Luigi Di Biase is a prominent electrophysiologist, section head of Electrophysiology, director of Arrhythmia Services, and professor of Medicine (Cardiology) at the Albert Einstein College of Medicine, New York, USA. In addition, he serves as senior researcher at the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Texas, USA. He was inspired to take up medicine by his father and enjoys playing football and spending time with his family.
When did you first decide you wanted a career in medicine?
During my childhood I liked to follow my father’s lead and take care of my great-grandparents and grandparents. Because of this, at the age of five, I was already able to measure the blood pressure of my great-grandmother with a stethoscope. This experience meant that my father had a major influence on my decision to choose medicine as a career, although I think I would have chosen medicine without this influence. As well as my father ’s influence, my mother was a great support and my grandparents, like my parents, helped me in upbringing and my grandmothers—Non na maria ‘IA” e Nonna Antonietta “Etta”— together with their husbands, Luigi and Vincenzo, have been influential in supporting me during my time abroad and during my medical school time and childhood.
I have liked many other things and thought I might go to law or business school when I was younger but in the end I realised that what I really wanted was to be a physician and to be able to take care of people and my relatives. The law and business was not compatible with this and medicine became my passion.
Why did you choose to specialise in cardiac arrhythmias?
Once I had chosen medicine as my career I needed to choose a subspecialty. There was no doubt that something “hands on”, and requiring clinical expertise, would be my choice. The important and essential role played by the heart in the human body and the chance to choose a subspecialty of medicine that allowed a hands on approach pushed me into cardiology. Pacemaker implantation and implant able cardioverter defibrillators (ICD) where my first interest—this is in part because my dad implanted the first endocardial pacemaker at the University of Bari when I was five—but soon after learning about arrhythmias with electrophysiology (EP) study, I discovered that the emergent field of ablation that was growing at my University in Bari. This provided me with the possibility of eliminating problems for patients with ablation and led me to quickly choose electrophysiology as my preferred field.
Who were your mentors and what influence did they have on your career?
The first part of my career was in Italy and I had several mentors at the University of Florence and University of Insubria at Castellanza and Varese but the real mentor of my career I met in the US during my first research experience at the Cleveland Clinic. This was where I met Andrea Natale. This was a moment of fortune in my life because he has been my mentor and he still is a mentor and a friend. Natale has been able to guide me scientifically and clinically. He has helped me to love more of what I already loved, which is electrophysiology and ablation. Due to my European training and legislation in the US, my training with him has been able to last for about 8 years. This has allowed a very close relationship and an exceptional learning curve.
What is your most memorable patient case?
I aim to improve my patients’ quality of life, stamina, mood and exercise tolerance. Catheter ablation of atrial fibrillation has allowed me to reach these goals. Many of the patients I have ablated are now off medications and feeling better and happier. A particularly memorable case is a younger patient in his 50s with long-standing persistent atrial fibrillation due to a rate control strategy decision. He was sent to me for an ICD implant since his EF [ejection fraction] had deteriorated to 25–30%. The patient had so many years of AF that he felt OK in AF. After restoring sinus rhythm with ablation, his EF improved, no ICD was needed and more importantly patients told me, “I have never felt this good in my life. I ‘thought’ I was feeling well but I actually now realise how much better I feel in the sinus. Doctor you have given me a new life.”
What do you consider the most important development in arrhythmia management and research during your career?
During my career, the most important thing I learned from my mentor Andrea Natale, and what I try to teach to my fellows, is to question everything we do and why we do it. Medicine is full of common beliefs that come from the experience of humans and humans make mistakes. Therefore consensus documents and guidelines represent some evidence but not all of the evidence. There is always room to say: can this be done in a different way? Why do we do this, this way and not in another way? Question everything, like a child that constantly asks their parents why. The best research comes from this. Together with Natale we asked: is interrupted anticoagulation during ablation the only way to do this? Are the pulmonary veins (PVs) the only thing responsible for AF or is there more reasons. We have seen many, many patients in AF with isolated PVs. From that, we knew it was not just from PV and we developed the NON PV trigger approach that includes superior vena cava, coronary sinus posterior wall and left atrial appendage as the relevant structure in different patients. Can the ablation of ischaemic cardiomyopathy only be done during VT or can we do it in sinus rhythm with the homogensation approach? Is the CHA 2DS2-VASc score sufficient? Is there any other risk factor for stroke? We found left atrial appendage morphology a risk factor for stroke in addition to the CHA2DS2-VASc score. Is ablation successful in patients with heart failure when compared to amiodarone? Also, can the response to cardiac resynchronisation therapy at three months predict the response at one year follow up? All these have changed the way we practise medicine.
What are your current areas of research?
Ablation of atrial fibrillation and VT are still the main areas.
What are the best ways to improve patient care for those with arrhythmia?
By being critical and unbiased by industry and personal interest/ego. It gives the ability to provide patients with the best care.
What are the best periprocedural anticoagulation strategies for avoiding the risk of stroke in patients undergoing catheter ablation for atrial fibrillation?
When I started my career it was a red flag and considered dangerous and contraindicated to treat a patient with a therapeutic international normalised ratio (INR). Today it is the standard-of-care, the opposite, and this is due to work I did with my mentor Andrea Natale.
What are the advantage and disadvantages of robotic catheter navigation compared to manual, when treating atrial fibrillation?
Robotic navigation of ablation has the advantage of no exposure of X–rays to the physician and provides excellent contact and precision. The disadvantages are the workflow and cost.
What impact have cardiac resynchronisation therapy devices had on treating cardiac arrhythmias?
They have improved mortality outcomes and the quality of life for many people. With resynchronisation devices, we are able to give patients improved exercise tolerance. There is also a reduced need for remodeling (reduction in LV chamber size and measures of mitral regurgitation), reduced mortality, and reduced need for hospitalisation in patients in sinus rhythm.
What conferences are you most looking forward to in 2018?
I like conferences to be unbiased and with a practical view of medicine. HRS (Heart Rhythm Scientific sessions, 9–12 May 2018, Boston, USA), EHRA (The annual congress of the European Heart Rhythm Association, 18–20 March 2018, Barcelona, Spain), ACC (American College of Cardiology’s 67th Annual Scientific Session and Expo, 10–12 March 2018, Orlando, USA) and ESC (European Society of Cardiology congress, 25–29 August 2018, Munich, Germany) are the cornerstones but the Atrial Fibrillation Symposium in Orlando this past January and the VT Symposium (13th Annual International Symposium on Ventricular Arrhythmias, 12–13 October 2018, New York, USA) in New York play a great role too.
How do you like to spend your time outside of work?
I like playing football and going on beach vacation and to explore new continents and countries. Spending time with my family is a privilege and provides me with great happiness
2014-Section head of Electrophysiology and Director of Arrhythmia Services at Einstein/Montefiore, New York, USA
2014-Senior Researcher at the Texas Cardiac Arrhythmia Institute at St.David’s Medical Center, Texas, USA
2017-Professor of medicine, Department for Medicine (Cardiology) Einstein/Montefiore, New York, USA
Employment and Qualifications
2000-M.D. Medicine, University of Bari, Italy
2004-Cardiology residency University of Bari, Italy
2006-Master degree Electrophysiology and Pacing, University of Insubria, Varese, Italy
2007-Research fellowship at the Cleveland Clinic, Cleveland, USA
2008-ESC State of the Art Featured Research Award
2008-Best international publication as first author for a manuscript published in a journal with high impact factor from the Italian Society Cardiology (SIC)
2009-10 SIC Young Investigator Awards
2011-Best Paper Award from CardioRhythm
2011-Best Abstract competition, University of Kansas, Kansas City Heart Rhythm Symposium
2011-Best abstract Award World Conference of Electrophysiology, Athens
2011-Italian Society for Cardiovascular Research: Valsalva Award
2011-William Harvey Award: Italian Society of Cardiology
2012-Best Abstract Award ECAS (European Cardiac Arrhythmia Society), Munich, Germany.
2013-Young Investigator Award (oral) 6th Asia Pacific Heart Rhythm Society (APHRS) and CardioRhythm, Hong Kong
2015-Best Poster European Society of Cardiology (London, UK)
2016-Best Poster European Society of Cardiology (Rome, Italy)