- a conversation with Dr. Péter Kupó, Head of the Electrophysiology Laboratory at the Heart Institute
Dr. Péter Kupó chose a difficult path by stepping out of his comfort zone and working hard like a medieval journeyman, acquiring, and bringing to Pécs the knowledge that has made the Electrophysiology Laboratory of the Pécs Clinical Centre a pioneer internationally. We talked with the young clinician about the revolutionary catheter ablation in the treatment of arrhythmias and the enthusiasm driving him.
Interview by Miklós Stemler
Around one million people belong to the UP Clinical Centre Heart Institute Electrophysiology Laboratory’s health service area, where about 700 patients with arrhythmia are treated every year. Although Dr. Péter Kupó, assistant professor and head of the laboratory, originally intended to specialize in a different field, an experience as powerful as a revelation led him to choose arrhythmology, which proved to be a good decision, and not only for him.
From general practice to the Heart Institute
All of this was, however, preceded by a few earlier decisions and experiences, such as those formative childhood years when he spent time in his grandfather’s GP ward and even accompanied him to see patients on several occasions. These experiences had such an impact on him that, as a teenager, his choice of a career in medicine was unquestionable. However, he hesitated until the last moment where - in Budapest or Pécs - he would choose to achieve his goals.
“I was originally drawn to Budapest, but then I had an inspiration that I should come to Pécs, so it ended up being the first on my list of places to apply. It was obvious that I would be admitted to both universities based on my scores. It was really a kind of inspiration because I hardly knew this city before, I had only been here twice. Something just drew me here - and looking back, it was a great decision,” recalls Péter Kupó.
At the university, he was interested in the clinical subjects, particularly cardiology.
“The heart is the centre of the body, a kind of mystical organ, and even as a medical student I was very interested in it. Then I had a sense of achievement and decided that I really wanted to do this: I did very well in my cardiology exam, not only got an A, but also connected with Professor András Komócsi. I could not wait for the exam period to be over, and I immediately contacted him to see if I could join his work in some way. He told me to visit him regularly at the institute, and we also came up with a TDK topic.”
Professional reorientation due to shock
This could have been the home straight, but an experience - just like when Pécs became the first choice instead of Budapest - turned Péter Kupó in a slightly different direction.
“Professor Komócsi’s specialty is coronary angiography, or hemodynamics, and for a long time I imagined my future in this field. When I was a sixth-year student, I went to the then director of the clinic, Professor Szabados, and told him that I would like to work at the clinic if it was possible, specifically in the field of angiography. He said that he would support employing me, but before deciding, I should spend a day in the electrophysiology laboratory. So, I did; that was my first visit here.”
What he had seen in the lab had a huge impact on him - but this time it was more of a shock than a sense of achievement in an exam.
“As a sixth-year student, you are almost a doctor, you have learned and seen a lot. At that age, whatever the topic or question, you understand what it is, and you can contribute to it - at least that is what I thought. But when I came here, I realized while watching a series of interventions that I did not understand a word of what they were talking about.”
However, instead of doing what most of us probably would have done, leaving everything behind and returning to his comfort zone, Péter Kupó chose the opposite path.
“I was so shocked by the complexity of the work here that I came out of the lab thinking, ‘I have to learn this’. I went back to Professor Szabados with the idea that I would like to do my residency here if there was an opportunity, and he was very supportive. That is how I ended up here under the then head of the lab, Professor Simor.”
The astonishment of sixth-year student Péter Kupó was not surprising, given that electrophysiology is a relatively new field in cardiology, and one that, without any exaggerations, allows revolutionary interventions. The so-called catheter ablation, which uses catheters to remove clots causing arrhythmia by heat treatment using targeted tissue fracture, began to become widespread after the turn of the millennium and is still a rapidly developing field. Its importance is huge, since catheter ablation is a low-risk, low-stress, overnight procedure that can replace a lifetime of medication. Moreover, it potentially affects 5% of the Hungarian population.
“Around half a million people in Hungary suffer from arrhythmia, although it is important to add that we are talking about a spectrum of conditions ranging from those that do not really affect everyday life and have few complaints to those that are life-threatening. However, it is safe to say that in the more severe cases where arrhythmia has a serious impact on quality of life or is even life-threatening, it is strongly recommended because it has minimal risk, but it is a highly beneficial intervention.”
Guild years
After graduating in 2015, Péter Kupó joined the lab as a resident, and later participated in several study trips to electrophysiology labs abroad, which encouraged him to learn even more.
“I was a bit jealous of the residents working there because I saw that they were better at performing interventions than I was. I thought it would be beneficial for both me and the institute if I could go somewhere where I could further develop my skills. At that time, the University of Szeged Electrophysiology Department had already had a structured two-year fellowship program, accredited by the European Heart Rhythm Association, which relieves fellows of various obligations, such as on-call and administrative tasks, but in return the fellows have to work in the laboratory all day, where they learn catheterization from experienced colleagues and later perform it under their supervision. I was the first Hungarian doctor to get admitted in the fellowship, and it was there that I acquired the knowledge that enabled me to work independently.”
After two years of “guild” practice in Szeged, he returned to Pécs in 2020, and in addition to his specialist and PhD degree, he also obtained the European arrhythmologist license.
“This is not compulsory, but doctors with such a licence are taken very seriously. It is a six-hour, 120-question test, harder than the specialist medical exam, and it is not a score-based test: the top 50 percent get it every year, and the rest can try again, no matter how good their scores were.”
The secret to success: self-confidence, composure and diligence, diligence, diligence
In January 2022, the institute’s leadership appointed him to lead the Electrophysiology Working Group, which involves 600-700 interventions per year. Although catheter ablation is among the low-risk procedures, it certainly takes some courage to terminate clots in a living heart using a catheter.
“As a beginner, I was obviously a bit nervous, and it is a big responsibility to perform interventions in another person’s body – especially when it is one of their vital organs. But you also have to see that anyone who undertakes such work has to be able to manage the stress involved. It requires a healthy amount of self-confidence, which of course comes with experience too, but it is also a matter of aptitude. People working in catheter labs need to be able to do this – if only because, fortunately rarely, but there can be difficult situations when calm, very quick and good decision-making is essential.”
According to Péter Kupó, diligence is equally important in addition to composure and self-confidence, as electrophysiology is a field requiring lots of knowledge.
“My wife is a witness to the fact that I often studied at home even at ten o’clock at night, and even today I sometimes go through the interesting cases of the day and analyze the results in the evenings. We also tell the residents who come to our lab to understand that they have to invest a lot of time and energy to be good at this. Diligence, perseverance, and humility towards the profession are essential for success, and some manual skills are also required.”
Fight against harmful X-rays
We can perhaps top all this with the ambition driving Péter Kupó and his colleagues to continuous development and innovation. The most important of these is the X-ray-free catheter ablation, in which the laboratory in Pécs is considered a pioneer internationally.
“X-ray has traditionally been an integral part of catheter ablations, since it is the imaging method allowing us to follow the course of the intervention. However, this is problematic for several reasons. First, there are special patient groups in terms of X-ray – for example, pregnant women and young children – where it is very important to consider whether it is worth performing the intervention using X-ray at all. We also have to think about the staff who, on the one hand, are exposed to radiation for several hours a day and, on the other hand, have to wear heavy lead clothes as part of their protection against it, which inevitably leads to musculoskeletal problems over the years, decades. We have concrete data showing that, as a result of exposure, the rate of left hemisphere tumours among people undergoing invasive cardiological interventions and the rate of left breast tumours among female workers are significantly higher than the population average.
“Fortunately, we now have two solutions to replace the X-ray. One is three-dimensional mapping. This involves using special mapping systems to scan the inner surface of the heart with catheters, which can be displayed on a monitor. The virtual anatomical map is then used as our working surface to visualize catheter movements and ablation lesions. The second is intracardiac ultrasound, or intracardiac echocardiography, which means that we use a special ultrasound catheter to follow what is happening in the heart in real time: we can monitor catheter movements, assess anatomical variations that could potentially complicate the interventions, and even the contact between the catheters and the heart. With these two methods, we can completely eliminate the use of the X-ray, which my colleagues and I implemented for the first time in Pécs in 2017. Last year we became an international training center thanks to our work in this field, and recently we have had arrhythmologists from several countries in the region come to learn the method alongside Hungarian colleagues.”
Repaying the trust
Another important effort in arrhythmology today is to increase the effectiveness of catheter ablation in the treatment of atrial fibrillation, which is the most intractable arrhythmia.
“In the case of atrial fibrillation, we are dealing with a very small arrhythmia where catheter ablation has been shown to be a more effective strategy than medication, but sometimes the arrhythmia can return despite the successful ablation. Hopefully, we can achieve a breakthrough in this field soon, if only because atrial fibrillation affects 300,000 people in Hungary.”
Péter Kupó’s enthusiasm is palpable, which can be explained with his love of his work and the supportive environment – although it is hard to separate the two.
“We are in a special situation because we have the most modern equipment at our disposal, we can perform all the interventions and it is also a unique opportunity to be entrusted with such a responsible position at such a young age. This also obliges me to make the best of it and to add more talented and hard-working young people to the team, to build a team that can compete internationally because electrophysiology is a »team sport«. I think that our lab is a great choice for young colleagues interested in arrhythmia because they can get the necessary professional basics and have the opportunity to try them out and practice them here. Gaining experience is very important in addition to acquiring theoretical knowledge. Of course, all this would not be possible without the support of our head of the institute, Professor Cziráki, and the institute’s leadership, which we can return by raising the reputation of electrophysiology in Pécs not only in Hungary but also internationally.”
Photos:
Lajos KALMÁR