For Tim Betts, a career in medicine was a natural choice. After graduating he knew he wanted to be a cardiologist and, with a fascination for arrhythmias and ECGs, he became hooked on electrophysiology. His research is focused on novel ways to improve the implant success and response rates to cardiac resynchronisation therapy (CRT) and was involved in the STAR AF2 trial which showed that there may be no need for additional procedures after a patient with persistent atrial fibrillation (AF) undergoes pulmonary vein isolation (PVI). In this interview he speaks to Cardiac Rhythm News about the challenges and joys he has experienced as an electrophysiologist.
Why did you decide to go into medicine and why, in particular, did you choose to specialise in electrophysiology?
The honest answer about going into medicine is that it was a natural path for those who were doing well at school. My father was a paediatrician in a university hospital with a very successful clinical and academic career and I am sure that had an influence too; there is a natural instinct to follow in one’s parents’ footsteps. I think it is very difficult for teenagers of 15 and 16 to know what they want to do as a future career, but in the UK that is the point at which you have to start aiming for medical school. I think there is a lot to be said for entering medical school as a graduate in one’s early 20s—although it’s easy for me to say that now!
Specialising in electrophysiology (EP) was a much easier choice. After graduation I knew I wanted to be a cardiologist and was always fascinated by arrhythmias and ECGs. As soon as I saw interventional electrophysiology, I was hooked. The combination of applying logic to solve arrhythmia diagnoses, the practical skills required for catheter manipulation, the ability to dramatically improve young people’s lives with ablation of highly symptomatic supraventricular tachycardia and the rapid growth in technology means that an EP’s practice changes year on year so there is never a dull moment. I must also confess that I quite liked understanding a subject that most people thought was far too complex to take on, even if it labelled me as a “nerd”.
Who are your mentors and what influence have they had on your career?
My number one mentor is professor John Morgan, who introduced me to EP when I was a trainee in Southampton, guided me through my postgraduate research and has also been a role model for how to combine a busy clinical job with research, teaching and working with industry for the greater good. I also spent 18 months in Chicago as an EP Fellow and received wonderfully comprehensive training at Northwestern University under Alan Kadish which set the foundations for how I practice EP today. I should also thank Yaver Bashir, who welcomed me to Oxford 15 years ago and is responsible for the friendly, collegiate, forward-thinking EP Team that I have the privilege to work with today.
What do you consider to have been the biggest development in cardiac rhythm management?
If I have to single one thing out, I think pulmonary vein isolation ablation has had the biggest impact. In many centres it is the most commonly performed procedure. It has significant financial implications for healthcare purchasers and providers. It is responsible for the rapid growth in the number of EPs. Implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) also have to be right up there. The subcutaneous-ICD has become a regular part of our practice as, being an extraction centre, we are only too familiar with the long-term consequences of transvenous leads.
In Oxford, the development of the Arrhythmia Nurse Specialist has had the greatest impact on cardiac rhythm management (CRM) practice. We have a fantastic team of experienced cardiac nurses who provide arrhythmia outpatient clinics and telephone consultations. They can prescribe antiarrhythmic drugs and take informed consent. They also undertake the cardiac physiologist role in the lab, running the EP and 3D mapping systems. They educate colleagues and have a national leadership role. We could not survive without them!
What has been the biggest disappointment?
I am going to say atrial fibrillation ablation again! There have been many small advances over the 20 years I have been performing PVI, such as irrigated-tip radiofrequency ablation, then 3D mapping, then contact force as well as cryoablation and laser, which have made procedures quicker, safer and more effective, yet we are still a long way from perfection. Single procedure AF ablation success rates are disappointing and the best way to ablate persistent AF remains controversial and hotly debated. I suspect that we still do not really have a proper understanding of the electrophysiology behind AF. It is a very heterogenous condition and therapies should be tailored and individualised by understanding the underlying mechanisms. We are only just beginning to realise we need upstream therapies to complement the rather basic approach of burning the left atrium. In that respect, we are years behind our coronary intervention colleagues, who also perform palliative intervention but combine that with statins, antiplatelets, aggressive targeting of comorbidities and adjunctive cardiac medication.
I have also been frustrated by the debate over percutaneous left atrial appendage occlusion. I wish the early random control trials had compared the Watchman (Boston Scientific) to no treatment in people with contraindications to anticoagulation, rather than to warfarin in people without contraindications as that would have answered the questions that have delayed the widespread introduction of this therapy. I believe it is a therapy that can reduce embolic stroke in these vulnerable people who currently have no alternative.
What is the highlight of your career so far?
There is nothing better than a super-responder to CRT. Seeing that someone’s ventricle has normalised and heart failure symptoms have disappeared when they bounce into clinic full of life restores my faith in what we do. I wish it happened more often!
I also love seeing the “lightbulb moment” when teaching on our EP courses. When a student grasps one of the many EP principles, be it entrainment, para-Hisian pacing or a device feature or algorithm, it is very rewarding.
What is your current area of research?
At present my research is focused on novel ways to improve the implant success and response rates to CRT. I have developed a technique to puncture the ventricular septum to deliver a left ventricular endocardial pacing lead for people with failed conventional CRT implants. I am also participating in trials of ultrasound left ventricular stimulation with the WISE-CRT system. This is a fascinating paradigm shift in how pacing stimulation is delivered and holds a lot of potential.
In my pursuit to understand more about the mechanisms behind AF and how they can be targeted using ablation, I am researching the use of the ACUTUS Medical mapping system. This allows global non-contact mapping of AF to try and identify and target drivers such as focal firing, rotational activity and areas of abnormal conduction.
Our CRM Team also contributes to multicentre commercial studies, including MORE-MPP-CRT, the PRAETORIAN S-ICD trials and ASAP-TOO.
What are the current challenges in electrophysiology?
We need to get better results and “more bang for our buck”. We need to improve AF and ventricular tachycardia ablation single procedure success rates. We need to have better selection of patients for complex devices and we need to improve CRT response rates and the magnitude of response. As technology advances we need to know how to use it wisely and responsibly in a cost-effective manner. Having all these challenges is what keeps the job interesting!
Of the research you have been involved in, which piece do you think has had the biggest clinical impact?
We were a big recruiter to the STAR-AF2 trial. Prior to that we would treat patients with persistent AF with extensive ablation including linear lesions and ablation of complex fractionated atrial electrograms. The fact that the trial showed no incremental benefit any ablation above and beyond PVI was sobering. We know perform PVI alone as a standard approach, unless patients are part of a research project. It has made procedures shorter and we do not get nearly so many atypical micro-reentrant atrial tachycardias at re-do procedures, but it presents a dilemma of what to do if there is more AF after successful PVI.
I have also become a “high power” ablator PVI after our PiLOT-AF study showed that short-duration, 40W lesions on the posterior LA wall led to fewer oesophageal temperature alerts and superior first pass isolation.
What has been your most memorable case?
You remember a case because it went very well or very badly. I think you learn more from the ones that go wrong because it forces you to evaluate and if necessary change practice. For example, we now perform oesophageal temperature monitoring in every patient undergoing AF ablation ever since a patient died from an atrio-esophageal fistula. There are also the successes, although by definition that usually means they do not return to the clinic to remind you how well they are doing. I still get a Christmas card from the teenager with the para-Hisian pathway successfully ablated with cryo after failing at another centre, and a bottle of whisky from the man with the left ventricular endocardial lead implanted through the ventricular septum having failed two conventional procedures who responded so well he is off the transplant list and back at work.
If you had not been a medical doctor, what would you have been?
Well, in my dreams I would have been a rock star, tech billionaire and successful novelist, possibly all three. In reality, I have never given it much thought—which I hope means I have made all the right choices.
Outside of medicine, what are your hobbies and interests?
I run a lot. I love competing in races from 5K to marathons. Age is not a barrier to improvement! Every now and then I have a moment of madness and enter an ultramarathon. Last year I ran the Comrades in South Africa (88 km uphill) and previously I have run 100 miles non-stop and seven marathons in seven days to raise money for the Oxford Heart Centre. As a result I carried the Olympic flame through Oxford when the 2012 Olympics were held in the UK—my proudest moment!
- Consultant in Cardiology and Cardiac Electrophysiology, Oxford University Hospitals NHS Foundation Trust
- University Research Lecturer, Oxford University Department of Cardiovascular Medicine
- Clinical & Research Lead, Cardiac Rhythm Management Clinical Service Unit, Oxford
- University Hospitals NHS Foundation Trust
Education and training
- MD (Southampton University, 2003)
- MBChB (Birmingham University 1991)
- CCT Cardiology 2003 (Wessex Deanery, UK)
- Clinical Fellowship in Cardiac Electrophysiology, Northwestern University (Northwestern
Memorial Hospital), Chicago, 2001-2
- MRCP (London, 1994), FRCP (London, 2010)
Current and recent research
- Steering committee member EWOLUTION registry (NCT01972282), CASA-AF (NCT02755688)
- UK PI for RE-CIRCUIT (NCT02348723), ASAP-TOO (NCT02928497)
- Local PI for MORE MPP CRT (NCT02006069), PRAETORIAN (NCT01296022), UNCOVER-AF
- (NCT02825992), CardioMEMS HF System OUS Post Approval Study (NCT02954341), WiCS-LV
- Post Market Surveillance Registry (NCT02610673)
- British Cardiovascular Society
- British Heart Rhythm Society
- British Medical Association
Areas of expertise
- Cardiac Rhythm Management in adults
- Devices: Brady pacing, ICD’s (including
subcutaneous ICD’s), CRT, lead extension
- Catheter ablation: SVT’s, flutter, ATach, AFib (parox and persistent), VT (including
- Percutaneous left atrial appendage occlusion to prevent thromboembolic stroke