Cardiovascular Medicine

BWH Cardiac Arrhythmia Service is national “go to” resource for complex cases.

Electrophysiologists at the Brigham and Women’s Hospital (BWH) Cardiovascular Center are a resource for colleagues around the country, helping them manage their patients with complex cardiac arrhythmias.

Referral process

Laurence M. Epstein, MD, Chief of the Cardiac Arrhythmia Service and Director of the BWH Electrophysiology and Pacing Laboratory, and his colleagues work in partnership with primary care physicians, family care physicians, clinical cardiologists, and other electrophysiology specialists, offering the full spectrum of support from advice and consultation through advanced treatment modalities including:

• Catheter ablation of difficult-to-manage arrhythmias, including atrial fibrillation,
• Implantable cardioverter-defibrillator (ICD) placement,
• Cardiac resynchronization,
• Laser extraction of transvenous pacemaker and ICD leads,
• Antiarrhythmic drug therapy, and
• Investigational devices and ablation technologies.

The Cardiac Arrhythmia Service provides:

• Consultation with our colleagues on treatment options and management of complex cases,
• Evaluation of patient history, evaluation of a faxed tracing, and a recommendation that allows physicians to treat their patients effectively in their offices when possible,
• Seamless referral,
• Timely appointments for referred patients,
• Communication throughout the consultation and treatment process.

“Following treatment, our goal is to return all patients to the care of their own physicians and to remain available to physicians and patients who may have questions or concerns,” says Dr. Epstein.

A recent referral

Recently, Barry J. Karas, MD, an electrophysiologist at Baystate Medical Center in Springfield, MA, referred a patient to Dr. Epstein for catheter ablation to treat refractory atrial fibrillation (AF). For appropriately selected patients, this technique has a 70 to 80 percent success rate. Following the procedure, some patients are able to come off their antiarrhythmic medications entirely; others achieve successful symptom control on medications that previously were ineffective.

Dr. Karas says, “My patient felt his quality-of-life was diminished as a result of his atrial fibrillation and medications had failed to give him adequate relief. In addition, he was using a lot of resources – particularly nursing and paraprofessional staff in my office – unproductively. He was dissatisfied because he was still having symptoms, and we were unhappy because we couldn’t help him. It was a no-win situation, and he decided to explore the option of a potentially curative ablation.” Dr. Epstein determined that the patient was a good candidate for catheter ablation and performed the procedure a few weeks later.

Five months post-procedure, the patient is doing well and has had no further episodes of AF. Dr. Karas says, “He is living a productive life, and his disabling arrhythmia is no more than a bad memory.”

“The whole process, from consultation through referral, treatment, and follow-up was very simple for me and for my patient,” explains Dr. Karas. “My patient feels better, and I appreciate the comfort of having easy access to a colleague with excellent advice and superb clinical skills to help me manage my more complex patients.” Dr. Epstein concludes, “Atrial fibrillation is the most common arrhythmia, affecting more than two million people in the United States. As the population ages and AF becomes even more prevalent, catheter ablation will be an increasingly important technique in our therapeutic toolbox.”

Referrals and Information

The Brigham and Women’s Hospital Cardiac Arrhythmia Service welcomes physician inquiries and referrals. For questions, contact Dr. Epstein via e-mail at lmepstein@partners.org or fax a tracing to (617) 277-4981. Or, call our Physician Referral Service at 1-800-MD-TO-BWH and we would be happy to assist you.

Dr. Karas’ patient: A complex case for referral

Patient profile

A 59-year-old man was referred to the Brigham and Women’s Hospital Cardiac Arrhythmia Service for refractory symptomatic atrial fibrillation. He had a four-year history of paroxysmal atrial fibrillation and had failed a trial of medication.

Evaluation

His work-up included an ECG, thyroid function tests, an echocardiogram, and a stress test, the results of which were unremarkable. The patient had a structurally normal heart and was otherwise healthy. Because he had a history of symptomatic atrial fibrillation, had failed medical management, and had no contraindications, it was determined that the patient was an appropriate candidate for catheter ablation.

Treatment at BWH

The ablation was performed in the Electrophysiology Laboratory at BWH with the patient under conscious sedation. Under fluoroscopic guidance, catheters were advanced through the femoral veins into the coronary sinus and across the fossa ovale into the left atrium. Intracardiac echocardiography (ICE) was used to confirm catheter placement and to allow direct visualization of the pulmonary vein ostium. In order to minimize the risk of stroke, the patient received injected anticoagulant medications during procedure.

Mapping of the left atrium and pulmonary veins was performed with an advanced mapping system that renders an accurate three-dimensional representation of the anatomy. A radiofrequency catheter was used to empirically isolate the pulmonary veins. Small scars (6 to 8 mm in diameter) were created at the junction of the left atrium and the pulmonary veins to prevent the electrical signals originating in the pulmonary veins from entering the atrium. In addition, ablation was performed at other sites to modify the substrate required to maintain atrial fibrillation and atrial flutter.

Post-procedure

The procedure took two hours. The patient tolerated the procedure well, was monitored in the hospital overnight, and was discharged the following day. He remained on anticoagulant and antiarrhythmic medications for three months and was monitored by his own cardiologist. Three months post-procedure his cardiologist began weaning him from his medications. He continues to do well and has had had no further incidents of atrial fibrillation.