McGovern who we trained and recruited to the faculty a few years later. The three of us worked closely, productively and happily together for more than 20 years. We were supported by Muriel Corcoran, Joanne Meleshuk and Beth Kelly, who for decades contributed immeasurably to the administrative and research functions. It was an extraordinary time during which the unique energy, drive and total commitment to excellence of that small group were in large part responsible for the clinical and academic success of the service. I enjoyed those years more than any other time in my professional career.
As the director of the AF Symposium, could you tell us what are the main highlights of next year’s meeting?
The 2017 AF Symposium (12‒14 January, Orlando, USA) will mark the 22nd year of the meeting. The upcoming Symposium will focus on a wide range of topics related to recent developments in AF. A partial list includes: advances in basic science, genetics and the epidemiology of AF; population screening for AF and the implications of device-detected AF; multidisciplinary approaches to stroke prevention with an emphasis on mechanical devices for left atrial appendage exclusion; advances in ablation therapy for paroxysmal AF including improvements in lesion formation and durability; current and future directions in ablation for persistent and long-standing persistent AF; new technologies for mapping and ablation of AF; strategies for optimising the safety and economic impact of AF ablation; and recent clinical trials of new devices seeking FDA approval and regulatory issues in AF ablation. Because of their popularity in the past, we will continue to have sessions dedicated to interactive discussions between faculty and attendees focused on challenging cases in AF management including clinical decision making, pharmacological and mechanical stroke prevention, antiarrhythmic drugs and complex technical issues in catheter ablation for AF. We will continue the tradition of real-time case transmissions from leading centres in the field of AF ablation and, new in 2017, we are planning a session devoted to late-breaking clinical trials and first-report clinical investigations in AF. Networking with colleagues and faculty will, as in past years, continue to be an important part of the meeting.
Outside of medicine, what other hobbies or interests do you have?
Most of my interests outside of medicine involved outdoor activities including skiing, hiking, fly fishing, scuba diving and learning to fly gliders. In recent years, these activities have been eliminated by orthopaedic problems, so I swim regularly for sanity and exercise. My wife and I are committed theatregoers and Boston has a vibrant and diverse theatre scene. As I get older, I place increasing value on time with family and friends, and try not to let work intrude as much as it has had in the past. I am a reader and love great writing, both fiction and nonfiction. I am also working on a family and personal history for my kids, including old photographs from my parents’ and relatives’ collections, some of which are more than a hundred years old. Time is the greatest limitation, but I find the act of recalling and interpreting the past a fascinating and fulfilling, albeit highly subjective, exercise.
2016 Founder and director emeritus, Cardiac Arrhythmia Service and Clinical Electrophysiology Laboratory, Mass General Hospital (MGH)
1978 Founder and director, Cardiac Arrhythmia Service and Clinical Electrophysiology Laboratory, MGH
1978 Founder and program director, Clinical Cardiac Electrophysiology Fellowship Training Program, MGH
1995 Founder and director, International AF Symposium
2007 Co-director Deane Institute for Integrative Research in Atrial Fibrillation and Stroke, MGH
2010 Co-director, MGH Atrial Fibrillation Program, MGH
2014 Professor of Medicine, Harvard Medical School
1967 BS. Tuffs University, Medford, USA
1971 MD. Harvard Medical School, Boston, USA
Postdoctoral training in Cardiology
1973‒1975 Research and clinical associate, and commisioned officer, United States Public Health Service Hospital, Staten Island, USA
1975‒1977 Clinical and research fellow, MGH, Boston, USA
1977‒1978 Research fellowship, American Heart Association, Boston, USA
1978‒1979 Charles A King postdoctoral research fellowship award, MGH, Boston, USA
1981‒1986 Established Investigator Award American Heart Association
1997 Michel Mirowski Award for Excellence in Clinical Cardiology and Electrophysiology
2002 Pioneer in Cardiac Pacing and Electrophysiology Award Heart Rhythm Society
2015 KCHRS Pioneer in Electrophysiology Award 2015 University of Kansas Medical Center
2016 Omran Alomran Endowed Chair in Cardiology at MGH