Ice cold heart therapy

BALTIMORE (Ivanhoe Newswire) -- A trial fibrillation affects about 2.7 million Americans. It's a condition that causes heart palpitations, shortness of breath and dizziness. If left untreated, it can be life-threatening. Now doctors are freezing the problem away.

Terry Smith loves walking and wood-working, but the retired police officer had to slow down when he found out he had an irregular heartbeat. "I think my heart rate was over 220 at one time." Smith told Ivanhoe.

He had atrial fibrillation; faulty electrical signals caused his heart to beat out of whack. If untreated, A-fib can lead to heart failure or stroke.

When meds fail, radiofrequency ablation is used to heat the heart and destroy tissue that causes the irregularity, but it isn't always effective.

Instead of heating the heart, Dr. Jeffrey Banker, a Heart Rhythm Specialist at Sinai Hospital in Baltimore, is now freezing hearts with cryo-ablation. "It actually does cure it. It gets rid of the signals and gets rid of the arrhythmia altogether in many patients." Banker told Ivanhoe.

Doctors thread a catheter through the groin and inject liquid coolant through a small balloon, freezing the heart tissue. This restores the heart's rhythm for about 90 percent of patients.

Terry Smith had the procedure and is back to enjoying another one of his pastimes; collecting toy trains.

"I haven't been in A-fib since I had the procedure, this last one. I've been fine." Smith said. Meaning he can focus less on his health and more on his hobbies.

Most cryo-ablation patients go home the same day and can resume normal activities the next day.

Studies show cryo-ablation is less likely to damage heart tissue than radiofrequency ablation.

BACKGROUND: Atrial Fibrillation (A-fib) occurs when disorganized signals cause the heart's upper chambers to contract rapidly. Blood begins to build up in the atria and doesn't get moved to the ventricles properly. This leads to the upper and lower chambers of the heart not functioning together and can cause heart palpitations, shortness of breath and stroke if not treated. A problem with a heart rate or heartbeat is called an arrhythmia and A-fib is considered the most common of all arrhythmias. A-fib is not always a short-term disorder, but could linger into a condition that lasts for years and most commonly affects those who have high blood pressure, rheumatic heart disease and coronary heart disease. Obesity, diabetes and lung disease are also risk factors for developing A-fib. (Source: http://www.nhlbi.nih.gov/health/health-topics/topics/af/)

TREATMENT: There are a number of treatment options for those living with atrial fibrillation including lifestyle changes and medications. In order to decrease the risk of stroke, blood clot prevention takes place. Doctors recommend blood thinners like aspirin, heparin and dabigatran to keep blood from clotting in the atria of the heart. Medications to control heart rate are another way people can fight A-fib. Rate control medications slow down the beating of the ventricles and bring the heart rate down to normal levels and are commonly recommended by doctors for people dealing with A-fib. (Source: http://www.nhlbi.nih.gov/health/health-topics/topics/af/treatment.html)

NEW TECHNOLOGY: A new procedure is using cryo-ablation to fix irregular heartbeats. In the past, radiofrequency ablation was used to destroy faulty tissue in the heart that was causing irregularity, but now doctors are claiming that cold therapy using cryo-ablation may be more effective. The cryo-ablation procedure uses a balloon technology to block an arrhythmia by using coolant through a catheter that runs from the groin area to the heart. This freezing method can be tested for its effectiveness before any permanent scarring is done to the arrhythmia site. (Source: http://www.theheartinstituteny.com/catheter-ablation/)

FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT:

Helene King
LifeBridge Health
410-601-2296
hking@lifebridgehealth.org

If this story or any other Ivanhoe story has impacted your life or prompted you or someone you know to seek or change treatments, please let us know by contacting Marjorie Bekaert Thomas at mthomas@ivanhoe.com

Jeffrey Banker, M.D., Heart Rhythm Specialist at Sinai Hospital, talks about atrial fibrillation and a new procedure to treat it.

We're talking about a new procedure for a-fib could you tell me what a fib is and how many people it affects?

Dr. Banker: Atrial fibrillation is a very common electoral disturbance in the heart and it affects millions of people around the world. In America probably two to three million people have it and it occurs at any age, with or without heart disease.

How would you treat it before?

Dr. Banker: Historically what we had to do was try to slow the heart down and control the blood flow to the heart. To do this we used medicines and blood thinners. That is something that we did up until about ten years ago when we started doing procedures to try to cure the rhythm.

What kind of medications would you use?

Dr. Banker: There are two classifications of medications that we typically use. One is a medicine that just slows the heart and one is a medication that will actually prevent the arrhythmia from occurring. The problem is that the medicines are more suppressive lifelong therapy, and they don't always work.

Can you tell me about the new procedure?

Dr. Banker: In the last decade or so we started doing a catheter-based procedure where we would put catheters up in the heart much like an angioplasty or an angiogram and we would actually try to cauterize and "silence" the electrical signals that cause arrhythmia. The problem is that there are many electrical signals in the heart that can cause this problem and it's hard to get all of the signals at once. It was a relatively long procedure and it wasn't always so successful.

How long was it?

Dr. Banker: Originally the procedures were anywhere from four to five hours and then slowly as the technology involved it became more of a three to four hour procedure. But again, the real problem was that there was a lot of recurrence of the arrhythmia, even after the procedure.

Why do you think that is?

Dr. Banker: Probably because there are so many of these signals in the top chamber of the heart called the atrial that was causing this arrhythmia that it was very difficult to pinpoint and get rid of all these signals at once. The other aspect is that the catheter itself that we use, delivers what we call an ablation lesion or heat only at one point at a time, like the tip of a ball-point pen. So, we really didn't have the tools or the technology to be successful.

Terry told me that he didn't even know that he had a-fib is that a common thing?

Dr. Banker: He didn't know that he had a specific arrhythmia but what he experienced was rapid beating of the heart, difficulty exercising, having shortness of breath, and so his performance wasn't what it used to be. He wasn't specifically aware that his heart was racing or going fast which often also presents itself as a symptom.

What about other people, what are the other symptoms?

Dr. Banker: The atrial fibrillation can be without symptoms or as Terry described it can just present itself as external shortness of breath, or fatigue. Quite often patients will feel the heart beating rapidly, or feel like there's a fish swimming around in their chest. It's just something irregular and fast and just very abnormal and not related to them doing exertion. The technology we originally had, which I was discussing was ablation using heat or cauterizing. In the last few years, and most recently here at Sinai in the last six months to a year, we began using a new piece of technology which is called the cryo-ablation balloon. This technology ablates the electrical signals that cause atrial fibrillation by inflating a balloon in the chamber that causes the atrial fibrillation and actually removes a lot of these electrical signals at one time by freezing large areas of tissue in the heart. The result is that we're able to apply a circular or ring-shaped ablation, isolate the abnormal signals and thus prevent the abnormal heart rhythm much more effectively and see pretty much a decrease in recurrence and a more successful procedure in a much shorter period of time.

So it's just decreasing it, is not really getting rid of it?

Dr. Banker: No, it actually does cure it. It gets rid of the signals and gets rid of the arrhythmia altogether in many patients.

Could it come back?

Dr. Banker: Recurrences can occur in two situations. Either have the areas that we freeze, and when they thaw, the tissue still remains active. Or the arrhythmia may subsequently originate from a new area of the heart not yet identified by science and therefore not "targeted" during the procedure. I would say eighty to ninety percent of the time they're cured. As a result they don't need medications however they may still need some blood thinning medicines but their symptoms should improve significantly and they won't need any other medicines to control arrhythmia.

How long does the procedure take?

Dr. Banker: Now with this new technology we can do the procedure in ninety minutes. Sometimes it takes a little bit less, sometimes a little bit more and because we can effectively remove these electrical signals by freezing in a wide area at once, there is less application of the ablation that we have to give, and we can do the procedure much quicker.

After they get the procedure what does their life look like, when can they go back to work?

Dr. Banker: Because it's a catheter-based procedure and we insert everything through a small puncture site in the groin, basically they go home the same day and within a day or so they are returned to their normal activity. The advantage of catheter-based procedures in general is that there isn't any surgery, there isn't any cutting of muscles or bones, and there isn't any recovery time. Soon as the procedure is over it's just a matter of the sedation wearing off and them getting up and around. So, the recovery time is actually very, very limited and they're back to their normal lifestyle very, very quickly.

Terry said he went back to work a day after?

Dr. Banker: Yeah, that really has to do with how quickly they heal and the fact that what we do inside the heart doesn't really need to be healed. So, exercise is not limited, work is not no matter how strenuous the work is. None of that is really limited right after the procedure.

If you don't get a-fib treated in time or ever what kind of problems can that lead to?

Dr. Banker: So the problem is if the atrial fibrillation, even if it is asymptomatic, a lot of times does present silently. It can still cause the heart to get weak because the heart is rapidly beating for periods of time that's unknown to the patient, and as a result the heart can weaken and cause congestive heart failure. The second thing is that because the heart is beating so rapidly and quickly and it irregularly blood pools in the heart which can cause blood clots, which are the number one cause of stroke. So, even if it's undetected or I should say asymptomatic it can still cause significant problems and does need to be dealt with. Anybody who experiences palpitations or feels their heart is beating irregularly, or just notices a change in there exercise tolerance really should see a cardiologist to have this evaluated.

Once you start noticing this fish sort of swimming when should they go see the cardiologists?

Dr. Banker: I would say right away. Often times a patient will have a symptom and then by the time they get to the physician the symptom has gone away. Just because a patient has a palpitation or feels their hearts beating irregular and they go to their doctor and the EKG shows that their heart rhythm is normal, doesn't necessarily mean anything. It doesn't rule out that they have atrial fibrillation. However, we have many ways to monitor the heart long-term from home, from a smart phone, over the computer, over the Internet. Typically if a patient complains of these symptoms, even if they've seen their doctor and the doctor doesn't find anything, the next step is to do monitoring either for twenty-four, forty-eight hours, two weeks, or four weeks, even up until implanting a very, very tiny heart monitor, which we often do under the skin to monitor the heart up to two to three years. So even if a patient has very, very irregular symptoms the most important thing is to try to make a diagnosis and there's many ways to do that. Obviously the first step is to see your physician.

Terry said that he's almost completely off his medication is that uncommon or are most people like that?

Dr. Banker: The results that we've seen are that the first few months after anybody has a procedure for atrial fibrillation, we typically keep them on some of their heart medicines to make sure that in the healing process any arrhythmias they may have as a result of the heart, for example the freezing, doesn't have too many arrhythmias, and that can happen. Typically we will keep a patient on their heart medications for two to three months after a procedure and then after that three month period we stop the medication.

This whole freezing thing, can this be used for any other condition other than just a-fib?

Dr. Banker: We use ablation to cauterize or freeze almost every arrhythmia that exists and there's a variety of different arrhythmias. We also use cryo-ablation in different areas of the heart to take care of other arrhythmias as well as the heat radiofrequency process as well. So yes, absolutely we can and this particular balloon is designed for atrial fibrillation, but the delivery of this energy source we can use for almost all the arrhythmias that we see.

Is there anybody who is not a good candidate for the freezing balloon?

Dr. Banker: It depends, sometimes the fibrillation, if it lasts long enough the heart will stay in fibrillation. It's a condition we call permanent atrial fibrillation. Once the triggers of these abnormal electrical signals that cause the arrhythmia are no longer the main problem, but the heart has sort of settled in to this abnormal rhythm somewhat permanently as the name states, any ablation procedure won't necessarily be successful because the hearts already decided in various pathophysiologic reasons to stay in this abnormal rhythm, then they wouldn't be a candidate. Other than that, anybody that's just experiencing bursts of this arrhythmia or experiencing it for a few months at a time; they're excellent candidates for this procedure.

So when somebody comes in how do you know to use the heat or the new one?

Dr. Banker: So it depends, typically we will start with the balloon and recommend that first line. Again, because someone has never had an ablation before and they've never therefore, we'll say failed an ablation or failed their medications, we would start off with the balloon because we know it's a quicker procedure, it's a safer procedure and it seems to be a more effective procedure. It could be that if we missed a signal here or there and then down the road the arrhythmia returns, we can then consider going in with our radiofrequency, and our heat catheter and just touch up points here and there. It's not exactly clear what the strategy should be because again, most patients seem to be successfully treated with the balloon. If it were not to work we would probably start with the balloon and then go with the heat method second.

Are there any downsides to this?

Dr. Baker: So any procedure has risks to it, the catheters themselves need to be introduced into the heart. There's risk of bleeding that can happen because we use heavy blood thinners when we do the procedure. There are some complications that are associated with the procedure however they're usually pretty rare. I would say overall the risk of major complication for ablation used to be as high as five to six percent, but now ten years later, with our experience, I would say it's down to probably maybe one to two percent. However, anybody who's going to undergo an atrial fibrillation ablation really needs to get it done in a center that does a lot of these procedures, and really needs to get the procedure done by doctors who do a lot of these procedures. Since it's an elective procedure, a patient really needs to ask around and find out about the good centers and what their experience is. Any physician that wants to do the procedure, the patient should definitely find out how many they've done, what kind they've done, what the results are and what their complication rates are. So experience counts and now that it's greater than almost 15 years since we've been doing atrial fibrillation ablation the results are getting better and the complications are decreasing, but the patient should definitely inquire about where they're getting this procedure done.

Now with this new procedure I understand you are one of the three hospitals in the US doing this.

Dr. Banker: Well actually we're one of the three in Maryland doing it and there are more hospitals around the country doing the procedure. It started originally in Europe probably about five or six years ago and it came over to the states within the last few years and it started really in the clinical trials. It's really probably been the last year or so that it's becoming more and more readily available. I would say in any major metropolitan area there are probably at least one or two centers that are offering the procedure. Maybe not in every community hospital but in every major metropolitan center, especially in academic centers, there are at least one or two departments that are offering this procedure. So a patient can definitely search locally and see what's available and then maybe even search a little broader if it's not available in their market.

This is a pretty big deal you help a lot more patients, how exciting is this for you?

Dr. Baker: Well it's very satisfying and one of the most frustrating things is that we were doing these procedures and often times they weren't successful and patients were still required to be on medications and they would still require the blood thinning agents and it was really unsatisfying to put them through all this and oftentimes they would need a second ablation or even a third ablation and those still weren't successful. So having this technology that makes the procedure quicker and more successful is very satisfying. Getting patients you know off their medications and on with their lives, and when you talk to them you really can promise them a cure.

Is there anything else that you would like to add?

Dr. Banker: We didn't really say too much about you know what causes the disease but I mean for the layman population I think that's enough, I don't think there's really anything more needed.

Is there something that causes it?

Dr. Banker: Well there are basically two kinds; one type of patient is what we call the lone atrial fibrillation. Usually the young or middle-age patients don't have any heart disease and for whatever reason they just start having the arrhythmia. The second type of patient is a patient that actually does have heart disease, a patient that's had heart attacks or heart valve disease, and as their heart starts to deteriorate a bit as a result of their heart disease, they develop this arrhythmia as a secondary phenomenon. The type of arrhythmia, the type of atrial fibrillation we're targeting with our ablation, is mostly what we call the lone atrial fibrillation.

Terry mentioned that he had the cryo-ablation, the heat, to fix two flutters.

Dr. Banker: Right, when we first met Terry he came to us with a flutter and it's interesting that there are a lot of different types of arrhythmias, and atrial fibrillation sometimes uses a generic term to mean arrhythmias from the top chambers of the heart. But, they're actually different types of arrhythmias. Atrial fibrillation is the most common but there's also an arrhythmia that Terry originally presented with called atrial flutter, which was a more organized arrhythmia on the right side of the heart and that's something we've been ablating for decades. When he first presented it we took care of his flutter and then subsequently he had a different type of flutter, a different type of arrhythmia altogether which we also ablated. These are things that we standardly would use the heat for. Ultimately, when we got rid of all the flutters, he subsequently came back in with arrhythmia and this was true atrial fibrillation. That's when we for the first time decided do an atrial fibrillation ablation and therefore we went to the balloon. That's a very common thing a lot of patients will have, a combination of different arrhythmias and sometimes it gets very confusing because doctors might use the terms loosely when they speak to the patient, whether it's the cardiologist speaking or the heart rhythm specialist speaking, and they may actually be speaking very specifically but when they go to one doctor they're in one arrhythmia and when they go to another doctor they're in another. So it can be a little confusing for the patient, it's very important for the patient obviously to get all the records and all the EKGs that they have and uh-- and really try to present all their data to the physician that might be doing the procedure.

Does insurance cover this procedure?

Dr. Banker: Sure, absolutely. Insurance covers any type of ablation.

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.


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