C AR DI AC MERRCY HEARRT MONITOR INSTITUTE For healthcare pro fes sion als Spring 2005 Mercy General provides new options for atrial fi brillation treatment By Gearoid O’Neill, MD Vision Statement Atrial fi brillation is the most common cardiac fi brillation. The most popular approaches are In conjunction with the arrhythmia prompting hospitalization. It is associated “segmental pulmonary vein isolation” and “circum- Sisters of Mercy, our with a doubling of mortality due principally to the ferential pulmonary vein ablation.” In the former, cardiovascular care related stroke risk and development of heart failure. strands of myocardial fi bres coming from the out- team is dedicated to providing patients with Symptoms of atrial fi brillation, including fatigue, side sleeves of the pulmonary veins are interrupted com pas sion ate, quality, dyspnea and palpitations, can have a profound im- using radiofrequency ablation (RF). In the latter, cost-effective care pact on quality of life. wide circles are drawn with RF, enclosing each pair through state-of-the of pulmonary veins without necessarily setting out art ad vance ments in research, diagnostic Rhythm maintenance to prove electrical disconnection of the veins to the screen ing, surgical The mainstay of treatment is stroke prevention and left atrium. In addition, a line is drawn from the and interventional the strategic choice of rate or rhythm control. High- bottom of the circle surrounding the left pair of pro ce dures, clinical education and risk patients should receive coumadin anticoagulation. veins to the mitral valve. In some centers an addi- preventive/wellness An alternative of plavix plus aspirin is currently tional line is drawn across the roof of the left atrium. programs for the undergoing evaluation in the ACTIVE trial. The oral Both techniques are more effective in patients with im prove ment of paroxysmal rather than persistent atrial fi brillation. car dio vas cu lar health. direct thrombin inhibitor ximelegatran held great promise on the basis of the SPORTIF trials. How- Success is seen in 60% to 70% of patients, though Cardiac Monitor — ever, the FDA advisory committee, at a meeting in frequently a second procedure is required. a resource for you September 2004, recommended that the drug not be Distribution of Cardiac A number of procedure-specifi c complications have approved citing concerns regarding liver toxicity and Monitorr is intended for been recognized. Pulmonary vein stenosis can be bleeding complications. cardiologists and pri- very severe and result in pulmonary hypertension. mary care physicians. The information included Drug therapy is usually the fi rst-line strategy for The physiological effect can be the same as severe in this newsletter is pro- maintenance of sinus rhythm. One of the most mitral stenosis. Recently, reports have appeared vided as an educational commonly used agents is amiodarone. Though regarding atrio-esophageal fi stulae, which usually service. Mercy Heart result in fatal sepsis. It is felt that these complications Institute respects your not actually FDA approved for this indication, it privacy. If you prefer not is widely used because of its effi cacy and ease of may relate to the disruptive effects on the collagen to receive any further use. However, amiodarone is associated with very matrix of the heat energy from the RF. communications from us, signifi cant and potentially lethal toxicities. It is now please send a brief note Cryoablation and Maze procedure to Andrea Blankenship, required that patients receiving the drug be given Administrative Secretary, written information about the risks. It is felt that the Mercy General’s EP Lab has launched a trial Mercy Heart Institute, toxicity of the molecule is due to the iodine moiety (ICE-PAF) of cryoablation to accomplish pulmo- 3939 J Street, Suite 220, nary vein isolation. Instead of using heat energy, Sacramento, CA 95819, in the compound. A new amiodarone-like compound and include the mailing — but without the iodine — is currently undergoing tissue is frozen to –80 C. Preliminary data indicate label from this newsletter evaluation at Mercy in the MIAI trial. continued on page 2 if possible. It may take up to 30 days to process your request. Ablation strategies Some of the most exciting recent developments involve ablation strategies designed to “cure” atrial 1 Mercy Heart Institute Cardiologists and CAR DIAC Cardiac Surgeons MONITOR Michael L. Chang, MD, Medical Director RESEARCH Cardiac Electrophysiologists ICDs and implications of Peter Jurisich, MD NEWS Padraig G. O’Neill, MD recently reported clinical trials Arjun D. Sharma, MD Stephen I. Stark, MD By Gearoid O’Neill, MD Larry J. Wolff, MD Cardiac Surgeons Few innovations have had such a profound treatment of some heart failure patients. Resynchro- John R. Dein, MD Richard J. Kaplon, MD effect on survival as the Implantable Cardioverter nization therapy is accomplished by pacing the left Allen S. Morris, MD Defi brillator (ICD). This device can recognize the ventricle at the same time or slightly before the right Stephen J. Rossiter, MD onset of ventricular fi brillation or tachycardia and ventricle. The usual technique involves placing Frank N. Slachman, MD immediately deliver corrective electrical therapy. a lead into the coronary sinus and advancing it to a Cardiologists Arvin Arthur, MD Its value in secondary prevention is long established. lateral branch vein under fl uoroscopic guidance. Najam A. Awan, MD Unfortunately, this group represents only the tip of the Patients with long QRS duration (>130msec) were Philip M. Bach, MD Scott B. Baron, MD iceberg as far as sudden death victims are concerned. studied fi rst. A marked improvement in functional Rohit Bhaskar, MD status and reduction in hospitalization for heart David A. Bayne, MD The major thrust over the last 5 years has been primary failure was seen in 70% of treated patients. Mercy Raye L. Bellinger, MD prevention. We have sought to identify those indi- Larry E. Berte, MD General enrolled patients in a number of pivotal trials Dennis R. Breen, MD viduals at high risk of malignant arrhythmic events evaluating this therapy, including COMPANION Alan R. Cabrera, MD and implant the device before the fi rst event occurs. Peter R. Callaham, MD and RHYTHM-ICD. Jack W. Casas, MD The MUSTT (at Mercy General) and MADIT Michael L. Chang, MD Unfortunately, it has not been possible to accu- Kenny Charn, MD trials were the fi rst to identify groups at risk. These John Chin, MD rately predict the patients who might benefi t. We studies identifi ed patients with CAD, LVEF <35% Michael A. Davis, MD do know that positioning the LV lead on the lateral Patrice Des Pois, MD and inducible VT as high risk and showed the sur- wall provides the best prospect for benefi t. Also, we Mark H. Eaton, MD vival value of the ICD. More recently, the MADIT2 Georg Emlein, MD are questioning whether a wide QRS is a necessary Daniel C. Fisher, MD study showed a 27% survival advantage for ICDs requirement for benefi t. It is known that mechani- Melvin D. Flamm, Jr., MD when implanted in patients with prior myocardial James M. Foerster, MD cal desynchrony can occur even with a normal QRS. Michael Fugit, MD infarction and residual LVEF <30%. The regulatory Tissue Doppler imaging is a new echocardiographic Jonathan A. Hemphill, MD authorities (CMS) approved ICD implantation in Stanley C. Henjum, II, MD technique that allows non-invasive evaluation of this group but limited payment for the implants to Elizabeth Hereford, MD the phenomenon. Studies soon will be under way Mehrdad Jafarzadeh, MD the group with QRS duration >120msec. A retro- Roy F. Kaku, MD to examine the benefi ts of resynchronization in the spective analysis had shown a greater magnitude of Brian Kim, MD population with normal QRS duration. Joseph A. Kozina, MD effect in patients with a wider QRS. Edmond Lee, MD Timothy Y. L e e, M D In January 2005, the SCDHeFT trial was reported Reginald I. Low, MD David J. Magorien, MD in the New England Journal of Medicinee. Mercy was Nick Majetich, MD among the highest enrolling centers in the United John A. Mallery, MD Atrial fi brillation Walt Marquardt, MD States. The study looked at patients with heart fail- continued from page 1 Harvey J. Matlof, MD ure of any etiology and LVEF <35% and compared Malcolm M. McHenry, MD Peter Miles, MD ICDs to amiodarone and placebo. Amiodarone that the ultra structural changes noted with RF are Stephen L. Morrison, MD produced no survival benefi t when compared to not seen when the freezing probe is used. Thus, Gopal Nemana, MD this may translate into a lower risk of pulmonary M. Michele Penkala, MD placebo. In contrast, the ICD produced a 23% Nayereh Pezeshkian, MD reduction in mortality. CMS has since approved the vein stenosis or atrio-esophageal fi stula. Jagbir S. Powar, MD implant of ICDs in this population. David K. Roberts, MD Maze surgery has been part of the therapeutic Sailesh N. Shah, MD Karanjit Singh, MD The bottom line as far as this data is concerned is that armamentarium at Mercy for many years. The Kevin L. Stokke, MD any patient with an LVEF <35% should be considered procedure requires open chest exposure and thus Rajendra S. Sudan, MD Patricia A. Takeda, MD for prophylactic ICD implantation. has been mostly limited to patients requiring bypass Daniel D. Vanhamersveld, MD or valve surgery. However, a new technique using William Vetter, MD Mark A. Winchester, MD Biventricular pacing a thorascopic approach is being offered at Mercy. David E. Woodruff, MD A new twist on device implants relates to the Through port holes on both sides of the chest the Mercy/CHW surgeon can introduce a fl exible ablating catheter Cardiovascular Services development of biventricular pacing devices.