David Kenigsberg, MD, Clinical Cardiac Electrophysiologist at Florida Heart Rhythm Specialists talks about the new FDA approved Atrial Fibrillation treatment utilizing the Heartlight X3 Endoscopic system.
What is atrial fibrillation?
Dr. Kenigsberg: Atrial fibrillation is the most common arrhythmia, and it becomes more prevalent as people get older. It is an abnormal rhythm that comes from the pulmonary veins which occur in the posterior portion of the heart coming off the left atrium. There are typically four pulmonary veins, and they have triggered activity that is misfiring, and that activity results in turning the top chambers of the heart into an extremely fast, irregular rhythm. Instead of the heart beating as it should, it kind of wiggles like a bag of worms. That promotes blood clots that can cause thromboembolic disease, like stroke or other forms of thromboembolism like heart attacks. In addition, it causes symptoms with the most common being shortness of breath, palpitations, chest pain, fatigue, dizziness, and lightheadedness. It can also cause people to fully pass out. In addition, when the heart beats so fast over time, it can result in the heart function worsening called congestive heart failure and cardiomyopathy. So atrial fibrillation is not only a nuisance, and not only causes symptoms, but it increases a patient’s chance of having a lot more morbidity as they get older and potentially increase their chance of mortality, especially if they have other concomitant illnesses. The first line of treatment for atrial fibrillation is either to give medication or, if the patient elects not to take medication, we can offer them a potentially curative procedure called ablation. Ablation means to destroy electrical tissue in a specific and predesignated fashion with an energy source. Historically, the energy source was radio frequency energy, like a microwave, where we would go up with a small 3.5-millimeter ablation catheter that has irrigation or fluid coming off the tip and go in a point-by-point fashion around the pulmonary veins where the atrial fibrillation comes from to electrically isolate the veins. That was an exceptionally long and tedious process and it resulted in gaps and when you have gaps in those lines, that can result in further arrhythmias. So, it is not highly effective, and it is a very tedious and time-consuming process. In addition, different operators and skill sets can come out with different results. There is also a balloon technology developed that could freeze the veins to electrically isolate them called a cryo-thermal balloon which took the energy to the pulmonary veins and the area around it. It is an incredibly good technology, but a very one-size-fits-all tool. More recently, there has been the development of a laser balloon, which is fully compliant and can go into the vein to take the shape of the vein. So, whether you have a nine-millimeter right middle pulmonary vein that is extremely small or a 3.8-centimeter common left pulmonary vein that is extremely large, this balloon can fit and allow us to provide an energy source to the area that we are trying to ablate. It also allows us to adjust the laser beam to go deep into an area or pull out and be more Antrel, which is, in my opinion ideal because it gives a wide area circumferential ablation, which is what we are looking for to treat atrial fibrillation.
Are there particular patients this would be the best option for?
Dr. Kenigsberg: Atrial fibrillation ablation is for patients that have symptoms and are looking to be treated or potentially cured, patients who have concomitant illness like congestive heart failure or cardiomyopathy, patients that have tried medication and have failed it. But this is to treat the symptoms of atrial fibrillation and improve the amount of time the patient remains in normal or sinus rhythm.
After the surgery, how long is the recovery?
Dr. Kenigsberg: It takes several months for the scar made by the energy source to form. Once the scar forms, we know what the success of the procedure is. Data suggests that the success of the procedure is about 81%.
Why wasn’t your patient, Felicia Hunter, a candidate for the regular procedure?
Dr. Kenigsberg: Mrs. Hunter came to me with highly symptomatic atrial fibrillation, and she was looking for a potential cure, with a chance to come off the medication, and not feel the symptoms that she was having. When she came to me, she described symptoms of palpitations, dizziness, lightheadedness, shortness of breath, fatigue, and inability to carry out her daily activities without having to stop or think about taking her medication. Her procedure was scheduled, and she was reluctant at first to have anything done, as most people are. But after I explained to her the potential benefits, which was the chance of not having to take medication long-term, not feeling the symptoms any longer and to potentially be cured with an incredibly low risk of complication the patient was excited about the opportunity. After a long back and forth discussion, she elected to go forth with the procedure. I performed a cardio focused HeartLight X3 laser balloon ablation on her and it went seamlessly. We gained access to both of her groins and the jugular vein in her neck. We put all the requisite catheters in, which is typically one in the right femoral vein, two in the left femoral vein, one in the right internal jugular vein, and then put the balloon in the left atrium. Then went about electrically isolating each of the four pulmonary veins with the laser. The procedure took approximately an hour and a half, and the patient went to recovery and went home within a day. She did not have any procedural complications or concerns, and she has done very well. We have been able to stop her medications and she seems overwhelmingly happy with the result.
After somebody has this procedure, are there any limitations on activities they should not do?
Dr. Kenigsberg: For the first week after we put catheters in the body, we recommend no heavy lifting and no submerging in a body of water like a lake, pool, or bath. They can take a shower. But people are usually more energetic and able to carry out more activities after the first week. Once I had a patient have this procedure done and then fly to Singapore the next day without any issues. That is extreme but most people do very well, and they can possibly ambulate out of the hospital and carry out their activities as soon as the next day.
You mentioned the balloon worked for about 81% of patients. What happened with the other 19%?
Dr. Kenigsberg: Like all procedures, there is a stated effectiveness of the procedure and it is not that the procedure itself fails. So, immediately after the procedure, the patients leave the room in normal rhythm. The question is, do they return to atrial fibrillation and do they stay in it? The likely reason patients go back into atrial fibrillation after a successful procedure is there are other targets outside of the pulmonary veins that were successfully isolated that are now causing the atrial fibrillation, and that probably accounts for 20 % to 30% of patients. So, when we talk about success rate, some of the patients will have to have a second procedure, and they will have to go on a medication. But by and large, most patients enjoy normal rhythm after one or maybe two procedures.
The patient mentioned when her heart palpitations first happened it was happening constantly for days. What would cause that?
Dr. Kenigsberg: Atrial fibrillation I think of as a spectrum-type problem. At the beginning, patients have noticeably short episodes. They have a long space in between episodes. As time goes on, they have more and more episodes, and they become closely spaced together to the point where they are in it all the time. The time to intervene with someone in atrial fibrillation is at the beginning of the spectrum. That is when we get the greatest opportunity to fix the problem. As it progresses, there is so much damage that occurs to the chamber that it becomes challenging to fix it by doing a pulmonary vein isolation. So, we recommend that patients have this procedure early on. She was progressing to a point where her palpitations were lasting hours and up to days, and that is the point where we must do something because once it becomes persistent or permanent, then it is incredibly challenging to cure. Some people state that the success rate in those patients is as low as 30%.
So how new is this?
Dr. Kenigsberg: The procedure itself has been done in Europe for many years and it has been done in the United States. But the X3 procedure, which is the latest balloon, was FDA approved earlier on this year. So far at West Side, we have done over 50 and are approaching 60 procedures, which is the most in the United States. We were also the first in the southeast to do the procedure and the second in the United States to be able to do this procedure. This is the third iteration of the laser balloon, and the difference between this iteration and the prior version is this balloon has a motor which can move the laser beam in a specific fashion around the circle anteroom of the pulmonary vein, which makes the procedure much more rapid which is helpful for the safety of the procedure and the patient.
What are the potential consequences if the patient thought I am just going to deal with it and not worry about it?
Dr. Kenigsberg: Patients can develop a weakened heart muscle which is called cardiomyopathy. That can result in congestive heart failure symptoms, which is the accumulation of fluid in the lungs which makes people feel like they are drowning in their fluid, they cannot breathe, cannot walk far, and they get swollen legs. Heart failure is a potential complication of not taking care of atrial fibrillation. Having to deal with the symptoms sometimes makes people fatigued and they cannot get out of bed and go to work so they lose their job. So, it effects their daily living. They cannot carry out their own daily activities and need assistance. It does not allow them to exercise and that makes them become sedentary and develop other health problems including obesity, which is one of the largest growing health problems in the U.S. today. So not taking care of atrial fibrillation can result in a whole slew of medical problems that will be challenging to deal with. As it progresses, it makes it more challenging to deal with the atrial fibrillation itself, so taking care of atrial fibrillation early on is really the best way to have a good end-result.
What does this do for a patient’s quality of life?
Dr. Kenigsberg: Patients who are atrial fibrillation symptomatic and who have had an ablation typically have an improved quality of life based on many studies. Most of it has to do with the fact that they have had a procedure where their episodes are shorter, and maybe have totally gone away, and they are cured. It has also been shown that patients that have atrial fibrillation and have this procedure have an improved quality of life, regardless of how much atrial fibrillation they are having. So, this procedure drastically improves patient’s symptomatology and quality of life.
Are there any surprising signs or symptoms that people tend to miss when it comes to atrial fibrillation?
Dr. Kenigsberg: People will pass out for a whole slew of reasons. They have congestive heart failure, chest pain, dizziness, lightheadedness, and shortness of breath. Not all patients with atrial fibrillation have palpitations and not all palpitations are atrial fibrillation either. The best way to figure this out is to see a cardiac electrophysiologist to be able to ascertain exactly what the problem is and figure out how to best treat it.
Anything I did not ask that you feel people should know?
Dr. Kenigsberg: Yes, I think that it is important to point out that West Side Regional Hospital has remained on the cutting edge of ablation, device, and arrhythmia therapy. I took over as the director of the lab in 2007, and we have seen a lot of progression in the field of electrophysiology. We have seen a lot of cutting-edge technology come to the hospital to treat our patients. We have patients that drive to us from three or four counties north, south, and west of us, and we are well known in the area for doing a good job in heart health but especially for arrhythmia care.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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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