Riccardo Cappato, Director, Centre of Clinical Arrhythmia and Electrophysiology, Policlinico San Donato, Milan, Italy, and President of the European Cardiac Arrhythmia Society, spoke to Cardiac Rhythm News about his career, advances in cardiac rhythm management, and his passion for crime fiction.
When did you decide you wanted a career in medicine?
I think I never had any other discipline in mind, but medicine. My first memory in this regard goes back to childhood, and I remember my answer to this same question raised by my grandfather. It is funny, because the answer came out straight and clear, although it was the first time I was required to conceptualise it. Sigmund Freud would be happy to speculate about an apparently obvious cause influencing my choice; namely, that my mother was diagnosed with a rheumatic heart disease at the time when she was pregnant with her only son. But who really knows… I also thought about becoming a pilot or a skiing instructor at some time during my adolescence, but it was never a serious thing.
Why did you decide to specialise in cardiac electrophysiology?
I was always fascinated by the power of a surface ECG to disclose the mystery of the heart beat. The capacity of the human mind to draw inferences as to whether the heart is sick or not and which disease is underlying that specific ECG morphology fatally attracted me. So, it was electrocardiography which brought me into cardiac electrophysiology. Electrophysiology became a subsidiary discipline. In my imagination, it was like you had to immerge yourself into the depth of the heart electrical ocean, investigate the events occurring in its profoundness and then re-emerge with a larger degree of knowledge enabling you to better interpret the infinite amount of events occurring on the surface of the sea, the ECG. Deductive science, the one required with ECG interpretation, has also a lot to deal with the mysteries in literature, one of my true passions. During my first years as a cardiologist, I remember the analogies masterfully depicted by Leo Scamroth in his educational books, in which he introduced ECG puzzles, using for each of them a title leading back to Sir Arthur Conan Doyle and the mysteries of Sherlock Holmes! That turned into a very successful way to further attract me to this discipline…
Who have been your greatest influences?
In such a multifaceted discipline as medicine, you are influenced by almost everything new you listen to or read; so, I would like to say that many people have significantly influenced me. However, you need teachers to give you the methods required in order to best interpret new information. In this regard, I had a wonderful teacher, Dr Paolo Alboni (the one who recently raised international attention to the efficacy of the “pill in the pocket” strategy for the treatment of paroxysmal atrial fibrillation), at the beginning of my career in Ferrara, Italy. Years later, my second teacher was Dr Karl-Heinz Kuck in Hamburg, Germany, with whom I had the privilege to work for about eight years. Their lessons and their figures continue to be a source of inspiration in my daily practice.
What have been your proudest moments?
There are several. The first I remember relates to the end of my first official temporary contract, in the emergency department of a local hospital in the surroundings of my home city, Ferrara. Following four months of intense activity, the Dean of the hospital called me to congratulate the group (four physicians) who had served with essentially no previous experience in clinical medicine. That was a special moment, because I had the first verification that my work was appreciated, that I was in some way on the right track. Then, when I was asked to take a leading position in one of the most important electrophysiology laboratories in the world, in Hamburg, in the early 90s, where I joyfully spent about seven years between Eppendorf University and St Georg Hospital. Another proud moment came in the year 2000, when I was contacted by the prestigious San Donato Hospital in Milan, to become Chief of the local Arrhythmia and Electrophysiology Department where I am still working. During these same years, together with Dr Gust Bardy from the Washington University of Seattle and Mr Keegan Harper, I started the research and business project that is currently introducing an entirely subcutaneous defibrillator to prevent sudden death into clinical practice. Finally, when I was recently appointed the position of President of the European Cardiac Arrhythmia Society.
How has electrophysiology evolved since you began your career? Where do you see this field going in the next ten years?
I was fortunate enough to experience the booming of two extraordinary disciplines in electrophysiology: catheter ablation of cardiac arrhythmia, and implantable cardioverter defibrillator technology. These disciplines have contributed dramatically to the development of electrophysiology. On the one side, catheter ablation has provided clinicians with the incredible opportunity of curing in one or two sessions of a few hours duration, patients who have been suffering from cardiac arrhythmias for variable time, sometimes many many years. On the other side, implantable defibrillators have offered the unprecedented opportunity to deliver a therapy which enables prevention of sudden death in patients at risk of developing malignant cardiac arrhythmias. Given the tumultuous development of scientific and technological processes, a ten-year frame represents a wide perspective. There are different fields in which electrophysiology is expected to evolve including drug genomics, which will allow for individual predictions on drug response, new drug discovery, subcutaneous pacing, new energy sources and modes for safer and more effective interventional curative treatment of cardiac arrhythmias. It is also possible that current research will provide a tool to re-activate communication between electrically disconnected cardiac areas, such for example in the case of atrio-ventricular block.
How far do you think it is possible to go regarding advances of drugs for arrhythmias?
Little conceptual steps may have enormous significance in our field. For example, the discovery of new molecules capable of matching the current efficacy of oral anticoagulants, but not requiring regular blood sampling for individual titration would very positively impact the current routine of patients suffering of atrial fibrillation. And several molecules are right now under clinical investigation. Dronedarone, an amiodarone analogue without iodine linkages, has recently been successfully tested for the treatment of atrial fibrillation. As mentioned above, clinical applicability of the knowledge gained in drug genomics will allow a safer and more effective individualised approach of currently available and future drugs. The conceptual and chemical challenge of antiarrhythmic drugs is related to their inability to exert a “use dependence” effect on the trans-membrane channel gates. It remains to be understood whether this is a structural inability, which will never be defeated regardless of the new molecules that will be developed, or is a limit of the presently available agents. Should the second option become possible, antiarrhythmig drugs would abruptly increase their efficacy power, because they would then only act when the tachyarrhythmia ensues and their power would be directly related to the severity of the arrhythmia.
You have led two surveys on catheter ablation for atrial fibrillation, showing increase in the number of procedures performed worldwide. What was the impact of the ablation in the arrhythmia treatment?
During the first survey, monitoring the years between 1995 and 2002, the mean success rate without antiarrhythmic drugs was 52%, and raised to 75% with the use of previously ineffective antiarrhythmic drugs. In the second survey, monitoring the years between 2003 and 2006, the success rate raised to 70% without and 80% with antiarrhythmic drugs. Notably, recent improvement was further corroborated by the evidence that sicker patients with more complex types of atrial fibrillation were recruited in the second survey.
Data recently published from these surveys showed the risk of death was one for every 1,000 catheter ablations performed. Do you think it is possible to make the procedure safer?
The driving force behind this specific analysis was to increase awareness about the presence of this catastrophic complication, its incidence and the precipitating causes. It is of note that tamponade was the most frequent cause of death. Now we know that 2.5% of patients experiencing this complication may ultimately die. Increased awareness in this case may lead to earlier recognition, prompter and more effective compensation which would ultimately lead to a successful treatment of almost all if not all cases. With regard to atrio-oesophageal fistulae, a condition which almost inevitably leads to death, we now know that they are the consequence of high energy delivered to the posterior atrial wall and that cannot be predicted in the single case. We can prevent it by avoiding RF delivery at the posterior wall. It is interesting to note that many of us have ablated the posterior wall, and still continue to do so despite the lack of evidence that this is mandatory to improve clinical outcome.
You are president of the European Cardiac Arrhythmia Society (ECAS), which was founded in 2004. What has been the society’s contribution to the development of electrophysiology research?
ECAS was generated with the mission “to provide equal access to therapy across Europe”. Europe represents a heterogeneous territory with wide degrees of medical levels. In particular, health care providers do not support medical systems with similar level of resources. ECAS is very focused on reducing these gaps, which implies a larger degree of activity in daily practice, and higher standards of education. Coherent with this mission, ECAS encourages and supports all research activities focusing on methods that help reduce gaps among countries and ultimately benefit patient access to better and more appropriate therapy.
Outside of medicine, what other interests do you have?
Reading. I love Mysteries and specifically all the classics such as Arthur Conan Doyle, Dashiel Hammet, Raymond Chandler, Rex Stout, Mikey Spillane. The ability of their characters to investigate mysteries across the complexity of human nature represents a source of inspiration that inherently influences my daily approach to patients, science and private life.
Ferrara, Italy, 2 May 1958
Education and training
1983 – Graduation in Medicine, Università degli Studi di Ferrara
1987 – Specialisation in Cardiology
1984-1989 – Residency at the Divisione di Cardiologia of the Arcispedale S Anna, Ferrara
1985 – Habilitation in clinical practice in the American Educational Commission for Foreign Medical Graduated
1982 – Guest, Cardiology Department of the University of Alabama in Birmingham, US
1984 – Guest, Cardiology Department of the Medizinische Hochshule Hannover, Germany
1987-1989 – Assistant in the First Aid and Internal Medicine Departments of the Local Healthcare Unit 33, Codigoro and Comacchio, Ferrara
1989-1996 – Assistant in the Cardiology Department, Arcispedale S Anna
1992 – Guest in the Clinical Electrophysiology Laboratory of the Cardiology Department of Universität Krankenhaus Eppendorf, Hamburg, Germany
1996 – Assistant in the II Department of Internal Medicine, AK St Georg, Hamburg
– Consultant in the Cardiology Department, Ospedale Civile, Cento (Ferrara)
– Consultant in the clinic Congregazione delle Suore Ancelle della Carità, Poliambulanza, Brescia, Italy
– Since February 2000, Director, Centre of Clinical Arrhythmia and Electrophysiology, Policlinico S Donato, S Donato Milanese, Milan, Italy
Groups and societies
Member of the National Association of Hospital Cardiologists since April 1995
Member of the Scientific Programme Organising Committee of the European Society of Cardiology Working Group on Arrhythmias in the period 1998-2000
Member of the Italian Arrhythmology and Clinical Pacing Association since June 1998
Member of the Sudden Death Task Force, European Society of Cardiology
Member of the Italian Cardiology Society since April 2003
Member the of Scientific Sessions Committee, Heart Rhythm Society
Fellow of the European Society of Cardiology since July 2003
Section Editor of the Heart International Scientific Journal since November 2005
Associated Editor of Giornale Italiano di Aritmologia e Cardiostimolazione
President of the European Cardiac Arrhythmia Society (ECAS) since June 2007
Chairman of the 1st Scientific Sessions of the ECAS
Fellow of the Heart Rhythm Society (FHRS) since April 2008
Approximately 10,000 electrophysiology studies and/or ablations performed
1,250 pacemakers or implantable cardioverter defibrillators implanted
2,000 coronary angiographies and 500 percutaneous transluminal catheter angiographies performed
Promoter and coordinator of the BEDS (Brescia Early Defibrillation Study), a trial on early defibrillation on population in the Brescia county, still ongoing since 1998 (with up-to-date inclusion of 2,250 victims of cardiac arrest)