Surgeon Discusses Customized Atrial Fibrillation Surgical Treatment

Surgeon Discusses Customized Atrial Fibrillation Surgical Treatment

March 10, 2009 5:52 AM CT

Cardiothoracic surgeon, Dr. Ralph Damiano, of Barnes-Jewish Hospital in St. Louis, MO, spoke with at Boston Atrial Fibrillation Symposium 2009. He shared information about new custom approaches to surgical and catheter ablation treatment of atrial fibrillation that he had presented at Boston Afib.

View the video:  Dr. Damiano on Customized Atrial Fibrillation Treatment
See Video Transcript Below

About Ralph J. Damiano Jr. MD:

John M. Shoenberg Professor, Surgery
Chief of Cardiac Surgery
Washington University School of Medicine
Barnes-Jewish Hospital

Dr.Damiano specializes in coronary artery bypass graft (CABG), valve repair and replacement, surgery for atrial fibrillation, and hypertrophic cardiomyopathy and minimally invasive cardiac surgery. Other areas of clinical interest include endoscopic coronary artery bypass grafting; surgery for ventricular tachycardia; and transmyocardial laser revascularization (TMR).

Medical School: Duke University School of Medicine, Durham, North Carolina, 1980

Residency: Surgery, Duke University Medical Center, Durham, North Carolina, 1982

Research Fellow: Duke University Medical Center, Durham, North Carolina, 1984

Senior Residency: Surgery, Duke University Medical Center, Durham, North Carolina, 1988

Editorial Board:
Journal of Cardiovascular Surgery
Journal of Thoracic and Cardiovascular Surgery
Journal of Laparoendoscopic and Advanced Surgical Techniques

Associate Editor:
Journal of Thoracic & Cardiovascular Surgery

Dr. Damiano’s Profile     Contact info

Video Transcript:

Mellanie:  This is Mellanie True Hills reporting from Boston Afib. I’m with Dr. Ralph Damiano of Barnes-Jewish and he has presented here at Boston Afib. I’ve asked him to give us a summary of some of the things that he talked about in his presentation here.

Dr. Damiano:  Thank you Mellanie. What we we’re talking about is perhaps what the future of ablation for atrial fibrillation may look like.

As many of you probably know, there are very successful catheter and surgical procedures now for the treatment of atrial fibrillation in the appropriate patients. But for the individual person, we still don’t have a procedure that we know will work all the time. Part of the problem is not completely understanding the mechanism, that is what’s causing precisely the afib and where in the atrium it’s coming from in the individual patient.

What we talked about yesterday is some exciting new work in our laboratory in which we’re using some of the really startling new advances in diagnostic and imaging modality to try to help us define in each patient almost a custom ablation operation or catheter procedure that would be designed precisely for your afib and your atrium.

What we do is we put people—and the other exciting thing part about this is these new imaging tests and diagnostic tests are all very non-invasive—it really involves basically for a patient just having a CT scan. From the CT scan we get the exact dimensions, replicated perfectly, of you own atrium.

During the CT scan, we put a jacket of electrodes on patients and, if you’re in afib at the time, it maps your afib, and then with some pretty sophisticated engineering we can take the electrical signals from the surface and actually predict where they came from on the heart. We basically take those surface electrical signals and then replicate exactly how the heart activated to create that. The heart is really the generator of electricity in the heart—nothing else generates electrical impulses like that—and then it just gets radiated and then we just basically solve how that happened.

What it does is, in a very non-invasive way and in about 5 minutes, lets us know exactly what caused the afib and lets us know the electrical properties of the atrium, and then hopefully, eventually, will let us design a custom operation for each patient.

Our goal would be—right now, even if you do the ablation or the operation often perfectly, we still have patients who fail because in the individual patient you really can only guess at what caused it—I think within the next few years we will actually reach a point where, for patients, we’ll be able to tell you this is what caused the afib and this is what we need to do. Then the patients can be assured certainly, if that operation is done correctly, that they have an extremely high chance of success. So in our mind this is very, very exciting.

The new technology is called ECG imaging. So again, it is almost if you can imagine like having a regular EKG done like you would in your doctor’s office where they stick a few electrodes on the chest; of course, with this technology, we stick about 250–300 [electrodes] on your chest. Instead of just giving a little recording, it actually gets to recreate exactly how the heart and atria activate when they are in afib, so I think it’s a potentially huge breakthrough. Once we understand the mechanisms of afib better, I think that we can design even better interventional procedures for the treatment of the arrhythmia.

Mellanie:  Absolutely, so the idea of being able to customize a solution for each patient is fascinating because we know that every afib patient is different. It’s my understanding that you’ve found a little bit different mechanisms for paroxysmal versus persistent, and so that really allows you to customize the treatment based on what you learn about the heart, and that’s fascinating. You guys do the full maze, the full box-lesion set?

Dr. Damiano:  We do both the full maze and really the gamut of minimally-invasive procedures, which mainly involve isolation of the pulmonary veins right now.

What we talked about at the conference is, even in patients with paroxysmal afib, sometimes it’s not the pulmonary veins, and it would be really helpful to know before then because what we would like to do is if your afib is coming from the pulmonary veins and we have an operation that should work a hundred per cent of the time, and it’s defining those patients, and then if it’s not, then let’s go after where it’s coming from.

So what’s happened is that the present idea of just saying “Okay, you’re paroxysmal, this is the operation, which for us in many cases now is a very minimally-invasive pulmonary vein isolation, and if you have a really long-standing afib we need to do a full maze, which can be done, while through a small incision, it’s still bypass.” If we understand the mechanism I think we’ll be able in the future to design a really minimally-invasive operation that works well for everybody, but it would be different for every patient. The one thing we all have to remember, and patients should remember, is that afib is not just one disease—it is extremely different. In some patients it comes from a single area and seems to be driven from that area, and in other patients it involves almost the whole atrium—sometimes it comes from the right atria, sometimes from the left, sometimes it comes from the roof of your atria. It’s very, very different, and the one thing we’ve learned in almost twenty years of mapping patients who were referred to us for atrial fibrillation surgery is that these mechanisms are very complex in some patients, and in other patients, quite simple.

The big question is could we define that before we go in to do a procedure rather than waiting to see if the procedure works and then tell you, “Well, I guess your afib was more complex than we thought.” What we would like to do is know it ahead of time so you can go ahead, for the first time, and you get one procedure and you have a pretty good success idea that that will work.

Mellanie: Absolutely. It’s a fascinating development, and the ability to really customize this and to know what you’re doing before you go in, what you’re going to deal with when you get in there, is absolutely fascinating. Dr. Damiano, thank you so much for sharing with us what you reported on here at Boston Afib.