Discovery

by Jaron Terry, APR
An entire floor of Ohio State’s newly expanded Ross Heart Hospital is now dedicated to electrophysiology (EP) treatment and care, accommodating one of the largest and most advanced EP programs in the country. With arrhythmia cases expected to double in the next 30 years, Ohio State clinicians and researchers are rapidly developing new approaches to diagnosis and treatment.

“Virtually anything that is novel, innovative and on the leading edge in electrophysiology is occurring in our EP program at Ohio State’s Heart Center today,” says William Abraham, MD, FACP, FACC, director of the Division of Cardiovascular Medicine.

“With the recent addition of a nationally noted authority to lead EP, this program is now one of the subspecialty areas that are garnering national recognition for the Center,” adds Abraham, who also is a professor in the Departments of Internal Medicine and Physiology and Cell Biology.

With a team of 11 electrophysiologists, Ohio State’s Heart Center now has one of the highest-volume ablation programs in the nation. Ablation involves deactivating tissue that is causing electrical short-circuits in the heart. Because the team performs thousands of the same types of procedures every year, the high volume translates into high quality.

“We have very good data that demonstrate superior quality,” explains Abraham.“Our EP program’s outcomes are among the very best in the nation. This relates directly to having the right people performing the right procedures with high levels of skill,” he adds.

When the Heart Goes Haywire
When electrical signals in the heart travel in a precise and uniform manner, they produce a normal heartbeat – about 60 to 100 beats per minute. But when there is a “short-circuiting” of the electrical signals, an arrhythmia (also referred to as dysrhythmia) happens instead.

There are several types of arrhythmia that can disrupt the normal coordinated beating of the heart, causing weakness, fatigue and palpitations. One serious disruption of the heart’s normal electrical activation is atrial fibrillation, in which abnormal electrical signals cause erratic and rapid beating of the heart and result in incapacitating symptoms, including shortness of breath and significant difficulty moving. If untreated, the risk of stroke and heart failure is substantially elevated.

Today, atrial fibrillation, which is the most complex arrhythmia, affects 2.3 million Americans. That number, already 60 percent higher than 20 years ago, is expected to double in the next 30 years as the population ages. That’s why Ohio State’s Heart Center is garnering somuch attention for the strides it has made in the field.

Daoud, who is certified by the American Board of Cardiovascular Disease and the American Board of Electrophysiology, notes that while ablation – the use of radiofrequency heat to selectively destroy tissue responsible for the electrical short circuit – has been used for many years, recent technological advances in ablation have revolutionized the treatments that can be offered to cure, rather than merely to treat, atrial fibrillation.

Short Circuit Fixes
“Electrophysiologists at Ohio State were actually the first in the nation to successfully treat atrial fibrillation with a circular catheter-guided ablation in 1999,” Daoud notes. “Now, with Stereotaxis and advancements in catheter-based technology, we are routinely restoring normal heart rhythm, even in advanced stages of atrial fibrillation.”

The Stereotaxis Magnetic Navigation System at Ohio State’s Heart Center is an advanced ablation tool that allows precise treatment for atrial fibrillation and other arrhythmias. With magnetic navigation, electrophysiologists can control the catheter by magnetic forces, which provide a far greater range of movement for the catheter. Because of this flexibility, magnetic navigation allows therapies to be tailored to the patient’s unique anatomy.

“With Stereotaxis, magnetic fields are created by two powerful magnets encased on pivoting arms on either side of the patient. Because the new catheters – which are extremely flexible – have magnets incorporated into their tips, they are pulled by the magnetic fields surrounding the catheter, rather than being pushed by human hands,” Daoud says.

The magnets, which aid electrophysiologists in creating a virtual “road map” of the heart’s anatomy, not only give them extremely precise control, but also enable them to precisely navigate back to specific areas based on computer-driven vectors. High-resolution digital imagery and user-friendly joystick technology allow them to quickly and accurately ablate the source of the rhythm abnormality, regardless of the variances in the cardiac anatomy.

This dynamic environment is a rich training ground for future EP specialists. Daoud says that he and his colleagues are gratified and excited to train the next generation of electrophysiologists in this novel technology, and in other procedures and techniques. The Electrophysiology Fellowship trains in the management of both patients with complex arrhythmias and those who require devices to be implanted or extracted.

Personalized Care
Daoud points out that, while medications known as beta blockers or calcium channel blockers are usually the first treatment of choice for some arrhythmias, Ohio State’s Heart Center takes a personalized approach for each patient. For example, management of arrhythmias can be achieved with medical therapy, implantation of devices or with catheter ablation. Since The Ohio State University’s electrophysiology program is adept at each modality, the goal is to design a personalized treatment strategy that not only considers the type of arrhythmia but also the multitude of other features that are part of the patient’s healthcare needs. In some circumstances, to achieve optimal results for a particular patient, a combination of approaches will be recommended, such as medications plus implanting the newest generation of medical devices. A cardioverter defibrillator is a device that can automatically recognize a deadly arrhythmia and provide an electrical shock to restore normal rhythm and save a life.

For atrial fibrillation, catheter ablation often provides a cure, sparing patients years of medications, many of which poorly control the arrhythmia and have side effects. With the cure rate for catheter ablation approaching 85 percent at one year, it is generally the treatment of choice for patients who have not benefited from medical therapy.

The Heart Center’s prestige also comes from its distinction as one of only four medical centers in the United States that offer a newly developed, totally thorascopic approach to treating atrial fibrillation – the “autonomic”Maze procedure performed by John Sirak, MD. Pencil-sized incisions in the chest allow a thoracoscope to safely ablate culprit nerve fibers on the surface of the heart – with no need for cardiopulmonary bypass, as in the traditional “anatomic”Maze procedure.

Each patient is evaluated by the electrophysiology-led Atrial Fibrillation Clinic, which is staffed by specialists in echocardiography and cardiothoracic surgery, as well as by pharmacists, specialized nurses and other professionals who provide integrated, personalized care.

Research
Many patients are found to be candidates for emerging technologies, which are available through a number of active research protocols and clinical trials. From July 2006 to July 2008, the number of Food and Drug Administration-approved, externally-funded electrophysiology clinical research trials at Ohio State increased nearly fourfold – from six to 22, while an additional eight are in the contract/submission process.

“The latest hotbed of research is in developing a technique where we are able to ablate in a circular manner using balloon technology,” Daoud says. He explains that because many cases of atrial fibrillation involve the left side of the heart – where the pulmonary veins are located – and because these veins are circular, this new emerging technology holds great promise.

“We’re very excited about these possibilities, as our philosophy is to be sure we’re doing what’s in the best interest of each patient.”

Thomas Ryan, MD Heart Center Director Reflects On Ohio State's Success Heart disease remains one of the biggest health crises in this country today. Despite the medical profession’s advances in treatment, leading to significant improvements inmortality rates, heart disease continues to be the No. 1 killer of adult Americans. That is why our work here is so vital. As a national leader in advancing the science of heart care, we are absolutely dedicated to providing the highest-quality, most advanced treatments possible through our wide portfolio of services. Our patient care capabilities are specialized, personalized and comprehensive. We provide every cardiovascular treatment available, including prevention, invasive and noninvasive diagnostic services, interventional services, cardiothoracic and peripheral vascular surgical services, patient care clinics and rehabilitation. In addition, through clinical trials, we make novel therapies and experimental treatments available to our patients that offer the hope of attaining the best quality of life possible. By translating our basic science discoveries into real-life patient care, we are improving people’s lives. We strive not only to discover new information and make new contributions to the understanding of heart and vascular disease, but also to pass along that information to the next generation of clinicians and researchers. We take seriously our academic mission of teaching and research, continually adding new specialty and subspecialty fellowship programs, internship opportunities and continuing medical education. Our unique configuration – Ohio State’s Heart Center encompasses the Dorothy M. Davis Heart and Lung Research Institute, the Richard M. Ross Heart Hospital, the Division of Cardiovascular Medicine, the Division of Cardiothoracic Surgery, and the Division of Vascular Surgery – allows us to reap the advantages of multidisciplinary initiatives, and to collaborate with many other departments and key research areas across campus to improve health. In addition, we are fully committed to creating the future of medicine by advancing the field of personalized health care through research, patient care and education. We are accomplishing this by developing and leveraging genetic discoveries to better understand and treat cardiovascular disease, by tailoring each patient’s care to his or her own unique cardiac needs and by training the heart-care specialists of the future. Electrophysiology is only one of the many specialized teams whose clear goals, focused experts and substantial, dedicated resources figure prominently in our program. If you would like to learn about other areas in which we are advancing the science of heart care, please visit our Web site at www.medicalcenter.osu.edu/go/heart. Thomas Ryan, MD Director, The Ohio State University Heart Center Professor of Internal Medicine John G. and Jeanne Bonnet McCoy Chair in Cardiovascular Medicine

from left: William Abraham, MD Emile Daoud, MD RaulWeiss, MD Steven Kalbfleisch, MD, Thomas Ryan, MD