Download Volume 10, N .2 March 2013

The
Heart Institute
Newsletter
Volume 10, No.2
March 2013
Message from the Head of
The Heart Institute
To all our friends
Best wishes for
A Happy and Kosher Passover
Dear friends and supporters,
Pessach as the spring festival is always a hopeful doorway to the future and new
beginnings. Here in Jerusalem we hope that the visit of US President Barak Obama and
the newly-formed Israeli coalition government will both be bringing us into a new era
building a peaceful tomorrow.
From The Hadassah Heart Institute, I wish to extend to you our deepest appreciation of
your continuing interest and support, as well as best wishes for a very happy Passover
holiday. I am certain that, with your good will behind us, we will continue to advance in
clinical diagnosis, research and teaching.
As always, we welcome your comments, questions and contributions to our newsletter. You
are also warmly invited to visit us virtually on our website, at
http://www.hadassah.org.il/English/Eng_SubNavBar/Departments/Medical+departments/Cardiology.
Shalom and Chag Sameach,
Professor Chaim Lotan
The Heart Institute Newsletter, Vol 10, No.2, March 2013
Editor: Donna Zwas-Zfat
Associate Editor: Judith Shidlowsky
Ablation of Atrial Fibrillation:
A State-of-the-art Approach to a Common Heart
Rhythm Disturbance
It is estimated that 5 million Americans suffer from atrial fibrillation.
Atrial fibrillation is an arrhythmia (abnormal heart rhythm) involving the top chambers (atria)
of the heart. Atrial fibrillation may lead to a high risk of a stroke (blood clot that travels to
the brain) and weakening of the heart muscle.
For many years only medical therapy was available. Certain drugs are used to slow down
the heart rate, and for certain patients, more complex medications that affect the electric
impulses within the heart are used to attempt to control the rhythm.
Of course, most of the atrial fibrillation patients also require some form of blood thinning.
Dealing with this issue is a life-long tedious affair for both the doctor and the patient.
In recent years, an invasive procedure was developed to prevent the arrhythmia without
the use of these medications. At The Hadassah Medical Center in Ein Kerem the
Electrophysiology department has taken a lead in this field of invasive atrial fibrillation
control.
Ablation of atrial fibrillation is an invasive technique that is used in the treatment of
atrial fibrillation. Ablation is the removal or melting away of an unwanted structure or tissue.
Ablation of atrial fibrillation can be accomplished with different techniques; the most
established approach is via radiofrequency ablation around the pulmonary veins. The
pulmonary veins bring oxygenated blood from the lungs back to the left-sided upper
chambers or atrium.
Atrial fibrillation ablation can be performed from the inside of the heart via catheters that
are introduced via veins in the groins or neck; in this case, no incisions are made.
Alternatively, it can be accomplished from the outside of the heart with either open heart
surgery or via a thoracoscopic approach. The more common approach is the first, or
catheter based. In this case, the catheter that delivers the ablative energy can use
radiofrequency, ultrasound, laser or cryothermic energy. The ablative catheter is able to
deliver lesions only from its tip, which is from 4 to 8 mm long, shaped like a match point.
The ablation points are centered in the left upper chamber of the heart, or left atrium. A
series of ablation points are used to establish a line of lesions. The purpose of this line is to
block the trigger points of Atrial Fibrillation and create a barrier to the propagation of the
arrhythmia. Other lines of lesions and ablation points inside the left and right atrium are
often made, and areas of complex fragmented signals, called CFAE, are also treated with
ablation points in order to reduce the risk of recurrent AF. The procedure takes between
2 and 4 hours and occasionally needs to be repeated. As a general rule, older patients with
more heart disease and more frequent, longer episodes require more extensive ablation
procedures. A technique using a cryoablation balloon, capable of creating lesions all
around its perimeter, is also being used with comparable results in patients with
paroxysmal atrial fibrillation.
The Heart Institute Newsletter, Vol 10, No.2, March 2013
Editor: Donna Zwas-Zfat
Associate Editor: Judith Shidlowsky
At Hadassah Ein Kerem, the Electrophysiology department physicians (Heart Rhythm
Specialists) have been performing these procedures for many years. We are constantly
improving are approach with the most advanced catheter technologies. Our results and
procedure times are comparable to world-wide standards. Our team has trained locally and
abroad at the finest arrhythmia centers. Our director, Professor Shimon Rosenheck,
originally learned the technique from Dr. Carlo Paponne, who is credited as first developing
the technique for widespread usage.
We also recently installed the latest 3D heart imaging system (CARTO 3) to map the
electrical circuitry of the patient’s heart during ablation without exposing the patient to
extended periods of X-rays. This technology is the state-of-the-art. It was invented in Israel,
and Hadassah was among the first centers in the world to apply this technology when it
was still in the developing stages.
CARTO 3 allows us to import a CT image of the heart directly into the map to insure
accurate anatomical imaging. Also, the system determines the contact force that the
catheter applies, which helps avoid complications. The “contact-force” feature is not
currently available in the US.
Furthermore, Hadassah was very involved in the clinical research to prove the safety and
efficacy of newer blood thinning medications. Lastly, our atrial fibrillation follow-up clinic
service tracks the patients receiving these new therapeutic approaches, and diagnoses any
change in the patients’ well-being immediately.
With access to new technologies and seasoned electrophysiologists, Hadassah is leading
the way to control atrial fibrillation.
CARTO-3 image of the left atrium, showing the location of ablation lesions
The Heart Institute Newsletter, Vol 10, No.2, March 2013
Editor: Donna Zwas-Zfat
Associate Editor: Judith Shidlowsky
News of The Heart Institute
The Linda Joy Pollin Cardiovascular Wellness Institute:
Hadassah Cardiology has received a generous gift from Mrs. Irene Pollin, to create the
Linda Joy Pollin Cardiovascular Wellness Institute. The Institute is named for her daughter,
who was born with a congenital heart condition that she bravely fought for 16 years before
it took her life. The Institute will have a prevention clinic targeted toward women, where
research and gender-appropriate health education and care will be available. The staff will
include a specially trained nurse, nutritionist, fitness specialist, and mental health
professional, and will use the principles of behavioral cardiology to help with motivation to
change, and to help translate motivation into actual behavioral change. The Center will
have a website as well, with text not only in Hebrew, but also in English, Russian, and
Arabic.
In addition to running the clinic at Hadassah, the Center will reach out into various
communities—particularly those that are underserved, such as the Haredi and Arabic
populations--using an “ecological model.” Taking into consideration environmental and
social factors, this model involves forming partnerships with community leaders,
organizations, and the local schools, as well as working with Hadassah’s Patricia and
Russell Fleischman Center for Women's Health, the Hadassah-Hebrew University Braun
School of Public Health and Community Medicine, and the Israel Heart Society.
More to follow!!!
******************
Congratulations to Professor Shimon Rosenheck on his recent promotion. Professor
Rosenheck is the director of the electrophysiology laboratory at Hadassah, and has
published widely in the field of electrophysiology. His areas of interest include the
physiology of cardiac pacing tissue, the genetics of inherited diseases leading to sudden
cardiac death, and multiple clinical areas of electrophysiology including atrial fibrillation and
device function.
******************
Congratulations to Dr. Israel Gotsman and Professor Ronen Beeri on the receipt of a large
(and prestigious) grant from the European Union to study the long term effects of
periodontal disease on the heart.
The Heart Institute Newsletter, Vol 10, No.2, March 2013
Editor: Donna Zwas-Zfat
Associate Editor: Judith Shidlowsky
?? Questions and Answers : ??
Atrial Fibrillation
Q: What is atrial fibrillation?
A: Atrial fibrillation is a cardiac arrhythmia that occurs when the atria, or collecting
chambers, are no longer being paced by the native pacemaker system of the heart. The
atrial tissue begins to contract chaotically, rather than synchronously, leading to the loss of
the additional filling of the ventricular chambers of the heart that occurs when the atria
contract normally. Because of the random signals traveling around the atrium, a pacing
signal arrives at the ventricles in an irregular fashion, leading to an irregularly irregular
rhythm. In some people the rhythm comes and goes, and in others it becomes permanent.
Q: Is atrial fibrillation dangerous?
A: The rhythm itself is rarely life threatening. Frequently the very rapid heart beat causes
palpitations and discomfort. The rapid rhythm may lead to weakness, lightheadedness,
and shortness of breath. In the long term, the chaotic motion of the atrium may lead to
blood clot formation within the atrium. If the blood clot travels to the brain or another
location, it may cause a stroke or organ damage. A scoring system is used by physicians
to determine who is at risk of blood clot formation, to determine who needs to take blood
thinners.
Q: What causes atrial fibrillation?
A: Atrial fibrillation may be caused by any situation in which the atrium is subject to
elevated pressures, leading to scarring of the atrium and disruption of the electrical system.
Examples include congestive heart failure and hypertension, where the pressures inside
the heart are elevated. Other situations that lead to elevated atrial pressures include
valvular disease or lung disease. Diseases of the electrical system of the heart may lead to
atrial fibrillation, and any situation that leads to scarring of heart tissue (such as a heart
attack or alcohol). Inflammation around the heart may also lead to electrical disruption, as
in pericarditis (the inflammation of the sac around the heart) or after open heart surgery.
Atrial fibrillation is very common, affecting more that 10% of people over 80 Risk factors
include aging, hypertension, any form of heart disease, sleep apnea, thyroid disease and
alcohol.
Q: How is atrial fibrillation treated?
A: The treatment of atrial fibrillation is individualized for the patient. Some people don't
even know that they have atrial fibrillation, whereas others are in extreme discomfort when
their heart does not pump regularly. Treatments for atrial fibrillation include:
o
medications to slow the heart, such as beta blockers and calcium blockers
o
medications to maintain a regular rhythm
o
blood thinners, to prevent stroke or other problems due to blood clots
o
cardioversion, a procedure whereby a medication or an electric shock is given so as
to reset the natural pacemaker of the heart
o
ablation (see the article above)
o
av nodal ablation, in which a pacemaker is implanted, and then an ablation
procedure carried out to damage the native (abnormal) pacemaker node in the heart
The Heart Institute Newsletter, Vol 10, No.2, March 2013
Editor: Donna Zwas-Zfat
Associate Editor: Judith Shidlowsky
News from our Cardiovascular
Clinical Research Center
The atrium in the basic science lab...
For many years, the thin walled atrium was considered to be merely a collecting chamber...
We then learned that the atria were endocrine organs, secreting hormones based on subtle
changes in pressure. These hormones communicate with the kidney and the sympathetic
nervous system to regulate the amount of volume in the blood stream and regulate blood
pressure.
Now we have found that the atria are the repositories of stem cells in the heart. Mapping
has shown that the atria of the heart contain much higher levels of resident stem cells than
the ventricles. Furthermore, Hadassah cardiologists have shown that the atrial
appendages are the major repository of stem cells in the heart.
It turns out the stem cells are frequently found in crypts, and the appendages of the heart
are filled with crypts that house these stem cells. It is postulated that when there is injury to
the heart, stem cells migrate from the appendage to the injured area of the heart, allowing
for some level of repair.
Hadassah cardiologists are now working on learning how to transform these stem cells into
full fledged cardiac myocytes. These techniques may eventually allow for cell therapy in
patients after heart attacks, or other heart damage.
The Heart Institute Newsletter, Vol 10, No.2, March 2013
Editor: Donna Zwas-Zfat
Associate Editor: Judith Shidlowsky
To All Our Friends and Supporters
The entire Heart Institute staff
Wishes you a very Happy and Kosher Passover
The Heart Institute Newsletter, Vol 10, No.2, March 2013
Editor: Donna Zwas-Zfat
Associate Editor: Judith Shidlowsky