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In this segment, Dr. Dan Beyerbach, Clinical Cardiac Electrophysiologist with The Christ Hospital Health Network, comes on the show with an update on advanced cardiac catheter ablation techniques.
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Update on Advanced Cardiac Catheter Ablation Techniques
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Learn more about Dan Beyerbach, MD
Dan Beyerbach, MD
Dan Beyerbach, MD came to Cincinnati from the Florida Electrophysiology Associates in Atlantis, FL. His education in electrical engineering and signal processing was fitting preparation for a medical career in electrophysiology. He has received numerous awards academic awards and honors in both technical and medical areas of study. Dr. Beyerbach brings extensive knowledge of clinical cardiac electrophysiology with a specialty focus in catheter ablation treatment of atrial fibrillation and ventricular tachycardia (VT).Learn more about Dan Beyerbach, MD
Transcription:
Update on Advanced Cardiac Catheter Ablation Techniques
Melanie Cole (Host): Catheter ablation techniques are constantly evolving. Since the early days of the first use of radio frequency ablation, in Wolf Parkinson White Syndrome, catheter ablation of arrhythmias has advanced, not only in terms of efficacy, but also by being extended to complex arrhythmias, such as atrial fibrillation and more. My guest today is Dr. Dan Beyerbach, he’s a clinical cardiac electro-physiologist with the Christ Hospital Health Network. Welcome to the show, Dr. Beyerbach, tell us a little bit about your background, and how you came to be at Christ Hospital Health Network.
Dr. Dan Beyerbach (Guest): Well, thank you Melanie for having me on. My route to Christ Hospital was long and winding. I initially started out as an electrical engineer, and developed an interest in medicine when I was doing research at the Massachusetts General Hospital in the field of cardiac ultrasound. And then I went into specialize in clinical cardiac electrophysiology, which is what I do today, and the two have made a pretty good marriage.
Melanie: So, what type of conditions are you treating and how has it changed over the years?
Dr. Beyerbach: Well, the incidents of atrial arrhythmias, in particular atrial fibrillation is on the rise. In fact, it’s been deemed an epidemic, right now. There are a large number of people every year in the United States, and indeed around the world who are developing atrial fibrillation, which is the most common rapid arrhythmia of the heart. And therefore, there’s been a lot interest in developing techniques to treat atrial fibrillation, and very specifically in developing tools for radio frequency and other energy source type ablation of atrial fibrillation.
Melanie: So, if someone is diagnosed with AFIB and they’ve gone through the first line of defense with their physician. Tell us about some of the basic ablation techniques you might use first.
Dr. Beyerbach: Well, the oldest technique is… you eluded to in your intro, is the radio frequency technique, and this is based on the principle of trying to eliminate the triggers that initiate episodes of atrial fibrillation. So, there are two ways to treat any arrhythmia with ablation. One is, you alter the sub-straight or the electrical conduction properties of the heart, and the other is you eliminate the triggers that cause episodes of the arrhythmia.
So, with atrial fibrillation, although there is no cure, we do direct our techniques, in the beginning in basic ablation, toward eliminating the triggers, and we know from previous studies in work that’s been done, initially by the group in Bordeaux, France, with Michel Haissaguerre and colleagues. That about 90% of the triggers that cause episodes of atrial fibrillation initiate in the pulmonary veins, therefore the pulmonary veins are the initial target, and we try to isolate them electrically by encircling them with the circumferential lines of ablation.
Melanie: So, then if this would be something that is a more basic technique. Speak about some of the advanced ablation techniques, Dr. Beyerbach, and even a little bit about the [INAUDIBLE 00:03:44] balloon and some other complex ablation techniques.
Dr. Beyerbach: When you’re ablating atrial fibrillation in pulmonary vein isolation, alone is not enough, as is sometimes the case, then you have to go for, what’s called, extra pulmonary vein triggers, and these can involve sights, such as the superior vena cava, the coronary sinus, the crista terminalis. So, when we undertake radio frequency catheter ablation, we will routinely also encircle the superior vena cava, and the ablate also in the vein called the coronary sinus, which runs around the backside of the heart between the upper and lower chambers. So, these are additional structures that we target in advanced ablation.
The more recent development of freezing technology called Cryo-balloon catheter ablation, has actually been very beneficial to patients, primarily, with Paroxysmal atrial fibrillation or with preserved left-atrial size. So, if the atrium is not grossly enlarged then Cryo-balloon technique appears to work very well, both for Paroxysmal and persistent atrial fibrillation. So, we’ve been using this for about six years now, and we’ve had some patients who’ve had a single treatment and are still free of arrhythmia. Doesn’t mean that they’re necessarily cured because atrial fibrillation is a chronic, progressive disease process, that involves deposition of scar tissue in the upper chambers of the heart.
So, there are a lot of factors that influence this process and we can’t stop them all, but altering the heart electrically is a target. Not just of radio frequency in Cryo-balloon energy sources, other energy sources have been tried, there’s an ultrasound source that works by heating the tissue. The most recently approved tool for treatment of atrial fibrillation is a laser technology, a laser beam technology, that also works by heating the tissue. So, these are actually in use, right now.
Melanie: Dr. Beyerbach, a new area of research that I find of fascinating. An innovation has emerged around new mapping systems that allow cardiologists to actually see the potential source of atrial fibrillation. Please identify for us, the role of pre, and inter-procedural imaging techniques that might optimize outcomes and increase the safety of the ablation procedures.
Dr. Beyerbach: When we perform radio frequency or Cryo-balloon catheter ablation of atrial fibrillation, we’d like to know what is the anatomy? Where are the veins? What is the structure of the atrium? And we always employ a three-dimensional, what we call, electro-atomic mapping system. So, there are 3D locating mechanisms that involve resistance techniques, and also magnetic techniques that identify the tip of the catheter.
So, we can put it up against the backwall and say, “I’m up against the backwall. Take a point here, or I’m on the mitral annulus, take a point here. Or I’m going to map now in the pulmonary vein, take points here.” And this has become more and more sophisticated over the years. We now have automated mapping techniques where we can just move the catheter around in the left atrium, and the map is actually created.
Also, using AD-junks to these techniques, we now have the ability to map specific, what we call, Rota’s in the left atrium. So, atrial fibrillation has long known to be very disorganized, electric storm in the upper chambers of the heart, and the question is, for people with persistent atrial fibrillation. That is atrial fibrillation that lasts for seven days or more, what do we do extra to alter the sub-straight, such that atrial fibrillation cannot persist, and identifying Rota’s or areas where the electric current appears to be swirling around in the circles, like a hurricane. These are important points to ablate, and it’s been shown in multiple studies that if we do ablate these points, that we have better outcomes. So, we have number of different mapping techniques, advanced mapping techniques, that are directed at identifying these focal sources.
Melanie: That is so interesting, and at what point is a patient ready to turn to an ablation for treatment? When should they consider this versus medical treatment?
Dr. Beyerbach: Not everybody is suitable for atrial fibrillation, ablation procedures. Usually, the patients that are best suited are younger patients with Paroxysmal atrial fibrillation, atrial fibrillation that comes and goes on its own and does not last for longer than seven days. Patients who have a smaller size atria, these are patients that are going to have the best outcomes, long term, in terms of maintaining sinus rhythm, free of episodes of atrial fibrillation.
However, there is now a growing body of evidence that suggests that patients who have heart failure and heart failure is complicated by atrial fibrillation, have better outcomes, and lower mortality, if they undergo catheter ablation of atrial fibrillation. So, we are tackling some very difficult patients with catheter ablation because the outcomes are better, if patients have been tried on anti-rhythmic drug, and the anti-rhythmic is not working or has intolerable side effects, sometimes very slow heart rate, Bradycardia. Then these are patients that are suitable for catheter ablation. Also, younger patients who do not desire lifetime drug therapy are suitable for catheter ablation, and people are moving toward using catheter ablation as first line therapy, because now, particularly with the Cryo-balloon technique, we can be in and out of the heart in an hour or two, and the procedure is very safe.
Melanie: So, when would you like MD’s to refer to an electro-physiologist versus trying to manage the arrhythmias themselves?
Dr. Beyerbach: Anytime a physician is uncomfortable with managing atrial fibrillation, we would be happy to see the patient, there are a number of different issues that can make management of atrial fibrillation more complex, and we’re used to dealing with these issues, so we’re always willing and able to lend a hand. Certainly, if patients are having atrial fibrillation that’s refractory to medical therapy. It’s appropriate to refer to an electrophysiologist, rather than skipping from drug to drug. Let’s consider the patient for an alternative, usually catheter ablation, but there are other alternatives as well.
Melanie: Just touch briefly on the Watchmen device for us for a minute, Dr. Beyerback.
Dr. Beyerbach: Some people are not suitable for treatment with oral anti-coagulation, usually because they’ve had seriously bleeding. Sometimes just nuisance bleeding that’s repetitive, such as nose bleeds. Gastrointestinal bleeding is a frequent reason or in some cases, the patients just are not capable of administering blood thinners at home for a variety of reasons. These are patients that are sometimes suitable for an alternative, which is called the Watchmen left atrial appendage occluder device, and the theory behind is that we put a plug in the left atrial appendage, and that prevents blood clot formation in that structure of the left atrium. And prevents, therefore, embolization of the blood clot. So, we’ve been able to safely place this umbrella-like structure, we do treat with oral anti-coagulation for a short period of time, but ultimately patients are left with just the daily aspirin and the efficacy is almost equivalent to that of taking full dose of oral anti-coagulation.
Melanie: Where do you perform these procedures and where are you available to see patients in an out-patient setting?
Dr. Beyerbach: All of our catheter ablation procedures right now are performed at the Christ Hospital electrophysiology laboratory. We have four dedicated electrophysiology laboratories, which is very outfitted with the latest equipment, which it really requires a serious investment because of all the advanced technologies that we’re using. So, we try to centralize our ablation procedures and right now we’ve performed them at Christ Hospital. In terms of outpatient locations, I personally am available at the medical office building at the Christ Hospital campus in Mount Harvard. I’m also available in northern Kentucky in Fort Wright, and also up in Liberty township for office business.
Melanie: And in a brief summary, Doctor, please let other physicians know what you would like to tell them about AFIB, and advanced cardiac catheter ablation techniques, and when to refer to a specialist?
Dr. Beyerbach: Well, atrial fibrillation is certainly an epidemic right now, and the belief is that this is due in part to the aging population. We know that the incidents of atrial fibrillation increases with age, but also due to the obesity epidemic, that is an independent risk factor, but also is associated frequently with obstructive sleep apnea, which also promotes atrial fibrillation.
So, it is an epidemic. It’s not going away and we need to get used to dealing with it. In terms of when to refer, again, that would be for patients who are young, have normal size left upper chambers of the heart, are symptomatic with their atrial fibrillation, and don’t desire life-long therapy or for sicker patients who really cannot tolerate the rapid heart rates that are precipitated by atrial fibrillation, in particular patients with heart failure.
Melanie: Thank you so much, Dr. Beyerbach, for being with us today. You’re listening to Expert Insights, Physician views and news with the Christ Hospital Health Network. For more information on Dr. Beyerbach, and all of the Christ Hospital physicians, please visit, TCHPConnect.org, that’s TCHPConnect.org. This Melanie Cole, thanks so much for listening.
Update on Advanced Cardiac Catheter Ablation Techniques
Melanie Cole (Host): Catheter ablation techniques are constantly evolving. Since the early days of the first use of radio frequency ablation, in Wolf Parkinson White Syndrome, catheter ablation of arrhythmias has advanced, not only in terms of efficacy, but also by being extended to complex arrhythmias, such as atrial fibrillation and more. My guest today is Dr. Dan Beyerbach, he’s a clinical cardiac electro-physiologist with the Christ Hospital Health Network. Welcome to the show, Dr. Beyerbach, tell us a little bit about your background, and how you came to be at Christ Hospital Health Network.
Dr. Dan Beyerbach (Guest): Well, thank you Melanie for having me on. My route to Christ Hospital was long and winding. I initially started out as an electrical engineer, and developed an interest in medicine when I was doing research at the Massachusetts General Hospital in the field of cardiac ultrasound. And then I went into specialize in clinical cardiac electrophysiology, which is what I do today, and the two have made a pretty good marriage.
Melanie: So, what type of conditions are you treating and how has it changed over the years?
Dr. Beyerbach: Well, the incidents of atrial arrhythmias, in particular atrial fibrillation is on the rise. In fact, it’s been deemed an epidemic, right now. There are a large number of people every year in the United States, and indeed around the world who are developing atrial fibrillation, which is the most common rapid arrhythmia of the heart. And therefore, there’s been a lot interest in developing techniques to treat atrial fibrillation, and very specifically in developing tools for radio frequency and other energy source type ablation of atrial fibrillation.
Melanie: So, if someone is diagnosed with AFIB and they’ve gone through the first line of defense with their physician. Tell us about some of the basic ablation techniques you might use first.
Dr. Beyerbach: Well, the oldest technique is… you eluded to in your intro, is the radio frequency technique, and this is based on the principle of trying to eliminate the triggers that initiate episodes of atrial fibrillation. So, there are two ways to treat any arrhythmia with ablation. One is, you alter the sub-straight or the electrical conduction properties of the heart, and the other is you eliminate the triggers that cause episodes of the arrhythmia.
So, with atrial fibrillation, although there is no cure, we do direct our techniques, in the beginning in basic ablation, toward eliminating the triggers, and we know from previous studies in work that’s been done, initially by the group in Bordeaux, France, with Michel Haissaguerre and colleagues. That about 90% of the triggers that cause episodes of atrial fibrillation initiate in the pulmonary veins, therefore the pulmonary veins are the initial target, and we try to isolate them electrically by encircling them with the circumferential lines of ablation.
Melanie: So, then if this would be something that is a more basic technique. Speak about some of the advanced ablation techniques, Dr. Beyerbach, and even a little bit about the [INAUDIBLE 00:03:44] balloon and some other complex ablation techniques.
Dr. Beyerbach: When you’re ablating atrial fibrillation in pulmonary vein isolation, alone is not enough, as is sometimes the case, then you have to go for, what’s called, extra pulmonary vein triggers, and these can involve sights, such as the superior vena cava, the coronary sinus, the crista terminalis. So, when we undertake radio frequency catheter ablation, we will routinely also encircle the superior vena cava, and the ablate also in the vein called the coronary sinus, which runs around the backside of the heart between the upper and lower chambers. So, these are additional structures that we target in advanced ablation.
The more recent development of freezing technology called Cryo-balloon catheter ablation, has actually been very beneficial to patients, primarily, with Paroxysmal atrial fibrillation or with preserved left-atrial size. So, if the atrium is not grossly enlarged then Cryo-balloon technique appears to work very well, both for Paroxysmal and persistent atrial fibrillation. So, we’ve been using this for about six years now, and we’ve had some patients who’ve had a single treatment and are still free of arrhythmia. Doesn’t mean that they’re necessarily cured because atrial fibrillation is a chronic, progressive disease process, that involves deposition of scar tissue in the upper chambers of the heart.
So, there are a lot of factors that influence this process and we can’t stop them all, but altering the heart electrically is a target. Not just of radio frequency in Cryo-balloon energy sources, other energy sources have been tried, there’s an ultrasound source that works by heating the tissue. The most recently approved tool for treatment of atrial fibrillation is a laser technology, a laser beam technology, that also works by heating the tissue. So, these are actually in use, right now.
Melanie: Dr. Beyerbach, a new area of research that I find of fascinating. An innovation has emerged around new mapping systems that allow cardiologists to actually see the potential source of atrial fibrillation. Please identify for us, the role of pre, and inter-procedural imaging techniques that might optimize outcomes and increase the safety of the ablation procedures.
Dr. Beyerbach: When we perform radio frequency or Cryo-balloon catheter ablation of atrial fibrillation, we’d like to know what is the anatomy? Where are the veins? What is the structure of the atrium? And we always employ a three-dimensional, what we call, electro-atomic mapping system. So, there are 3D locating mechanisms that involve resistance techniques, and also magnetic techniques that identify the tip of the catheter.
So, we can put it up against the backwall and say, “I’m up against the backwall. Take a point here, or I’m on the mitral annulus, take a point here. Or I’m going to map now in the pulmonary vein, take points here.” And this has become more and more sophisticated over the years. We now have automated mapping techniques where we can just move the catheter around in the left atrium, and the map is actually created.
Also, using AD-junks to these techniques, we now have the ability to map specific, what we call, Rota’s in the left atrium. So, atrial fibrillation has long known to be very disorganized, electric storm in the upper chambers of the heart, and the question is, for people with persistent atrial fibrillation. That is atrial fibrillation that lasts for seven days or more, what do we do extra to alter the sub-straight, such that atrial fibrillation cannot persist, and identifying Rota’s or areas where the electric current appears to be swirling around in the circles, like a hurricane. These are important points to ablate, and it’s been shown in multiple studies that if we do ablate these points, that we have better outcomes. So, we have number of different mapping techniques, advanced mapping techniques, that are directed at identifying these focal sources.
Melanie: That is so interesting, and at what point is a patient ready to turn to an ablation for treatment? When should they consider this versus medical treatment?
Dr. Beyerbach: Not everybody is suitable for atrial fibrillation, ablation procedures. Usually, the patients that are best suited are younger patients with Paroxysmal atrial fibrillation, atrial fibrillation that comes and goes on its own and does not last for longer than seven days. Patients who have a smaller size atria, these are patients that are going to have the best outcomes, long term, in terms of maintaining sinus rhythm, free of episodes of atrial fibrillation.
However, there is now a growing body of evidence that suggests that patients who have heart failure and heart failure is complicated by atrial fibrillation, have better outcomes, and lower mortality, if they undergo catheter ablation of atrial fibrillation. So, we are tackling some very difficult patients with catheter ablation because the outcomes are better, if patients have been tried on anti-rhythmic drug, and the anti-rhythmic is not working or has intolerable side effects, sometimes very slow heart rate, Bradycardia. Then these are patients that are suitable for catheter ablation. Also, younger patients who do not desire lifetime drug therapy are suitable for catheter ablation, and people are moving toward using catheter ablation as first line therapy, because now, particularly with the Cryo-balloon technique, we can be in and out of the heart in an hour or two, and the procedure is very safe.
Melanie: So, when would you like MD’s to refer to an electro-physiologist versus trying to manage the arrhythmias themselves?
Dr. Beyerbach: Anytime a physician is uncomfortable with managing atrial fibrillation, we would be happy to see the patient, there are a number of different issues that can make management of atrial fibrillation more complex, and we’re used to dealing with these issues, so we’re always willing and able to lend a hand. Certainly, if patients are having atrial fibrillation that’s refractory to medical therapy. It’s appropriate to refer to an electrophysiologist, rather than skipping from drug to drug. Let’s consider the patient for an alternative, usually catheter ablation, but there are other alternatives as well.
Melanie: Just touch briefly on the Watchmen device for us for a minute, Dr. Beyerback.
Dr. Beyerbach: Some people are not suitable for treatment with oral anti-coagulation, usually because they’ve had seriously bleeding. Sometimes just nuisance bleeding that’s repetitive, such as nose bleeds. Gastrointestinal bleeding is a frequent reason or in some cases, the patients just are not capable of administering blood thinners at home for a variety of reasons. These are patients that are sometimes suitable for an alternative, which is called the Watchmen left atrial appendage occluder device, and the theory behind is that we put a plug in the left atrial appendage, and that prevents blood clot formation in that structure of the left atrium. And prevents, therefore, embolization of the blood clot. So, we’ve been able to safely place this umbrella-like structure, we do treat with oral anti-coagulation for a short period of time, but ultimately patients are left with just the daily aspirin and the efficacy is almost equivalent to that of taking full dose of oral anti-coagulation.
Melanie: Where do you perform these procedures and where are you available to see patients in an out-patient setting?
Dr. Beyerbach: All of our catheter ablation procedures right now are performed at the Christ Hospital electrophysiology laboratory. We have four dedicated electrophysiology laboratories, which is very outfitted with the latest equipment, which it really requires a serious investment because of all the advanced technologies that we’re using. So, we try to centralize our ablation procedures and right now we’ve performed them at Christ Hospital. In terms of outpatient locations, I personally am available at the medical office building at the Christ Hospital campus in Mount Harvard. I’m also available in northern Kentucky in Fort Wright, and also up in Liberty township for office business.
Melanie: And in a brief summary, Doctor, please let other physicians know what you would like to tell them about AFIB, and advanced cardiac catheter ablation techniques, and when to refer to a specialist?
Dr. Beyerbach: Well, atrial fibrillation is certainly an epidemic right now, and the belief is that this is due in part to the aging population. We know that the incidents of atrial fibrillation increases with age, but also due to the obesity epidemic, that is an independent risk factor, but also is associated frequently with obstructive sleep apnea, which also promotes atrial fibrillation.
So, it is an epidemic. It’s not going away and we need to get used to dealing with it. In terms of when to refer, again, that would be for patients who are young, have normal size left upper chambers of the heart, are symptomatic with their atrial fibrillation, and don’t desire life-long therapy or for sicker patients who really cannot tolerate the rapid heart rates that are precipitated by atrial fibrillation, in particular patients with heart failure.
Melanie: Thank you so much, Dr. Beyerbach, for being with us today. You’re listening to Expert Insights, Physician views and news with the Christ Hospital Health Network. For more information on Dr. Beyerbach, and all of the Christ Hospital physicians, please visit, TCHPConnect.org, that’s TCHPConnect.org. This Melanie Cole, thanks so much for listening.