Wilkoff speaks about the beginning of his career, the future of electrophysiology and how he enjoys spending time with his family, working with computers, reading, participating in church activities and travelling.
When did you decide you wanted a career in medicine?
I first considered medicine as a career when writing my essays for college admissions. I loved science and math. I discovered that I could study biomedical engineering, math, science, and engineering and prepare for medical school. I did not know that I wanted to treat patients because the only physician that I knew was my childhood paediatrician. It was my understanding that with a Doctor of Medicine (MD) degree, I would have the credentials to do almost anything from engineering, patient care, teaching or research. As it turned out, I underestimated my opportunity.
Why did you decide to specialise in cardiac electrophysiology?
At first I thought I wanted to be a paediatrician, the only type of doctor I knew anything about. However, my first rotation was in paediatric oncology and it was far too depressing. Despite this, I loved surgical procedures, physiology and biomedical engineering. My only exposure to computers had been with punch cards or machine language programming, essentially controlling the zeros and ones. Cardiac electrophysiology did not have formal fellowships and the ones that did exist did not consider pacemaker therapy as a part of electrophysiology, but I saw both as one discipline. Fortunately, I was not the only person to see it that way. The lure of mixing surgery, computers, physiology and engineering just seemed perfect.
Who have been your greatest influences?
When I was a cardiology fellow, there was a single day conference of the Northeast Ohio Society of Pacing and Electrophysiology. Sy Furman spoke at that conference along with others, and he was absolutely inspirational. He continued to be so throughout my career. Stephen (Rick) Schaal, who headed the electrophysiology (EP) programme at The Ohio State University, believed in me and allowed me to learn EP and pacing at the same time. During a two-year EP fellowship I was given the opportunity to obtain funding through the Central Ohio Heart Association Affiliate, do animal research, learn to implant pacemakers, establish a pacemaker implantation laboratory, a pacemaker follow-up clinic and be primary investigator for several pacemaker clinical trials. No one else seemed to think that pacemakers were worth pursuing. During my EP fellowship I visited Charles Byrd, who was at that time in Miami. He was my initial surgical role model and later on sponsored my membership of North American Society of Pacing and Electrophysiology (NASPE), ultimately inspiring me to pursue transvenous lead extraction when my father’s pacemaker became infected. The other major influence was my father who required a pacemaker, and had the misfortune of having the infamous Medtronic 6972 lead, pacemaker infections, two lead extractions, ablations of atrial tachycardias and atrial flutter and a biventricular (BiV) pacemaker. Finally, James Maloney provided the opportunity for me to work at the Cleveland Clinic and enter the NASPE community.
What have been your proudest moments?
The first was when I passed the initial NASPExAM and then was immediately selected to be on the writing committee. It validated that my self study, with only an informal alliance of supervising mentors, had succeeded in allowing me to achieve a measure of excellence. Two additional most memorable moments were the presentation and publication of results of the DAVID (Dual chamber and VVI implantable defibrillator) trial and selection by my peers to be an officer in the presidential track of the Heart Rhythm Society (HRS). The DAVID trial was significant because, despite my incorrect expectation of a positive result, it provided one of the most impactful and directional bits of data influencing the therapy of many thousands and the selection by HRS because it validated that my peers believed that my contributions and voice had value.
How has electrophysiology evolved since you began your career and where do you see this field going in the next ten years?
When I started out, pacing was not really part of mainstream EP. ICDs were not FDA-approved, required a thoracotomy and lasted only a year. Dual chamber pacemakers were unipolar, anti-tachycardia pacing (ATP) was only atrial, rate adaptive pacing was just being investigated and there was no ablation. In the next 10 years, I think that management of the data that are collected by the implantable devices and remote management of patients with integration with electronic medical records will dominate the field. We will take increasingly strategic approaches to the care of our patients, managing them with broad integration of National Cardiovascular Data Registry (NCDR) data, remote interrogation data and electronic medical record data to produce quality care.
How far do you think it is possible to go with regard to advances in lead extraction?
The most important barrier to making major advances in lead extraction is providing a way to train physicians. To do this there needs to be an extraction simulator and there needs to be a commitment to quality with measurement of outcomes. The most exciting development is that there is now a community of lead extractors. Now there are hundreds of people invested in these techniques. Less than 10 years ago, it was only a boutique technique.
You have been involved in the development of several devices. Which of them has had the greatest impact on the treatment of arrhythmias?
The most important development is the one that few know about. I worked with two people from Toronto, Hart Katz and Harold Wodlinger and developed the digital storage EP lab computer. This original EP lab recorder was produced by Biomedical Instrumentation. Although I was only part of the team, it was prototypical of my collaborations with industry partners. Clearly this same paradigm was followed with Cook Pacemaker, now Cook Vascular, and Louis Goode. We did an extraordinary number of iterative changes with locking stylets, extraction sheaths and techniques.
Tell us about one of your most memorable clinical cases.
My first BiV pacemaker was done on a patient before there were leads or sheaths. He had a first degree atrioventricular (AV) block, left bundle branch block (LBBB) and systolic dysfunction with monthly admissions for heart failure decompensation. I was unable to implant the originally right ventricular (RV) lead in the coronary sinus (CS) so I implanted a dual chamber (DDD) pacemaker and it did not help. I had Cook Pacemaker make me a CS sheath and then implanted the same lead in an LV branch. It still did not help as the patient continued to have monthly admissions. I then did an AV optimisation echo and, in the ten years subsequent to this, there has not been another heart failure admission. This case illustrates the clinical mandate, the fruitfulness of collaboration with industry and the importance of continuing to ask questions and to innovate.
What are your current areas of research?
I am working on understanding how to reduce ICD shocks, optimisation of cardiac resynchronisation therapy (CRT), improving the implementation of transvenous lead extraction and developing a care pathway that collects the data collected through remote interrogation to optimise ICD and CRT therapy. The most critical portion of my work includes the integration of digital communication and the electronic medical record to improve the consistent delivery of quality device therapy. Although this is not research in its purest sense, it is the development of the regulatory, reimbursement, health policy paradigms and the quality and outcomes care pathways that have dominated my creative efforts.
Outside of medicine, what other interests do you have?
I do not have a lot of free time, but I spend every minute I can with my wife who, as my partner has enabled everything; three sons, one married with two wonderful grandchildren and two getting married this year and the terrific women that they have found. I find my efforts as a physician, scientist, teacher, administrator and developer of technology to be an expression of the working out of my God-given calling and are a result of talent, training, passion and hard work. I also love to work with computers and technology, so a few of my toys include using these tools. Other hobbies are reading, church activities and travelling. Right now my most significant time efforts include helping my three sons to launch their careers. This mentoring of my sons and mentoring of young EP fellows and younger EP staff consumes a great deal of time.
Bruce L Wilkoff
Positions
January 2005–Present Professor of Medicine, Cleveland Clinic Lerner College of Medicine of, Case Western Reserve University, The Cleveland Clinic, Cleveland, USA
July 1987–Present Staff cardiologist, Department of Cardiovascular Medicine, Cardiac Pacemakers and Electrophysiology Section, The Cleveland Clinic
July 1994–Present Director, Cardiac Pacing and Tachyarrhythmia Devices
October 2007–Present Associate Section Head Pacing and Electrophysiology Section
October 2008–Present Acting director, HVI Information Systems & Services
July 2000–2005 Medical Director of Clinical Electrophysiology Research
July 1991–1996 Director, Cardiovascular Computer Unit
March 1992–2004 Associate professor of Internal Medicine, The Ohio State University/The Cleveland Clinic Foundation, Health Science Center, Cleveland
Education
June 1976 Northwestern University Technological Institute, Evanston, USA, BS Biomedical Engineering
June 1979 Ohio State University College of Medicine, Columbus, USA, MD
Post graduate affiliations
July 1986–July 1987 Clinical Associate, Department of Cardiology, Section of Cardiac Pacing and Electrophysiology, The Cleveland Clinic
1984–1986 Research Fellowship, Cardiac Electrophysiology and Pacemakers, Ohio State University Hospital and School of Veterinary Medicine, Columbus
1982–1984 Cardiology Fellowship, Case Western Reserve University, University Hospitals of Cleveland, Cleveland
1979–1982 Internal Medicine Residency, Case Western Reserve University, University Hospitals of Cleveland, Cleveland
Honours
Phi Eta Sigma, Beta Mu Epsilon, Tau Beta Pi
Journal reviewer
American Heart Journal, American Journal of Cardiology, American Journal of Medical Science, Annals of Thoracic Surgery, Circulation, Cleveland Clinic Journal of Medicine, Europace, European Heart Journal, European Journal of Cardiac Pacing and Electrophysiology, Follow-up Forum, Heart, Journal of the American College of Cardiology, Journal of the American Medical Association, Journal of Cardiovascular Electrophysiology, Journal of Electrocardiology, Journal of Interventional Cardiovascular Electrophysiology, Mayo Clinic Proceedings, Heart Rhythm, Pacing and Clinical Electrophysiology, University Grants Committee, Research Grants Council of Hong Kong
Editorial board
Associate Editor - Pacing and Clinical Electrophysiology (PACE), Journal of Cardiovascular Electrophysiology, Heart Rhythm, Journal of Interventional Electrophysiology, Circulation, Circulation EP, World Journal of Cardiology
US patents
17 June 2008 Cardiopulmonary functional status assessment via metabolic response detection by implantable cardiac device
3 February 2004 System and method for determining safety alert conditions for implantable medical devices
4 December 2001 System and method for determining safety alert conditions for implantable medical devices
20 February 2001 Non-programmable automated heart rhythm classifier
16 March 1999 Automatic Adjustment of Detection Rate Threshold in an Implantable Antitachycardia Therapy Device
15 August 1995 Energy Efficient Multiple Sensor Cardiac Pacemaker
