Practical Electrophysiology, Third Edition: Interview with Todd J. Cohen, MD

The third edition of Practical Electrophysiology is being published this May. Previous editions of the book were published in 2005 and 2009, respectively. In this special interview, Dr. Todd Cohen from Winthrop University Hospital talks about some of the new features included in the third edition of this highly popular book series.

A lot of updates have gone into this book. First tell us more about the updated chapter on Basic Life Support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support. What have been some of the most important changes to the guidelines? 

The guidelines were completely updated in 2015. We’re very fortunate to have had Doug Beinborn, MA, RN guest author this chapter; he highlighted a number of important features. New Advanced Cardiac Life Support (ACLS) recommendations include a stronger emphasis on compressions, at a rate of 100-120 compressions per minute and a depth of 2-2.4 inches. There was also a configuration change from A-B-C (airway-breathing-circulation) to C-A-B (circulation-airway-breathing) in the guidelines. The use of oxygen is recommended during resuscitation, and end-tidal CO2 monitoring is now mandated. Biphasic therapy and single-shock treatment at full output are emphasized for defibrillation, as well as a number of other Advanced Cardiac Life Support  changes. In addition, vasopressin has been removed from the algorithm altogether, with an emphasis on early administration of epinephrine. Amiodarone continues to be a first-line therapy as an antiarrhythmic drug, and lidocaine remains an acceptable alternative. There were also many changes in Basic Life Support  and Pediatric Advanced Life Support guidelines. 

Another interesting feature in the chapter is information about a handheld mechanical CPR device called the ResQCPR^™ System, which I was fortunate to be involved with as a co-inventor. This technology is now incorporated in ZOLL Medical’s CPR system as well as the LUCAS 2^® Chest Compression System manufactured by Physio-Control, Inc.

A new chapter in this edition covers Anesthesia and Sedation for Cardiac Electrophysiology Procedures (guest authored by Richard Fuss, MD, FABA and Carl Schmigelski, MD, FABA). Why was it important to incorporate a chapter on this?

Since patient safety is our number-one concern, the addition of an anesthesiologist in many of our complicated cases adds a component of safety, comfort, and airway protection to the procedure. It is important for electrophysiologists and their staff to have an understanding of conscious sedation, deep sedation, and general sedation, and know that these are serious medications that require appropriate vigilance and management throughout the procedure. 

An additional new chapter covers Robotic Devices in the Electrophysiology Laboratory (guest authored by Daniel Kersten). I know that you are responsible for inventing one of the newer FDA-approved systems. What in your opinion are some of the most important new technologies, and where does the system that you helped invent fit in? 

It’s interesting that some of the very expensive and more complicated systems have fallen a little bit by the wayside, while some of the simpler and easier technologies have started to gain some traction. For example, in the second edition of Practical Electrophysiology, a product that I invented (the Amigo Remote Catheter System from Catheter Robotics) was in “The Future of Electrophysiology” chapter, and now it is FDA approved. We are using this technology at Winthrop University Hospital, and have been told that I am the number-one user of the Amigo Remote Catheter System in the state of New York. This technology can safely and effectively treat SVT and VT procedures. I just finished a complicated SVT case using this robotic system, and was able to get an excellent result without wearing a radiation protective apron. It is the only robotic cardiac ablation technology used at our hospital. Catheter Robotics is getting closer to launching their second-generation Amigo^® II Remote Catheter System, which is a smaller, lighter, and less complicated robotic system that is featured in the “The Future of Electrophysiology” of this edition.

What can you tell us about the new chapter on Preventing Cerebrovascular Events in Patients with Atrial Fibrillation: Drugs and Devices (guest authored by Roger Kersten, DO, FACC)?

Again, we were very fortunate to have this chapter guest authored; Dr. Kersten specifically highlighted the variety of novel oral anticoagulants (NOACs). It’s important for electrophysiologists to be aware of these different drugs and know how to manage them periprocedurally or during a bleeding complication. In addition, there are some newer techniques coming out to help prevent a stroke in patients with atrial fibrillation; these include left atrial appendage occlusion devices and techniques, such as the WATCHMAN device (Boston Scientific) and LARIAT Suture Delivery Device (SentreHeart, Inc.). Our hospital just successfully launched our WATCHMAN program with two of our electrophysiologists, Dr. Joseph Germano and Dr. Sameer Parekh. The ability to offer left atrial appendage occlusive procedures is an important component of any comprehensive atrial fibrillation program and center. 

New also in this edition is supplementary video content. Tell us more about what is included and who it is available to. 

My intention for the video component was to talk about the specifics related to each chapter from the setting in where I work, typically in the lab or a conference room. This content is only available to those who have purchased the book, and there is a method to which the reader can securely access the web content and watch these videos to further understand the importance of these points in each chapter. 

The quizzes in the third edition are almost double in size! How are the Practical Electrophysiology materials beneficial for educational purposes?

It’s important to test one’s knowledge and assess the information as one learns. In addition, the certification processes for allied professionals as well as electrophysiologists are getting more and more important. Certifications are offered through the Heart Rhythm Society as well as through the American Board of Internal Medicine. However, having additional questions to test oneself is crucial in bringing that information to the forefront and driving home the key points that may be important for certification. 

How have you incorporated Practical Electrophysiology into your practice?

I provided the first two editions to my staff in our very busy and active lab. In particular, new members in the lab utilized the book and found it very worthwhile for getting on board with current technology, devices, techniques, medications, issues related to patient safety, and other critical information necessary for them to function in a contemporary EP lab. 

Is this book still considered an “EP 101” guide for beginners? What advances do you think we’ll continue to see in electrophysiology?

It is absolutely an EP 101 guide for beginners, and could also be used as a refresher for those who are more experienced but need to bone up on the latest guidelines. Since so many things have changed since the last edition in 2009 — including changes in guidelines, implantable devices, mapping systems, the treatment of AF, cryoablation, robotic therapy, and left atrial occlusive devices — this book was almost completely rewritten. For example, MRI compatibility with implantable devices has become the standard, implantable cardiac monitors are now injectable and more commonplace, and the subcutaneous defibrillator is now available and in its second generation. In our facility, we are also using the wearable defibrillator as a compliance tool to protect patients who may be at risk for sudden death but may not be able to receive an implantable defibrillator at the present time. For example, a patient may be at risk for sudden death due to severe left ventricular function, but may not necessarily “yet” qualify for an implantable defibrillator due to a timing issue (recent myocardial infarction, coronary artery bypass surgery, or percutaneous coronary intervention).  The wearable defibrillator can protect the patient during this period of time in which the heart can remodel and potentially improve. If the heart function does not improve, an implantable defibrillator may be warranted. Another example is in a patient who had an implantable defibrillator removed secondary to an infection. The wearable defibrillator can protect this patient until their infection is completely resolved and he or she can receive another implantable defibrillator. All of this is covered in this book. 

What other projects are you currently working on?

Right now, I’m working on a whole series of devices that hopefully will help make EP procedures and device implants simpler and safer. I’ve developed a line of products known as the “EZ” line of products, including the patented EZ OFF^™ device, which replaces the “dumb” ablation connector cable that attaches any ablation catheter to its generator or console. This “smart” device allows the doctor to have direct manual control so that they can terminate ablation therapy at will. Having that control should make it easier for the doctor to prevent certain complications such as heart block, perforations, and damage to the phrenic nerve. A second product is called the EZ HOLDER^™, which should be released soon; the EZ HOLDER^™ allows electrophysiology and ablation catheters as well as pacemaker and defibrillator leads to be easily held in place and not move during a procedure. This can be helpful if an operator needs to free up his hands for other work or if the operator needs to carefully administer ablation in a certain location, hold EP catheters in place while cardioverting or defibrillating, and hold implantable leads in place while others are manipulated. In addition, it allows the doctor to be able to remove a sheath while maintaining the LV lead in position, while keeping the other pacing or defibrillation leads in place. 

Lastly, one common difficulty involves the explantation of implantable loop recorders; the new loop recorders are so small, it’s difficult to identify exactly where they are located (along with their depth) in the human body during explant surgery. In fact, during a recent procedure, an operator had difficulty finding the loop recorder implant, which resulted in some bleeding during the procedure.  I developed the EZ FINDER^™ to help with these explant procedures. The EZ FINDER^™ is a sterile medical device that can precisely locate implantable loop recorders and mark where it is, in order to help with the explantation of that device. These three “EZ” to use devices currently are awaiting approval. 

Is there anything else you would like to add?

I’d like to thank the HMP publication staff for all of their help with the preparation of this book. I’d also like to thank my research interns Jin Ju Yi and Daniel Kersten, my physician assistant Alexandru Mitrache, PA, and our administrative team (led by CEO John Collins) for all their support during my educational endeavors.