Ablation for atrial fibrillation may take great skill and precision, but for many patients it's the best solution.
It wasn't long after he arrived at Yale to head the Complex Ablation Program that Joseph Akar, MD, PhD, treated his first patient. The 68-year-old man was in heart failure due to uncontrolled atrial fibrillation (Afib). An anti-arrhythmic medication caused side effects that were so severe he had to discontinue taking it. During the complicated procedure, Dr. Akar was able to restore the patient to normal sinus rhythm.
More than a year later, the man is able to maintain normal heart rhythm on his own, with no medication, and his heart function is back to normal. "Atrial fibrillation, while not immediately life threatening, can cause stroke and have a significant impact on quality of life," says Dr. Akar.
In his practice, Dr. Akar sees patients with cardiac arrhythmias that are symptomatic, have failed medical management and are potentially deadly. Of these, A-fib is the most common. Most likely due to the aging population and the increase in conditions associated with heart disease, A-fib is on the rise. Between 12 and 16 million cases are projected in the United States by the year 2050.
There are multiple drugs to treat the condition. The best of them have less than a 50 percent likelihood of keeping the patient in sinus rhythm over a period of one to two years, but toxicity and side effects can be severe. "There are more and more data indicating that ablation is much more effective than medication in terms of maintaining normal sinus rhythm. This has been demonstrated to significantly reduce symptoms and enhance the quality of life of patients with A-fib, and may lead to improved overall outcomes, although this evidence is preliminary," says Dr. Akar.
Although ablation has been around for two decades, techniques have been refined and the number of conditions it can be used to treat has expanded in recent years. The Yale-New Haven Hospital Heart and Vascular Center is the first in Connecticut to offer epicardial VT ablation, which targets ventricular tachycardia a potentially lethal rhythm that sometimes originates on the outer surface of the heart. In the past, this condition was treated with medications that often were not effective or open heart surgery.
The procedure involves accessing the pericardium, which is the lining of the outer surface of the heart, using a needle inserted underneath the rib cage. "It requires a fair amount of expertise, because the space we're trying to access is really a virtual one—it is only one or two millimeters," says Dr. Akar, the only Yale physician who performs the procedure."You have to be precise in order not to puncture through the heart muscle." Otherwise the procedure is similar to other radiofrequency catheter ablation. Dr. Akar locates the problem areas using a catheter to measure voltage in areas of healthy tissue and scar, or induces the arrhythmia and uses 3-dimensional mapping to localize the short circuits.
When patients have asymptomatic arrhythmias like A-fib, they generally do not need ablation procedures. But others have symptoms such as palpitations or shortness of breath that can be frightening. "When you restore them to sinus rhythm, they're grateful because in a sense you restore normalcy to their lives," he says.
Name: Joseph G. Akar, MD, PhD
Title: Associate professor of medicine; director, Yale-New Haven Hospital Complex Ablation Program
Area of expertise: Clinical electrophysiology, radiofrequency ablation of atrial fibrillation and ventricular tachycardia, defibrillators and cardiac resynchronization therapy
Place of birth: Beirut, Lebanon
College: Pennsylvania State University
Med School: University of Pittsburgh
Training: Residency in internal medicine at Yale-New Haven Hospital; fellowship in cardiology and cardiac electrophysiology, University of Virginia; PhD in molecular and cellular physiology, University of Virginia
What is most challenging to you in academic medicine? Electrophysiology is a specialty that demands a high level of clinical activity in order for procedural skills not to deteriorate. The most challenging aspect in academic medicine is in developing significant research efforts while also maintaining a high level of clinical output.
What is most rewarding? Improved patient outcome is the most rewarding aspect of clinical medicine. Whether it is improving the quality of life by restoring normal rhythm to a patient with symptomatic atrial fibrillation or terminating life-threatening ventricular tachycardia. But the academic aspect is also extremely fulfilling. The thrill of discovery and making insights into the pathophysiology of disease as well as potential therapeutic interventions is extremely rewarding and is the reason I am in academic medicine.
What do you like most about your practice? The rich academic environment of Yale is unparalleled and being surrounded by fantastic clinical colleagues makes it a pleasure to come to work every day.
Personal interests or pastimes? I love watching and playing soccer, and I really enjoy traveling, both domestic and overseas.
Last book read: The Brief Wondrous Life of Oscar Wao by Junot Díaz
What would you do to improve our clinical environment if you had a magic wand? In an ideal world we would have universal delivery of excellent affordable health care to all individuals.