Program of Excellence

If the ideal doctor-patient encounter is a time of warmth and caring, physicians in the Yale Electrophysiology and Arrhythmia Service provide that in consultations and follow-ups, and in support groups where people who live with abnormal rhythms share emotional stories.

Actual treatment is a different matter. For instance, in order to ablate a cardiac arrhythmia, doctors work in one of three dedicated procedure suites, using some of the most high-tech equipment in Yale-New Haven Hospital. They’ll spend several hours moving catheters through a patient’s veins and into spaces inside the heart, tracking progress on a computerized map as they seek out and eliminate offending tissue.

“Just trying to find out where the arrhythmia is can take a long time. You may not know precisely where it is until you’re doing the procedure,” said Mark Marieb, MD, clinical director of the practice. “You’re mapping, taking recordings from multiple areas and monitoring it on the computer system. The area to ablate needs to be precisely located. It can take hours and it can be intense.”

The work is clearly a passion for six highly skilled Yale Medical Group physicians and a dedicated practice staff. Dr. Marieb left a robust private practice to serve as clinical director of Yale Medical Group’s service. Joseph Akar, MD, PhD, came to direct the Complex Ablation Program. They join clinicians with long-standing reputations, including Drs. William Batsford, one of electrophysiology’s original pioneers; Jude Clancy, Rachel Lampert and Lynda Rosenfeld.

In the past several years rhythm disorder treatments have improved, thanks in part to new tools such as catheters that can access smaller veins, intracardiac ultrasound that provides better imaging during procedures, and 3D mapping systems.

Yale’s group also underwent an expansion in the past few years, hiring Drs. Akar and Marieb, and expanding its dedicated electrophysiology lab staff to its current size of 15 nurses and 10 technologists. A recently renovated treatment area in Yale-New Haven Hospital has three procedure rooms that function like operating rooms, with strict regulatory requirements for sterility. Doctors see patients in Branford, Derby, Guilford and New Haven.

In addition to catheter ablations, the physicians implant defibrillators, cardiac resynchronization devices and pacemakers—easing dizziness, fainting and palpitations, and reducing the risk of sudden death for patients. They also use drugs to help control rhythm problems.

They say their practice stands out in Connecticut for several reasons:

• The service is the oldest and largest of its kind in the state, providing 400 new outpatient evaluations and 4,100 follow-ups a year.
• Physicians provide every available treatment, from device implantation to ablation therapy, and treat patients regardless of age or difficulty, including those with valve disease, structural heart disease or long-standing persistent atrial fibrillation.
• The service is the only one in Connecticut to offer comprehensive treatment of ventricular tachycardia—a potentially lethal heart rhythm—including device therapy as well as endocardial and epicardial ablation.

The work is demanding. While a pacemaker implantation may be completed in an hour, some complex ablations have taken as long as eight hours.

“You really have to wear two hats—the internist’s hat and the surgeon’s hat,” said Dr. Akar. “Like other fields of internal medicine, it is very cerebral. We analyze signals and try to figure out from which areas of the heart they originate and what kinds of rhythms a patient is having. So there’s a lot of intellectual effort that goes on in terms of the diagnosis and management of the patient. But similar to the surgeon, we are also very procedure-based—and some of that is highly technical.

Radiofrequency delivery needs to be very precise and accurate, and when we perform certain cardiac ablations, we access a space that is on the order of one millimeter—literally. You have to rely on a lot of expertise in order to do that,” he said.

They are filling important gaps in the state. In January 2011, Dr. Akar was the first and is still the only doctor in Connecticut to perform nonsurgical epicardial ablations for ventricular tachycardia, a rhythm that can cause multiple painful defibrillator shocks, fainting or even death. “We have patients who are so grateful they we can do this for them. Any other modality would require more extensive surgery and have lower success rates and higher morbidity,” he said.

Meanwhile, Dr. Clancy has continued to do more lead-extraction procedures than any other physician in Connecticut. A lead is a wire that delivers energy from a pacemaker or defibrillator to the heart muscle, and it should be removed if it malfunctions, or causes excessive scar tissue or infections. But many doctors leave leads in even as they insert new ones, and Dr. Clancy, using a laser technique, has removed as many as six old leads from one patient.

“I think, in the current day, if you’re practicing high-quality electrophysiology, you have to have a program to take out leads. It’s necessary if you want to completely eradicate infection, and it’s an important part of a strong academic, high-quality program,” Dr. Clancy said.

In addition to her clinical practice, Dr. Lampert is researching the physiological effects of psychological stress—anger, danger and negative emotions—on patients prone to arrhythmias, and the precipitation of those arrhythmias.

“Having a device such as a defibrillator can have a big impact in someone’s life. There have been restrictions on exercise, or patients can experience shocks at the end of life. One of my goals is lessen the impact of having a defibrillator so that patients can live as normal a life as possible,” Dr. Lampert said.

She will soon begin working with Jeffrey Weinreb, MD, chief of Magnetic Resonance Imaging (MRI), to test a pacemaker that is compatible with MRI, which has long been thought to interact negatively with cardiac devices, as well as to evaluate the safety of MRI for patients with devices in general.

Having a forum to teach all of this to upcoming physicians is another thing that makes the program stand out, and it keeps the physicians fresh, said Dr. Rosenfeld, director of Yale’s Clinical Cardiac Electrophysiology Fellowship Program, which provides two fellows a year with opportunities for superb clinical training and research. “We’ve always had a tradition of teaching the basic physiology of electrophysiology, and to love the beauty of that rather than just doing the procedure,” she said.

The fellowship program has changed dramatically since Dr. Rosenfeld was a fellow in 1981. (Drs. Clancy and Lampert also completed the fellowship.) “It’s ‘Star Wars’ now. We’re teaching techniques that weren’t done then. But it’s all one-to-one with an attending physician, and fellows have graduated responsibilities throughout their training.”

In April 2010, the practice added another element: a patient and family education and support group that has drawn as many as 50 participants, and is also unique in the state. “We’ve found there is actually a big need for this,” said Marianne Cosentino, APRN, atrial fibrillation program coordinator. Some patients with the disorder experience a great deal of stress because they never know when they’ll have an episode, she said.

“It’s helpful for the person to have a chance to talk about their experiences and fears. We tell them if they have questions, call and talk to us rather than sit home and worry. Their feelings and concerns are important and should be addressed,” she said.

Often it can be fixed, and doctors in the practice feel they’ve found their calling in making their patient’s lives normal again. “This work is not for everyone. If you’re not a very patient person, it’s not for you,” said Dr. Akar. “You need to have a love for the field and a love for patients, and we do love it.”