10-Minute Interview: Jignesh Shah, MD

In this 10-minute interview, we speak with Dr. Jignesh Shah from the Gill Heart Institute at the University of Kentucky in Lexington. Tell us about your medical background and how you came to work in the field of cardiac electrophysiology. What interested you about the cardiac field? After my Internal Medicine residency, I spent a year in India and was exposed to electrophysiology. I was mesmerized by the electrophysiologist’s ability to induce arrhythmia, locate the structures critical to the arrhythmia based on the physiology, and successfully ablate the same to cure the arrhythmia via percutaneous access. I was impressed by the combination of understanding of physiology and use of technology for this curative procedure. I was fortunate to get the opportunity to train under Mark Josephson, MD, one of the legends in the EP field, who furthered my understanding of electrophysiology and honed my skills in ablation. The physiology of the human heart continues to intrigue me and keeps me interested in this field. Describe your position as a cardiac electrophysiologist and Assistant Professor of Medicine at the Gill Heart Institute at the University of Kentucky. What is a typical day like for you? As a faculty member at Gill Heart Institute of the University of Kentucky, I spend most mornings participating in teaching conferences and training the cardiology fellows on the basics as well as nuances of cardiac pathophysiology and management. Later, I am either in the EP lab performing simple device implants or complex ablations, or in the clinic consulting patients with heart rhythm related disorders. I visit outreach clinics once a week to consult patients and occasionally perform procedures at the local community hospitals. On a daily basis, my colleagues or I consult inpatients at the UK hospital for electrophysiology issues ranging from post-operative atrial fibrillation (AF) to incessant ventricular tachycardia (VT). At least once a week, I head out to the Biomedical Engineering Department to work on some of the cardiac arrhythmia related research projects in progress. As you can notice, my day is very varied, so an interesting case or learning opportunity is always around the corner! What is one of the more unusual cases that you have worked on? I had a middle-aged patient with ischemic cardiomyopathy and past myocardial infarction (MI) and an ICD implant, who had VT storms on a monthly basis. He had 2 VT ablations, but continued to have VT storms despite these. He was placed on the maximum dose of amiodarone and mexilitene, to no avail. At this point, the patient was transferred to us. Noting the wide QRS, we upgraded the ICD to a biventricular ICD. This stopped the VT storms and enabled us to decrease the doses of antiarrhythmic medications. At the 6-month post-upgrade follow-up to the biventricular ICD, the patient had not had a single VT episode. Interestingly, at 8 months post-op, during device interrogation the LV lead was accidentally turned off and the patient had a recurrent VT storm. However, once the LV lead was turned back on, he has not had any more episodes of VT for the past 5 months. This was a good demonstration of the effect of wide QRS on the incidence of VT and the little-known effect of biventricular ICDs in preventing VT. What aspects of your work do you find most rewarding? Tackling complex life-threatening or life-impeding arrhythmias while continuing to learn the complexities of the cardiac conduction system, training the cardiology fellows who help you grow by questioning you, and having the ability to work on translational research with the Biomedical Engineering Department to bring research from bench to bedside are the most rewarding aspects of my day-to-day work. Tell us about your research interests. Are you currently involved in any research initiatives or clinical trials? I am interested in understanding the risk versus benefits of ICD shocks. There is no doubt that appropriate ICD shocks can save lives. However, we are beginning to understand the long-term adverse effects of inappropriate ICD shocks. I am interested in understanding the role of digital signals in ICD electrograms in accurately predicting self-terminating versus persistent ventricular arrhythmias as well as differentiating SVT versus VT. This will help us avoid inappropriate or unnecessary shocks. I am also trying to understand the dose response relationship between the energy delivered during ICD shock and its effect on survival. This will hopefully lead us to deliver the most optimal shock to have the best immediate outcome without adversely affecting the patient in the long term. I see that you recently participated in a Q & A about heart rhythm disorders for patient education. I agree that it is crucial to help educate patients and spread the word about heart arrhythmias. What is one of the most commonly misunderstood aspects of heart rhythm disorders that you hear from patients? The most commonly misunderstood aspect of heart rhythm disorders is that they are one entity. Hence, patients come with pre-conceived notions as to what is needed based on an anecdote of how a certain friend’s or neighbor’s heart rhythm was treated, and they expect the same treatment for themselves, whether it is a pacemaker/ICD implant or ablation. To get them to understand how there are different types of heart rhythm disorders and how all of them have individualized therapies is challenging. What advancements do you hope to see in the field of cardiac electrophysiology in the next five years? What specific areas need more attention? We continue to make progress in the techniques and instruments used for pulmonary vein isolation. Over the next 5 years, I hope the technology evolves to make it a safer and more effective procedure. I hope we are better able to risk stratify “at risk” populations for sudden cardiac death. Among those that receive ICDs, I hope to see improvement in the technology to make inappropriate shocks a thing of the past, while increasing efficacy of low-energy shocks. What advice would you give to others in EP who are currently at the start of their career? At the start of their career, one has to focus on improving clinical acumen and being selective in taking patients to the EP lab. Keeping the patient at the center of decision making, although a cliche, always leads to better clinical decisions and patient outcomes. Being able to perform simple implants and ablations safely and effectively early in one’s career prior to taking up more complex ablations is a key to long-term success. Medical communities reward proceduralists who are affable, available and able. Hence, even the most able and skilled electrophysiologist needs to be affable and available to the patients as well as referring physicians in order to build a successful career. Has anyone in particular been helpful to you in your growth in this field? In addition, what medical textbooks or online cardiac resources have you utilized that you can recommend to other medical professionals? As the saying goes, “it takes a village...”! I have been fortunate to have interacted and trained under Dr. Mark Josephson and Dr. Yash Lokhandwala (India), both of whom have taught me the cognitive and technical aspects of electrophysiology. As a fellow, I participated in numerous teaching conferences all over the country and learned from different teachers nationally and internationally. The key textbooks that have increased my understanding of cardiac electrophysiology have been: Clinical Cardiac Electrophysiology: Techniques and Interpretations by Dr. Mark Josephson, Cardiac Arrhythmias: An Integrated Approach for the Clinician by Dr. Eric Prystowsky, Clinical Electrophysiology Review by Dr. George Klein and Dr. Prystowsky, Cardiac Electrophysiology: From Cell to Bedside by Dr. Douglas Zipes and Dr. Jose Jalife, and Catheter Ablation of Cardiac Arrhythmias by Drs. Shoei K. Stephen Huang and Mark Wood. Is there anything else you'd like to add? During the training period, focus on decision making as much as if not more than acquiring the procedural skills. Keeping the patient at the center of the decision making process will always enhance patient care and build a good career. Even the most skilled electrophysiologist needs to be affable and available to gain the trust of their colleagues and patients. Best of luck!