Removing irregular heart rhythms is a highly technical job

New tools and state-of-the-art laboratories are allowing Yale Medical Group’s electrophysiologists to meet a rising demand for care.

(September, 2010) When Mark Marieb, MD, told Kristen Klansky that the catheter ablation procedure to treat her arrhythmia would trigger the fluttering heartbeat that brought her to him in the first place, it made her nervous. She was only 32 and didn’t want to take risks. But her heart had twice sped up to 250 beats per minute while she was relaxing at home.

“It’s similar to when you exercise intensely, and your heart rate accelerates, but maybe two or three times as fast. But unlike exercise, your heart continues to race, even at rest,” she says.

While maneuvering wires inside patients’ chests, Mark Marieb, MD, and his colleagues can watch their location on a monitor, thanks to a 3-dimensional mapping system.

Marieb, clinical director of Yale Medical Group’s Electrophysiology and Cardiac Arrhythmia Service, the largest service of its kind in the state, assured her that he had performed hundreds of similar procedures, eliminating risk of sudden death in some cases, and easing such symptoms as dizziness, fainting and palpitations.

New state-of-the-art laboratories

In fact, the demand for electrophysiology treatments has increased so much that Yale-New Haven Hospital has opened a new state-of-the-art electrophysiology laboratory this year, with dedicated nursing and laboratory staff, and five other dedicated electrophysiologists, including Joseph Akar, MD, PhD; William Batsford, MD; Jude Clancy, MD; Rachel Lampert, MD, and Lynda Rosenfeld, MD.

The hospital plans to open a second state-of-the-art laboratory and renovate a third—their original one—by early next year. All are designed to function like operating rooms, with strict regulatory requirements for sterility.

Arrhythmia cases on the rise

“Doctors are treating more arrhythmia nationally, partly because the population is aging, and because treatments are becoming safer and more effective, and we’re able to do so much more for patients,” says Marieb, who joined Yale Medical Group last year.

Arrhythmia includes any disorder of heart rate or rhythm, including heart beats that are too slow, too quick or that have an irregular pattern. Klansky, a pharmaceutical company employee and one of Mark Marieb’s younger patients, had Wolff-Parkinson-White Syndrome, a rare congenital arrhythmia characterized by an extra electrical pathway in the heart.

Atrial fibrillation, the most common rhythm abnormality, causes the heart’s two small upper chambers to quiver rather than beat rhythmically. It affects as many as 2 million people, is usually found in people over 65, and is associated with high blood pressure and obesity. Its incidence is on the rise, in part due to the aging population, but also for reasons that are unknown.

Range of treatments

Yale Medical Group doctors provide a range of treatments, including:

• Catheter ablation, which removes faulty electrical pathways from the hearts of patients who are prone to abnormal rhythms.
• Defibrillator implantation, involving implantation of a device that shocks an irregular heart back to normal, preventing sudden death.
• Cardiac resynchronization, a procedure to synchronize the left and right ventricles of the heart, improving cardiac function in some patients with congestive heart failure.
• Pacemaker implantation, which inserts a device that regulates the heart beat.

Better tools, less radiation

Rhythm disorder treatments have become more effective, and one reason is that electrophysiologists are using better tools, such as tiny guide wires that allow them to work in small veins, remote robotic navigation and other cutting-edge technologies.

Yale Medical Group’s electrophysiologists find another advantage is the use of intracardiac ultrasound. It provides better imaging of the heart during procedures, while cutting down on the need for X-rays and unnecessary radiation. While maneuvering wires inside patients’ chests, Marieb and his colleagues can watch their location on a monitor, thanks to a 3-dimensional mapping system that utilizes radiofrequency waves much like a car’s global positioning system (GPS).

High tech ablation procedure

Joseph Akar, MD, (left) and Mark Marieb, MD, locate and treat abnormal heart rhythms using GPS-like devices and other high-tech tools.

Some procedures take several hours. “Just trying to find out where the arrhythmia is can take a long time,” says Marieb.

When he performed Klansky’s high-tech catheter ablation, Marieb sedated her, inserted five catheters into her femoral veins and threaded them up to her heart. He followed the progress of the catheters on a monitor using the GPS-like mapping device, then set off the abnormal arrhythmia, which can be done with medication or catheter stimulation. He used an ablating catheter to cauterize the malfunctioning tissue.

Weeks later, Klansky can finally relax in the knowledge that her arrhythmia will not return. “I’m able to return to the gym, and drink coffee again, two triggers that I formerly avoided,” she says. “It’s such a relief to no longer live in fear.”