Dr. Melvin Scheinman: 40th Anniversary of Catheter Ablation

Forty years ago, patients with abnormal heart rhythms had few treatment options: frequently ineffective medications, or open-heart surgery.

UCSF cardiac electrophysiologist Melvin Scheinman, MD, now the Walter H. Shorenstein Endowed Chair in Cardiology, spent years developing a new approach. In 1981 he performed the first catheter ablation in humans, threading a catheter through a blood vessel into the heart and successfully delivering an electric shock to short-circuit the arrhythmia. That innovation has revolutionized the care of millions of patients worldwide, relieving their suffering and even curing many of their arrhythmias.

“Dr. Scheinman’s contribution to the field has been one of the most transformative in all of electrophysiology,” said Jeffrey Olgin, MD, Ernest Gallo-Kanu Chatterjee Distinguished Professor in Clinical Cardiology and chief of the UCSF Division of Cardiology.

Treating Arrhythmias without Surgery

Dr. Scheinman arrived at UCSF in 1965 as a cardiology fellow, drawn by exciting research underway at the Cardiovascular Research Institute, as well as the chance to work with leaders such as electrocardiographer Maurice Sokolow, MD, chief of the Division of Cardiology, and Lloyd Hollingsworth “Holly” Smith, Jr., MD, legendary chair of the Department of Medicine.

After fellowship, Dr. Scheinman joined the UCSF faculty, and founded the Coronary Care Unit (CCU) at San Francisco General Hospital (SFGH). That experience fueled his fascination with heart rhythm disorders. In the mid-1970s, he spent a sabbatical year at Duke University working with cardiac electrophysiologists Harold Strauss, MD, and John Gallagher, MD. “I learned about fundamental electrophysiology, and how to do mapping of heart rhythm disorders in humans,” said Dr. Scheinman.

The idea for catheter ablation evolved from the surgical experience of treating arrhythmias. “Surgeons could open the heart and find the key areas in the electrical system in patients who had very, very severe heart rhythm disorders like atrial fibrillation with very rapid rates,” said Dr. Scheinman. “They destroyed the conducting system that allowed impulses to go from the top of the heart to the bottom.” While this could help control atrial fibrillation, many patients were ineligible for the surgery because they would be unable to withstand such an invasive procedure. “The idea was to devise a way to put a catheter in through a vein, pass it into the heart, and do the same thing that surgeons did – only without opening the heart,” he said.

He spent the next three years pursuing this vision. Until this point, catheters had only been used to detect electrical signals in the heart for diagnostic purposes. Dr. Scheinman conducted experiments to identify catheters that had sufficient strength to carry large electrical currents that were powerful enough to strategically destroy heart tissue. “It was a whole different use for these electrode catheters,” he said.

He and his colleagues submerged catheters in buckets of saline and discharged high-energy electrical currents through them. “Most catheters would just shred apart,” said Dr. Scheinman. “It looked like a series of wires that were exposed to fire. We were trying to identify catheters that had high resistivity and could accommodate large surges of current flow without exploding…. This is now a multibillion dollar business, but the original engineers didn’t have any insights into what this kind of treatment would eventuate.”

Through trial and error they found a catheter made by the company Bard which was up to the task. One of Dr. Scheinman’s research fellows, Chilean physician Rolando González, MD, led tests of catheter ablation in animal models. Laboratory technician Booker T. Pullen helped design the electrodes and equipment to safely perform this procedure. Dr. Scheinman and Dr. González also traveled to Southern California to observe the work of James Beazell, who worked for a pacemaker company and had developed a catheter approach for delivering high-energy shocks in animals.

In addition, they collaborated with Saroja Bharati, MD, and Maurice Lev, MD, two prominent cardiac pathologists based at the Hektoen Institute for Medical Research in Chicago. Dr. Scheinman’s team sent them the ablated animal hearts to determine whether the procedure was safe and effective. “They very carefully dissected the hearts and found that while there was a lot of scarring in the region where we produced the block, it didn’t destroy blood vessels or valves, and didn’t clog the arteries,” said Dr. Scheinman.

The First Patient

In 1981, Dr. Scheinman and his team were finally ready to offer catheter ablation to patients after perfecting their technique and performing 10 consecutive successful ablations in animals. A retired oil field worker named Paul Anderson came to UCSF suffering from atrial fibrillation, the most common abnormal heart rhythm, in which the upper chambers of the heart quiver rather than contracting in a coordinated manner. The arrhythmia is caused by aberrant electrical signals that cause this chaotic activity in the heart.

“He was a very nice person with a wonderful family,” said Dr. Scheinman. “[His heart] would go very, very rapidly during the atrial fibrillation, and because he also had heart failure, he would go into severe heart failure that couldn’t be controlled with drug therapy.” Mr. Anderson also had severe chronic rheumatoid arthritis and severe chronic obstructive pulmonary disease (COPD), which made him ineligible for surgical treatment of atrial fibrillation.

Dr. Scheinman met with Mr. Anderson and explained the possibility of doing a catheter ablation to treat his arrhythmia. However, Dr. Scheinman asked a colleague, David Hess, MD, to obtain informed consent from the patient. “I had invested so much of my life into this that I didn’t think I could fairly present it to him,” said Dr. Scheinman. Dr. Hess obtained Mr. Anderson’s consent, but had second thoughts and called Dr. Scheinman the night before the procedure. “He told me, ‘Maybe you should do more animal work,’” Dr. Scheinman recalled. “I said, ‘No, we’ve done three years of preclinical research, and I’m not going to learn any more from that. Either the patient accepts it or not.”

When he came to work on the morning of April 9, 1981, Dr. Scheinman wasn’t sure whether Mr. Anderson was ready to go forward or not. “I came by, and he was really symptomatic and pretty miserable,” said Dr. Scheinman. “His lungs had filled with fluid, what we call pulmonary edema, and he couldn’t breathe very well. He didn’t have too many other options. He was a very stoic, salt-of-the-earth kind of guy, and he said, ‘Get on with it!’”

Dr. Scheinman’s team, which included Fred Morady, MD, Ruey Sung, MD, and Dr. González, treated the patient in the new angiographic laboratory. “We were, of course, very excited,” said Dr. Scheinman. “It went very smoothly, and was actually much easier than the animal experiments.” The team found it simpler to locate their navigational landmark, a group of fibers that carry electrical impulses through the center of the heart called the His bundle, in their patient compared with animals. They were then able to strategically ablate a spot further upstream to prevent chaotic electrical activity from traveling from the top to the bottom of the heart.

“It was very, very quick,” said Dr. Scheinman. “You deliver a shock, and then it’s all over and done with.” Interrupting the aberrant electrical activity created a new problem of a very low heart rate, so the team then implanted a pacemaker to maintain a heart rate sufficiently high enough to ensure adequate blood flow to the body.

The procedure was successful. Although the patient’s atrial fibrillation eventually returned, it was easily controlled with medication, and he ultimately lived five more years before dying of congestive heart failure. “We were able to take care of his arrhythmia, which had been a major problem, and to control his pulmonary edema,” said Dr. Scheinman. “He was very happy about that.”

He is characteristically modest about this landmark achievement. “What I did was a very primitive first step,” said Dr. Scheinman.

40 Years of Innovation

Since 1981, the field has exploded, and continues to develop to treat increasingly complex cardiac arrhythmias. For example, Dr. Scheinman’s group was the first to successfully use catheter ablation to treat patients with a rare genetic disorder called Wolff-Parkinson-White Syndrome, in which they are born with an extra electrical pathway in the heart that can cause severe, life-threatening arrhythmias. One of his former fellows, Fred Morady, MD, was one of the first to describe the use of catheter ablation to treat a large series of these patients.

Another of Dr. Scheinman’s former fellows, Jonathan Langberg, MD, was among the first researchers to investigate the use of radiofrequency energy instead of direct current to perform ablations. “Radiofrequency energy is a lot safer, less traumatic, and can be pinpointed to a greater extent than high-energy shocks, which were harder to control,” said Dr. Scheinman. “It came into being in the late 80s and is now the standard of use in catheter ablative techniques.”

Some of his many other achievements included learning how to successfully ablate sinus node disorders and atrial flutter. Dr. Scheinman also defined the role of diagnostic procedures for patients with bundle branch block, which has provided foundational guidance for implanting permanent pacemakers. He also defined the role of pacing and use of an internal defibrillator in patients with long QT syndrome, a congenital abnormality associated with risk of sudden death, especially in children and young adults. His group also demonstrated that intravenous amiodarone could be an effective treatment for serious ventricular arrhythmias.

Although he stopped performing catheter ablations himself a few years ago, he still goes to the Electrophysiology Lab to advise on interesting cases. His current research focuses on better understanding the mechanisms of heart rhythm disorders by analyzing electrophysiology studies. “The more you understand the mechanisms, the better able you are to devise therapies,” said Dr. Scheinman.

Even though he pioneered catheter ablation, Dr. Scheinman still marvels at how the field has evolved. “Nowadays we’re using it for incredible things, such as treating people with severe, life-threatening arrhythmias coming from the ventricles,” he said. “Many of our treatments can actually cure patients, such as those with atrial fibrillation. This, to me, is outstanding. I also never dreamed that we would have techniques to map heart rhythm disorders. The advances made by industry to help produce animations of heart rhythm disorders are very exciting.”

Treating Genetic Arrhythmias

Dr. Scheinman looks forward to future developments. “The next big thing is using genes to cure people,” he said. “That’s in its infancy now, with animal models. In my view, in the next decade that’s going to really take off, where we could deliver genes and enhance functions that have been lost, or block functions that are abnormal. I think that’s going to be fantastic.”

In 2003, Dr. Scheinman spent a sabbatical year at UC San Diego working with Kenneth Chien, MD, who later became one of the co-founders of Moderna Therapeutics. “I learned a lot about genetics and molecular medicine, which had a profound influence on my career,” he said.

After he returned, he founded the UCSF Comprehensive Genetic Arrhythmia Program, which brings together experts in electrophysiology, cardiology, genetics and genetic counseling to diagnose and treat inherited, potentially life-threatening arrhythmias. “The typical case is the young soccer player who suddenly collapses and has to be resuscitated,” said Dr. Scheinman. “We’re learning more about these disorders every day, and discovering new genes that are associated with these types of heart rhythm disorders. The program also provides genetic testing and counseling to patients’ families, because they may need proactive treatment as well. It’s a very exciting area in cardiac electrophysiology.”

In addition to providing patient care and conducting research about these rare disorders, the program also presents educational seminars where patients and their families can learn more about their conditions from world-class experts.

‘Every Day is a New Challenge’

From an early age, Dr. Scheinman’s parents and yeshiva education fostered his work ethic and commitment to helping others. He was born in New York, the fourth of five children, and grew up in Brooklyn. His father immigrated from Berlin and his mother from a Polish village. While they had little opportunity for formal schooling themselves, they expected their sons to become doctors and their daughters to pursue teaching or nursing – goals which all five children later fulfilled. Their father worked seven days a week in the family’s grocery store, and Dr. Scheinman and his siblings also helped out as much as they could.

At age 16, Dr. Scheinman enrolled at New York University, then transferred to Johns Hopkins University, where they had an excellent biochemistry program. “I loved biochemistry, but learned that I couldn’t function in a laboratory alone,” Dr. Scheinman said in a 2001 interview with the American Journal of Cardiology. “I had to interact with people.”

After graduating at the top of his class with a bachelor’s degree in biochemistry, he earned his medical degree from Albert Einstein College of Medicine in New York, developing an interest in cardiology. “I was just amazed that these very astute clinicians could look at a chest X-ray and predict exactly what a patient’s abnormality was, and its severity,” said Dr. Scheinman. “At that time, many medical disciplines were more empiric. Cardiology and electrocardiography were a lot more science-based.”

While he got an excellent education, the professors were brutal if medical students were unprepared, suggesting that they abandon medicine and drive trucks instead. “There was an incredible impression that you had to treat medical students like they were subhuman so they would learn,” said Dr. Scheinman. “The students were terrified, and it had the opposite effect. I said, ‘If I ever become a teacher, I will never do that.’”

He then went to the University of North Carolina at Chapel Hill, which had a relatively new internal medicine residency program in a community with an intimate, small-town feel. “The patients were usually townspeople, and the doctors treated them like equals,” said Dr. Scheinman. “That conditioned me to sit down and talk with patients as if I were visiting a friend in their house.”

As a faculty member, Dr. Scheinman made good on his early vow to encourage rather than berate the next generation of physicians, and has won many teaching awards. “I like interacting with young, bright people, which we are very fortunate to have here at UCSF,” he said. “They inspire me to keep asking questions. Every day you teach, you learn something. That’s the remarkable thing about being in academic medicine: every day is a new challenge.”

He advises trainees to think creatively. “At UCSF, everyone is smart,” said Dr. Scheinman. “I try to encourage people to also be innovative. Think out of the box, whatever comes to your mind, and then try to figure out, what are the three best ways to attack a problem?”

“I came to UCSF in the 1980s for my training after medical school in large part because Dr. Scheinman made UCSF the ‘epicenter’ for innovation in electrophysiology,” said Dr. Olgin, Chief of the Division of Cardiology. “I was very fortunate to have been trained by him.”

“Currently we perform about 1,200 curative catheter ablation procedures a year at UCSF, and these lifesaving procedures are commonly performed worldwide,” said Edward P. Gerstenfeld, MD, chief of the Cardiac Electrophysiology and Arrhythmia Service and Melvin Scheinman Endowed Professor of Medicine. “The entire field of catheter ablation, and all the patients who have benefitted, owe a debt to Dr. Scheinman. That he continues to be an active teacher, researcher and contributor to the field only further highlights his continued passion for cardiac electrophysiology.”

Besides medicine, Dr. Scheinman loves opera and classical music, has season passes to the 49ers and Giants, and enjoys walking and hiking. Every year he travels to Cambodia to teach, lecture and advise his colleagues there in the electrophysiology lab. “It’s very fulfilling,” he said. On weekends, he also delivers food to people in need through his synagogue. “Helping the underserved is important to me, and I get a lot of joy out of that,” he said. He and his wife, Margaret, also appreciate spending time with their three grown children and nine grandchildren.

“There are wonderful people at UCSF who are doing a lot of great work,” said Dr. Scheinman. “I don’t see myself as a big hero – I’m just a bit player. It’s been a very, very exciting ride, and I’ve been very fortunate.”

 

- Elizabeth Chur