Regulating The Beating Heart

By Dr. Jeffrey Lee
Interviewed by Melissa Moniz
Wednesday - March 26, 2008
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Dr. Jeffrey Lee

Dr. Jeffrey Lee
Medical Director of Hawaii Medical Center’s Atrial Fibrillation Center and Clinical
Associate Professor of Surgery at UH-Manoa

Interviewed by Melissa Moniz

How long have you been at Hawaii Medical Center? Ten years.

What is your medical specialty? Cardiothoracic surgery.

Can you discuss what you do at Hawaii Medical Center?

I am one of a team of cardiac surgeons who work there. About a year and a half ago we launched our new program for atrial fibrillation surgery. Being physician-owned, Hawaii Medical Center proved to be the perfect place to launch this new program. Hawaii Medical Center saw the benefits of the procedure for patients and made it relatively easy to get the capital investment needed to establish Hawaii’s first Atrial Fibrillation Center. In the first six months, we did four cases and then once we realized the incredible effectiveness of this procedure, we ramped up to do 29 more. Since the program’s inception we’ve successfully performed a total of 33 cases.


Can you describe the procedure?

The procedure is probably better first explained by discussing the cause of atrial fibrillation. Atrial fibrillation is an irregularity of the heart rhythm that originates from the pulmonary veins. To stop atrial fibrillation, we need to electrically isolate the pulmonary veins from the heart. Twenty years ago there was a surgeon on the Mainland, Dr. James Cox, who originated the type of surgery for treating atrial fibrillation, which required actually cutting to separate the pulmonary veins from the heart, then sewing these structures back together again. But that required open-heart surgery.

The holy grail of medicine over the past 10 years was to re-create what Dr. Cox did with a more minimally invasive approach. So instead of having to open the chest and stop the heart and cut the heart away from the pulmonary veins, what we do now is make a few tiny incisions underneath the right arm and simply lay a catheter on the surface of the beating heart, right at the anatomic separation of the heart from the pulmonary veins. Laser or microwave energy is then emitted from the catheter, allowing us to form a line of ablation which acts to electrically isolate the heart from the pulmonary veins.

When the irregular heartbeat attempts to reach the heart now, the impulse is then stopped by our ablation line. We can treat atrial fibrillation very effectively in this manner. The procedure itself takes about two to three hours in the operating room. And, on average, the patient can go home the next day.

Can you further explain what are the dangers of atrial fibrillation?

Atrial fibrillation can reduce your cardiac efficiency and output by about 20 percent, and because it does that many are not getting as much blood to their organs as they might need. This can result in people feeling palpitations, weak, tired and short of breath. But it’s more than just that, it’s not just these symptoms. Atrial fibrillation is well-known to increase the risk of stroke and death because the heart is beating in such an uncoordinated fashion. Atrial fibrillation has been estimated to approximately double your risk of stroke and also death. It also can be age dependent. If you’re over 70 and you’re untreated for atrial fibrillation, your risk of stroke can be more than 50 percent over 10 years.


How has the response been from the patients who have received the surgery?

Just fantastic. They really appreciate even having an option that was never offered before. The alternative for them is being on Coumadin for life or taking other drugs. So far we’ve had an early success rate of about 80 percent. They feel so much better, and there’s a very high satisfaction rating. So they definitely feel better and many of them, after we study them again after about three months, we’re taking them off all their medication. So a relatively minor surgical procedure gets them off all such medication and potentially significantly reduces their risk of stroke and death - an incredible trade-off, in my opinion.

So is this a one-time treatment, or will they have to later have a follow-up surgery?

This is a one-time treatment, and that’s one of the differences to the alternative to this procedure, which is catheter-based ablation that often has to be repeated. That’s when a specially trained cardiologist burns the inside of the heart to try to form the same ablation line that we are forming by burning from the outside of the heart. At this point, the patients have to travel to the Mainland for this type of ablation.

Who are good candidates for this procedure?

Any patient who has atrial fibrillation who is symptomatic, or has had complications of atrial fibrillation or had a prior history of a stroke or temporary stroke. Intolerance to medication is also an indication. They have to have failed at least one trial of an anti-rhythmic medication. Patients who have recent onset of atrial fibrillation when it’s still paroxysmal (coming and going) do the best, although more chronic patients are also still candidates. So it’s very broad as far as who should be considered for this life-saving procedure because most patients are symptomatic, and most patients will fail treatment with anti-arrhythmic medications. Guidelines have been created by the American College of Cardiology and are published on our website, www.hawaiimedcen.com

 

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