FORT LAUDERDALE, FL (Ivanhoe Newswire) - It's a debilitating heart condition that can often be fixed with the right treatment. Now, doctors are using new imaging technology to make that treatment more accurate and effective.
"When your heart starts going that fast and your chest is pounding and you just feel like you're going to pass out, it's a frightening experience," Carla Schindeler told Ivanhoe.
Like more than five million Americans, Carla Schindeler has a racing, irregular heartbeat called atrial fibrillation. About 35 percent of people with it will have a stroke, but doctors like Ahmed Osman can destroy the heart tissue that causes the problem with a catheter procedure called ablation.
"What we are trying to achieve with ablation is hopefully isolate and silence the triggers for atrial fibrillation," Ahmed Osman, M.D., cardiac electrophysiologist at Broward General Medical Center said.
Doctors need precise imaging to get the best results during an ablation. Now, this technology helps them see the heart in real-time like never before.
"It has clearly and dramatically changed the way we manage the disease," Dr. Osman said.
By inserting a tiny probe in the vein, doctors get images in different planes and virtually reconstruct the left atrium. Three-dimensional mapping then enhances how doctors view and treat the heart.
"We are able to navigate very accurately inside the left atrium and achieve electrical isolation of the veins," Dr. Osman said.
Carla was treated with help from the new imaging system and says she's never felt better.
"I feel so much more comfortable now doing things because you just don't live in fear that something's going to go amiss," Carla said.
The risk of atrial fibrillation increases with age. Researchers expect the condition to affect nearly 16 million Americans by the year 2050.
BACKGROUND: Atrial fibrillation (AF or afib) is the most common type of arrhythmia. An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.
Millions of people are affected by AF, and the number is steadily rising. Men are more likely than women to have the condition. In the United States, AF is more common among Whites than African Americans or Hispanic Americans. The risk of AF increases as you age. It is uncommon in children. However, about half of the people who have AF are younger than 75. People who have AF but don't have symptoms or related heart problems may not need treatment. AF may even go back to a normal heart rhythm on its own. SOURCE: (www.nhlbi.nih.gov)
CAUSE: Atrial fibrillation is due to a malfunction in the heart's electrical system; it occurs when the electrical signals don't travel through the heart in a normal way. Damage to the heart's electrical system is most often the result of other conditions that affect the health of the heart, such as high blood pressure and coronary heart disease (CHD) SOURCE: (www.nhlbi.nih.gov, www.stopafib.org)
SYMPTOMS: Symptoms vary from patients to patient. Some patients describe AF as feeling like skipped heartbeats, followed by a thud and a speeding up or racing of the heart. Other symptoms may include: shortness of breath; weakness or problems exercising; chest pain; dizziness or fainting; fatigue; and confusion SOURCE: (www.nhlbi.nih.gov); (www.stopafib.org)
TREATMENT: Treatment for AF depends on how often the patient has had the symptoms, how severe they are, and whether they already have heart disease. General treatment options include medicines, medical procedures, and lifestyle changes. Doctors may consider performing a Cardioversion. Cardioversion is when the doctor places paddles or patches on the chest to electrically shock the heart to restore normal rhythm SOURCE: (www.nhlbi.nih.gov); (www.mayoclinic.org)
3-D IN THE OR: Catheter ablation may be used to restore a normal heart rhythm if medicines or electrical cardioversion don't work. Because of the shortcomings of fluoroscopy, some electrophysiologists use electroanatomic mapping systems, which provide colorful 3D images that show variations in a patient's anatomy. These systems may assist doctors in assuring that lesions are contiguous and in reducing complications, such as perforation of the heart or esophagus. In addition, the use of an electroanatomic mapping system may lessen the time that doctors and patients are exposed to radiation. Electrophysiologists create a real time 3D view of the heart by positioning a mapping catheter in the heart. When the doctor moves the catheter in a sweeping motion, the systems track the catheter's location. ( Source: Stopafib.org)
Dr. Ahmed Osman, Medical Doctor, Cardiac Electrophysiologist, Medical Director of EP Lab and EP Services at Broward General Medical Center talks about treatment for atrial fibrillation.
I am going to have you give me a little bit of an overview of what atrial fibrillation is and how common it is.
Dr. Osman: Atrial fibrillation is the most common clinical arrhythmia or rhythm problem of the heart that we encounter as cardiologists. Up to 5% to 10% of patients above the age of 60 suffers from this disease. It describes a very irregular, chaotic heart rhythm which is typically felt as palpitations or heart fluttering and patients sometimes feel dizzy, lightheaded with it. There are several risk factors for it. The more common ones are hypertension (high blood pressure), coronary artery disease, any form of heart failure, but we also see alcohol involved in many patients as well. It is quite symptomatic to many patients. Patients feel weak, tired, short of breath, lightheaded. They clearly feel a decrease in the exercise capacity and they are quite bothered by it.
It is obvious to patients who have it that this is what is happening and that it is something in my heart or do they just feel tired and they are not quite sure what is wrong?
Dr. Osman: The majority of patients feel the irregular heart rhythm or heartbeat and also feel the rest of the symptoms which are the fatigue or the weakness. Some patients are totally asymptomatic and we just encounter or diagnosis that disease by doing EKGs.
It is not constant though, right? Doesn't it come and go?
Dr. Osman: Very good question. Initially, it starts as paroxysms or episodes that are self terminating. As the disease progresses, the episodes become more prolonged, more sustained and sometimes becomes permanent. There are several considerations that you have to keep in mind when we are treating atrial fibrillation. The most important one is the risk of strokes. Atrial fibrillation when persistent for long periods of time can cause clots to form inside the left atrium which is the left upper chamber of the heart and those clots can break off and cause strokes. This actually constitutes up to 20% of the cases of strokes that we see on an average time. The first consideration in this disease is anticoagulation or blood thinning. There are several options for doing that including the traditional, long-established drug called Coumadin or warfarin. There are also newer medications or drugs that have been released that are much easier to take that do not require chronic monitoring of the blood levels for Coumadin.
If and when the Coumadin stops working and does not work as well, ablation is the option? It was RF ablation right, and now we have cryoablation as another option?
Dr. Osman: We talk about ablation or trying to cure this rhythm in patients who are very symptomatic who have failed medical therapy. Ten years ago, we realized that a lot of the triggers for atrial fibrillation live in the veins connected to the left upper chamber or left atrium and we started targeting these veins with isolation electrically and we have realized that we can really control the symptoms and disease and slow down the progression and cure many of these patients. Sometimes, it does require a second procedure, but what has really revolutionized the treatment of atrial fibrillation is our better understanding of the anatomical base for it, particularly the pulmonary vein triggers that initiate the disease and that is where imaging comes into play. Imaging has clearly revolutionized the way we treat this disease with very accurate mapping including images obtained from CT angiograms of the left atrium. We can very nicely reconstruct the left atrium and we are able to navigate very accurately inside the left atrium and achieve electrical isolation of the veins.
Some of this that you are talking about is the 3-D mapping that you have. Is that called something or just 3-D mapping?
Dr. Osman: There are several ways of achieving 3-dimensional mapping or 3-D mapping. There are 2 big companies; one is CARTO and one is Endocardial Solutions, ESI and they use different technologies to achieve more or less the same goal.
You have the CARTO Mapping?
Dr. Osman: We have both technologies at Broward General. One very nice addition to what we can do is use real time, live, instantaneous reconstruction by using ultrasound. By that, I mean, intracardiac ultrasound with an ultrasound probe introduced into the right atrium which can obtain images in multiple planes and allow us to reconstruct the left atrium very accurately and true to real size.
The ultrasound probe, how is that? You said, it is intracardiac? It must be tiny, obviously?
Dr. Osman: It is a tiny probe that is inserted through the vein all the way into the inside of the right atrium and we can rotate that probe from outside and obtain images in different planes and basically reconstruct the left atrium.
So, you put it in the right atrium, but it gives you images from the left atrium?
Dr. Osman: Yes, correct. Ultrasound travels. There is some depth to the images that we can obtain and we can very accurately delineate the pulmonary veins. We can delineate the walls of the left atrium and we can also do Doppler which evaluates for leakages, for velocities of the blood flow within that chamber.
The technology that you are using, it is all this CARTO technology, I guess since we are doing the CARTO sound. So, you are using the ultrasound in addition to using 3-D mapping, but those are two different things? You could use one without the other?
Dr. Osman: So, the way we do CARTO sound is as follows. We want to obtain the accurate reconstruction of the left atrium as we can see it under ultrasound from the intracardiac probe and then what we do is, we use the CARTO system, which is the backbone of the imaging of the 3-D mapping system to localize the catheters that we have inside the heart. So, once we obtain that shell, that 3-dimensional shell, we are able to see our catheters inside that chamber very accurately and navigate inside it and be able to deliver the lesions in a very accurate fashion.
Why is that so important to be able to see like that?
Dr. Osman: Well, the primary target of atrial fibrillation ablation is pulmonary vein isolation electrically. The other name for it is pulmonary vein antral isolation which means that we want to prove that once we have done these lesions very accurately around the pulmonary vein os or opening that that vein is silent electrically. So, accuracy is of utmost importance. That is why we also have other technologies instead of using radiofrequency, we can use cryoablation which freezes the tissues and the way that we are delivering that nowadays is by using a balloon that we inflate at the opening of the vein and hopefully circumferentially isolate the vein electrically around its os.
How much has the new imaging, the imaging that has come out in the last few years, how much has that changed the way you treat patients and how well patients do?
Dr. Osman: It has changed things 180 degrees. In the last 10 years, it has clearly and dramatically changed the way we manage the disease as well as the results that we obtain when we manage atrial fibrillation. Atrial fibrillation used to be a black box disease and we used to try multiple different antiarrhythmic medications with multiple side effects and tolerability issues for the patient which were traditionally and notoriously ineffective in controlling the disease. At the same time, the disease was progressing in that each and every patient in the sense that it was becoming more progressive, more persistent and sometimes we would give up and we call it permanent because we have tried a lot of things and we are not able to cure it or control it. What we are trying to achieve with ablation is hopefully isolate and silence the triggers for atrial fibrillation and typically those are in the pulmonary veins and hopefully modify the natural history and the progression of the disease, so the patients are saved from the deterioration that occurs both structurally and electrically in the upper chambers and hopefully get them to lead healthy, active lives without the symptoms.
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