Pill-In-The-Pocket, Then Ablation at Stanford by Dr. Zei and Force Sensing Catheter Clinical Trial
by Mark Lowry, 2012
A-Fib Starts in 2002
I started having cardiac arrhythmias in ~2002. It was not properly diagnosed as Atrial Fibrillation (A-FIB) until ~2005. My symptoms were a widely erratic heartbeat that was quite noticeable to me, light-headedness, and shortness of breath. This condition itself is not life-threatening, but it sure does screw up quality of life, and there is an increased chance of stroke with people who are in A-FIB a lot.
My first cardiac doc put me on digitalis and something else that I can’t recall. This made me feel very tired all the time, so asked doc #2 if there wasn’t another treatment. He suggested the catheter RF ablation process. At the time the success rate he was claiming was only 70%, and it sounded like a pretty big deal. So I asked him why I couldn’t just take a pill whenever I felt an episode. He said, yeah he could order that (it seems like they should have suggested this right off the bat, since I was in A-FIB only occasionally.. why take a drug if you didn’t have to?). So, I carried Rythmol with me all the time, but I typically only needed to use it on average once every couple of months. And I tried to remember to take a baby aspirin each day.
Pill-In-The-Pocket Stops Working
However, over the last year or so the episodes became more frequent. In the last several months they become very frequent, and physical exertion would tend to bring them on. When swimming I could only get my heart rate up to about 110 bpm without breaking into A-FIB. And grinding a winch on a sailboat or any strenuous activity would bring it on. Previously, I could easily push to 150 bpm and beyond, so this was really screwing up my workout and lifestyle. It was time to consider other treatment approaches.
Researching the Internet, Choosing Stanford and Dr. Zei
So, I researched the catheter ablation process (again) online and found this site (www.A-FIB.com) which I found to be quite useful. It seemed like the success rates were higher than previously advertised, but it was greatly dependent (like many skilled medical procedures) on who was doing it. Stanford University Hospital was recommended by several sites that I looked at. So, I made an appointment with them. I met with Dr. Zei. He is a clinical associate professor at Stanford Medical School, the director of their Electrophysiology Department, and has a PhD in electrophysiology in addition to his MD.
I was impressed with him, especially the fact that he had a PhD in electrophysiology. This indicated to me that he was probably a good thinking, problem-solver, not just another “cookbook” doc. He spent close to an hour with me and subsequently answered lots of questions via email… you don’t see that very often. He indicated that their success rate was as high as 90% with people who fit my profile.
So, I decided to have them do it. And I agreed to be a test subject in a clinical study that could help them advance the state-of-the-art in this area (they were testing a slightly modified ablation probe, one that had a sensitivity to touch, or pressure (Biosense Webster SmartTouch). Seemed like a good thing to do, to help advance the technology, and the risk appeared to be quite low.
Explanation of the Ablation Process
In this procedure they snake at least 3 catheters through various veins to access the heart, both femoral veins and a vein in the neck. They use the catheters to map out the electrical impulses, looking for the errant ones that are causing the atria to misfire. Also, one of the catheters has a high power RF transmitter (think microwave oven, here). They use the RF to “ablate” or destroy the tissue on the surface. When scar tissue forms, this blocks the errant nerve impulses and only allows the correct impulses to trigger the atria. They use other catheters and various tubes to run cooling fluid past the ablation tip to keep the temperature down. In my case I think they put a total of 6 tubes of one kind or another into me during the procedure. So here’s a rough chronology…
Wednesday: Preliminary Tests—Mark’s Ablation Procedure
Reported to Stanford. Had several tests done, echo cardiogram, EKG, and a very, very long cardiac MRI (about 1.5 hours stuck in that damn tube, trying to stay still). No sedation was required for any of these. For the study, they wanted to capture an EKG with me in A-FIB. But the first time they tried, I was not in A-FIB. But around lunch time I felt myself going into A-FIB, so I paged the study coordinator (a very nice and helpful RN, Linda), and she hustled me in through the back door to get the EKG captured with me in A-FIB. I was asked to discontinue using the Rythmol two days prior to the procedure. It is easier for them to find the tissue that needs to be zapped if you are in A-FIB while they are doing the procedure. But, they also have ways of triggering the bad nerve impulses, using electrical and chemical excitation. However, they hope that the patient presents in A-FIB for the procedure.
Monday: Trans-Esophageal Echocardiogram (TEE)
Had to report to Stanford for another test requiring sedation. This was a trans-esophageal echocardiogram. A significant risk in the ablation procedure is burning the esophagus, so they want to image the heart through the esophagus to figure out how close the target heart tissues are to the esophagus, in addition to getting another overall look at the heart, looking for clots, etc. During the ablation procedure they also run a temperature probe down your esophagus to monitor how hot it is getting. This didn’t take long, but getting knocked out with the sedation destroys the rest of your day.
Tuesday: The Ablation
The main event. Reported to Stanford a little before 0600, so we had to get up at O’dark-thirty to get there in time. They soon had me in the prep ward, shaving my groin and putting an IV in each arm. (They are fond of poking lots of holes into you). There I was visited by the anesthesia doc, his fellow, and by Dr. Zei, followed by his fellow, the head surgical nurse, and Linda the study coordinator. Since Stanford is a teaching hospital (of world renown), the fellows (these are subspecialty guys who have already served a cardiac residency) are actively involved in your care. With all these folks coming and going, makes you feel kind of popular, if it wasn’t for all the holes they were poking in ya, and everybody wanted to check out your groin to make sure it was prepped….
Finally, they rolled me into the operating room. Everybody introduces themselves again, and they explain everything that they are going to do to me (again) and do I have any questions? (They all seemed to be in a weirdly festive mood)…It occurred to me to ask if I could back out at this point, but I decided they may not appreciate my warped sense of humor, and I wanted to take great care to not piss anybody off (I maintain this is a good posture with people who will shortly hold your life in their hands). So I wished them all good luck, and before I knew it, I was under.
About 4.5 hours later, I woke up in the recovery room with a couple of the nurses calling my name to bring me out of my stupor. Very groggy, of course, but didn’t feel too bad. Then they went to work pulling out all the sheaths that were stuck into various veins. They put you on massive doses of blood thinner to prevent clotting while they are doing the procedure, so stopping the bleeding when they pull out these sheaths is a pretty significant part of the recovery process. One by one, they pull out the sheaths and apply a lot of pressure to the puncture wound to stop the bleeding. Nothing else, as far as I know, just pressure.
Once they have the bleeding stopped, they observe you for a while. A few minutes after they had pulled everything out, I felt something warm and sorta spurty on my right thigh. This didn’t seem like a good thing. I rather casually mentioned this to the attending nurse, and she quickly pulled up my gown (they like to do this a lot too) and started applying a lot of pressure and cleaned up the mess. She was kinda freaked out by this and thanked me profusely for quickly letting her know this was happening.
Once they observe the puncture wounds for a while, they put some special see-through bandages over them. Then they give you the bad news, you have to lay completely still for 6 hours to make sure that the wounds begin to heal. (Now they tell me!) At this point my back is already killing me from lying in one position for many hours already… I now have to go 6 more hours without moving!
Intermediate Cardiac Care War
After they were satisfied that the bleeding had stopped, they moved me to the “Intermediate Cardiac Care” ward, where I waited out my 6 hours of immobility. “Fortunately”, one of the other tubes they stuck into me was a Foley catheter, so there is no need to get up to pee (remember they don’t want you moving at all for 6 hours). More on this damn Foley thing later. Finally, after over 12 hours of immobility I am allowed to move.
My bed was in a room with four other beds (partitioned by curtains). All the patients are hooked up to machines that automatically monitor heart beat (like an EKG), oxygen levels in the blood, and blood pressure. These monitors are hooked into their network system and are monitored at the nurses’ station just across the hall. There were typically several licensed practical nurses (LPN) in the room at any given time, and RNs, doctors and phlebotomists coming and going at all hours. A noisy, busy place.
All care is documented through their central computer system. Every time they give you a drug they scan your wrist bracelet and then ask you your name and date of birth. And when you complain of anything, this too is entered into the computer. Then they enter the drug(s) that they gave you into the computer (I think they may scan the IV drugs into the computer). All of the nurses were continually looking at computer screens and entering data as they went. Stanford makes fairly wide and effective use of computerized medical records which is a good thing, less screw-ups especially with medications, etc.
Sometime during this day, one of the less likeable LPNs asked me whether or not I wanted the Foley removed. She indicated that I had to have a bedpan if I got the Foley removed. It was pretty clear that she really did not want to go the bedpan route, and it didn’t sound too good to me either. So I elected to keep the Foley in. What a mistake!
Tuesday Evening—Chest Pain
Around 8PM I noticed increasing chest pain that got worse upon taking a deep breath. This got progressively worse until the pain was at “kidney stone” level. The on-call cardiac resident showed up and did a very long echo scan looking for any fluid buildup around the heart. Eventually, he convinced himself there was none. Once I complained of the pain, they increased the frequency of checking my vitals and kept saying they all looked good. Finally, they started pushing 25 mg of Fentanyl once every hour into my arm. That helped. But this drug dissipates rapidly in the system, so once an hour was just not enough. Eventually, by about 0400 Wednesday they finally got me a push button Fentanyl system that allowed me to push 25 mg every 15 minutes into my arm. So I held this button in my hand for the first couple of hours; and every time the light came on (signaling that I could have another dose), I would push the button. Finally, this was controlling the pain to a manageable level.
Wednesday: Dr. Zei Takes Care of My Chest Pain
After a very long and sleepless night my pain was under control, but it was still not clear what was causing it. I had to wait for Dr. Zei and his entourage to make their rounds so I could get his diagnosis. By about 0900 he showed up with a couple of his fellows and his RN, Angela. He believed that the pain was due to an inflammation of the pericardium, due to the ablation process. He said normally this is not much of a problem, but clearly was in this case. He then recommended Toradol which is a powerful anti-inflammatory drug and a pain killer. About an hour later they started pushing a Toradol IV into my arm. Within minutes I could detect that the pain was moderating. Within an hour I was pushing the Fentanyl button less frequently, and by mid afternoon I had ceased pushing any Fentanyl. Pretty dramatic change. They also put me on Lasix which is a diuretic to help me get rid of the extra fluid in my body. Most of this was cooling fluid (saline I suppose) that they injected into my system to cool the ablation tip (not exactly sure of the plumbing route). They were also detecting some fluid in my lungs, which needed to go. Also, they upped the frequency of visits from the friendly phlebotomist to something like every 4 hours to more closely monitor things like electrolyte levels.
One More Night In the Hospital
On his morning rounds Dr. Zei had indicated that, given the rough night I had had, he thought I should consider staying another night for observation, but that we could make the final call in the afternoon. Angela stopped by several times during the day to see how I was doing. On her last visit late in the afternoon we made the decision to stay in the hospital one more night for observation. Linda, the RN coordinating the study, also stopped by several times to see how I was doing.
Thursday: Removing the Foley Catheter and Going Home!
After another mostly sleepless night, I got the 0500 visit from the phlebotomist who wanted to take more blood just as I was drifting off to sleep. I didn’t get back to sleep after that. But my pain was essentially gone. So other than not sleeping, I felt pretty good. Deb arrived by 0730, and we were then essentially in wait mode to get discharged. Dr. Zei and his entourage stopped by around 1000, and we all agreed that I could go home. Yipeeee! But one more big event needed to take place… I could finally get that Foley catheter removed. What a nasty invention. Very painful peeing the first couple times after they removed the damn thing, and still is. Then it took until about 1:30 PM for the bureaucracy to catch up and get me discharged. So, we finally got home around 2:30.
Was finally able to take a shower! I could hardly stand myself any longer. Weighed myself and was 8 pounds heavier than the day I went into the hospital. Yikes! Was that all extra fluid?
I have lots of drugs to take on a pretty regimented basis and have to give myself a shot of Lovenox twice a day for a few days, until the Coumadin kicks in. Kinda creepy giving yourself a shot, but it doesn’t hurt. I will be on Coumadin (a blood thinner) for 2-3 months as a precaution, and anti-acid drugs to protect my esophagus (as a precaution).
Feeling Better—No A-Fib!
Weighed myself and have lost all 8 pounds of extra fluid. Feeling much better! Able to pee without much discomfort. Sunday went for a nice-and-easy 1.5 mile walk in the local park. Monday went for a more vigorous 2 mile walk. Today went for a 2.5+ mile walk, up and down some significant hills. I’m now able to breath deeply without any discomfort or involuntary coughing. Did some work from home today, and will do more tomorrow. Plan to be back in the office by Thursday. Probably won’t be able to get back to swimming until next week though.
Thus far, I have detected no A-FIB at all, only a skipped beat a few times per day. So, thus far, it appears to me that the ablation has been successful. Probably won’t know for sure, though, for another couple of months. The real test for me will be whether or not I can get my heart beat cranked up to maximum without the rhythm falling apart. That test will have to wait till next week.