Addressing AFib with the Power of Academic Medicine

Sep. 23, 2020

September marks National Atrial Fibrillation (AFib) Awareness Month, a critically important time to raise awareness for this life-threatening condition.

What is AFib?

AFib is an irregular, rapid heart rate that commonly causes poor blood flow. Symptoms vary and—if left untreated—so do outcomes, where patients have a higher likelihood in developing heart-related complications, like strokes and heart failure. 

At UC Health, we provide world-class patient care with science-based innovation. We spoke with Alexandru Costea, MD, director of the Electrophysiology Laboratory at the University of Cincinnati Heart, Lung and Vascular Institute and professor in the Department of Internal Medicine at the UC College of Medicine, to learn more about the innovative treatments his team does along with how they have been providing compassionate care through academic medicine.  

For five years, UC Health has had an active Watchman Program for patients. Can you describe the program and how it improves patient’s lives? 

Atrial fibrillation is by far the most common arrhythmia encountered in our practice and is a serious healthcare problem. The main concern with this irregular heart rhythm is related to the potential for developing blood clots in the heart, which could subsequently lead to a stroke. The majority of patients are well served by using anticoagulation – medication aimed at reducing the clotting capacity and therefore prevent stroke. As our treated population is aging, additional conditions may prevent the use of oral anticoagulation. Good examples would be patients who had a prior episode of bleeding and/or required blood transfusion or patients who are at increased risk of falls.

For these special categories of patients, we can use an alternative to anticoagulation – a left atrial appendage closure device. This device, Watchman, functions as a filter that is implanted in the left atrial appendage – the source of strokes in atrial fibrillation. After a successful implant, our patients can come off oral anticoagulation while being protected from a stroke.

By combining catheter ablations with Watchman procedures, your team is providing innovative solutions for high-risk AFib stroke patients. What are the benefits to this, and how do you know when a patient needs a rare procedure like this? 

Atrial fibrillation ablations are performed for patients with significant symptoms and or heart failure. Success rates vary, however in general, they are above 70% with the main goal of the procedure being a correction of the rhythm problem substrate while not having any impact on the indications for oral anticoagulation.

Watchman implants are conversely designed to remove the need for anticoagulation without any effect of the arrhythmia occurrence or recurrence. Both procedures involve similar risks and potential complications while submitting the patient to the same type of pre- and post-procedure care.

In patients with symptomatic atrial fibrillation and a significant risk of bleeding for anticoagulation, a joint procedure will address both problems simultaneously without additional risks or a need for a staged procedure.

As our teams experience with this approach grows and with mirroring technological advances we have available, I envision this being a standard joint approach in the near future.

It is important to mention that such a procedure will require a multidisciplinary team involving not only EP but also cardiac anesthesia, cardiac surgery and structural cardiology.

UC Health is the region’s only AFib Program with atrial fibrillation ablation with JET ventilation. What is this technology and how is it used when treating patients?

In general, patients undergoing atrial fibrillation ablation will be under general anesthesia for the duration of the procedure. General anesthesia will provide 8-10 breaths per minute for the patients through our ventilators. We have noticed that these deep 8-10 breaths per minute are leading to considerable lung excursions with an inevitable motion of our ablation catheter while performing the ablation itself. This lack of stability can lead to a longer procedure duration and potentially a lower success rate. Jet ventilation is a special type of rapid shallow breathing used with a dedicated ventilator. With the approach, the patient receives 100 breaths per minute at a much lower volume and lung expansion but is just as effective for the breathing status.

With this approach, the ablation catheter is far more stable while delivering more effective ablation lesions.

We feel that this leads to a shorter procedure duration with less time under general anesthesia for our patients and a more effective ablation.

Can you describe your new 3D mapping technology and what advantages it provides for patients and the operating team?

We have acquired new mapping technology that allows us to treat a variety of completed rhyme problems. Without this new technology, our options were limited, especially in patients who had cardiac surgical interventions or multiple ablations in the past. 

In general, a mapping system functions as a GPS. We place a catheter in the heart and with point-by-point mapping; we acquire several 100-point delineating anatomy voltage and activation timing. With the previous version, we were able to collect up to 5,000 points. Currently, however, we are able to collect up to 10,000 points, which provides much higher density and detail of a map. Of note, the mapping time is shorter. As such, we have collected a series of 10-15 patients who had either failed ablation or fails surgical a tribulations ablation and treated them successfully with this new technology. It is our protocol not to use X-rays for procedures. In conjunction with the mapping system, we are able to offer unique treatment options for our patients.

What type of cardiac research is UC Health doing in AFib?

We have several research clinical projects that involve patient outcomes, efficiency and new technology. Currently, we are part of an international registry for AFib. Specifically, for patients who are treated with this new mapping system and with minimal exposure to X-rays. We are also collecting data on outcomes of patients with complex arrhythmias that can only be addressed with current technology. In parallel, we have very strong basic research lab that is applying artificial intelligence in clinic practice.

6) What type of treatment plans does UC Health offer patients that help reduce and/or eliminate hospital stay?

It has been our protocol for several years to send patients who received a device implant home the same day. Recently, we have extended this same protocol to patients with AF ablations. After a careful screening process and discussion with the patient, we are able to discharge them eight hours after their procedure, as long as there are no complications. This is unique on a national level, as patients typically spend at least one night in the hospital post-ablation. In our series, we have encountered a great safety profile and substantial patient satisfaction scores. From the patient’s perspective, in addition to recovering in their own home, patients appreciate the minimal exposure to the hospital as the COVID-19 pandemic continues.

Are you receiving patients from outside the region?  

Due to our results and workflow, we have been asked to perform live procedures for other medical centers, fellows in training and other physicians. We are excited for the opportunity as we hope our approaches will help patients elsewhere.