Atrial Fibrillation Summit, 2003, Cleveland Clinic

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Posted by Sarah on November 28, 2003 at 00:21:52:

I DON'T KNOW HOW THIS WILL "PASTE", I KNOW I'LL LOOSE MY HTML, AND IT SEEMS BEST IF YOU USE YOUR DOWN ARROW, TO READ. THOUGHT THIS MIGHT HELP SOMEONE WITH DECISIONS. S.

Atrial
Fibrillation
Summit

Friday/Saturday, August 1-2


This report is definitely from a layman/patient’s point of view, whose spelling and terminology is of said same. So bear with me friends. I’ll try to put direct quotes into quotation marks, and my “interpretation, or opinion” in a colored print when it’s within the speakers comments.

I have to thank Dr. “Bob” Schweikert for giving in to my persistent request to attend the summit as probably the only lay person there. He gently suggested that I keep a low profile and not ask any questions. J I missed some of the A.M. presentations, because of the shuttle from the Holiday Inn.

The exhibits were fascinating to me: Ablation catheters (cryo, radio frequency, ultrasound) basket like things to insert into the veins, chest spreaders, the coolest life like detailed models of the heart, clamps, saws, artificial heart, artificial valves of every kind, and a “lasso” RF that open chest surgeons can use to wrap around the outside of the hearts pulmonary veins and administer energy to burn through the thickness of the muscle and block off the AF pathways.

There was a curved bi-polar RF clamp that I saw Dr. Gillinov use to isolate two PV’s, front to back on the outside of the heart, and then those oval burns that encircled each of the two PV’s were connected with ablation lines, through to the Mitral isthmus to completely block the errant AF’s. (More about this surgery later)

My notes are as follows:

Dr. Kenneth Ellenbogen, of Richmond, VA; on making Linear Lesions for AF Ablation

“Ablations done with linear lines are still very difficult to do! (Dr. Natale developed the loop cath tool) “The percent of success is still not as good as we’d like.” “Also, many hospitals will only permit the 1megahertz (?) of energy to be used when trying to ablate using RF energy.” ( It’s hard to get the burns all uniformly close together, eliminating any gaps, plus being sure to burn the depth that’s needed to completely seal off errant rhythms.) He discussed the problem of not curing AF, and having to use blood thinners. “Coumadin is a terrible drug to be on, and aspirin has not been proven to prevent stroke.”


Dr. Warren Jackman, Oklahoma City, OK; on Sterotaxis Magnetic Navigation for PV-LA Junction Disconnection


His presentation was based on an experimental method of using a soft catheter, which lays on tissue, (like wet spaghetti) and moves with it, as the heart continues to beat, and administers a solid “line” of lesion. He is combining this method with robotics, and has been practicing on dogs.

There were questions and answers, stimulated by the presentations, which centered on the inadequacy of aspirin, and blood thinners. There are apparently many patients who can’t get their INR levels within the therapeutic range, with warfarin, or unable to take blood thinners. One surgical solution, is to use the little “basket” I described seeing at the exhibits, that is inserted into the left Atrial appendage. This appendage is a little “cul-de-sac” that looks, from the outside, like a little “ear” sitting atop the left atrium. This is a place that blood can get caught up in, and form clots during AFib. It seemed to be the place where the docs felt blood clotting strokes gather. SO…they put this catheter in that has a folded up wire like basket, up into this appendage, and opened it, to fill this appendage with basket.

Other doctors just remove this appendage, which doesn’t seem to be needed. Sort of like and appendices I guess. One comment is that a left sided, enlarged heart, may have to be reduced, in order to improve the efficacy (contractibility). Six to eight centimeters seems to be the “too large” size.

A statement was made that Maze is only 50% effective for people who are in “chronic” Afib. Dr. Cox disagreed, and said that “There are very few true “chronic” AF patients. They are very rare, and almost always, start and stop on their own.” (More about that later) Then someone cited CC’s 80-95% Maze/ablation cure rates. The Cleveland Clinic moderator, chided the EP’s by saying, they never have had a death from doing a Maze surgery….. “except once, when a patient died during an immediate follow-up ablation attempt, after the surgery, which had to be the EP’s fault”.(Which was a friendly jab, poked at EP’s)

***Live Case: Treatment of AF, Live surgery! Way Cool! Performed by Dr. Gillinov, on a 60yr old man who had 30yrs of Atrial fibrillation.

The entire summit was held in a very large room, shaped like a curved, 180deg. curved, and tiered amphitheater. It had just opened two months prior, by the Intercontinental Hotel and Convention Center. Each curved, tiered row, had connecting desks, made of what looked like rose wood or teak. Each person had their own luxurious black, high backed rocker/swivel leather chair! On each desk were a microphone, electrical plugins for laptops, and a switch, that could be pushed when you wanted to speak, or ask a question, so everyone could hear the give and take of discussions. I sat behind the back row and isle, in an area, set back into the back wall, which gave a great view of the entire delegation. My “booth” mates were different each day, and it was noted that one particular doctor, spent most of his time watching the stocks, playing solitaire on his laptop, while listening to the presenters. “

I felt so very privileged to be there, and observe a live operation, and hear the surgeons talk back and forth with Dr.Gillinov, while he worked! The live surgery that Dr. Gillinov performed, was a Cox Maze III. “ This is done on an arrested heart, that is “cross clamped”, and on heart/lung bypass. Few surgeons perform this type of operation, outside Cleveland.” “The 60yr old, male patient, would be expected to be in the hospital 9-12days.” He had a pacemaker, (which I don’t remember, was left in or not) had been diagnosed with Paroxysmal AF , with heart disease, (not lone Afib!) Had clogged coronary arteries, received two bypasses and replacement of two valves. Dr. G. considered his atrium large at 7.5cm.

In past years, LAF, (lone afib), was the criteria before doing the CoxIII Maze procedure. It has enjoyed a 92% cure/success rate for over 10yrs. The problems with this surgery are that it is done on: (1)- an arrested heart (2)- Cross clamp time (3)- 9 to 12 days hospitalization (4)-few surgeons are able to perform this complex operation. (5)-my notes say the pacemaker was a problem, but I don’t know whether that was for this patient only, or all patients.

By the time the camera was in place, so we could observe what Dr.G. was doing, some of the work had already been done, but it appeared that he was removing a diseased coronary artery from the epicardium. He snipped away the translucent tissue holding it to the heart muscle, and pulled it away. It seemed so obvious to me that it was “unhealthy”, with blue lumpy bumps interspersed with white plaque.

The ablation burn lines were done with an instrument that looked like a curved speculum, covered with material that transferred the energy source/RF to the heart tissue. It was clamped at the base/neck of this appendage (little ear) that most of us have on top our left atrium. He removed the atrial appendage, and turned it inside out, for us to see whether there was a blood clot in it, which there wasn’t. After he removed the appendage, he showed us the inside of the atria at the site the appendage was removed. He wanted us to see that he’d not left a “cul-de-sac” where blood could still clot, and that the “burn” had gone completely through the heart muscle, to the inside; sealing off abnormal electrical pathways that cause AF.

He placed the ablation clamp, then stepped on a pedal, that delivered the RF energy through the handle of the tool to the areas he wanted ablated. While the EP surgeon ablates from the inside out of the heart, Dr. G. made his burns with the tool, on the outside, and around the pulmonary veins. From front to back around each set of two PV’s, he encircles the veins with ablation burns, and then makes a burn line that connects the two encircled vein burn lines. He checks to see if the burns are completely through to the inside. (they looked whiter than the other heart tissue).

Dr.Gillinov then did the replacement of the Mitral valve! WOW!!! I think it was one of Dr. Cosgrove’s designed valves. If the man had not needed so much done during this session, he would have tried to repair it, but the man had been on the heart/lung machine, with the heart clamped off (stopping blood flow) it wasn’t safe. It takes more time to repair than replace with a new one. So the fellow got an artificial valve.

I watched as the surgeon prepared the area of the bad valve. He used cryo tool to freeze tissue at the site of the Mitral valve. It was a round disk with a handle, that when he stepped on a pedal, it frosted up real fast, and froze the tissue. I could see the tiny papillary muscle attachments (like parachute strings) that attach the leaflets of the Mitral valve.

He had all this “ready made” needle and thread…. hair like sutures with curved needles already attached. He was so fast! He sewed through areas around the patient’s valve tissue, and attached each suture at intervals around this artificial valve. The valve was white, ringed with soft material to insert the needle through, pull it out, grab another one, put it through the humans heart tissue, pull up about six inches to where someone is holding the artificial valve, attach it through the outer ring, grab another suture, and do this a bunch of times! Maybe 20-30times, fast!

Then he gathered up these “threads”, half in one hand, half in another, and gently pulled apart, sliding the new valve down the length of the thread, and it seated itself….plop, into the round, open space. His hands and fingers then just “flew” as he made knots, tying each suture securely, holding the valve in place. It can now open, and close smoothly, as the heart pumps blood from chamber, to lungs, to chambers, and out through the Aorta, while the new leaflets seal nice and tight, preventing any back pressure leaks. WOW again!

I thought how cool it would be if the valve were made of material that glowed in the dark, so you wouldn’t miss it during X-ray. I’ll tell you, I was so exited about that first day’s events, that my adrenaline was sky high! I was pumped up and wanted to share everything!! I went back to my hotel, and discovered that the rest of the family really didn’t want to know….Aggguh! I was so relieved, when Dr. Schweikert stopped to talk to me a couple of times, and we had such animated conversation. It was just downright fun!

As an open heart surgeon, Gillinov talked about how good it is to be able to “see” what he’s doing, as opposed to EP’s. There was no blood to obscure the process, he can see the quality of the burns, and that it’s easier to place the catheter where you want it, because there is direct visual access. This is, as apposed to fluoroscopy that the EP’s use.

However, we’re dealing with Afib, which is an “invisible” errant electrical impulse! Dr. Schweikert pointed out, that the surgeon is unable to do an EP study while doing open procedure, and doesn’t know if he’s got all the errant rhythms or not. The EP has to be called in to do an EP study and possible catheter ablation. Consequently, Dr. Schweikert says that at Cleveland Clinic, surgeons and EP’s depend on one another’s skills, working closely together, sometimes being called to the OR, to do an EP study after the open Maze. He made sure I knew that the little “jabs” they gave one another, did not reflect any unhealthy competitiveness.

The EP/catheter based approach has to deal with “bubbles”……heat from an energy source that burns the lesions causing the blood to bubble, since, (as an ablation survivor), it’s done on a mildly sedated patient, while the heart is pumping away! The bubbles tell the EP if it’s hot enough, OR if it’s too hot, and will damage the heart. They learn to look at bubbles. Another disadvantage, is that the EP can’t “see” whether he’s burned the thickness/depth that’s necessary, and has to depend on the computerized equipment he uses, to tell him if the abnormal electrical impulses were blocked, or not. If you get Afib, Aflutter signals on your computerized EP study equipment after you’ve burned, you burn the same spot again, or look for gaps between lesions.

Alternate energy sources

In Dr. Gillinov’s OR, he had all the alternative energy sources that could be used to make ablation lesions, if needed. Several of the attendees seemed impressed with CC’s “collection” of tools. He spoke about the (A)-Cryo tools: (I didn’t write down the complete term, sorry) this is good when working close to other organs, a safe, easy to use method. However, it’s slow.

(B)-Microwave: Faster than Cryo, burns deeper, and while effective, is still too unfocused.

(C)-Radio Frequency, irrigated tools. Used by EP’s , is fast, can “focus” width and depth of lesions well, but better with endocardial than epicardial use.

(D)- The Ultra Sound and Laser tools haven’t had much experience, and not enough data so far to use regularly.

It was a shock, that one doctor said that his hospital wouldn’t let them use more that one energy source per operation, like Gillinov had just done, using RF and Cryo. I guess it drives up the cost, but I can see where the surgeons would be resentful, being forbidden to use the appropriate tool, when they felt it was necessary, by some bean counter, who’s not in the trenches.

Conclusion: With the improvements that are being made, advances in surgery; it begs to question…”Is EP ablation really quicker than open chest/heart (cut ‘n sew) surgery anymore?

Lunch the first day: When I registered, the very nice lady asked me to stay for lunch. Dr.S. had left my name at the registration desk, and I received my name tag and badge, just like the other attendees. I wondered how much each of them had paid to attend, I’m sure it was costly. I felt a brief pang of guilt…..very brief. The nice registrar said, “You’ll want to stay for lunch, won’t you?” and when I hesitated, she insisted I should because it was going to be “very nice.” It was.

I sat by an EP from Pennsylvania, and a Cardiologist from CC. The room and table service was elegant. I had not brought “business” type clothes with me, so I wore the darkest colors of sports clothes I had so as not to stand out and embarrass Dr. Schweikert. Our meal was lovely, and both my lunch partners and I finally admitted to each other that we weren’t sure what meat we were eating! After doing an autopsy, we decided it was stuffed chicken, which had been anatomically rearranged and with a weird bone sticking out of it. They both were very enthusiastic about the summit, and talked AFib the whole time.

I didn’t want them asking me too many questions, exposing me as a common layperson, crashing their event. I didn’t want to do anything that might embarrass Dr.S. making him feel he had made a mistake letting me in, so I just catered to the male ego, and expressed great interest in them, and their work! It worked like a charm!

Part of the discussion centered on the difficulty in developing proficiency in new techniques, without a mentor/teacher available. Having someone with experience, lessens the “learning curve” time, figuring a surgeon has about 150 patients that he/she is practicing on, while becoming proficient. They both agreed with one speaker, who felt that much of the Ablation and Maze procedure should only be done by reputable teaching/research hospitals who can keep control of quality and accountability. This makes AF cure less available, but I totally agree.

(This is part 1 of a 2 part report)

SER


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