Massimo Santini, director, Department of Cardiovascular Diseases, S Filippo Neri Hospital, Rome, Italy, and chair of the International Symposium on Progress in Clinical Pacing (2–5 December 2014, Rome, Italy) performed the first fulguration of the atrioventricular node of resistant supraventricular tachycardia in Italy; he also implanted a pacemaker in the Italian president Carlo Azeglio Ciampi, 10 years ago. Santini speaks to Cardiac Rhythm News about his views on advances in antiarrhythmic drugs, genetics and cardiac arrhythmias, and ECG screening.
When did you decide you wanted a career in medicine and why did you choose to specialise in cardiology and electrophysiology?
Since I was an adolescent, I always wanted to become a medical doctor. During my fourth year of medical school, I used to visit the Cardiology Division of the University Hospital [Policlinic Umberto I] and I remember being impressed by the many interesting diagnostic and therapeutic (invasive and non-invasive) procedures that a specialist in cardiology could perform. Furthermore, I became fascinated with the field of cardiac arrhythmias and therefore decided to study electrophysiology.-
Who were your mentors and what influence did they have on your career?
Professor Vincenzo Masini, director of the Cardiology Department of San Camillo hospital  was my main mentor. He was an expert clinician with a strong interest in research. He taught me the importance of scientific speculation and encouraged me to always look for new effective therapies.
What is your biggest motivation to work in medicine?
I love my job and my biggest motivation to work in medicine is that it allows me to help people, enhance their quality of lives and make them live longer.
What have your proudest moments been?
My proudest moment happened approximately in 1980 when I performed the first fulguration of the atrioventricular node of a resistant supraventricular tachycardia. It was the first type of ablation at that time and it was the first in Italy and the second in Europe. Many Italian newspapers spoke about this technique and I was very proud of having performed it successfully.
Could you tell us about one of your most memorable clinical cases?
My most memorable clinical case happened approximately 10 years ago when I implanted a pacemaker in the president of Italy [Carlo Azeglio Ciampi]. This was big news all around the country. I remember, at the time of the operation, it was difficult to maintain the privacy of the president as there were crowds of journalists around the clinic. For me, it was a great experience to operate on a president who was deeply loved by Italians.
In your view, what has been the most important development in cardiac pacing during your career?
Many important developments have happened during my 40 years of work in cardiac pacing. Certainly, dual-chamber pacemakers signed the history of pacing and similarly the advent of implantable cardioverter-defibrillator (ICD) therapy and remote monitoring of implantable devices.
What about leadless pacing? Are you an advocate of this new technology?
I believe that the concept of a leadless pacemaker is fascinating and certainly in line with the needs of the patients who require cardiac pacing. We are only at the start of this new project; we still need more experience, better and affordable devices, double- and triple-chamber leadless devices, etc. But this will be definitely the direction to go on the research of next generation devices.
How close are we to developing an effective antiarrhythmic drug?
Unfortunately, we have not had a new effective and safe antiarrhythmic drug for over 25 years. We continue hoping and waiting for a valid and safe drug; however, it seems still far to come.
What about the current antiarrhythmic drugs, what are their limitations?
The current antiarrhythmic drugs, still very effective, have several limitations and contraindications. For example, amiodarone is not well tolerated by the patients on a long-term basis, Class 1C drugs (flecainide and propafenone) cannot be administered in the presence of cardiac insufficiency or myocardial infarction.
The only real news in the drug treatment of atrial fibrillation were the new oral anticoagulants, which are very effective and safe. They have been studied in large trials and are now used in clinical practice.
In your opinion, what recent catheter ablation technology will have the greatest impact in the field?
At present, radiofrequency-based systems are the most used ablation technologies for the treatment of atrial fibrillation. Cryoballoon ablation is also becoming widely used. Surgical and hybrid ablation techniques have also recently gained an interesting space in this field.
What could you tell us with regards to the latest advancements in genetics and cardiac arrhythmias?
Genetic pathologies have been significantly addressed by researchers in the last 20 years. For example, the Brugada syndrome has created a lot of debate and treatment in the last years. Modern technologies have allowed us to understand in more detail the mechanisms of genetic pathologies and to create more appropriate therapies.
What are your current areas of research?
Currently, I am very interested in the invasive and non-invasive treatment of atrial fibrillation.
I am also researching, in the prevalence of genetic abnormalities in Roman teenagers. I have just finished performing 25,000 ECGs in Roman schools with very interesting preliminary data. These data will probably become available by the end of the statistical analysis at the end of 2014 or beginning of 2015.
Performing ECG screening in athletes is advocated in Europe, especially in Italy; however, clinicians in the USA do not seem to be in favour of this practice. What is your opinion on the subject?
By Italian law, all athletes who perform competitive sports should be screened. This has allowed, over the years, to discover many potentially threatening cardiac pathologies and also to stop athletes against their willingness. We do not believe it is correct allowing athletes to make a decision, which could potentially cost their lives. In many instances, as they are very young and often very well paid, they will accept the risk to continue competing. To me it seems very appropriate to have a specific law that requires athletes to be controlled by a special committee of very expert cardiologists without any conflict of interest.
Throughout your career you have been an active member of scientific committees of international congresses; what has been the most valuable reward from engaging in these commitments?
International congresses allow you to participate and stay updated in electrophysiology from a global perspective. International congresses give you the opportunity to discuss with your colleagues face to face, understand how they manage patients and show how you work. It is fascinating. Furthermore, it helps you to network with industry contacts and to look for new technologies.
You are the chair of the International Symposium on Progress in Clinical Pacing; could you tell us what the highlights of this year’s meeting are?
At Progress in Clinical Pacing 2014, as usual, cardiac pacing and electrophysiology will be the key topics for discussion. This edition will have particular interest in educational courses specifically designed for young electrophysiologists. Atrial fibrillation (with more than 20 sessions), remote monitoring of implanted devices, the female role in electrophysiology, among others will be the subjects for discussion. In addition, much attention will be paid to the emerging technologies in the field like the leadless pacemaker, the subcutaneous defibrillator, the injectable loop recorder, the new leads for ablation and mapping systems, vagal stimulation for heart failure, etc.
You lead a heart foundation called “Il Cuore di Roma”, could you please tell us what is the most relevant impact it has had in the community?
Il Cuore di Roma (The heart of Rome) is particularly dedicated to the research of cardiac arrhythmias in the young and to educate the general population on how to avoid and treat cardiac arrhythmias and their complications. The next campaign of the foundation, to be launched in 2015, will be called “Keep your Rhythm” and will teach the general population to check their radial pulse and to understand if they are in atrial fibrillation. It will be advertised on TV, cinema, newspapers, congresses, etc.
Outside of medicine, what other hobbies or interests do you have?
Before university, I used to love and practise fencing and used to have very good results. Currently, I love to go sailing and I have a special passion for dogs in general and West Highland White Terrier (my dog) in particular. I love travelling for tourism, but I believe my true hobby has always been my work and my relationship with human beings.
Professor of Advanced Electrophysiology at “Tor Vergata” University, School of Medicine, Rome, Italy
2012 Chairman of the Global Arrhythmias (GAF)
2012 Chairman of the South-East-Europe Forum (SEEF)
2009 President of the World Society of Arrhythmias (WSA)
2008 Chairman of the Euro – Japan Arrhythmia Forum (EJAF)
2004 Vice-president of ECAS (European Cardiac Arrhythmias Society)
2004 Editor-in-chief of the Italian Textbook of Electrophysiology and Cardiac Pacing (AIAC)
2001 Director Department of Cardiovascular Diseases, S Filippo Neri Hospital, Rome, Italy
1998 Editor-in-chief of the Italian Textbook of Cardiology (ANMCO)
1992 Director Cardiovascular Department, S Filippo Neri Hospital, Rome, Italy
1970 Medical doctor with full honours. University of Rome “La Sapienza” Medical School
1973 Postgraduate in Cardiologiy with full honours, University of Perugia, School of Cardiology
Gold medal ANMCO
Silver medal of AIAC
Gold medal of Ministry of Public Health
Grand Officer of the Italian Republic