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Physicians Update

 
Summer 2010

New Approaches Offer Hope for Patients with Arrhythmia

07/14/2010

PU-Summer10-ArrhythmiaSeveral million Americans have cardiac arrhythmias — problems with the electrical system that controls the heartbeat, producing abnormal rhythms — and some 400,000 die suddenly each year from the condition. But in the last two decades, electrophysiology has had a dramatic impact in physicians’ ability to deal with these problems. The UCLA Cardiac Arrhythmia Center has been a pioneer in this arena, developing the use of new technologies and approaches to curing patients, many of whom are unable to benefit from anti-arrhythmic drug therapies. Kalyanam Shivkumar, M.D., Ph.D., director of the UCLA Cardiac Arrhythmia Center, discusses the evolution of electrophysiology and UCLA’s role in this rapidly advancing field.

How has the standard of care for arrhythmia evolved?
Atrial fibrillation, the most common sustained arrhythmia, causes significant symptoms for many patients even when the ventricular rate is well controlled. For these patients, controlling the rhythm appears to be a better strategy than controlling the rate. However, anti-arrhythmic medications are often ineffective and can cause significant side effects. This has led to a growing role for non-pharmacologic therapy, including cardiac surgical procedures and electrophysiology techniques such as radiofrequency catheter ablation.

PU-Summer10-Dr. ShivkumarWhat is radiofrequency catheter ablation? How does it work?
If we can identify a restricted area where these abnormal rhythms originate, we can thread wires into the heart and deliver a small amount of current to cauterize heart tissue in the desired location. This approach, assisted by electroanatomical mapping, has been a major advance in cardiology, with a higher success rate than medical therapy in curing abnormal heart rhythms. In the 1970s, curing major rhythm problems required surgery that carried many risks and a long hospital stay. By the 1990s, the same problem was treated in an hour or two with this catheter-based therapy, and the patient went home the same day.

What have been the key advances in electrophysiology since that time?
One of the key developments has been our ability to perform complex procedures not just from inside the heart (endocardial ablation), but from outside the heart (epicardial ablation). Epicardial ablation was developed in Brazil; UCLA was the second center in the nation, and the first in the western United States, to offer this procedure for cardiac arrhythmia patients. By threading a wire just under the ribcage to the outside of the heart, we are able to gain access to new areas on the heart’s surface, where the abnormal rhythm is often originating.

At UCLA we have also learned, through the epicardial approach, to use balloons to protect structures that surround the heart, such as the esophagus, and nerves that control breathing; these nerves can be injured if you burn from the inside. We also have developed innovative new ways to cure ventricular tachycardia arrhythmias in which we surgically cut nerves to the heart that are responsible for the arrhythmia.

How important is electroanatomical mapping to the success of such an approach?
Accurate imaging and detailed anatomic knowledge of the pericardial space and neighboring structures are critical. At UCLA, we have been among the first to use robotic mapping systems — using a computer and a joystick to control two large magnets that guide the catheter to the trouble spots, reducing radiation exposure and potentially providing more control than hand movements.

PU-Summer10-ShivkumarWhen should a patient be referred to a large center like UCLA’s?
We feel that no case is too small. We see ourselves as an extension of community teams. A great deal of effort is made to ensure that we coordinate our work very closely with community practices so that the patient doesn’t have to be removed from that setting. We see ourselves as comprehensive specialists — a resource for seeing patients and helping to decide on the best overall course of management.

Where is this field headed?
Just as endocardial ablation led to a revolution in the treatment of cardiac arrhythmias, advances in the epicardial approach and wider use of the technique will have a major impact in the next decade. We have begun to use new technologies such as cryoablation — freezing heart tissue — and, most recently, high-intensity focused ultrasound. We think in addition to treating heart arrhythmias, electrophysiologists are going to play an increasingly central role in dealing with structural heart problems. In the long run, stem cells and other treatments that are going to be used for tissue repair of the heart will be in the realm of electrophysiology. It’s an exciting time for what is really the newest discipline in cardiology.

For more information about arrhythmia care at UCLA, go to: http://arrhythmia.ucla.edu





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