10-Minute Interview: William H. Sauer, MD

Dr. Sauer is an Assistant Professor of Medicine and the Director of Electrophysiology Laboratories at the University of Colorado Hospital (UCH) in Aurora, Colorado. Tell us about your medical background and how you came to work in the field of electrophysiology. What interested you about this field? All of my education and training is from a single institution in Philadelphia — the University of Pennsylvania. I initially became aware of the field of electrophysiology while studying bioengineering as an undergraduate at Penn. In fact, it was electrophysiology that initially attracted me to the field of medicine as an engineering student. The idea that an implanted device could save a life was a foreign concept and almost seemed like science fiction to me. I never before recognized this aspect of medicine and thought that it offered so many more advantages over pharmaceutical or surgical strategies to treat disease or injury. Later as a medical student, I learned about catheter-based techniques to treat a variety of cardiac conditions, including arrhythmias. This combination of technology and dramatically effective results made electrophysiology a natural choice for me early on in my education. Describe your role as Director of Electrophysiology Services at the University of Colorado Hospital as well as Director of the integrated electrophysiology program of the University of Colorado Denver. What is a typical week like for you? University of Colorado Electrophysi-ology has four affiliated hospitals and clinics that serve as the sites for its clinical, research, and training programs. These hospitals are the University of Colorado Hospital; Denver Veterans Administration Medical Center, directed by Dr. Paul Varosy; Denver Health Medical Center, directed by Dr. Christopher Lowery; and St. Joseph Hospital, directed by Dr. Laurent Lewkowiez. Most of my time is spent on the clinical and administrative responsibilities pertaining to the clinical program at UCH and the fellowship training program. I also engage in several research projects. Although I have varied interests and responsibilities, during a typical week, you can always find me in the EP lab at some point in the day teaching fellows, pointing out an interesting phenomenon, or becoming involved in a challenging case. Tell us about the new technology recently added to UCH’s EP labs. How has this changed your procedures or techniques? Both electrophysiologists and patients have benefitted from the technology available in our EP labs, including biplane fluoroscopy, high-resolution intracardiac echocardiography, and electroanatomical mapping systems. We recently added Carto 3 (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA), a new electroanatomical mapping system that will become more widely available later this year. This new system allows us to visualize multiple catheters without the need for fluoroscopy. In addition, we can use shells made from intracardiac echocardiography or a roving catheter to merge with a CT or MRI scan, greatly enhancing the precision of catheter ablation for all arrhythmias. For our complex ablations, we are using much less fluoroscopy, and can be more confident with regard to our understanding of cardiac anatomy, visualizing catheter contact in real time. For simple ablations, we are able to clearly define the anatomy of the slow pathway region or the cavotricuspid isthmus, even when we are not using the merge or intracardiac echocardiography functions. What is one of the more memorable EP cases you have been involved in? This is a hard question to answer, because there are so many memorable cases, each with a unique aspect. Although there is a tremendous amount of satisfaction when succeeding at a particularly challenging ablation, there is nothing more gratifying than successfully ablating a poorly tolerated incessant ventricular tachycardia (VT). This is a dramatic and lifesaving result that taps into what inspired many to go into medicine. One such case presented as an urgent transfer to UCH after an initial ablation attempt failed. The patient had early signs of multisystem organ failure and was emergently ablated while the heart transplant team initiated the work-up for a left ventricular assist device placement as a bridge to transplant. After epicardial access was obtained and a lesion was delivered, the tachycardia slowed and then terminated. There was a sigh of relief, followed by cheers in recognition of a life saved in the EP lab. I am still involved with the care of this patient, and periodically have happily interrogated an implanted defibrillator that has not recorded any recurrent VT over the past three years. What aspects of your work do you find most rewarding? The most rewarding aspect of my work is teaching fellows about the fundamentals of electrophysiology. The field of electrophysiology has progressed and the clinical workload can take away the emphasis of the fundamentals of electrophysiology by turning trainees into “implanters” or “ablationists.” What aspects do you believe are most challenging? The administrative tasks remain the most challenging aspect of my work. Effective administration is only appreciated if it is absent. This principle sets a high expectation for developing a program and devoting a significant amount of time, ensuring an effective system is in place. Tell us about your research interests. Are you currently involved in any research initiatives or clinical trials? My research interests encompass two broad areas within electrophysiology: 1) The evaluation of clinical strategies to diagnose, prevent, and treat ventricular arrhythmias. These projects include methods to improve implanted defibrillator and cardiac resynchronization technology, the role of VT and ventricular fibrillation ablation for prevention of ICD therapy and sudden death, and the identification and characterization of certain high-risk populations such as those with cardiac sarcoidosis and congenital heart disease. 2) The application of basic electrophysiologic principles in the electrophysiology laboratory to improve catheter-based management of arrhythmias. These projects include case reports of high educational value describing interesting electrophysiological phenomena observed in the EP lab, the evaluation of pacing maneuvers for arrhythmia differentiation in the EP lab, and physiologic effects related to catheter ablation of arrhythmias. In addition, I am fortunate to collaborate with many of my colleagues (both EP and non-EP investigators) who are moving the field of electrophysiology forward. The research program at the University of Colorado ranges from the characterization of the cellular properties of the sinus node to the pharmacogenetics of antiarrhythmic drug therapy to arrhythmia outcomes research evaluating nationwide practices for device implantation and AF ablation. What advancements or changes do you hope to see in the field of cardiac electrophysiology in the next year? What specific areas of EP and/or patient care need the most attention? Like most EPs, I am eager to see new technology that will make atrial fibrillation (AF) ablation safer and more effective. AF represents the most common arrhythmia and the treatment options we have, while revolutionary compared to what was available 10 years ago, have a long way to go. New ablation and mapping systems (including Carto 3) show some promise for improving our ability to control this difficult arrhythmia. With regards to a specific area of EP that needs attention, I think that catheter ablation for ventricular tachycardia and ventricular fibrillation remains an under-recognized and under-appreciated treatment option. While many advocate catheter ablation as a first- or second-line therapy for other arrhythmias, ablation for ventricular tachycardia is often reserved for only the most symptomatic patients who have failed several drugs, despite evidence suggesting a survival benefit with ablation. I believe that increased recognition, along with improvements in mapping and ablation techniques, will lead to a lower threshold for offering this procedure in the future. What advice would you give to others in EP who are currently at the start of their career? Electrophysiology is an exciting field within cardiology and medicine. There is no doubt in my mind that the field will continue to evolve and technology will continue to develop. My advice is to stay active with the changing field, recognize the major changes as they occur, and always be mindful of the fundamentals of the field as this will remain the only constant. Has anyone in particular been helpful to you in your growth as an electrophysiologist? In addition, what medical textbooks or online EP resources have you utilized that you can recommend? I feel that I have benefited from a tradition that has occurred at the University of Pennsylvania over the past 30 years. This began with Mark Josephson, who passed on the tradition of the highest quality training to Frank Marchlinski and Dave Callans, who in turn passed this tradition on to me and my colleagues. I feel obligated to do the same with my fellows. I recommend Mark Josephson’s textbook, Clinical Cardiac Electrophysiology, which is now in its fourth edition — no electrophysiologist should be without it. Is there anything else you'd like to add? I think that we covered a lot. Electrophysiology will continue to evolve and I hope that you and your readers will continue to stay active moving the field forward.