Douglas Packer

When did you decide you wanted a career in medicine? Why cardiology and electrophysiology?

I decided to become a doctor sometime during the seventh or eighth grade. It seems that desire had always been there. I suppose I was strongly influenced by one of the general practitioners in town who was not even my personal physician. Based on those interactions, I found him to be very knowledgeable, if not erudite. He simply seemed to provide an excellent example of the very best in medicine, one worth emulating.

Shortly thereafter, I decided to pursue either cardiology or cardiac surgery. I was enamoured by the heart, simply from looking at the family encyclopaedia that had acetate film layered images of the heart. I also had some exposure to physiology in an early biology class in high school. Early in my internship and residency at Duke University, I decided on cardiac electrophysiology. I would watch Dr John Gallagher round and interacted with him in the management of patients with Wolf Parkinson and White Syndrome or ventricular tachycardia. In electrophysiology, I felt that my own personal interests came together. When I was in high school, I worked at the family car dealership in the service department. My area of interest and expertise was the electrical systems of the car. In college, I majored in chemistry, but was most interested in physical chemistry in general, and quantum mechanics in specific. Medical school was a bit disappointing because of the rote memorisation aspects of it. It was exposure to electrophysiology, however, that brought back all of the interest from my younger years and college. I was sold on the study of arrhythmias from that point on.

Who has inspired you in your career and what advice of theirs do you remember today?

I have been fortunate during my career to have had excellent mentors. In medical school, one of my mentors was Dr Maxwell Wintrobe who rounded with us on our hospital service. Dr George Cartwright similarly took an interest in my career in internal medicine. At Duke, one of my early role models was Dr Eugene Stead, while another mentor was James B Wynegarten. In cardiac electrophysiology, I had the good fortune of training with Dr John Gallagher and later did a “post doc” training period with Eric Prystowsky. While each of these individuals is very different, each had a very specific drive to achieve excellence in all that they did.

They took a hard-core academic approach to medicine, and were actually quite demanding. I found that it was a great thrill to be part of great programmes with great mentors. They taught me how to critically analyse critical data and ask the appropriate next questions relevant for either research endeavours or in the treatment of patients with various cardiac diseases.

What have been your proudest professional moments?

I suppose that the very proudest moments came at the time of finishing a long and very complicated case, where it was absolutely unclear at the beginning what the underlying rhythm abnormality was, and where its anatomic origin was, but eventually being successful in treating that abnormality. There is nothing as invigorating as confronting a very complex case in seemingly hopeless patients and coming out with an observation that is critical in the elucidation of the arrhythmia mechanism and its elimination. I have frequently felt the same sense of accomplishment in pursuing research and successfully completing innovative projects. All of the other professional accolades that have come along through time were simply icing on that kind of cake.

Which innovations in cardiac electrophysiology shaped your career?

When I started in cardiac electrophysiology, we used fairly rudimentary recording systems with no more than 8–16 channels captured on magnetic tape and recorded on paper roles. Patients underwent surgery as a definitive treatment of problematic arrhythmias. Over the years, the development of defibrillators and biventricular pacing has been very important. More importantly in shaping my own career has been the development of advanced mapping technologies and ablation capabilities. Personally, the development and application of three-dimensional imaging has had the greatest impact on my practice. The ability to sue three-dimensional images and integrate them in four and five-dimensional mapping displays have been critically important in moving cardiac electrophysiology into its next era.

As president of the Heart Rhythm Society, what have your biggest projects and achievements been?

As president of the Heart Rhythm Society, I have had the opportunity of working closely with great people with great minds. These have been both within the physician contingent, but also the staff and James Youngblood, the CEO of the Heart Rhythm Society. Working together, we have taken a very close look at all of our past operational approaches. This has been based on a nicely crafted strategic plan. The most important projects have been the implementation of the strategic plan and development of ideas using task forces, work groups, and individual teams. We have accomplished much as a group. Most importantly, the Heart Rhythm Society has developed a much more robust research culture, in which clinicians are increasingly active. We have looked forward into the blue sky of the future to push forward science, discovery, and innovation. We are now developing many different projects to better fund our research endeavours and move forward with clinical trial networks. We have also been successful in securing specialty status for cardiac electrophysiology within the Federal Government. This is critical as it acknowledges the pre-eminence of our society members in dealing with cardiac arrhythmias. This becomes an even more important point when we look at the development of quality metrics and performance measures to identify both the best and most difficult parts of our practice. The society has also looked deeply into its own soul to question many of our past practices with an eye towards taking the next steps in achieving greater progress.

Ablation is now an increasingly popular treatment of atrial fibrillation. How do you see this field in the future?

Ablation of atrial fibrillation serves as a paradigm or guide for approaching other cardiac arrhythmias. Within the near future, we will see fairly straightforward ablation of ventricular fibrillation in the development of ablative techniques and technologies for the more effective elimination of ventricular tachycardia. In the field of atrial fibrillation, cell therapy, which will become commonplace. The development of more straightforward ablation energies and the quest to move to catheter-free ablation of atrial fibrillation will be realised through the development of external energy sources.

As principal investigator of the CABANA (Catheter ablation vs. antiarrhythmic drug therapy for atrial fibrillation) trial, what are your thoughts on the results so far?

CABANA is a critically important trial because it questions long-term outcomes of ablation. While our hypothesis is that catheter ablation will be superior to state-of-art drug therapy, this needs to be proven over the course of a carefully conducted randomised clinical trial. We will also find out whether the costs of ablation are sustainable within our current healthcare system. We fully anticipate that CABANA will be a positive trial in identifying the success of ablative intervention in eliminating symptoms and improving the quality of life of many patients. This has already been demonstrating in the pilot study. We now need to determine whether treatment of atrial fibrillation decreases mortality. There are many reasons to believe that will be the case. I am most impressed with the dedication of the investigators that are now working on the CABANA trial.