Hybrid procedure gives another option to those dealing with atrial fibrillation

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During the first few months of 2010, Richard Nania was, in his own words, a physical mess.

A disabled former employee of a title insurance business, Mr. Nania of Ingram had several medical problems, including diabetes, congestive heart failure, bouts of gastrointestinal bleeding and edema.

He also had chronic atrial fibrillation, a rhythm problem in the heart that had caused structural changes to his left atrium, an upper cardiac chamber. He was at "fairly high risk for a stroke," according to his cardiothoracic surgeon, Robert Moraca of Allegheny General Hospital.

About 90 percent of people with arrhythmias are treated with medication, Dr. Moraca said, and Mr. Nania was on the blood thinner Coumadin, or warfarin. But his cardiologist, Douglas Schulman, stopped the drug because of the gastrointestinal bleeding.

Another option was catheter-based cardiac ablation, a procedure in which scars are created within the part of the heart tissue disrupting the rhythm, preventing abnormal electrical signals from triggering the arrhythmia. These ablations are done by having an electrophysiologist insert a catheter or thin tube into a vein in the groin and thread it into the heart. Less often, because it is more invasive and requires more hospitalization, the ablation is done via open-heart surgery.

Neither type of ablation was quite right for Mr. Nania.

"The catheter ablation alone was not a good treatment because he had a large left atrium with structural changes and chronic atrial fibrillation," Dr. Moraca said. With really large atria, the procedure has a lower success rate because of the large amount of atrial tissue that needs to be eliminated.

"A surgical ablation would have been very invasive," he added. Called a Maze procedure, that would require open-heart surgery.

But over the previous two years or so, a few hospitals across the nation -- between 10 and 15, Dr. Moraca said -- had begun offering a third type of ablation called a hybrid cardiac ablation. It is a combination of the catheter and surgical procedures, with the latter being done by smaller, minimally invasive incisions than open-heart surgery. The procedure is reserved mostly for people with longstanding atrial fibrillation and dilted left atria.

Dr. Schulman and Dr. Moraca proposed Mr. Nania become the first patient at AGH to have the new procedure.

"We thought [the hybrid] would be a better option for him," Dr. Moraca said.

"[It] takes advantage of the benefits of the best characteristics of catheter ablation and the best benefits of surgical ablation," said AGH electrophysiologist William Belden, who does the hybrid procedure with Dr. Moraca.

Mr. Nania listened to an explanation of the ablation and agreed. He said he doesn't remember thinking the fact that he would be the first bothered him. "I felt confident, so if I was the first it didn't matter," he said. "I didn't want to die. They didn't have to cut my chest open. I said, 'Let's go for it.' "

He had the surgery June 22, 2010, and went home in three days. The procedure did what it was supposed to do: cure his atrial fibrillation.

"I last saw my doctor in July [2011], and I was in normal rhythm at that point," Mr. Nania, now 57, said recently. Asked how he was feeling he said, "Better, definitely much better. I'm on medication, but I haven't had any internal bleeding. ... Everything is less than what it was before. I'm glad I had the procedure done."

When Dr. Moraca and Dr. Belden did Mr. Nania's ablation they had to transport him between a cardiothoracic suite and an electrophysiology suite. About six months ago, they began using a special suite with room for both of their equipment and their teams.

The surgical portion is usually done first and takes about an hour, while the catheterization takes about four hours.

"I place a small scope about the size of your finger into the heart sac and ablate the back of the heart," Dr. Moraca said; he does so with lesions almost the length of an index finger.

"And then Dr. Belden comes in with the catheter and ablates the areas which I was unable to ablate." Dr. Belden's catheter, the tip of which is about the size of a pencil eraser, also allows him to measure electrical charges affecting heart rhythm.

"[Surgeons] can lay down the main tracks," Dr. Belden said. "My advantage of the catheterization is I can measure the electrical signals inside the veins, so I finish the job by coming in and connecting the lines [needed] to complete the isolation" of the parts of the heart causing the atrial fibrillation.

Dr. Moraca and Dr. Belden have done seven more hybrid ablations since Mr. Nania's, and they're considering using the procedure for another arrhythmia called ventricular tachycardia.

"I think the key to what [Dr. Belden] and I have done in working here is trying to work in a more collaborative fashion to treat each patient as an individual and their disease as an individual disease and to tailor the best treatment for them, whether it's a catheter ablation or a hybrid, rather than the same tool for everything. ..." said Dr. Moraca.

"It allows us to obtain better outcomes and improve patients' quality of life."

He said probably only 5 to 10 percent of atrial fibrillation patients screened for potential ablation would be candidates for the hybrid procedure. But that's still a pretty big number, considering that there are 2.2 million known patients with atrial fibrillation nationally and probably many more who have not been diagnosed.

And that particular arrhythmia is expected to be the "next major epidemic in heart disease," he said, citing a projection from Mayo Clinic that by 2020 there will be 71/2 million to 9 million people with atrial fibrillation in the United States. In addition to congenital heart defects, the condition is thought to be caused by health problems, including high blood pressure, heart attacks, lung disease and viral infections.

Pohla Smith: psmith@post-gazette.com or 412-263-1228.


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