01:53pm Monday 23 October 2017

Ablation therapy restores heart’s healthy rhythm

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The pleasant 64-year-old from Toombs County, Ga., who loves cutting grass on the six-acres she shares with husband Jerry, two dogs and an ever-increasing number of cats, was just exhausted. She couldn’t even enjoy helping her husband, a distance trucker, work on his truck on the weekends.

“I got to where I couldn’t hold out, didn’t have any energy, was short of breath,” Hitchock said. When her gynecologist checked her blood pressure last August, he wanted to send her to the emergency room immediately. Instead, she went to her primary care doctor and, eventually, a cardiologist for two attempts to jumpstart her heart and help restore its productive rhythm. She tried anti-arrhythmia drugs as well. But the racing would always resume.

“Think about it: When should your heart race? Your wedding day, when you are on a treadmill, when you are running a 10K,” said Dr. Adam Berman, Director of Cardiac Arrhythmia Ablation Services at Georgia Health Sciences University. “It should not be racing when you are sitting there watching a movie. But her heart races constantly; she never has a cool-down period.”

In Hitchcock’s case, the atrium, the collecting chamber of her heart, “jiggles” instead of beats, causing the blood to pool in her heart rather than help energize her body.  It also increases her stroke risk. “I say the heart begins to get a little lazy,” Berman said.

With the increasing lifespan and more folks living with heart disease, a growing number of Americans are living with an electrical charge emanating from an area of their heart that disrupts rather than enables the heartbeat. High blood pressure, previous heart attacks and genetics are risk factors for arrhythmia; the jury is still out on obesity. The result is irregular, largely inefficient beating. Berman claps his hand rapidly to illustrate how the beats can be synchronous but way too fast or all over the map. Sometimes the cause of the palpitations is misdiagnosed as well: Berman has treated patients taking anti-anxiety meds who later learned they didn’t need them.

Patients can feel faint, tired and, when it’s the ventricle, the pumping chamber, that “jiggles,” they can drop dead. “These are people you hear about: Uncle Jimmy went out to get the newspaper and was found dead in the driveway,” Berman said.

Implantable defibrillators, or shock boxes, have helped many “Uncle Jimmys” avoid a potentially deadly heart rhythm, like ventricular fibrillation. When these devices sense the abnormal activity, they shock the heart to help correct it. “Those patients probably would have died 25 year ago. With the device, you can still make your daughter’s wedding,” Berman said. These patients find their way to him and ablation when they grow weary of being shocked and/or the medicines stop working.

Ablation therapy, destroying the small area of heart tissue causing the commotion, is potentially curative and can be used for basically any type of arrhythmia. The latest iteration uses two huge magnets – rather than the physician’s hands – to precisely maneuver the heat-producing catheter. An added benefit is that it takes 30 pounds of lead weight off physicians like Berman who previously spent hours standing at the bedside.

Now, sitting at a safe proximity from the radiation, Berman looks more like he is checking email on the 50-inch monitor than correcting Hitchcock’s heart problem. Working within a three-dimensional map of her heart, he uses a mouse to point the catheter – which he likens to a wet spaghetti noodle that cannot perforate the heart – exactly where he wants it. The better news is he can keep it on point as long as needed.

“It’s a little bit of humility but at some point you have to say, ‘Look at the automotive industry, looked at the aircraft industry, look at the microprocessor industry.’ It’s all automated because the machine does it reproducibly in the same place every time. It does not fatigue.” Even at 39, Berman concedes that a series of difficult bedside cases can be physically draining. “You want reduced fatigue in your doctor,” he said. In fact electrophysiologists can face long-term consequences including orthopedic complications that can shorten careers and increased cancer risk that can shorten lives.

But even better than robotics’ advantage for physicians, is the precision it affords patients, Berman said. “Robots do it better,” he said, joking that the technology may one day eliminate him. “I can say, ‘Move one millimeter (.03937 inches) and it moves, magnetically, one millimeter. If you think you can do that reproducibly with a human hand inside the beating heart, you are wrong,” he said emphatically. No matter the experience, the hand is going to move with the beating heart.

“This thing just sits there,” he said of the flexible catheter that turns holiday red while burning and leaves green circles where work has been done. Even with all the technology, it’s a painstaking task isolating pulmonary veins so they can still help move blood through Hitchcock’s heart but no longer contribute to her atrial fibrillation or jiggling. “You basically have to draw an electrical circle around the entrance of the vein,” Berman said.

He measures his progress as squiggly yellow and blue lines that depict the abnormal rhythms begin to flatten. The esophagus, found behind the left atrium of the heart and which doesn’t respond well to heat, gets nearly as much attention as those colorful lines. Heat can create a deadly connection called a fistula between the food tube and heart that can result in death from overwhelming infection. One of his team members is the designated “weather person” to keep constant tabs on the esophagus’ temperature. Berman stops regularly to let it cool and prescribes ulcer medicine for several months afterward to keep it cool. If he gets concerned the esophagus is getting and staying too hot, as he did with Hitchcock, he momentarily returns to the bedside where he uses the stiffer, hand-held catheter and cold temperatures to “burn” the heart. Char created by the burning is another potential hazard that Berman avoids by prescribing blood thinners to avoid a stroke.

Georgia Health Sciences Medical Center was among the first in the nation to get the Stereotaxis technology and is among its most experienced users. In the first year of operation, the center performed about 150 procedures, including the one on Hitchcock, and became a national teaching site for physicians wanting to learn the Stereotaxis system.  Georgia Health Sciences Medical Center also is testing a competing robotic system that likely will benefit smaller hospitals because it does not have the same physical requirements of the big magnet system. It also will soon join the National Institutes of Health funded-CABANA trial based at the Mayo Clinic examining the more global issue of whether ablation is superior to drugs and heart rate control devices such as defibrillators at reducing mortality rates.

About a week after her procedure, Hitchcock at least was voting for ablation.  “When I woke up in recovery I could already feel a difference. I feel good like I should.”


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