Dr. Robert Fishel – JFK Medical Center – Radio Frequency Ablation Treatment- Full Case


– So Atrial fibrillation
is one of the most serious and also unfortunately
one of the most common cardiac rhythm disorders
that physician’s see. Cardiologists have to deal with this problem all the time. It’s common in people who are older, and it’s also seen in
people who are younger. Atrial fibrillation is the result of the upper chamber of
the heart just quivering. Ordinarily, during the normal sequence of activation of the heart
the upper chamber beats once and sends blood to the lower chamber, the ventricles, and then they beat once. And this happy sequence continues, for most patients about 100,000
times a day, the heart beats and the two chambers talk
to each other continuously. The atria beats then the ventricles beat. With atrial fibrillation the
rhythm in the atria becomes disorganized and the atria
just starts to quiver. The actual rate in the atria
is over 500 beats a minute but because it’s so fast, all
you see if you were to look at the upper chambers,
it just sort of quivers. And when it quivers it doesn’t send blood to the lower chamber as it should. The lower chamber sort
of beats irregularly. So if a patient has atrial fibrillation, if they take their pulse,
they’ll find that it’s irregular, that it’s all over the
place and because of this, when patients with atrial fibrillation try and do things, they’ll
often times have symptoms. The symptoms can be palpitations, can be shortness of breath,
can be a feeling of… It’s like a fish flopping
around in a patient’s chest. Those can all cause a patient
to have lifestyle problems, they have difficulty exercising, they have difficulty sleeping, they just feel ill at ease when they have atrial fibrillation. Those lifestyle symptoms
are an issue for patients but the biggest issue for physicians is the fact that the upper chamber is really not moving blood
with atrial fibrillation. It’s just quivering. And when blood doesn’t move, blood clots. And so as the upper chamber quivers, parts of the upper chamber can form clots and if these clots break off
they go to the lower chamber and then that blood gets
pumped out into the body and can cause a stroke
or peripheral embolism. Either way, it’s a bad problem
with atrial fibrillation. And patients with atrial fibrillation many of them at least, not all of them, but many of these patients need long term anti-coagulant therapy,
long term blood thinners to prevent strokes and
clots and the other issues we see with atrial fibrillation. And so, the issues with
atrial fibrillation are that if you treat it, you’re replacing
one problem with another. The issues with
anti-coagulation are bleeding and a lot of other issues including interactions with other medications. And patients need to
be on these medications for life if they have atrial fibrillation. And in addition, they still have the symptoms of atrial fibrillation. Palpitations, shortness of
breath, difficulty with exertion, while they’re on blood
thinning medications. One of the things that we can
do with atrial fibrillation patients is we can put them
on antiarrhythmic drugs. On rhythm control medications. The problem with those
types of treatments is that, again, you’re replacing
one problem with another. Even if medications
work, and they only work in about half the patients
but even if they work the patients need to be on
these medications for life. Medications oftentimes
have systemic side effects, they can slow the pulse. Some of these medications
can have fatal side effects and some of the side effects
can accumulate with time for some of these medications we use. And you end up replacing
one problem with another for many patients with
atrial fibrillation. Including the issues of
the potentially fatal side effects that many
of these medications have and the fact that they only work for about half the patients. Because of the issues
with anti-coagulation and because of the issues
with treating patients with medications and because the issues that both of those therapies are life long and the patients oftentimes
still have atrial fibrillation and the symptoms associated
with atrial fibrillation, catheter ablation is now available for many patients with
atrial fibrillation. Now, if we’re gonna do a catheter ablation for someone with atrial fibrillation we would like the patient to at least have tried an antiarrhythmic drug and shown that a simple
treatment doesn’t work. As I said, for many patients
with atrial fibrillation antiarrhythmic drugs don’t
work or they have side effects and for at least half the patients, probably more than half
the patients in fact, the simple treatments don’t work, but it’s worth a try for most people. If the simple treatments don’t work and the patient’s still symptomatic with atrial fibrillation
then there are things we can do which can potentially cure people of their atrial fibrillation. And the thing that we’ve been doing for about the past, almost 15 years now in electro-physiology
that really has been a major advance in the
field of treatment for heart rhythm disorders
is catheter ablation. With catheter ablation
for atrial fibrillation the areas in the upper chamber
that are actually causing the fibrillation, the areas
that are actually driving the rhythm disorder are
found and are eliminated. And when you do this, you can oftentimes cure a patient of their problem and in many patients
this is a permanent cure. And if they are found
to be cured permanently many of these patients can stop all of their medications that
they previously were taking for atrial fibrillation including anti-coagulant therapy in many patients and antiarrhythmic therapy. Now, catheter ablation
for atrial fibrillation has not been a perfect science. It has worked for many patients but the problem is for many
patients you’ll do an ablation and the patient will initially be fixed or will initially have a good result but then a few weeks later,
or a few months later, the atrial fibrillation comes back. And the reason why that
occurs in most patients is because of something
called reconduction. And what that means is that the areas that you have ablated,
that you’ve eliminated, were only stunned during
the ablation procedure and were not permanently eliminated. And the problem for electrophysiologists is it’s difficult for us to
tell at the time of a procedure whether or not we’ve actually destroyed the tissue permanently or only stunned it and prevented it from
conducting electricity, electrical signals acutely
during the procedure. And unfortunately you
can’t leave a patient on an electrophysiology… On the table here for
a week to wait to see if you just stunned the tissue. So you have to stop the procedure and hope you have actually
permanently eliminated the abnormal tissue that’s
causing atrial fibrillation. But for many patients in the
past that wasn’t the case. For about a third of the patients we previously did ablations on they would have to have
a second procedure. Repeat procedures, unfortunately, for atrial fibrillation
are a fact of life. One of the reasons why
they’re a fact of life that you have to repeat procedures in order to fix patients
with atrial fibrillation is because you have to be
careful when you do an ablation that you don’t put too
much pressure on the heart. ‘Cause if we put too much
pressure on the heart you could potentially have complications like damage to collateral
structures near the heart. There are a lot of sensitive
structures near the heart you wouldn’t want to ablate
so you don’t wanna put too much pressure in the area. And you also don’t
wanna increase the power of the ablation catheters to the extent that you are also gonna
heat collateral structures and potentially damage them. So, until recently, we
have had to be very careful when we do ablations,
that we just do enough hoping we fixed it and, actually, acutely we’ll see interruption
of electrical conduction but has it been permanent,
is the question we have had. And because of this, this issue, about a third of the
patients, as I’ve said, who have undergone ablations
for atrial fibrillation will need to have a repeat procedure. So, now we have a solution
which appears to decrease significantly the number
of repeat procedures that are needed and increases the ability to cure the patient permanently
with a single procedure. And that is a technology
called force sensing. Force sensing. So, when we do an ablation
for atrial fibrillation one of the things we’re looking to do is to eliminate certain
areas of the heart. For example, in this particular patient this is the right upper pulmonary vein. Atrial fibrillation tends to occur from the structures in
the heart where the blood is drained from the lungs into the heart. So this area here, is
where atrial fibrillation tends to occur and there’s four of them, or five of them depending
on the patient but those are the areas where atrial
fibrillation tends to come from. The areas that drain blood
from the lungs into the heart. So the idea with the
ablation is to sort of put that structure in jail,
to put a fence around it. And what happens in the
pulmonary vein, when you’re done, you put a fence around it
should stay in the vein. So if atrial fibrillation starts here, it can’t get into the heart and the patient stays in normal rhythm. You have put that area in jail, that bad area that’s causing AFib and the patient’s heart
stays in normal rhythm. And if you’re successful, it should be a permanent fix for most patients. But, as I said, the issue is that… How do you know you’re
not just stunning tissue? And that acutely you seem to have isolated this area electrically but
then a week or so later the abnormal rhythm
recurs because you’ve only stunned the area and
reconduction has occurred. One of the major advances in this field over the past year has been force sensing. When we used to do ablations
for atrial fibrillation we’d put a catheter on the tissue, we’d use x-ray and we’d use this three dimensional mapping
system we have here and we would find the
areas we need to ablate, we’d create ablations around those areas and we would see electrical signals on our screen and we’d think
we were ablating those… We’d think we were touching tissue. But the problem is until about a year ago you didn’t know for sure if
you were touching tissue. And you didn’t know for sure if you were touching it hard or touching it softly. In fact, you could
potentially just be floating on top of the heart and see
a very nice electrical signal but you’re not actually touching the tissue with the catheter. And it’s sort of like trying to… A good analogy might be like trying to solder something with a soldering iron. If the soldering iron is just above the area you’re trying to solder you could be there all day and
you could see what looks good when you’re looking at it visually but unless you’re touching it, you’re not going to solder something. And it’s the same thing here. Until recently, you
could be above the area you were trying to ablate,
see a good electrical signal, and think we were ablating
it but only be delivering a minimal amount of energy to that tissue. Alternatively, you could be
touching the tissue very hard and not know it and think
you were safely ablating when in fact you were delivering a lot of force to the
tissue, potentially heating and causing damage to a collateral
structure near the heart. Because of this in the past we’ve had to be very
careful how we ablate. If anything, my preference, and I think the preference
of most patients is that it’s better not
to have a complication. And our complication rate is well under 1% for these procedures. But my philosophy is it’s always better not to have a complication. If we don’t succeed we can go back and we could do another procedure. Better to be safe than sorry. And so in the past, we had to be quite careful with what we did. Now things have changed dramatically now that we have force sensing. The way force sensing works… I have a catheter here which… It’s without magnification
but I’ll see if I can… Perhaps we can get some icons, some cartoons showing
this in greater detail. But the way it works
is there’s a very, very precision sensitive spring that actually can sense the force you’re applying to the tip of the catheter
in three dimensional space. So, in that direction, and that direction, and that direction so… I’m sorry, in that direction. So in the x, y, and z axis you
can actually sense the force and when I do a case later
you’ll actually be able to see there is a force vector which our three dimensional
mapping system will show. It’ll show us whether we’re
pushing on the tissue hard, whether we’re pushing on it soft, or whether we’re not touching it at all. By knowing how much force
we’re delivering to the tissue when we turn the heat on and ablate, we will know if we, in
fact, are delivering a good quality ablation to that spot. And this has been proven clinically to significantly decrease the
need for repeat procedures. The other thing, and this
is a three dimensional electro-anatomical map, it’s
a three dimensional map. We use a GPS system that
let’s us create a model of the patient’s heart and know exactly where we are and where we’ve been. The other thing that we now have is something called Visitag. And the way Visitag works
is the computer here will now actually place an ablation tag, and all of these pink and red dots here are ablation tags for
this particular patient. But if you just touch
the tissue for a second and you have the right type of force and you have the right power settings but you only touch it for a
second that’s not an ablation. The tissue has not been
eliminated, it’s just been touched. So the way this system works with Visitag is you actually have to be on the tissue with the right amount of force, for the right amount of time. And then the computer
actually places a tag there. So this is not done by somebody manually, the computer is actually saying, “Dr. Fishel, you have created “a high-fidelity ablation at that site. “That site now should be eliminated “and that elimination of the “abnormal tissue should be for good.” So now between force sensing and the ability of the
computer also integrate the force and the time and place a tag when both of them have been achieved. Force and time in that
spot when the power’s on you now have a high-fidelity ablation. This type of technology has significantly increased our ability to
fix atrial fibrillation with a single procedure and
also made the procedure safer. And this is a major thing
for me as a physician. There are very few things in medicine where you both have increased
efficacy and increased safety. For a lot of procedures, well yeah, “We can fix more patients
with this procedure “but there are more complications
if we try that procedure.” Or, “Oh, this procedure’s much safer, “but you don’t fix as many patients.” But with this technology
we have achieved both. And to me that is a major advance in the field of electrophysiology. We now have a higher success rate with a single ablation procedure, and have a lower risk of complications. ‘Cause we know whether
we’re not touching at all, or whether we’re touching
too hard with our catheter. …was what do the different colors mean? And actually what they are referring to, it’s a technical thing but since I know a lot of the people who
watch these videos online are fairly interested in
the technology behind this. That’s called a force time interval, and that’s displayed up here. The white is the minimum it will take in the force time interval
and it won’t display anything unless you have achieved what we consider to be a good quality ablation. But if there’s a spot that typically has thicker pieces of muscle like the front… This is actually the front
wall of the left atria here even though it doesn’t look that way, that’s actually the front… That area is near an area
called Bachmann’s bundle. It tends to have thicker
piece of muscle there. We’ll stay on that spot longer and instead of it giving us a pink dot, it’ll give us a red dot. The pink will slowly become red
as we’re doing the ablation. ‘Cause we have stayed on that spot for longer time with adequate force. So the different colors mean
you have a good ablation but some of them may be a
little longer than others. Now, there’s a downside to
staying onto a spot too long, which, as I said, you have to
worry about collateral damage. But this technology now give
you something you can measure. You know if you have the force. You know if you have too much force. You know if you don’t have enough force. And you know how much time. And this is really good
because it tells you “Yes, you have a good ablation.” Or, “Yes, you have a
really good one here.” So this is a catheter ablation. This is an ablation catheter, excuse me. And you can see how it’s steerable, how I can move it back and
forth with my right hand, I actually have a thumb
control I can use to move it. And this is actually a very, very, very sophisticated piece of medical equipment. What we’re gonna do today
is a catheter ablation for atrial fibrillation
basically from start to finish. So, I just wanna tell patients, this is basically, for the most part, a very easy procedure for
somebody with experience to do. Although it is something
that requires a doctor who has done a number of these. I don’t think you’d wanna go to a doctor who does these sort of as a side line. The way we do these ablations is we put little tubes in the… Sort of like IVs that we
put in the veins in the leg. The veins in the leg are very large. Could you lock the door there, please? (door bangs shut) Good, let’s start again. The way we do these procedures is we put little tubes in, called sheaths, these are put into the veins in the legs. We put a few of ’em in
and you can see that, basically, it’s a very small, little tube, and it goes into the vein in the leg. And from these sheaths we
can actually put catheters, these are basically electrical
wires, through the tube and up into the heart of the patient. Then when we’re in the heart we can record electrical signals, we can do our mapping and
we can do our ablation and eliminate the abnormal tissues that cause atrial fibrillation. I’m gonna start by putting the tubes in the leg of the patient and then I’m gonna put the catheters in and then we’re gonna do our map, our three dimensional map, and then from there we’re
gonna do our ablation. Today… Thank you. Today we’re using a technology
which I talked about in another segment called force sensing. And the way this technology works is it actually can
measure the actual force that the catheter is
pushing on the tissue. So unlike in the old days,
which were about a year ago, we now actually know
whether we’re actually floating on tissue or touching it. We know how hard we’re touching it and we wanna know whether
we’re touching it enough or touching it too hard. So when we do the ablation
we will know if we actually have good contact with the tissue and that’s what you need
to get a good ablation. We want to eliminate
certain abnormal areas that are causing atrial fibrillation. And the problem, until recently, has been that you really didn’t know if you really had good contact and how hard the contact
was and you need that. If you don’t have that,
patients can have a recurrence because you’ve only stunned the areas, and then the atrial
fibrillation comes back. You ready?
– Yeah, I’m ready. – Let’s get started. By the way, this is Steve Edmonton, one of our fantastic nurses here. We have Jay over there, we
have Michelle over there, we have our anesthetist in the back. We have an entire crew of people dedicated to doing this case from start to finish safely and effectively. And that’s, by the way, the
other thing that you need. If you see a doctor and
you have an ablation. You wanna not just have the doctor, you wanna have the facility, you wanna have the mapping equipment, you wanna have all the safety precautions that we typically take that are in place. You wanna be in a place
that has open heart surgery, although we have never, in my career, ever needed to use it
but we wanna have that in case there is some
type of complication. We wanna be ready for it. And really, the other thing we need, is we need a crew of
people who are technically experienced, who know
the equipment I need, who know how the procedure’s done. ‘Cause it’s not just me. It’s all the other people here including the gentlemen behind
us who you’ll see in a second Mike Driver who works
with Biosense Webster who is gonna help us
with our mapping today. Ready to get started? Let’s get started. So you can see it’s very easy for me to put these tubes in the patient here. There’s only a little needle stick. It takes me about a minute
to put each sides… To put the tubes in and we’ll typically use both groins in the patient, it’s just easier on the patient if the catheter is in both
sides rather than in one side. Thank you. Okay, so, Steve if you can just hold a little pressure here for
a second please, take that. Thank you. Hold some pressure there. So the tubes are in the right side. And we’re gonna put another
two tubes in the left side. Now, physicians will sometimes
put a number of different catheters in and it
depends on who you go to and their experience
and their comfort level but they’ll sometimes put
in ultrasound catheters and other types of mapping catheters. Our philosophy is that we’ll
use those if we need to, but we try and minimize
the trauma to the patient. So for most of the cases I do, we’ll usually just put in four sheaths. For a mapping and reference catheters and an ablation catheter. So, I’m gonna put another
two in on the left side now. It’s very easy to put these things in. Only takes about a second. So this is basically
the extent of the trauma that the patient has which is, at least for their groin,
is four needle sticks. The nice thing about this is
also these are in the vein, they typically heal
very well without a scar and with only a little bit
of a bruise which goes away in two to four weeks after
the ablation procedure. You can let go, Steve, that’s fine. And these are such small tubes, sometimes I have to wiggle them a little bit to get ’em into the skin. Alright, they’re in. And so now we have completed, basically, the surgical portion of
this ablation procedure. There’s gonna be no additional punctures or cutting or anything to this patient. We’re done with that. Everything else is gonna
be putting catheters in and actually finding
the areas in the heart where the abnormal rhythm’s coming from and fixing those abnormal areas. (x-ray machine squeaking) So we do need to use a little bit of x-ray but not a lot to put our catheters in. So could we lower the lights please? Lower the lights there please? Michelle? This is Michelle Rogers, our excellent electrophysiology nurse. And, Michelle, could you move the monitors a little closer to me please? So this is one of our catheters, it’s a quadripolar catheter. This is gonna go into the right atria. And you’re gonna see, I’m
gonna x-ray in a second and you’ll see on the x-ray… This particular patient has
a pacemaker defibrillator. – [Jay] You okay with the NG? – The NG’s good. What Jay is doing is she’s
actually putting some x-ray dye into the esophagus of
this particular patient to make sure that we are
careful with the esophagus which is one of the structures we wanna be careful about
when we do an ablation. If you look at the x-ray you’ll see the… That’s good Jay, you can pull it out. She’s putting some x-ray dye in and it’s a safety precaution and really safety is number one to us. We wanna try and be as safe as possible when we do these ablations. Gonna put another reference
catheter into the heart now. This is a 10 electrode catheter but you can see how
small this catheter is, it’s sorta like a thick
hair, the size of it. So this is minimally
traumatic for most patients having these things in,
they just have four tiny, little holes in the veins of
the leg, basically big IVs. And when you pull ’em out,
patients can usually go home… Many patients we can send
’em home the same day even. And they can go back to work the next but since we’re using a general anesthesia, we usually keep people overnight
just to be on the safe side in case they have any side
effects from the anesthetic or from the ablation or
anything else although typically that’s not an issue
for most of our patients. Okay, very good. So that is in the coronary
sinus, this catheter, which is one of the veins in the heart. Now, we are ready to go over
to the left side of the heart which is where atrial
fibrillation comes from. So I have to change this
little tube for a longer tube. Can do that right now. Move the monitors a
little bit closer please. Very good, thank you. So what Steve is doing
is he’s loading a sheath, it’s a long sheath, same size
as the other one just longer. So we’re gonna need that
’cause this entire tube is going into the heart, okay? – [John] What does Steve’s lead do? – So, the leads on the
left side of the groin are reference and pacing catheters. This allows us to pace the heart and to sense electrical
signals from the heart. So that’s what we have in
the left side of the groin. And we need those in order to pace and sense while we’re doing the ablation. The sheaths on the right side, and the electrodes on the right side, one of them is used for mapping, to create a map and
I’m gonna show you that in a couple of minutes how we actually create a three dimensional
model of the patient’s heart. And the other one is the
catheter we use for ablation. To eliminate the abnormal tissues that are causing atrial fibrillation. Okay, you can pull that out Steve. So, what I’m gonna do
now is something called a transeptal catheterization. Now, it sorta sounds a little
scary to a lot of patients because in order to
fix atrial fibrillation we have to go into the
left side of the heart. So we have to make a little puncture between the right side and the left side to get into the left side. But the fact of the matter is the heart is basically just a giant blood vessel. And whenever you put an IV in or do any type of operation involving the vascular system of the patient you need to put a little bit
of a hole in a blood vessel and these little holes
will typically heal. And this is typically a very routine and not a very difficult
procedure for us to do with the vast majority of patients. Only take just a second to do. But it sorta sounds scary but if it’s done with experienced hands it’s not an issue. We always check to be sure
we’re in the right spot. I’m doing that right now. Which I am. And so that is the extent
of our first transeptal, what we just did here. And we’re gonna give some heparin to the patient to make sure
that the blood stays thin. Since we’re now in the
arterial side of the heart, we wanna make sure everything
stays anti-coagulated here. That’s our first transeptal,
we have to do two of them. Alright. Okay. (mumbles to nurse) So the patient has a relatively common anomaly of his heart
in that he has already a small hole in his interatrial septum. That’s present in about
15% of the population. Nicely for us, the wire we’re using to actually get into the left atria just went across the
hole so I didn’t actually have to make a second
puncture in the heart. He already has one naturally. That’s present, by the
way, in 100% of people when they’re in the uterus,
when they’re babies, because the developing
heart needs that hole to provide oxygen to the body. But it typically seals
as people get older. But it’s easy for us to get across. So, anyway, now we have both… I need a heparin please. – [Steve] Yep. – Now I have both sheaths
in the left atria, these are the transeptals,
you can see how hard it is. It’s really not that hard, in experienced hands, to do a transeptal. It only takes a couple of minutes and it’s quite a safe thing
to do in experienced hands. Now, in inexperienced hands,
I’m not sure you’d want… A patient wouldn’t want this done, because we are purposely making
a small hole in the heart. If that hole is made in the
wrong portion of the heart, you know, you can have some issues. We typically don’t have any issues. We do, this particular
facility does well over 500 of these transeptals a year and we’ve never had any
issues that are really serious with the vast majority, if
not all, of our patients as far as this particular procedure goes. So now we’re gonna put… We’re done with all of our sheath access. We have two sheaths in the
left side of the heart, we have our wires for reference and pacing in the right side of the heart. Now we’re gonna start doing some mapping. And this particular catheter
is a circular mapping catheter. You can see how the circle I can steer and I can move it back and forth also. I can tighten the circle
or loosen the circle. And we’re gonna use this to actually help draw the anatomy of the heart. To reconstruct a 3D model of the heart. I’m gonna put this in the
left side of the heart, in the left atria now. You see on x-ray… John, if you can look
on the x-ray you can see that little circular tube is in the left side of the heart now. You see up there on the x-ray. This is our ablation catheter. Now as I described the other day, this is quite a sophisticated
piece of medical equipment. This has numerous different sensors in it. It has the ability to be steered. You can see the catheter,
if you look at it, it’s sorta crying, you see
how it’s weeping water? That’s from numerous laser
drilled holes at the tip. The idea with that is that
when you’re heating the tissue you don’t want the shaft
of the catheter to get hot, you don’t want blood to clot on it. So it’s continuously irrigated
as we’re doing the ablation. And that way only the tissue deep to the catheter actually gets hot. This particular catheter has a GPS sensor, it uses magnetic fields. It actually has three magnetic
phase sensors built into it and that’s how we can track
it in three dimensional space. We have a constellation of
electromagnets under the patient so that helps us track the catheter. This has two temperature sensors in it. This has irrigation ports in
it. It has steering in it. And it has a force sensor in it so it can actually measure the force. Not only the force in one plane, in all three planes to
actually get a vector for the force when we’re touching tissue. So we’ll put this in the heart now. Now my screens here… I’ll give you a quick rundown
of what I’m looking at on all of these screens in front of me. Okay, very good. Mike? Mike, you wanna zero please? Very good. – [Mike] We’re ready– – If you go up on your
(mumbles) volume, please. – [Mike] We’re ready to scan when you are. – Oh, you’ve done it
already, okay, very good. So, let me just give you a quick update on what I’m looking at here ’cause I’m looking at a number of screens. This is the patient’s x-ray. You can see there’s our
ablation catheter here. Here’s one of our sheaths we used to get into the left side of the heart. Here’s our other sheath, and here’s our circular mapping catheter we’re gonna use to build
the heart’s anatomy. This screen here shows me
the actual electrical signals being recorded from those catheters from the inside of the heart. You have different colors so it makes it easy for me to look at. Each color represents
a different catheter. We have four catheters in the heart, we have four different
colors on the screen. This screen in the middle
is a very important screen. This is our electro-anatomical
mapping screen. This screen is gonna show me
a three dimensional picture of the heart and also show
me where I need to ablate, where I’ve been, the
quality of the ablation, the force of the ablation
and so this is… As we do the case you’re
gonna see this green blob we’re looking at now is gonna start to look like a heart in a second as I start moving catheters around. So, what Michael’s doing is
he has the mapping machine set to record anatomy as I move the circular mapping catheter around. And as you can see, if you
look at the middle screen, and as I’m moving the catheter
we’re slowly drawing anatomy, the green blob is becoming, it’s sort of a bigger blob right now. But in a few minutes it’s
gonna look like a heart. Like a left atria. This really only takes a
couple of minutes to do to create a three dimensional map. I don’t know, John, if you’re
looking at the green screen… – [John] Yep. – …you can see it slowly getting bigger as I move the catheter around
and it’s filling in anatomy. It’s sort of like a paintbrush
the way the machine works where you move the
catheter it leaves a trail and slowly fills in the anatomy
in three dimensional space. You can see as I move
it, it slowly fill in more of the heart here and it’s anatomy. And before you know it we have something which looks like the heart. Which doesn’t look like it right now, but give us a couple of minutes. But it really only takes a
couple of minutes to do this. That’s the left lower
pulmonary vein there. There’s the left upper vein. There’s the right upper vein. Here’s your right lower, here. Okay, Mike, switch to mapping please. Now I switched my
paintbrush ’cause I wanna do additional painting with my steerable mapping catheter
and ablation catheter. My reference circular catheter is in the right lower pulmonary vein. We’re just gonna fill in
some additional anatomy here. It only takes a second
and before you know it, we are going to have, what looks like, a left atria to work with. I’m thinking, as a matter of fact, one day maybe we’ll even do a
live case with people online and they can actually ask
questions if they like as we’re doing the case
of what we’re doing. Now there’s a lot of patients out there who have atrial fibrillation,
it’s a very common disorder. And unfortunately for patients, it’s also something which
can really disrupt their life and even result in death from strokes and from bleeding from anti-coagulation and from medication side effects. So if you can fix it it’s the best thing. Okay Mike, you can segment the heart. Now, I gave some heparin,
which is a blood thinner, earlier since we need to keep… We’re in the left side of the heart, the atrial side of the heart
with our ablation equipment. You need to keep the blood thin so we’re now gonna check something called an activated clotting time to be sure that the patient’s blood
is thin but not too thin and not too thick when
we do this ablation. Okay, Michelle, our excellent nurse. Say hello, Michelle. – Hello Michelle. – That’s Michelle Rogers. The nurses we have here, by the way, I have had the pleasure,
like Jay Mordash here, of working with for almost two decades. And they are some of the finest nurses I have ever worked with. Most of them have worked
in the ICU before. They have (mumbles)
experience in critical care and in handling patients
who have complex issues. So, without them, and without Mike, I certainly couldn’t do my job well. As a matter of fact, I
couldn’t do my job at all without them and without Mike. Are you ready Mike? – [Mike] Yes, sir. Okay so, I’m gonna show you
the three dimensional map here. Now it’s not unusual, and you
notice I took off my gloves, that’s not unusual for us
to do during a procedure ’cause we’re going back and forth and this procedure is sort
of semi-sterile anyway. But here’s a 3D map of the heart and you can see there are
actually four blood vessels that feed blood into the heart. This is the right-sided veins. The right upper and right
lower pulmonary vein. Left-sided veins, left
upper and left lower. And these are the areas
where atrial fibrillation tends to come from, it tends to come from the pulmonary veins so
the idea with the ablation is to create a circle around
the veins and lock ’em in jail. So it’s sorta like the Las
Vegas when you’re done. Whatever happens in the
veins, stays in the veins. And you’ve created a fence, a barrier, between the abnormal tissue that’s causing fibrillation and
the rest of the heart. As you can see, when
the patient’s breathing that’s our circular mapping
catheter I showed you earlier. You can see it’s actually
moving in the heart as the patient’s breathing
and as the heart’s moving. And our ablation catheter,
you really can’t see it’s sort of inside, in the
middle of the heart right now, but as we do the ablation you’ll see it. This number here is the force. The ablation catheter
is touching something and showing seven grams of force. Previous to this technology, we didn’t know if we
were touching anything. We didn’t know if there was force or not. All we saw was a signal on it. That didn’t tell us if we had good contact or too much contact. So, yeah, go to PA please. Is our pace in? 650? You see the staff here, I don’t
even really have to tell ’em what I want ’em to do, we’ve
done so many of these cases they anticipate what I want and
good nurses and a good team, the nurse knows before the
doctor even asks what he or she might want and has it ready. And you can see that
Michelle’s sitting there at the pacing and recording system. Mike’s sitting there
at the mapping system. They know what I’m gonna wanna do next in order to have a good
result with this case. Okay, so if you looked at the
three dimensional map here. We’ll take 20 watts here. There’s a white dot there. And there’s a little arrow,
that’s the force vector. It’s showing where the force is pointing, it’s pointing towards the
back wall of the heart. We’re looking at the back
wall of the heart now. We’re showing nine grams of force. Now I’m gonna wanna have 10 in
order to get a good ablation. But by moving a little bit I can get 10. And you can come on here,
please, at 20 watts. – [Michele] 20 – Okay. Now, this particular system
has something called Visitag. And what that means, is the machine is not gonna place an ablation
point here unless I have enough force with the
ablation on for enough time, and there it is, that
little pink tag, you see it? That means that’s a real ablation. That means there is a
force and time on that spot while the power’s on, there’s enough force and enough time to actually
cause damage to that tissue. And that is what you want
during this procedure. You want to eliminate the tissue that’s causing atrial fibrillation. Not just stun it, but eliminate it. And here’s another one and you
can see what I’m doing here, is I’m gonna basically… It’ll become more evident in a second if you watch the map but
basically what I’m gonna do is create a circle
around the problem spots. – [John] What’s the problem with too much force or not enough? – [Dr. Fishel] So, the problem
with too much force is, you can see we’re near the esophagus here, and if we put too much force on it we can actually damage the esophagus. We take a lot of precautions
not to let that happen. But one of the biggest risk factors to damaging the esophagus is putting too much force on the heart in this area, tenting the heart into the esophagus and then you damage the esophagus. We don’t wanna do that,
we wanna be careful. You can also potentially, if
you really have a lot of force, it takes a lot, it’s not
something we ever really saw a lot of even without
this, but it can happen. If there’s a lot of
force you can perforate the heart with the catheter. By the way, that complication
is typically not something that’s really that terrible
even though it sounds bad, we can handle it, we’re
prepared for complications here. And we can handle it typically without having to do open heart
surgery or anything. But who wants to have to
put a hole in the heart? You don’t wanna do that. With force sensing that issue goes away. You know if you have too much force and you know if you don’t have enough. So you can see right now I
have 15 grams of force here, my force vector is pointing back towards the tissue I want to ablate. And you can see I’m slowly creating an ablation line around this problem area to isolate it electrically. – [John] Tell us the, just in brief words, why are you drawing this circle? What is it gonna achieve here? – So the circle’s being placed
around these little circles. These little circles
are the pulmonary veins. Those are the areas in the heart that drain the lungs of blood. It’s not really clear
to medical science yet why they’re so important
for atrial fibrillation. There’s some theories about it, but it’s not really 100% clear. But what is known is that
those are critical areas where atrial fibrillation lives. Where it comes from and where it starts in the majority of patients
is the pulmonary veins. The veins that drain the oxygenated blood from the lungs into the heart. So if you can put them in jail and you can electrically isolate them, which is what we’re gonna do here, we will fix atrial
fibrillation in most patients. At least in most patients who have paroxysmal atrial fibrillation which means they’re in and out of it. We will fix it. – [John] Who is not a
candidate for this surgery? – Well, I think every patient with atrial fibrillation we can look at. Typically though, we don’t like to do this ablation procedure on
patients who don’t have symptoms, unless there are other issues. We’d like to see somebody
who’s having symptoms. Atrial fibrillation
tends to be symptomatic in most patients but not in all of them. If they’re asymptomatic I’m
not sure I’d wanna do it. The other thing is if they can tolerate antiarrhythmic drugs,
rhythm control medications, you many not necessarily
have to do this ablation. You know, if a drug works why operate? The idea is here is to help
the patient’s lifestyle, not just life in general
but their lifestyle. And if they find relief with
medications that’s great. I would leave them on the meds. The problem is that medications only work for about 40% of patients
with atrial fibrillation. And the other roughly 60% of patients they either have a side
effect from medications or the medications failed to
work and they still have AFib. They might not have it as much, but they still have atrial fibrillation despite the medications. So, that’s really one of the reason why this procedure’s become so popular with patients because if it can get fixed they can get off their
antiarrhythmic drugs. They don’t have to worry about having palpitations all the time. They feel better cause their heart’s in normal rhythm all the time. Anti-coagulants can
oftentimes, not always, but oftentimes be
stopped in many patients. So it’s really a great thing
for somebody’s lifestyle. You have a tent there, Mike. Caliperize please on the PVs. – [John] Recovery time? – Well, so you’ll see this patient, this procedure’s gonna
take me about another, a little over another hour to do. We’re then gonna wanna wait a while and make sure we didn’t
just stun the spots. By the way, the nice thing
about this particular technology is the fact that you can measure force decreases the chances that
you have just stunned tissue. If you actually get this tag, you see the machine’s
putting these tags here. I’m not doing it, Mike is not doing it, the operator of the machine,
he’s just rotating the map. The computer is waiting to see that the catheter’s been on the tissue for a certain amount of force
at a certain amount of time before it actually
places a tag there, okay? Anyway, the idea with this is that if you can decrease the amount… That’s good, Mike, thank you. You can decrease the amount of areas that are just stunned you will have a patient who will be cured with a single ablation procedure. Unfortunately… What is it? Huh? – [Michelle] Two eight two – Okay very good, thank you. I’ll give her another 2000 in a second. Unfortunately, it was a fact
of life until recently… Go to the roof please. Is was fact of life until recently that patients with atrial fibrillation, if you did an ablation on them, would have to have repeat procedures about a third of the time. And one of the reasons why is because you just didn’t know if you
were actually destroying tissue or just temporarily stunning it. With this technology
you actually sorta know. Have you actually destroyed the tissue instead of just stunned it? As far as a recovery time goes, this patient’s gonna be woken up. About 15 minutes after I’m done they’ll wake him from anesthesia. He’s gonna need to lie
flat for a few hours because these tiny
little holes in his vein are gonna need to heal up. He’ll be able to walk around later today. We’ll watch him overnight, make sure he doesn’t have any more AFib, make sure he doesn’t have any complaints, make sure he’s stable. And if he is, he’ll go home in the morning and I’ll see him in six weeks. As far as activity goes,
usually we tell patients to take it easy for a couple of days. Not to, you know, engage
in any strenuous activity. No lifting of luggage or, you know… As far as, they go back to work usually a couple of days later
but we wouldn’t recommend any strenuous activity
for three or four days. And then three or four days post-ablation if they wanna do all their
usual stuff that’s not an issue. And I’ll tell you, I’ll contrast that with some of the other procedures like the maze procedure which is an open heart surgical procedure for
atrial fibrillation. That procedure the patient
can be hospitalized sometimes for over a week. There’s a lot of complications from that. Some of which are very, very serious. I mean, there’s
complications from this also, don’t get me wrong, if this
is done by an inexperienced operator you can have
very serious complications from an ablation procedure also. You need an operator
who knows how to do this and has the experience
and who can recognize an ablation if they get
to then treat it, okay? – [John] What percentage of patients that have had this procedure done have to come in and have it redone? – Well, it used to be… Come off. It used to be about a
third of the patients we’d have to do twice. With this new technology,
with the force sensing and the Visitag, the visual tagging… Come on here please, 30 watts. – [Michelle] 30 – It’s much less, the
recent clinical trial shows it’s about 85% of the patients who have this done with Visitag will have a cure of their
atrial fibrillation. For paroxysmal AFib at least, okay? It’s about 80, 85% of the patients with a simple procedure are fixed versus about 65, 70% of patients… Come off please. Fan there please. 65, 70% of patients
with the old technology. So the ability to sense
force is really great because it does two things for us. It improves safety and
it improves success. And that’s really a great thing for me to have both a safer procedure
and a more successful one and eliminate repeat procedures. So here you can see, I’m
gonna do this area here now. This is the front wall of the edge veins. Alright, so you can see
we have 16 grams of force, we’re pointing towards the front wall. Come on please. – [Michelle] 30 – Yep. These yellow signals on the
left lower screen in front of me are signals from the circular catheter we have in the right lower pulmonary vein. And when we’re done isolating these veins, you’re gonna see that they’re gonna either not be existent at all, or be dissociated, not have anything to do with
other signals in the heart ’cause we’ll have disconnected that structure from the
rest of the patient. Which is what we wanna do, we wanna eliminate the abnormal structure. Sort of like, somebody has appendicitis we wanna take out the
appendix ’cause that’s causing the problem and with atrial fibrillation the thing that causes the
problem in these patients is the pulmonary veins and
you wanna eliminate them from anything to do with
the rest of the heart. So you’re gonna see there’s another tag. So just watch my ablation catheter. Spin to the right a little
bit, Mike, on your map. There you go. You can see how it’s growing
ablation lesions as I ablate? The lesions are growing there
and I move it slightly… I’m gonna move it slightly
more inferior here, and it’s gonna grow
another lesion in a second. It won’t grow the lesion,
won’t display one, unless I’ve been on that spot with a certain amount of force
for a certain amount of time. As far as I’m concerned
that’s a real ablation. – [John] So this is just a single circle you’re drawing on the patient or– – [Dr. Fishel] So
there’s two sets of veins and our plan with this particular patient with paroxysmal atrial fibrillation was to basically to do two big circles around both sets of veins. And when we’re done both sets
of veins should be in jail and if they’re in jail, we’re done. So, the procedure usually
takes, from start to finish, and I’m teaching here and we’re talking, it usually takes about two hours to do. Which I think is really fantastic, when you can fix something
which has been a lifetime of problems for the patient in two hours. Two to three hours you’ve really done that patient a great service. Mike, lateral on the sub-view please. What I’m telling Michael is to
go to different views for me ’cause I need to see the
different views of the heart. And there’s a couple of
spots I still need to get. A couple of bald areas that I wanna get. Being 53 I know all about bald areas so, I don’t wanna have them if possible. I’m gonna see if I can
eliminate them here. There’s a tent there, Mike. So some of the tissue is tented. Yeah, there you go. He’s gonna eliminate that. So see this particular
model of the heart… That’s good, that’s good, you’re good. Particular model of the
heart was individualized… There’s still a little
bit of a tent there. Was individualized for
this patient’s anatomy. Sorta like not all shoes
fit, these are custom shoes. That’s good, Mike, that’ll
work. That’ll work. We made custom shoes for
this patient’s heart here. (chuckles) This is custom fitting we have here. – [John] What is Mike doing
and how is it helping you? – Well, so he basically is making sure the anatomy is correct and he’s moving the heart,
the cardiac map for me. So I’m gonna ask him to
move to right lateral now. Right lateral… You see how he moved the map? ‘Cause, you know, this is a
three dimensional structure, I need to look at in 3D and
since my hands are already full, I need Mike’s help for this. Now I’ll show you one other
thing. Stop ablating here. If you look at the force
sensing here it’s 19 grams. Now, I could make it higher, and I’m gonna do that since
we’re not on ablation. You see how the screen’s flashing? See how the screen is flashing
red, it’s saying 54 grams? It’s safe, by the way, for the patient. 54 grams if you don’t have ablation on. But I wouldn’t wanna ablate with that ’cause you could damage
a collateral structure, I just wanna show the safety
feature of this system. And a year ago, we didn’t
know whether we had 54 grams or no grams and now we know. How can you beat this? You have safety and improved efficacy. For me, I like that. I
think patients do, too. – [John] How many facilities
are using this technology and how many in Florida? – Well, I know we were the first
in Florida. I don’t know… Go to PA please. I don’t know offhand who has it now but I’ll tell you, I think
everybody should have it. Move your caliper to the right please. If they’re not using it I think it’s doing the patient a disservice. – [John] I think you said
that from the beginning, we happened to be the first in Florida– – Yeah. We were the first in
Florida to have Visitag and to have force sensing. And as far as I’m concerned,
if somebody’s not using it I don’t understand why
they wouldn’t use it. This is safer and more effective. Does it take more work? Yes. Do you need to have a
little more skill to do it? A little bit more. Come on here please. – [Michelle] 30 But it’s safer and more effective. You can avoid complications
that you’d otherwise get. And you improve your success rate. So, what is not to like
about force sensing and visual tagging of
real ablation regions using the force time interval? I think this is the only way to travel with atrial fibrillation
ablations right now. And by the way, that technology, this is a competitive field. And the technology that the
medical device companies offer the physicians may well
change in the future. This may well not be the best one. And if that’s the case we will change to what’s the best for the patients. Go to inferior please. So you can see I’m slowly
completing my circle here. It’s really pretty simple, it’s sort of like paint by
numbers for adults, okay? (chuckles) Paint by numbers you need to be careful. By the way, we have
just achieved isolation of that pulmonary vein,
for what it’s worth, as we’ve completed. And he took a manual dot there,
that blue dot he took there, he manually placed there
at the spot of isolation but as we completed the circle, we’re just gonna keep completing it so that there’s actually Visitags there so we haven’t just stunned the tissue we’ve actually eliminated it. Fan there please. There you go, very good, very good. – [John] So half the
procedure is done now? – [Dr. Fishel] So, half
the procedure is done now. The right-sided veins, you
can see there’s a circle here around the two right-sided veins and as we completed the circle, well, as we almost completed
it the actual conduction… Go down to 20 watts. – [Michele] 20 – In the veins went away. So as a patient this really isn’t that hard a procedure for them to have. Now, they do need a general anesthetic. You don’t have to have that, by the way, some operators don’t use it. We think it’s more
comfortable for the patient if they’re asleep completely. And I also think, I don’t
want them moving at all. ‘Cause it could change how this map looks if they move a little bit
and I need to have precision. This is all about precision,
doing this procedure. Precise movements of the catheter, good force of the catheter,
it’s all precision movements. I think that’s true, by the way, for anything in medicine
that you succeed at. Precision is the key to success. That’s true probably for
most things in life I guess. So you can see I’m just sort
of completing the circle here. – [John] Do people come to see you from around the country or where do they– – Yeah, I get a lot of patients who come from all around Florida
and I get, I would say, about 10% of my patients come from other areas of the country,
from outside the state. They’ve been treated with medications or attempted ablation,
or something like that for atrial fibrillation
they’re still having a problem and I end up seeing them. Most patients with paroxysmal
atrial fibrillation I could tell you, most of them we can fix. That’s not true for all of them but for the majority
of them we can fix them with an ablation procedure like this. They can be fixed. – [John] What causes AFib? – So, atrial fibrillation,
it’s not really known the cause of atrial fibrillation but what seems to be a common
factor for many patients is stretching of the tissues in the atria. And the things that stretch
tissues in the atria are things like high blood pressure, or a leaking heart valve. High blood pressure’s a very common thing we see in a lot of patients. But leaking heart valves also are common. For some patients you
don’t have an answer, they have lone atrial
fibrillation, it’s called and there’s just no… Take a point there, please. There’s just no answer. Why is it not Visitagging there? That’s good, give me one second John. Delete that point please. Delete the point (mumbles). There you go, very good
Mike. Now we have a Visitag. One second here. Want to complete this. So, to get back to the question why do patients have atrial fibrillation? Well, it seems to be that
stretching of the atria is an important component of it. And the pulmonary veins, which
drain blood from the lungs, are very important in causing AFib and maybe one of the
reasons stretch causes AFib in those structures is because they’re very thin
structures to begin with. That’s just speculation on my part. The pulmonary veins are thinner than most other tissues in the left atria and so they probably stretch first. And if you stretch a cell it’s basically sort of like a little
battery, every heart cell. And if you stretch it the
cell membrane starts to leak. And if it starts to leak
the cells can start to fire. Is that why atrial fibrillation tends to occur from the pulmonary veins? I don’t know. Is that why higher
pressures in the left atria and stretching of the left atria causes atrial fibrillation? I don’t know. But I can tell you that
that’s a common thing to see. That the pulmonary veins cause it and that there’s something in the past… Come off. There’s something in the
past, some type of stretching that’s causing the AFib in the patient. We have now completed
half of this procedure. While I’ve been talking to you folks. And if you look at the map here, Mike, could you mesh that map please? Yeah, that’s good. Very good. Now rotate it to the right septally. To the right septally, there you go. You see our circle? These are not points he drew there, that’s what the computer
says is a real ablation. And these are the veins and my catheter, my ablation catheter you
can see is sort of floating. You see I’m moving it?
The ablation catheter. You see it’s floating… Now it’s outside in the vein. See it’s outside of the vein here? Zoom in on the ablation
catheter on the right side Mike. Or on the left side, I don’t care just zoom in on it as much as you can. To show you how sensitive
this equipment is, look at the shaft of the catheter here. It’s floating in the pulmonary vein. If I rotate the ablation catheter, see it actually shows the
rotation of the catheter. You see the colors move? Okay? Rotate it in the other
direction, you see that? And if I bend it, it shows it bending. And it shows the force, you
see the force vector there? That’s the force sensor we’re seeing there – [John] It looks like there’s a space between that circle, is that a space– – [Dr. Fishel] That’s
the inside of the veins. That’s where the veins lead and I’m actually in a vein now
and the circle is around it. – [John] How do you know
that? Can you see it? – I know it because we did
a three dimensional map and when we drew the heart’s anatomy our circular mapping catheter
was touching the outside here so the inside has to be tissue free. So we know we’re in the
blood pool, basically. I mean if I look on my x-ray here, you can see I’m out in the vein here. I’m outside of the heart, okay? So let me show you something
else here. Sit down here. This yellow… The yellow signals here… Okay, I’m gonna show the
cycle map we’ve got up here. Then we’ll do the other side. It’s going very well, by the way. So the yellow set of signals here are from the pulmonary veins, from the right lower pulmonary vein. You see the signals
here, the signals here. There’s no signals there. And the reason there’s no signals there is ’cause we have isolated
the vein with the ablation. That vein has been put in jail so none of the electrical signals from the heart can
actually get into the vein. If you look at the start
of the case, though… Did we mark it? We marked it right? No? Yeah, good, here. If we look at the start of the case, or during the procedure I should say… Here are signals. Yellow signals,
pulmonary vein conduction. And as we’re doing ablation this is where we got isolation, someplace along here. This is a review screen,
okay, during the procedure. As we were doing the ablation… See if we can find where we got isolation. Here it is, oops. – [Michelle] I marked it. – Yeah I know, I’ll find it. So here’s the signals,
pulmonary vein’s potential, pulmonary vein potential. There’s some noise
there, no vein potential. No vein potential, no vein potential. That’s noise, okay? So I’m gonna eliminate that one to make it easier for you folks to see. No vein potential, no vein
potential, no vein potential. As we’re pacing you can see here. These are vein potentials here, and as we got isolation of
the vein and they went away. Three vein potentials, no vein potentials. That vein has been put in jail. And, by the way, this
signal here represents this catheter floating in the right
lower pulmonary vein. And this entire conduit, the
right pulmonary vein conduit I call it, has now been isolated. Everything there has now been put in jail.

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