Michael Gold (Michael E Assey professor of Medicine and medical director, Division of Cardiology, Medical University of South Carolina, Charleston, USA) is a pioneer in the development of new defibrillation techniques and pacing for congestive heart failure. He considers himself very fortunate for having been exposed, early in his career, to several of the most important innovations in clinical electrophysiology such as ablation of cardiac arrhythmias. Gold, who is chair of the Scientific Sessions of the Heart Rhythm Society (HRS) 2015 and 1st vice president of HRS, spoke to Cardiac Rhythm News about his involvement in various clinical trials, his views on the upcoming treatment options for heart failure and the highlights of this year’s HRS meeting.
Why did you choose to become a medical doctor and, in particular, why did you specialise in cardiology and electrophysiology?
I was initially more interested in research than medicine so I did a PhD in physiology feeling that this was a more rigorous scientific discipline. My focus was neurobiology and specifically cellular physiology of the brain. As a postdoctoral student at the University of Colorado I interacted with physicians and medical students more than as a graduate student. It became clear that there was much overlap intellectually with medicine and many research opportunities so I completed medical school training while still working in a physiology lab doing research. My research at the time focused on synaptic transmission in the brains of lampreys. The logical medical specialty for me was neurology. However, I enjoyed clinical neurology much less than cardiology. Therefore I changed my basic science research focus to cardiac cellular physiology and decided to pursue residency training in internal medicine and a fellowship in cardiology. Given my interest in cellular electrophysiology it was natural to specialise in clinical electrophysiology.
Who were your mentors and what wisdom did they impart to you?
Dr A Robert Martin was my postdoctoral mentor. Despite being the chairman of the department he was always humble and a team player being “shoulder to shoulder” with me in the lab helping with experiments. He also taught me the rigors of a quantitative approach to answering research questions. As a resident and fellow at Mass General in Boston, there were many mentors and role models there who helped shape my career. Drs Roman DeSanctis and Hasan Garan were two very different personalities, but shared a passion for clinical care, a great work ethic and a logical approach to solving clinical problems.
Which innovations in cardiac rhythm management have shaped your career?
I was very fortunate to be exposed to several of the most important innovations in clinical electrophysiology early in my career. At Mass General we started doing ablation during my fellowship career, which transformed electrophysiologists from primarily diagnosticians to physicians who could cure arrhythmias. Then, the following year, as a new attending at the University of Maryland, I met Dr Morton Mower who helped me to start doing clinical research on devices. While he and Michel Mirowski were best known for inventing the implantable defibrillator in Baltimore, they also were early pioneers in biventricular pacing. His support led to our work of the first clinical trial of biventricular pacing in humans. I initially collaborated with my friend and cardiac surgical colleague, Dr Andrew Foster, on the haemodynamics of biventricular pacing following coronary artery bypass graft (CABG), but subsequently focused on cardiac resynchronisation therapy (CRT) in heart failure.
Please name three main research priorities in cardiac rhythm management?
Non-pharmacologic therapy has dominated our treatment of arrhythmias over the past 20 years. Despite wonderful advances in this field, we remain inefficient in our application of many therapies. For instance, while ablation for supraventricular tachycardia (SVT) has success rates of well over 90%, our success for atrial fibrillation is much lower despite the rapid expansion of this indication. We need better tools and techniques for atrial fibrillation ablation. Similarly, implantable cardioverter defibrillators (ICDs) are highly successful for preventing sudden death but most patients never receive an appropriate therapy. Accordingly, better risk stratification is needed to maximise the benefit of this therapy. The third area of importance is improving diagnostics for clinical management. The role of remote monitoring for early detection of atrial fibrillation is well established. However, we are still rudimentary in our ability to identify and implement diagnostic modalities for heart failure and ischaemia. With rapid advances in miniaturisation of devices, implantable monitors can now become a reality.
As someone who has been involved in various clinical trials, which piece of research are you most proud of and why?
I would have to give two examples to this question as the research is very different. Early in my career I did lots of single centre research on defibrillation at the University of Maryland. We evaluated defibrillation efficacy helping to establish the value of transvenous leads, “hot” cans, biphasic waveforms and showing the stability of defibrillation efficacy. Our work and that of many others have made defibrillation so routine that we now question the need to test systems at all at implant. We essentially made this research obsolete. Later in my career at the Medical University of South Carolina (MUSC) I have been much more involved in multicentre trials and have been fortunate to have had leadership roles in many studies. The REVERSE (Resynchronisation reverses remodeling in systolic left ventricular dysfunction) study is probably one piece of research that I have enjoyed the most, in part because of my collaborations with the other members of the steering committee: Cecilia Linde, Jean-Claude Daubert and William Abraham. For a study that “missed” its primary endpoint, we have been able to learn much about the treatment of mild heart failure in CRT and these investigations continue.
What are your current research interests?
I continue to be intrigued by mechanistic studies to help us understand cardiac rhythm therapies. This includes left ventricular electrical delay, such as the QLV interval to predict response to CRT and guide left ventricular lead placement as well as applications of atrioventricular optimisation algorithms. Big data have also emerged as a powerful tool by using large databases to ask important clinical questions. I resisted such research for years because the scientific rigor and control is less for database research, but it has become clear that there are some hypotheses that can only be addressed with this methodology.
As a pioneer in the development of new defibrillation techniques and pacing for congestive heart failure, could you tell us what the latest advances in the field are and which are showing to be promising?
I think that there is relatively little new with regards to transvenous defibrillation techniques as this field is very mature. However, the development of subcutaneous defibrillation opens up new opportunities to study defibrillation. Much more research is ongoing for pacing in heart failure, including the identification of mechanical or electrical dyssynchrony measures to guide left ventricular lead position and optimise outcomes as well as improved lead technology. Hopefully this field will continue to progress with the development of leadless pacemakers so that left ventricular endocardial pacing becomes a standard. Finally, applying the techniques of CRT to other applications is an exciting and potentially important advance, such as peri-infarct pacing to prevent left ventricular dilation.
Given the negative results of NECTAR-HF, the first randomised, sham-controlled trial of vagal nerve stimulation for heart failure, what are your views on the future of this therapy for heart failure treatment?
There is an intense debate whether NECTAR-HF was negative because it was a well-controlled study or because it delivered inadequate stimulation. The current used to stimulate the vagus nerve was low and may be subthreshold for cardiac B-fibre activation. I am the co-principal investigator of INOVATE-HF (Increase of vagal tone in chronic heart failure), which is the first large study of vagal nerve stimulation. We use a proprietary electrode system [CardioFit System, BioControl Medical] that can deliver about 3X the current as used in NECTAR-HF. This will be the first pivotal study of vagal nerve stimulation for heart failure and more than 700 patients have already been randomised. Thus, I remain very open about the potential role of this modality for the treatment of heart failure and anxiously await the results of this study. It is exciting for me to be involved in this field since my PhD thesis included vagal innervation of the heart, so I have now come full circle in my career.
Of the research you have seen in the past year—as member of the editorial board of several peer-reviewed journals—which did you find the most interesting and why?
There is so much exciting research being performed globally that it is impossible to focus on a single project. The world of arrhythmia management is exploding with new ideas and findings including alternative energy sources for safe and simpler ablation. We also have leadless pacing, ICDs without transvenous leads, improved outcomes with CRT and new targets for therapy such as premature ventricular complex (PVC) ablation for ventricular tachycardia/ventricular fibrillation (VT/VF) storm.
As chair of the Scientific Sessions of Heart Rhythm 2015 and 1st vice president of the Heart Rhythm Society please tell us what the highlights of this year’s conference are?
As with most large conferences, the summits (AF, VT and leads) are always a highlight along with the late-breaking clinical trials. However, there will be some unique sessions this year. We will celebrate the 30th anniversary of the approval of the ICD with a session of the pioneers describing the early development and application of this technology. In addition, for the first time there will be a “Fellows track” with topics and speakers chosen by fellows to address some of their unique needs. Finally, the joint sessions will be very strong this year as more and more societies want to partner with the Heart Rhythm Society (HRS) for education at the premier meeting in the field.
Could you tell us what has your most memorable case been and why?
Memorable cases are typically those with dramatic patient benefit. I still recall a young man with Wolf-Parkinson-White (WPW) syndrome who would hang himself upside down from his fence in his yard to terminate his arrhythmias, which became disabling. We ablated him and for a decade he would come annually to a clinical correlation for first year medical students to explain how this outpatient procedure changed his life.
I also recall a young woman who developed atrial fibrillation postpartum, which was debilitating and prevented her from caring for her child. Before atrial fibrillation ablation was developed, she had an atrial defibrillator implanted and would shock herself to allow her to stay at home and not end up in an emergency room. This was one of the few success stories of this device, which today seems like such a crude treatment for an arrhythmia that we can frequently cure.
Finally, I just saw a 96 year old man with a left bundle branch block and heart failure. We implanted a CRT pacemaker in him last year. He was a super responder with improvement of his ejection fraction from 30 to 60%. He is now starting course work for a PhD!
What concerns you most about the practice of electrophysiology today?
The healthcare changes have made the practice of medicine much more challenging. Electrophysiology is not singled out in this regard. The regulatory and bureaucratic/documentation requirements have increased dramatically and become very time consuming. The reductions of reimbursement make us all more RVU conscious often creating conflicts with maximising clinical interactions or innovation. Hopefully, systems will continue to improve so that doctors can continue to spend more time caring for patients, focusing on quality and finding new treatments for diseases.
What is your treatment philosophy?
Pretend that every patient is your relative and communicate and recommend treatment as you would for family. Also, stay humble and acknowledge when you do not know what is best or if there is someone better than you to treat the patient. Communication, common sense and using your knowledge base are first principles that serve us well.
What advice would you give to physicians wanting to become electrophysiologists?
Remember that this is a career and not a sprint. Too many physicians short change their training because of rising educational debt, “jealousy” of the lifestyle of friends outside of medicine who have already started their career or fear of the job market. Pursue your passion because an extra year or two will serve you well for the next 30 years of your career. Get the best training possible.
Outside of medicine, what are your hobbies and interests?
Tennis, boating, and reading keep me occupied.
1981-1985 Medicine, University of Colorado
1985-1986 Internship (Medical), Massachusetts General Hospital
1986-1988 Residency, Massachusetts General Hospital
1979-1981 Postdoctoral Fellowship, University of Colorado
1988-1991 Clinical Fellowship, Massachusetts General Hospital
2002- Professor of Medicine, Medical University of South Carolina
2002- Michael E Assey Chair of Medicine, Medical University of South Carolina
2002- Medical University of South Carolina
2002- Ralph H Johnson VA Medical Center
2002- Director, Division of Cardiology, Medical University of South Carolina
1999- Journal of Cardiovascular Electrophysiology
2002- American Journal of Cardiology
2003- Current Cardiology Reports
2005- Journal of Cardiothoracic Renal Research
2009- Diagnostic and Interventional Cardiology
2010- The Journal of Innovations in Cardiac Rhythm Management
2010- Year Book of Cardiology
2014- HeartRhythm Section Editor
2014- Journal of the American College of Cardiology Section Editor
2015- JACC: Clinical Electrophysiology
Selected Awards and Honors
1985 Gold Headed Cane Award
1985 Joseph and Regina Glaser Research Prize
1992 Samuel J Katcef Fellow, American Heart Association
2011 The Anandi L Sharma Visiting Professor & The Simon Dack, MD, Memorial Lecturer, Mt Sinai, NY