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Joseph Akar, MD, PhD

Professor of Medicine (Cardiovascular Medicine); Director, Cardiac Electrophysiology Program, Internal Medicine; Director, Complex Ablation Program

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Joseph Akar, MD, PhD

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Yale Medicine

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Research Summary

I am currently an Associate Professor of Medicine in the Section of Cardiology at the Yale University School of Medicine and Director of Academic Electrophysiology and the Electrophysiology Laboratory at Yale-New Haven Hospital. During my fellowship in Cardiovascular Medicine at the University of Virginia Health Sciences Center, I completed a PhD in Molecular Physiology and Biological Physics. Following that I was Assistant Professor of Medicine at Loyola University Medical Center, Chicago and remained on faculty there for 5 years before joining Yale. I have dedicated my clinical and academic work over the past two decades to the study and treatment of atrial fibrillation (AF). I take a systems biology approach to the study of AF, from the cellular to the population science level. My PhD thesis during fellowship focused on the study of the subcellular distribution of elements during the development of electrical and structural remodeling in AF. I continue to study the role of atrial structural remodeling in AF and I have received NIH funding (R01) to examine non-invasive imaging of matrix metalloproteases in large animal models. I have collaborated closely with biomedical engineers using signal analysis techniques to quantify spatiotemporal organization in AF, and continue to utilize in silico computer modeling and non-linear dynamics methodology to study the basic mechanisms of AF. Clinically, I have expertise in intracardiac echocardiographic (ICE) atrial imaging and using it to eliminate ionizing radiation use during AF ablation. I hold special interest in device remote monitoring and outcomes research and have compiled the only device database capable of relating AF burden to clinical outcomes. I am a member of the Heart Rhythm Society expert consensus statement on Remote Interrogation and Monitoring for Cardiovascular Implantable Electronic Devices. I am also the PI of the YALE-CORE data analytic site for the national ACC/NCDR Atrial Fibrillation Ablation Registry, and I am a member of the steering Committee of the ACC/NCDR Left Atrial Appendage Occlusion Registry. My expertise in atrial remodeling and AF ablation is reflected in nominations for the writing group of the 2016 EHRA/HRS Expert Consensus Statement on Atrial Cardiomyopathies and the 2017 Heart Rhythm Society Expert Consensus Statement on AF Ablation.

Specialized Terms: Mechanisms of atrial fibrillation; Ablation of atrial fibrillation; Molecular imaging of structural remodeling; Pericardial fat and arrhythmogenesis; Effect of remote device monitoring on patient outcomes; Atrial fibrillation burden; Clinical outcomes

Extensive Research Description

I take a systems biology approach to the study of AF, from the cellular to the population science level.

1. Basic Mechanisms of Atrial Fibrillation. A major focus of pre-clinical and clinical research interest is the study of electrical and structural remodeling processes that lead to the development of AF. This has been a major theme of my academic work over the past two decades. During my fellowship training at the University of Virginia I pursued a PhD in Molecular Physiology and Biological Physics, focusing on the just recently described phenomena of electrical and structural remodeling in AF. I used animal models of AF to examine changes in the mitochondrial and subcellular distribution of different elements (Na, K, Cl, Mg) during the development of electrical remodeling. I also determined the relative contribution of atrial electrical and structural remodeling to the spatiotemporal organization of AF. I am currently the co-PI of an extramural NIH R01 grant performing non-invasive molecular imaging of activated matrix metalloproteinases as a substrate for the development of atrial structural remodeling and the precursor of fibrosis. The grant aims at developing novel techniques for early non-invasive assessment of AF vulnerability. This holds the potential for early detection and treatment of the disease before the onset of fibrosis. I have been collaborating with Dr. Lawrence Young and Dr. Fadi Akar to study the mouse model of AF induced by LKB1 deletion. My expertise in atrial remodeling has provided the opportunity to be a writing group member of the 2016 EHRA/HRS Consensus Statement on Atrial Cardiomyopathy.

a. Akar JG, Everett TH, Kok LC, Moorman JR, Haines DE. Effect of electrical and structural remodeling on spatiotemporal organization in acute and persistent atrial fibrillation. J Cardiovasc Electrophysiol 2002; 13:1027-1034.

b. Akar JG, Everett TH, Ho RH, Craft J, Haines DE, Somlyo AP, Somlyo AV. Intracellular chloride accumulation and subcellular elemental distribution during atrial fibrillation. Circulation 2003; 107:1810-1815.

c. Mukherjee R, Akar JG, Wharton JM, Adams DK, McClure CD, Stroud RE, Rice AD, Desantis SM, Spinale FG, Gold MR. Plasma profiles of matrix metalloproteinases and tissue inhibitors of the metalloproteinases predict recurrence of atrial fibrillation following cardioversion. J Cardiovasc Transl Res. 2013; 6:528-35.

d. Kim GE, Ross JL, Xie C, Su KN, Zaha VG, Wu X, Palmeri M, Ashraf M, Akar JG, Russell KS, Akar FG, Young LH. LKB1 deletion causes early changes in atrial channel expression and electrophysiology prior to atrial fibrillation. Cardiovasc Res 2015; 108:197-208.

2. Dynamics of Atrial Fibrillation. I have a long-standing interest in using signal analysis techniques to identify mechanisms and quantify spatiotemporal organization of AF. Given the clinical importance of objectively measuring the level of AF electrogram fractionation, I worked closely with biomedical engineers to use signal analysis techniques (Fourier transforms, entropy, cross correlations and wavelet analysis) to quantify AF organization in time and space. More recently, I have turned my attention to using the non-linear dynamics methodology of Recurrence Quantitative Analysis (RQA) to examine basic pathophysiological mechanisms of AF. Using computer modeling I am applying RQA in silico to differentiate differentiate different AF mechanisms (i.e spiral wave reentry “rotors” versus multiple wavelet reentry), and subsequently applying the RQA analysis on human AF signals obtained at the time of ablation.

a. Everett TH, Moorman JR, Kok LC, Akar JG, Haines DE. Assessment of global atrial fibrillation organization to optimize the timing of atrial defibrillation. Circulation 2001; 103:2857-2861.

b. Everett TH, Akar JG, Kok LC, Moorman JR, Haines DE. Use of global atrial fibrillation organization to optimize the success of burst pace termination. J Am Coll Cardiol 2002; 40:1831-1840.

c. Webber Jr. CL, Hu Z, Akar JG. Unstable Cardiac Singularities May Lead to Atrial Fibrillation. Int J Bifurc Chaos. 2011; 21: 1141–1151.

d. Hummel JP, Baher A, Buck B, Fanarjian M, Webber CL, Akar JG. A Method for Quantifying Recurrent Patterns of Local Wavefront Direction During Atrial Fibrillation. Comput Biology Medicine. 2017;89:497-504.

3. Reducing Ionizing Radiation During Fibrillation Ablation. I have significant expertise in the clinical use of intracardiac echocardiography (ICE) in order to eliminate ionizing radiation during AF ablation. I performed the first-in-man evaluation of the novel 3D ICE catheters and under my direction, the Yale-New Haven Hospital EP laboratory frequently hosts physicians interested in learning ICE skills and fluoroscopy reduction techniques. I am a writing group member of the 2014 Heart Rhythm Society Consensus Statement on EP Laboratory Standards, and the 2017 Heart Rhythm Society Consensus Statement on AF Ablation.

Ruisi CP, Brysiewicz N, Asnes JD, Sugeng L, Marieb M, Clancy J, Akar JG. Use of Intracardiac Echocardiography during Atrial Fibrillation Ablation. Pacing Clin Electrophysiol. 2013; 36:781-8.

a. Brysiewicz N, Mitiku T, Haleem K, Bhatt P, Al-Shaaraoui M, Clancy JF, Marieb MA, Sugeng L, Akar JG. Three-Dimensional Real-Time Intracardiac Echocardiographic Visualization of Atrial Structures Relevant to Atrial Fibrillation Ablation. JACC Imaging. 2014;7:97-100.

b. Haines DE, Beheiry S, Akar JG, Baker JL, Beinborn D, Beshai JF, Brysiewicz N, Chiu-Man C, Collins KK, Dare M, Fetterly K, Fisher JD, Hongo R, Irefin S, Lopez J, Miller JM, Perry JC, Slotwiner DJ, Tomassoni GF, Weiss E. Heart Rhythm Society Expert Consensus Statement on Electrophysiology Laboratory Standards: Process, Protocols, Equipment, Personnel, and Safety. Heart Rhythm. 2014 May 7, S1547-5271.

c. Yu R, Liu N, Lu J, Zhao X, Hu Y, Zhang J, Xu F, Tang R, Bai R, Akar JG, Dong J, Ma C. 3-Dimensional Transseptal Puncture Based on Electrographic Characteristics of Fossa Ovalis: A Fluoroscopy-Free and Echocardiography-Free Method. JACC Cardiovasc Interv. 2020 May 25;13(10):1223-1232

d. Ortiz-Leon XA, Posada-Martinez EL, Trejo-Paredes MC, Ivey-Miranda JB, Pereira J, Crandall I, DaSilva P, Bouman E, Brooks A, Gerardi C, Ugonabo I, Chen W, Houle H, Akar JG, Lin BA, McNamara RL, Lombo-Lievano B, Arias-Godinez JA, Sugeng L. Understanding tricuspid valve remodelling in atrial fibrillation using three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging. 2020 May 5:jeaa058. doi: 10.1093/ehjci/jeaa058

4. Registry Studies and Electrophysiology Outcomes Research. I have strong interest and expertise in registry studies examining cardiovascular outcomes. I headed the development a unique database of patients with cardiac devices by linking multiple different data sources. We used the ACC NCDR ICD Registry to derive baseline characteristics, the Boston Scientific Altitude registry to obtain a wealth of device and physiological data obtained via remote monitoring, Medicare claims to examine hospitalizations, and the social security death index to ascertain vital status. This one-of-a-kind database of ~30,000 patients allows the examination of cardiovascular outcomes associated with detailed device-, disease- and physiological device information. Our initial projects were to examine the determinants of remote monitoring and its effect on outcomes. We are now examining the relationship between device parameters (e.g. AF burden, RV pacing, etc…) on outcomes. Not only was this work presented as a Late Breaking Trial at the Heart Rhythm Society Scientific Sessions 2014, but also the registry expertise has provided me the opportunity be a writing group member of the 2015 Consensus Statement on Remote Monitoring, lead the Yale-CORE Data Analytical Site for the national ACC NCDR AF Ablation Registry, as well being a steering committee member of the ACC NCDR Left Atrial Appendage Occlusion registry.

a. Akar, JG, Bao H, Jones P, Wang Y, Chaudhry SI, Varosy P, Masoudi FA, Stein K, Saxon LA, Curtis JP. Use of Remote Monitoring of Newly Implanted Cardioverter-Defibrillators: insights from the Patient RElated Determinants of ICD Remote Monitoring (PREDICt RM) study. Circulation. 2013;128:2372-2378.

b. Slotwiner D, Varma N, Akar JG, Annas G, Beardsall M, Fogel RI, Galizio NO, Glotzer TV, Leahy RA, Love CJ, McLean RC, Mittal S, Morichelli L, Patton KK, Raitt MH, Pietro Ricci R, Rickard J, Schoenfeld MH, Serwer GA, Shea J, Varosy P, Verma A, Yu CM. Heart Rhythm Society Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. Heart Rhythm 2015;12:e69-e100.

c. Akar JG, Bao H, Jones P, Wang Y, Varosy P, Masoudi FA, Stein K, Saxon LA, Normand ST, Curtis JP. Use of Remote Monitoring Is Associated with Lower Risk of Adverse Outcomes Among Patients with Implanted Cardiac Defibrillators. Circ Arrhythm Electrophysiol 2015; 8:1173-80.

d. Al-Chekakie MO, Bao H, Jones PW, Stein KM, Marzec L, Varosy PD, Masoudi FA, Curtis JP, Akar JG. Addition of Blood Pressure and Weight Transmissions to Standard Remote Monitoring of Implantable Defibrillators and its Association with Mortality and Rehospitalization. Circulation: Cardiovas Quality Outcomes. 2017 May;10(5). pii: e003087. doi: 10.1161


Coauthors

Research Interests

Arrhythmias, Cardiac; Atrial Fibrillation; Cardiology; Catheter Ablation; Defibrillators

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