Interview With N.A. Mark Estes, III, MD, Director of the Cardiac Arrhythmia Center at Tufts New England Medical Center, Boston

Readers, we are so happy to be able to bring this interview to you. Dr. Estes has long been a pioneer in the EP field. He has focused much of his career in ICD and atrial fibrillation research. He has participated in many clinical trials, including the MADIT II and DEFINITE trials. In addition, he was recently named Top Doctor by Boston Magazine. Read further to find out what he is currently working on, and what his future plans are.

How did you decide to work in EP? Describe your background and medical training.

I did all of my medical training in Boston. Among the most challenging cases that I had as a medical resident and cardiology fellow was in the evaluation and management of complex rhythm disturbances. With that in mind, I felt that training in clinical electrophysiology and a career in that area would be one that was interesting and challenging. I did my EP training at Massachusetts General Hospital, and have been working in Boston as Director of the Arrhythmia Center at the New England Medical Center since that time.

What are some of your tasks as director?

I still do the full spectrum of procedures in the lab, including pacemaker and defibrillator implants, biventricular implants, and complex ablations, and very much enjoy that aspect of my time. Obviously there is a fair amount of time that is committed to the clinical care of patients outside the lab, as well as to research, teaching, and administration.

You have spent a lot of time researching ventricular arrhythmias. Are you currently involved in any research projects?

Yes, we are involved in a wide range of research projects relative to the prediction and prevention of sudden cardiac death. We have been involved in most of the major trials that have looked at the issues of sudden cardiac death, including the CABG Patch trial and DEFINITE trial. Currently we are involved in a multicenter trial looking at patients with arrhythmogenic right ventricular dysplasia trying to identify individuals who are at risk for sudden death and finding optimal strategies for diagnosing and managing these patients.

Was some of this research presented at the 2003 American Heart Association meeting?

Yes, there were some presentations at the AHA, but the trial is still in its early stages, so we do not yet have any conclusive data. However, it is something that we are extremely excited about because it is a condition which has been difficult to objectively diagnose, and optimal management strategies are not known at this point.

What is the name of this trial? When will data results become available?

It is called the Arrhythmogenic Right Ventricular Dysplasia (ARVD) trial, in which we are systematically gathering information on a group of patients with this condition and then looking at the long-term outcomes. It will be a matter of at least three years before the data becomes available, though.

Describe your work in ICD research.

We have been very much involved in trials looking at the role of implantable cardioverter defibrillators (ICD) in cardiac death. In addition, we have been involved with the evaluation of the role of the icd when used in conjunction with biventricular pacing for treatment of patients with advanced heart failure. We also have a particular interest in treating sudden death in athletes, and have been involved in a number of initiatives looking at the role of the implantable defibrillator in preventing sudden death in young individuals with hypertrophic cardiomyopathy, a fairly unknown condition in which approximately 1 out of 500 people in the general population have. In addition, many athletes are at risk for life-threatening ventricular arrhythmias.

What can we expect regarding ICDs in the future?

That is a good question. There are several trends that one can see with respect to icds. One is a refinement of the patient population in whom the icd has helped in preventing sudden cardiac death in a cost-effective fashion. Initially there will be technical improvements in the devices themselves, resulting in a smaller size and also in features that will allow us to optimally time the stimulation of the left ventricle relative to the right ventricle in those patients with congestive heart failure.

Describe the opening of the fourth EP lab at Tufts. When will it open? What new technology will it include?

Based on growth of the number of procedures and clinical referrals, we are undergoing a major expansion of our arrhythmia center at NEMC. We are currently building a fourth electrophysiology lab; we are also expecting to allow more outpatient areas as well. This is slated to be finished on May 1st, 2004. Currently we are approximately 10,000 square feet, and we are going to be expanding to about 19,000 square feet. We will be getting a new electroanatomic mapping system and new image processing capabilities. We are also going to be upgrading to a new fluoroscopy system with higher resolution fluoroscopy.

Describe the DEFINITE trial.

The DEFINITE trial was one in which patients with dilated cardiomyopathies or nonischemic cardiomyopathies who had impaired left ventricular function were randomized to optimal medical therapy versus optimal medical therapy with an icd. The results of the trial, which were presented at AHA, showed a very strong trend towards improved survival in the patients who were randomized with a cardioversion defibrillator.

Describe your work on MADIT II. What you do you think will be some of the future effects from the results of this trial?

Based on the MADIT II trial, there will be expansion of the indications for icd use in individuals who have had a myocardial infarction and have ejection fractions of less than 30%. The scientific design of the Madit II trial was very rigorous, and the results were conclusive. There was a 45% reduction in total mortality for those that received the icd versus those who were treated with optimal therapy. There are some reimbursement and educational barriers that need to be worked through first; however, any practicing internist, family practitioner, or cardiologist should be aware of the practical implications of the madit II trial for their practice.

You recently received an award as Boston Magazine's Top Doctor. What other awards have you received?

For several years, I ve been on Woodward/White s Best Doctors in America list, including this year s list. I have received a number of awards over the years through the American Heart Association, through Tufts University, and through other educational organizations as well.

What advances do you think will occur in EP in coming decades?

Of course, one of the great frontiers of clinical electrophysiology is atrial fibrillation. We have had a large number of scientifically sound trials that have given us an indication of the role of anticoagulation in atrial fibrillation, such as the clearer role of rate control versus rhythm control, as seen in the affirm trial. I think the great frontier now is developing safer, more effective techniques for curing atrial fibrillation with ablation.

Is there anything you would like to add?

I will say that the last two decades for clinical cardiac electrophysiology have been really extraordinary with regard to the advancement in our knowledge that has been grounded in basic research, well-designed clinical trials and applications of these results for patient benefit. It has been a very exciting area to be in.