Bruce Wilkoff: A pioneering cardiologist who dedicated his career to preventing sudden death finds a gift in death he's now facing

"But actually it has been a joy. We all know that we impact others, but rarely do we get to know how, who and how deeply. I have had that joy."

My conversation with Dr. Bruce Wilkoff, one of the leading experts of heart pacemakers and defibrillators in the world. We were colleagues working together for 14 years at Cleveland Clinic (1991-2005). Now he’s facing death from metastatic pancreatic cancer and has a remarkably upbeat perspective to share.

A recent (September 29, 2023) photo of Bruce (in the middle) receiving a lifetime achievement award for his work in cardiology

The quote in the subtitle was from Bruce’s email to me that prompted our discussion.

You can send him a message and follow him

https://www.caringbridge.org/visit/brucewilkoff

Transcript of our conversation (via A.I., not edited)

Eric Topol (00:00):

This is a real privilege for me to speak to my colleague Bruce Wilkoff, who I had the privilege to work with from 1991 to early part of 2005. And Bruce, when I got to Cleveland Clinic in 1991, he already was pioneering the field of cardiac pacing and devices. And he has persevered throughout all these years, and I really wanted to talk with him because only recently we connected by email with some important updates. So welcome, Bruce.

Bruce Wilkoff (00:34):

Thank you, Eric. It's been a long time, too long, and you made a big impact when you were with me at the clinic, but a lot of things have happened since that time as well. So I'm glad to update things. Some things more favorable than others, but quite frankly, I'm absolutely flabbergasted as to how bad news can be actually good news and insights come out of things. I think that happens all the time in science. I think some of the most important contributions I've made scientifically have been in trials that have been negative, and I'm sure you've had some of that experience as well. But in this case, I've learned a lot, not just scientifically, but about life itself. And they come in surprises. I mean, they come in these packages that you never expect.

Eric Topol (01:55):

So I definitely want to get into that. But first, I do want to talk a bit about the effort you've made throughout all these years. I haven't, this is the first time I've gotten to see you in 17 years. It's been a long time, a

Bruce Wilkoff (02:14):

Long time.

Eric Topol (02:15):

And in many ways I've missed you over that period. And so I'm glad to have this chance to reconnect. But before I get into what happened with your health issues, I wanted to talk a bit about sudden cardiac death because as you know with devices, many people who have cardiac defibrillators don't need them as it turns out, maybe 90% or more because they never are used, whereas there are people who need them, who don't get them. And I wondered because you've a leader, a pioneer of putting in these devices and taking out leads, which is dangerous, you've been the master of that around the world and so many other things you've done with cardiac devices. I just want to get your sense about the progress that's been made in that area, and particularly about sudden cardiac death, if you will.

Bruce Wilkoff (03:15):

Sure. Well, when we first started putting defibrillators in, we made people die twice before we gave them the privilege of a defibrillator, and we had to prove that they were going, this was going to happen about the year 2000 or so, we started to do what we call primary prevention defibrillators through scut heft, and through the MADIT-2 trial, we found out that there were a lot of people that their risk of sudden death was actually even higher in some cases than those people that had already exhibited sudden death. And we've sort of turned around, and as you were saying a second ago, thought that maybe we were putting in too many defibrillators in people, something that's not even come out yet. So this is science. We're going back over that, going back over these mega databases that we have now that where we can look at things through the registries and we find out, we ask the docs, docs like me, how often do they actually use the defibrillators?

(04:51):

And most are guessing less, and the answer is more. And so we're talking in the 40 to 60% range. And I think when this data comes out, people are going to be surprised. And the other part of that is, well, what about the people that never got a shock, never got a therapy, ATP (anti-tachycardia pacing) or shock? And you're going to make a choice, but their risk also is high. And so I think we think we've done a lot with these drugs and we have, I mean, I'm not trying to dis that in any way, but it turns out that there's going to be a sustaining benefit to implantable defibrillators. About the time that you left the clinic, I was on the board of trustees for the heart rhythm of society, and we were working on some things. Ultimately, it became president in 2011, and we developed a mantra where we would end death and suffering due to heart rhythm disorders. That was going to be our goal,

(06:20):

Perhaps a lofty and undoable goal, but you'll never reach it if you don't try. I mean, that's what you have to try to do. And we've kept that even though it's seemingly ridiculous that you could end death and suffering due to heart rhythm disorders. But I've essentially dedicated my life to doing that. What I also discovered, and you mentioned a little bit about lead extraction, some of the problems maybe with infection or with broken leads or with actually having problems with poorly functioning systems that needed some help. And I sort of modified that mantra to work with.

(07:19):

We have an amazingly effective therapy implantable defibrillators. If you have ventricular fibrillation, you have a defibrillator, it's going to work, it's going to do a great job. The value though, the net value of an implantable defibrillator depends upon its effectiveness minus its side effects and problems. And what I've basically dedicated the last half of my, and maybe more of that to reducing the morbidity of defibrillator therapy. So if you maintain the amazing effectiveness and then you reduce the morbidity of the therapy, the net value of the therapy increases remarkably. So for instance, if an implantable defibrillator, and we'll add (cardiac resynchronization therapy (CRT) into that as well, because a lot of the heart failure therapy, we even call it electrical therapy for heart failure, which is both CRT and ICD therapy. A lot of the problems that we have are with the leads, with the batteries, with the reliability and such like that. But if, let's say, we could take that morbidity and reduce it down to the morbidity of an aspirin,

(08:50):

But we had the effectiveness that we had their problems too, I mean without. But the point is that if you were able to reduce the morbidity of the therapy, the net value would be greater. And so I've been spending time learning about how to and when to remove defibrillator leads, how to reduce the risk of infection. So we did a worldwide study on the antibiotic envelope, which showed that we could reduce infection rates by 50% by using an implantable absorbable antibiotic envelope. We've shown how by programming the devices properly, we can reduce the rate of shocks and therapies by about 50% and improve the survival rate of the patients. So again, we're not to an aspirin yet, but the point is we have a very effective therapy and now we have less and less morbidity. The problem as it always is, is getting the physicians to actually implement what is known to be best therapy. At times. We had it with beta blockers, we've had it with everything as it goes along. So it is been a long and hard thing, but we have done it. So we have guidance documents and we have now more and more acceptance. It takes a generation, it took more than a generation to get beta blockers to be used.

(10:42):

It took way too long. And so now, and everything keeps turning around. Like I said, people develop the thought that maybe defibrillators aren't as necessary as RU said, but then you look at the data, what about that? Looking at the data,

Eric Topol (11:07):

It's just an extraordinary perseverance on your part and something to be immensely proud of and all the other people that you've trained and your disciples and your teams over the years. Now the other topic that grabbed me when I got your email, when I learned, you said, I have metastatic pancreatic cancer, and you wrote for the time being, I am doing well, unfortunately, much less progress has been made with pancreatic tumors like you. I have many friends over the years and I have been able to get access to help not only at Cleveland Clinic, but at Hopkins and the NCI National Cancer Institute. We'll see how this works out, but actually it has been a joy. So can you help explain that? Because this is really important stuff.

Bruce Wilkoff (12:00):

It is important stuff. So first of all, get into the philosophical part of this. I think each one of us underestimates the impact we have on other people. We all know that we impact other people. I mean, it goes without saying, but we really have no way of, no great metric of finding out how many people or how deeply we affect other people. And I found out something else is that it's not just that impact, but having the opportunity to communicate. So I've been taking all these years working on reducing sudden death, and people keep coming back to me and saying, oh, I'd rather die suddenly. I'd rather just fall asleep, fall asleep and be done with it. And I would've missed an unbelievable opportunity. So first of all, as you said, I've made a lot of friends, academic friends around the world, which has been one of the great blessings opportunities that I've had at the Cleveland Clinic and with academic medicine. It is one of those great joys that I know you enjoy as well.

(13:28):

And so I know men and women, people, their lives and such. You think superficially more or less, some less, more. You have the people at work, the people at the hospital where you work, you have the fellows that you work with. And we're talking about working, this is over 37 years for me as a fellow over 40 years, totally in academic medicine and lot. There are a lot of people there. And of course there's the friends, the people that you know at home at church. But what I didn't know was first of all, how many there were and second of all how deeply they felt and how important it was for me to express what was going on. So I used a tool, it's called CaringBridge. It's nothing particularly new, but it's an opportunity. It's a blogging site where you can put your story up there and you can blog and then people can respond. You don't have to say anything. I'm doing it for me. I'm not doing it for other people. But the other people, the impact, it just overwhelms me. As you said before, it's been a joy. And so far in two and a half months, there have been 650 some visitors over 7,000 visits.

(15:17):

And people, they just express things, impact that you've had on their lives, what's going on that I would never had if I had died. Suddenly, you never have the opportunity to be able to express that. And what's more is not everybody feels comfortable speaking out on a blog. I'm sure that doesn't surprise you. So I get in addition to that, emails, phone calls, other things, unbelievably deep, meaningful conversations that you had no idea, you had no way of knowing.

(16:08):

And if something, first of all, I hope this encourages people to express themselves not to have. It takes some courage to do so, but not really. I mean, life is a terminal illness. We're all going to die. And for the small slice of time where we're here, we might as well express ourselves and communicate with one another. It has been a blessing beyond blessings for me. It has been a fantastic journey. I have not enjoyed the pain. I have not enjoyed the GI upset and the other things that go along with that, but I would not leave it behind. I would not. And I think it's one of the biggest lies ever, that sudden death is a friend that sudden death is the way you should do it. Life is precious and it's only precious if you choose to talk and express yourself and talk to other people, people from every persuasion, people who probably disagree with each other violently at times.

(17:53):

It's just been something else. So I spent my whole life working on sudden cardiac death and preventing sudden cardiac death, not really realizing how important it was and how even I had been taken in to some extent with the opportunity that comes with dying quickly, avoiding the pain. You're avoiding pain, but you're not avoiding what's most important, which is relationships. So that's the story I've been wanting to tell, and it just keeps on going. I don't know how this is going to end. Well, I do know I, I'm going to die. Everybody dies. But I also know that I'm impacting people's lives. People have come back to me and they're changing the way they're living their lives because of the way we've been able to do this. So it is been a little bit of fun, a little bit of pain. And not everybody dies quickly. Some do, but I'm not particularly concerned about it.

(19:23):

The hospital you worked at the Cleveland Clinic, a little advertisement, they support me to the max. My partners support me to the max. The institution has done the same thing, provide great care, but I know that's not the only place. It is fun though. You think that you live in a universe where everybody does great things. You find out that there are people all over the institution that do the same thing. And it's not just one hospital. We have a great medical system in the United States. It has its problems, but we have overall a great medical system.

Eric Topol (20:12):

Well, you bring up this irony of having spent nearly four decades to try to prevent sudden death. And then you learned another dimension to that. What it has done for you in terms of this ability to connect with so many people beyond your family, your loved ones, your friends, these people that have written on the Caring Bridge and also separately are these people that you know your patients, who are all these incredible large numbers of people.

Bruce Wilkoff (20:45):

So they are my colleagues from around the world. So from all over Europe, all over Asia. I've gotten phone calls as well. They are from the hospital. It's interesting. It's hard for some people to express themselves about these things. I mean, that's not surprising, but some people have to do it face-to-face or have to do it with emails or ways to go about it. Some are, I'm a Christian and I'm actually a Jewish believer in Jesus. But some of these people are believers and some of these people are not believers. Some of these people come from different faiths altogether. I mean, it's remarkable how diverse the group is, and it has been a remarkable way that things have played out.

Eric Topol (21:59):

Yeah, it's fantastic mean. So these days, in terms of the pancreatic cancer, are you holding up with it or is it still giving you the challenges day to day?

Bruce Wilkoff (22:15):

No. Right now I'm feeling well, I'm going to get getting another CAT scan in November, and we're going to find out about that. There's one more aspect to this, I guess, and this is always true, but it's just becomes more poignant at this point. It's not whether you're going to die or not. What are you going to do with your time

(22:42):

And your legacy? And so it was so funny. I have these people that I've been mentoring. I have a endowed chair, and so I, I've got people working on projects that that's working on, and that's fantastic. I have people who I was going to retire at some point. I've been trying to mentor people in working on various projects, and it was going okay, but once there was a end of life moment there, it put an urgency on everything. So what happens? And so they were working on things, but now they're working on things with an intensity. So it has everything to do with the legacy that you get to do, which it's a little disappointing because what happens is we are wasting our time. There's so much we can do, and we try to think about what's the important thing to do. I would love to leave a great legacy. I mean, I know I've left some legacy, but I would like to maximize that legacy and at the hospital at other places where I'm working. But my ability to leave a legacy has been put into a super gear because people say, oh, well, he's not going to be here that much longer. If I'm going to learn something, I've got to do it now.

(24:38):

We all waste some time and we all need to relax and do other things as well. I've been telling my fellows for years is that you need to understand where your passions are and where your skills are and learn how to push on those things. You're going to have to do things that you don't like to do and that you're not as good at, because that's part of being a great partner. But learn strategically how to say yes to those things where you're skillful and you have passion. If you do that, then you can be extremely successful. If you plug along and you just do everything that comes before you, you're going to waste a lot of time and you really need to do that. And so what I've been trying to do is get people to understand it's time to turn it on and use your life and use it expeditiously. You can make a difference. You can have a legacy. And I'm very thankful for the opportunity to see that people apparently did appreciate who I was or what I was doing and the things that I've done. And I'm very thankful for that, and I'm thankful for this opportunity to express it to you.

Eric Topol (26:23):

Well, when you grabbed me with that note you sent, because I didn't know any of this, but of course what was so extraordinary is that you were lacing the comments with the joy you were experiencing, which in all the years of communicating people facing death, that was not one of the things I would typically have ever encountered, which says a lot about you, Bruce. I mean, you're a phenomenon as a person, as a physician. I know we care for many patients together over the years. And then now when people normally would say, I'm sorry, and have a sense of just desperate gloom, you have the light. You have seen what humanness and what the human bond can do, which is extraordinary. It's so bright and warm and comforting, and there's more of that to come. I mean, you're looking pretty darn good right now. You're holding up and it isn't.

(27:32):

You commented also later in your note to me about an expiration date, but that isn't known exactly. It may be of course in the months or year ahead, but it may be somewhat later. And I think your story, Bruce, and you are a great force of inspiration. I mean, most of us, when we think about getting a horrible new diagnosis, we think about what you said, I'd rather die suddenly than have to cope with all the therapies and the agony. And you've seen it in a different light, and you've communicated that to, as you said, hundreds of people and tens of thousands of back and forth visits. And not to mention your family, your loved ones, and all your colleagues there at the clinic. So Bruce, you really did grab me, and I wanted to share your experience because one of the things that people don't know about enough in medicine is the human to human bond. How important that is. We do it with our patients. We try to, but often it comes out is the people that went into medicine, and they could be some of them high tech people like you, working with all these very sophisticated devices over decades. But that basic human in its world of AI, the human touch, the human experience, you exemplify that in such a way that is really striking. And just to add on to your career, your legacy is your ability to find the positives in the midst of very threatening situation.

Bruce Wilkoff (29:26):

Well, thank you, Eric. That's part of what makes this wonderful, and some people live years, but it's like the question is what am I going to do today? What's next? And how can I make a difference today? And it is kind of cool because I am on medical leave. I mean, I've taken care of tens of houses of patients. I don't need to take lots of patients. And I know this is warm to your heart, but what we're doing is we're setting up a basic laboratory for helping us to learn how to better do lead extraction. We're setting up education network, which it's called lead connection.org, where we're making it easier for people around the world to get all the information, sort of a central, central hub. So what I'm hoping is that there's going to be a way of sustaining this kind of thought process and make a difference. And who knows what the rest of the legacy is. It hasn't been written yet.

Eric Topol (30:58):

Right. Well, I hope that this conversation we've had today will help get more people to come on to caringbridge.org and visit with you. I think they will. And I'm indebted to you. I feel lucky to have had the chance to work with you for many years and then this chance to reconnect at this time. I mean, you're teaching us, you're experiencing something that we could all benefit from. And I just think you deserve not just for your career, which has been in itself pretty amazing, the impact you've had in electrophysiology, cardiology devices, and all the things that you did. I remember the old days when you would be the first to take out these leads that could be life-threatening, and you were using laser and all these things, and nobody else would take this risk. And it was necessity for some of these patients to go on. But here, the path you're on with the ability to differentiate the tough part, but the positives, it's remarkable. So Bruce, thanks for joining. I hope we stay connected here in this time ahead because you've really touched me and I hope many others getting the chance to listen or watch our discussion. Yeah. What can I say? You're amazing.

Bruce Wilkoff (32:32):

Thank you, Eric, and thank you for this opportunity, this virtual connection. I mean, sometimes you feel like you're talking to no one, and sometimes and other times it's clear that you may make a big impact by doing these things. It's all evolving, isn't it? And so I'm learning more about this as we work with this. I mean, I was not a blogger. Yeah. And here I am.

Eric Topol (33:16):

You are now.

Bruce Wilkoff (33:17):

Yeah.

Eric Topol (33:18):

Well, the only thing I've missed over this is the chance to give you a big hug, but I hope that I'll have a chance to do that in the times ahead and let's stay connected. But thank you so much for sharing what you've been experiencing. There's no question that this is really important and a major inspiration. Thanks, Bruce.

Bruce Wilkoff (33:37):

Thanks, Eric. I appreciate it.