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Dr. Phillip Cuculich

At 55, A-Fib After Underwater Hockey, Then 2 Failed Ablations & a 3rd Using the ECGI Vest

By Martin Johnson, Champaign, IL. March 2018
With a post-script by Dr. Phillip Cuculich, Barnes-Jewish/Washington Un.

Martin Johnson

“My first A-Fib attack that I noticed, occurred in 2003 when I was 55 years old during a game of underwater hockey, an extreme sport requiring swimming under water while pushing a lead puck from one end of the pool to the other.

At first, I thought “well I did just swim 25 yards under water as fast as I could, so maybe this is just normal”. It lasted about 20 seconds.

The attacks quickly increased their duration to a couple hours each over the next couple months. I was forced to give up the game I’d been playing since age 37. I switched sports to softball, but that soon became impossible too, as I got an A-Fib attack every single game (but oddly, never at a practice).

A-Fib Progresses―Attack Just Sitting at Desk

For the first couple of years I only got attacks after physical exertion. As time went on, less and less exertion was required to trigger one.

I had my first attack without any kind of physical exertion while sitting at my desk at work. It scared me enough to see the local EP who recommended that I get an ablation. I thought that was too aggressive and instead started to try various drugs.

“My EP’s prognosis was―’ever more often, ever longer attacks until I would be in permanent A-Fib’”.

After going through 6 different drugs, most of which had no effect, one of which almost killed me and another that modified my attacks, I had no net improvement. My EP’s prognosis was “ever more often, ever longer attacks until I would be in permanent A-Fib”.

By 2010, I was getting approximately 24-hour long attacks approximately every four days plus occasional attacks triggered by physical exertion.

My First Ablation

I had my first RF ablation in July of 2010. I asked the EP if I should be in my natural A-Fib before the ablation, so that he could locate the problem cells. He said ‘no’. Instead, he induced A-Fib chemically. His approach was to isolate the PVs and draw several other lines in the left atrium. He then ablated the cells that he could detect taking part in the A-Fib that he induced.

He successfully got my heart back into Sinus Rhythm (SR), and was unable to further induce A-Fib. His OR report says that he expected this to have been a cure. (An O.R. [Operating Room] report describes what the EP did during the ablation.)

Two hours after the ablation, I was in A-Fib again.

In A-Fib Again―Leads to a Second Ablation

My A-Fib attack timing continued without letup— 24-hour-long attacks every 4 days. I agreed to a second ablation 6 months later.

“Two hours after the ablation, I was in A-Fib again.”

The OR Report for the second ablation was essentially the same as the first, and so were the results. After both ablations, I acquired new arrhythmias that annoyed me even while not in A-Fib. After about 6 months, the new arrhythmias abated, and my A-Fib pattern changed to 24 hours every 7 days—a small but welcome improvement.

Over the next five years, the attacks became longer and more frequent— by Jan 2016, I had 45 hours of A-Fib every 7 days.

Third Ablation? I Needed an Edge

Still I was not optimistic about a third ablation considering my previous poor results.

Medtronic ECGI vest

I decided I needed an edge—something that might be able to find whatever oddball A-Fib cause made me difficult to cure. The one thing that stuck out in my reading was the Medtronic ECGI vest used in Bordeaux, France by Dr Haissaguerre and others. [See How ECGI (Non-Invasive Electrocardiographic Imaging) Works.]

The 256 electrode ECGI vest enabled the graphic display of the electrical activity of the heart passively and totally non-invasively. Unfortunately, Dr Haissaguerre’s office would not respond to any of my attempts to contact him. And I learned that the FDA would not permit the use of the vest in the US as part of an ablation procedure.

Travel to St. Louis Where the ECGI Vest Was Invented

It seemed that all doors to the vest were shut. After some investigation, I discovered that the vest had actually been invented in the US at Washington Un. in St. Louis, MO. In January 2016

“I volunteered for a study…that might help me get use of the vest in spite of the FDA.”

I called up the inventor’s lab to get as much information as I could. I volunteered for a study with the hope of making connections that might someday help me get use of the vest in spite of the FDA.

In January 2017, I went to St Louis and got a CT scan and a vest recording for the study I had volunteered for. While there, I noticed a Dr. Cuculich come into the lab to borrow a vest. I immediately thought, this is the guy I need to keep track of.

FDA Approves Medtronic ECGI Vest―My New Hope!

Then the next month, Feb 2017, the FDA approved a commercial version of the vest made by Medtronic for use with A-Fib ablation.

By this time, I was having 48 hour attacks every 4 days. I called Medtronic to get a list of who in the US had bought the vest and who had any experience using it. To my relief, Barnes-Jewish Hospital in St Louis was one of only four buyers, and Dr Cuculich already had experience using the vest on non-A-Fib applications.

Now that I had located a possible vest practitioner, I still had to resolve other concerns. In particular, even Dr Haissaguerre in France didn’t use the vest on paroxysmal A-Fibbers. He only used the vest on patients with permanent A-Fib. I don’t know why. I was convinced that being in my natural A-Fib and not in chemically induced A-Fib, was essential to find the real causes. I also knew that I could put myself into A-Fib by physical exertion.

BisenseWebster Smart Catheter illustrations

Example of Contact force catheter (Biosense Webster)

Another Technology Edge: The Contact Force Catheter

Another technology that seemed important was the technique of dragging the catheter in order to burn a continuous line, rather than trying to burn individual dots. To help with this, a contact force catheter also seemed necessary. I first became aware of this due to a paper written by Dr Natale of Austin, TX. (see Resources below for article.)

A Concern: I Don’t Want to Lose My LAA

Another concern of mine was the insistence by some EPs to electrically isolate the Left Atrial Appendage (LAA).

“…in my mind…if the ablation worked, there would be no advantage to having closed off the LAA.”

During A-Fib, the blood in the LAA becomes stagnant, permitting the formation of clots.

But cutting off incompletely understood parts of one’s heart seemed exceedingly rash. Also, if the ablation worked, there would be no advantage to having closed off the LAA. So, closing off the LAA was just preparing for a failed ablation, in my mind.

About the Left Atrial Appendage (LAA)

What little is known about the LAA includes the fact that it is the source of heart stem cells needed for repair of the heart.

It was once thought that the heart cells you died with were the same ones you were born with. The latest belief is that about 40% of your heart is replaced during a full life.

This is a function I did not want to lose.

The LAA is also the source of a hormone which helps control blood pressure. The LAA also has a pumping function in parallel with the Left Atrium. And electrically isolating the LAA can often significantly reduce the contractile function of the LAA, thus making it a source of clots even when the heart is not in A-Fib.

Consulting Dr. Phillip Cuculich at Barnes-Jewish/Washington Un.

I called up Barnes-Jewish to inquire about my above listed concerns. Dr Cuculich called back and assured me that he was able and willing to meet all these requests:

1) Use the ECGI vest during ablation even though I’m paroxysmal;
2) To expect me to be in my organic A-Fib;
3) After getting me into Normal Sinus Rhythm, chemical induction of A-Fib was OK to track down more problems;
4) Use a contact force catheter and draw continuous lines rather than dots;
5) Leave my LAA electrically and physically intact.

Third Ablation―Running Up Flights of Stairs

The night before the scheduled ablation, I ran up and down a flight of stairs ten times which put me in my organic A-Fib in preparation for the following morning’s ablation.

On Nov 2, 2017, two Medtronic technicians fitted the 3-piece vest onto my torso. The ablation procedure took 5 hours—a lot longer than Dr Cuculich was planning on.

I woke up in NSR! The doctor noted that an A-Fib source in a pulmonary vein was active, but was already successfully being blocked by the ablation.

In Normal Sinus, But Short Bursts of A-Fib

Since the ablation 3.5 months ago, I have had about 15 A-Fib attacks totaling about 7 hours of A-Fib. [It’s not uncommon for A-Fib to reoccur during the three month ‘blanking period’ following an ablation.]

I believe every attack was triggered by drinking cold water. It took me a while to figure that out. I have not had an attack for the last month, during which I was able to remember ‘no cold water’!

Lessons Learned

For future reference: I read that Dr Cuculich was the lead investigator in a study of a totally non-invasive ablation procedure that uses the Medtronic vest to find the problems and ‘multi-beam focused radiation’ to ablate the errant heart cells.

I’m hoping that if I my A-Fib comes back, that the FDA won’t have been as slow permitting this new method, as they were with the vest (see Resources below for link).

In light of my experience, I would recommend that no one get an ablation without the advantage of the Medtronic ECGI vest. Without it, the EP is only guessing.

Using canonical ablation patterns that might have worked on some group of A-Fibbers, or using the old fashioned way of dragging a sensing catheter along the entire inner surface of a beating heart looking for electrical anomalies, is laughable to me.

It’s no wonder that my first EP couldn’t find the A-Fib sources inside my coronary sinus and right atrium. I welcome your emails.”

Marty Johnson
martyj1949(at)yahoo.com

Comments from Dr. Phillip Cuculic

Electrophysiologist Phillip Cuculich, MD

Phillip Cuculich, MD

“Thank you, Steve, for the chance to reply [to Martin’s A-Fib story]. And thank you, Martin, for sharing your story with the world. Brave patients and advocates like you are a powerful combination in today’s world of medicine.

Our understanding of any arrhythmia mechanism falls into two bins: the initiating event (triggers) and the sustaining circuit.

Over the past several decades, invasive procedures have identified common locations that harbor AF triggers, which is how pulmonary vein isolation has been an effective procedure to control AF for most patients. In general, we as a field have struggled in identifying reproducible non-PV triggers and the sustaining AF circuits.

One reason for our struggle is the tools with which we measure. A second reason is that each person’s AF is different, so the findings of one group of patients is not easily applicable to an individual patient that I meet for consultation.

Martin’s experience with noninvasive ECGI is a wonderful example of personalized medicine: treating an individual patient’s AF physiology. Credit for the development and clinical validation of this technology goes to the scientists, clinicians and industry development teams which include Dr. Yoram Rudy (Washington University), the amazing scientists who graduated from his lab, the intrepid clinical and investigational teams in Bordeaux, France, and the hard-working developers at CardioInsight and Medtronic.

Presently, thoughtful application of noninvasive ECGI is getting us closer to personalized AF treatment. Further development, testing, and refinement of the ECGI system is underway. While there is much more to accomplish in understanding the critical components of each individual patient’s AF, one cannot help but hear the hope dripping from the story that Martin shared.”

Editor’s Comments
I admire Martin’s tenacity in seeking his A-Fib cure after two failed catheter ablations. He educated himself about his disease and its treatments. Then he sought out an EP who would meet his needs, even drawing up a five-point check list to discuss before his third ablation. Well done, Martin!
Martin’s O.R. Report: Dr. Cuculich found all Martin’s PV’s were still not isolated or had re-connected. After his two previous ablations, all Martin’s PVs had connected/re-connected. Dr. Cuculich also found many gaps in Martin’s previous roof and mitral isthmus ablation lines.
ECGI Vest Found Hard-To-Map Drivers: The Medtronic ECGI Vest mapping system found Non-PV driver areas in Martin’s heart that easily could have escaped notice with routine mapping systems, areas such as the Coronary Sinus, Left Superior Pulmonary Vein and lateral Right Atrium.
During Dr. Cuculich’s ablation, Martin’s A-Fib/Flutter terminated when his Coronary Sinus was effectively ablated and isolated. This is considered the best outcome of an ablation. Most EPs would have stopped at this point. But because the Medtronic ECGI vest had indicated there were more A-Fib signal sources not yet ablated, Dr. Cuculich ablated those areas as well.
Medtronic ECGI Vest Very Effective! Martin’s A-Fib was a difficult case after two failed ablations. Instead of the usually 2-3-hour ablation, Martin’s took 5 hours, probably because the previous 2 ablation lesions made the third ablation more complicated.
The Medtronic ECGI Vest seems to be a major advance and improvement in the treatment of A-Fib. It certainly worked in Martin’s case. But at this time, few centers in the U.S. are using it and are only beginning to develop significant experience. This is because Medtronic wants the system to work as best as possible before making it more widely available.
What this means to patients: If you have persistent A-Fib or would be considered a potentially difficult case, try to find a center or EP with experience using the Medtronic ECGI Vest (even though you may have to travel.) It seems to be the next major advance and best mapping/ablation system on the market.

References for this Article

Kolata, G. A ‘Game Changer’ for Patients With Irregular Heart Rhythm. The NewYorkTimes.com, Dec. 13, 2017. https://www.nytimes.com/2017/12/13/health/heartbeat-tachycardia-radiation.html

Cuculich, P. S., et al. Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia. December 14, 2017. N Engl J Med 2017; 377:2325-2336. DOI: 10.1056/NEJMoa1613773. http://www.nejm.org/doi/full/10.1056/NEJMoa1613773

Ryan, S. The New Era of Catheter Ablation Technology: Force Sensing Catheters. A-Fib.com http://a-fib.com/moussa-mansour-md-force-sensing-catheters-2014-bafs/

Ryan, S. The Role of the Left Atrial Appendage (LAA) & Removal Issues. A-Fib.com http://a-fib.com/left-atrial-appendage-role-and-removal-issues/

Natale, A., et al. Paroxysmal AF Catheter Ablation With a Contact Force Sensing Catheter: Results of the Prospective, Multicenter SMART-AF Trial. Journal of the American College of Cardiology, 2014. ISSN: 1558-3597, Vol: 64, Issue: 7, Page: 647-56. https://doi.org/10.1016/j.jacc.2014.04.072

Learn about sharing your A-Fib story

Return to: Personal A-Fib Stories

If you find any errors on this page, email us. Y Last updated: Monday, May 28, 2018

ECGI vs. FIRM: Direct Comparison, Phase/Waveform Mapping-2014 Boston AF Symposium

Electrophysiologist Phillip Cuculich, MD

Phillip Cuculich, MD

2014 Boston AF Symposium

ECGI vs. FIRM: Direct Comparison, Phase/Waveform Mapping

Report by Dr. Steve S. Ryan, PhD

In a further discussion of the ECGI mapping and ablation system, Dr. Phillip Cuculich of the Washington University School of Medicine in St. Louis, MO gave a presentation entitled “Advances in and Limitations of Noninvasive Mapping of AF.” (For a detailed description and discussion of the ECGI system, see 2013 BAFS: Non-Invasive Electrocardiographic Imaging ECG (ECG).

Background: ECGI stands for Non-Invasive Electrocardiographic Imaging used at Yoram Rudy’s lab at Washington University in St. Louis to understand the mechanisms of heart rhythm disease. A similar system called Electrocardiographic Mapping (ECM/ecVUE) uses similar technology, but has been developed and tested for clinical use in Europe (http://www.cardioinsight.com) and has different goals. Each group works independently and has different ways to seek solutions.
The software used by the ECGI system to produce data and images from the multi-channel ECG mapping and CT scan is called CADIS.

POTENTIAL BENEFITS OF ECGI

Dr. Cuculich began by describing the potential benefits of ECGI:

•  Save time: Locate the arrhythmia in a single beat
•  Better Preparation: Understand and plan for the arrhythmia before an ablation
•  Avoid Frustration: Map and ablate unstable, transient or complex arrhythmias
•  Research Platform for Discovery: Identify and describe the mechanisms of arrhythmias

A-FIB PATTERNS OR SIGNALS AS REVEALED BY ECGI

After imaging patients with ECGI, A-Fib patterns are a combination of mechanisms:

•  In simple A-Fib, Dr. Cuculich showed movies of left pulmonary vein focal sites with 1 to 2 wavelets and a left-to-right activation pattern

•  In complex (Long-standing Persistent) A-Fib, he showed movies of four or more simultaneous wavelets, a high degree of wavelet curvature, and frequent wave breaks (no focal sites). The patterns tend to repeat and follow a preferred path.

FIRM AND ECGI COMPARISON

FIRM

ECGI

Inside the heart Outside the heart (body surface mapping)
Up to 64 contact electrodes to produce up to 64 electrograms 1000 reconstructed electrodes
QRST subtracted No signal subtraction
70% rotor, 30% focal Multiple wave fronts (1-4), 15% rotor
Stable beat-to-beat Transient focal activity, transient rotational circuits

(In the ECGI imaging/mapping system the number of points on the heart is changeable. But they have found 1000 to be a good number for reliable, detailed analysis.)

Dr. Cuculich compared ECGI data to recent invasive epicardial (inside-the-heart) mapping and body surface mapping (called “Phase Lock”). The data showed significant agreement between the imaging systems. Also, ECGI compares favorably to surgical maze mapping data.1

But compared to FIRM, the most common patterns of A-Fib Dr. Cuculich found were multiple wavelets, with pulmonary vein and non-pulmonary vein focal sites. Rotor activity was seen rarely.2

NO STANDARD DEFINITION OF “ROTOR”

There is no standard definition of a rotor. In Dr. Cuculich’s studies he used 2 rotations at the same spot as a “rotor.” This is perhaps why he found less rotors than in the FIRM system and in the CardioInsight system as described by Dr. Jais where they found 80% rotors. See: BAFS 2014 Jais, ECGi & Circular Catheter 

Another major difference in ECGI and FIRM is that ECGI uses wavelet analysis (activation of the wavefront), while FIRM and CardioInsight uses phase mapping to describe the behavior of the arrhythmia. The main point of Dr. Cuculich’s presentation is that one must be very careful when applying phase techniques, as it can introduce rotor behavior into the imaging map. Dr. Cuculich’s group is studying whether this rotor behavior may be a true cause for the maintenance of A-Fib or just an artifact.

ECGI—TOO MANY ELECTRODES?

In a conversation with the author, Dr. Cuculich brought up comments that perhaps ECGI/ECM uses too many electrodes to see stable rotors, that perhaps panoramic imaging with fewer electrodes could improve the identification of rotors. (ECGI has a much larger number of electrode points in the heart [usually 1000] compared to FIRM [64 max].) To test this hypothesis, he analyzed A-Fib using 64 spaced electrodes in each atrium vs. standard ECGI. It turned out that fewer electrodes did not help to visualize rotors.

PHASE MAPPING, WAVEFRONTS, WAVELET TRANSFORMATION, ACTIVATION PATTERNS

Dr. Cuculich introduced new concepts in the use of ECGI (at least to this author)—phase mapping and the importance of wavefronts or wavelet transformation in A-Fib signals. “ECGI uses wavelet transform looking at pure activation time.” He asked, “how does…phase mapping affect the result?” He related phase mapping to the CONFIRM concept of “phase lock” where a simple 12-lead ECG analysis can classify A-Fib mechanistically.3

Doctors (and we patients) are still struggling to understand what phase mapping and wavelet transformation actually mean. Dr. Cuculich’s studies of phase mapping techniques (Hilbert transform) in A-Fib show that phase mapping highlights and accentuates the curvature of a wavefront and thus indicates a rotor is present. According to Dr. Cuculich, phase mapping is highly dependent on the chosen cycle length. He concluded that “while published ECGI data used wavelet transform to identify activation patterns, phase mapping techniques (when performed carefully and correctly) may offer additive information.”

EDITOR’S COMMENTS:

We’re grateful to Dr. Cuculich for his comparison of ECGI and FIRM which helps us understand both imaging system better. But it’s definitely disturbing that both systems vary so greatly. Why does the FIRM system find 70% rotors and ECGI only 15%? Why are FIRM’s A-Fib signals stable and ECGI’s transient? Why does the FIRM system not focus on wavefronts and wavelet transformation?
One way to resolve these discrepancies would be to use a standard Lasso mapping catheter to meticulously map every potential A-Fib-producing spot in an animal or human with Long-standing Persistent A-Fib (where one would expect to find multiple A-Fib producing spots in the heart). Then immediately use both the FIRM and ECGI system to map the same heart and compare the results.
Perhaps the single biggest new discovery in human A-Fib mapping is rotors. But there’s considerable debate about their definition and behavior. Dr. Cuculich found that rotors are relatively rare (15%), whereas the FIRM and CardioInsight studies indicate that 70-80% of A-Fib drivers are rotors.
Dr, Cuculich introduced new concepts, insights and vocabulary to our understanding of A-Fib, (some of which I’m still having trouble wrapping my head around). Are wavefronts and wavelet transformation important in themselves or are they part of the development of rotors? Phase mapping and wavelet transformation applied to A-Fib is a major innovation that may lead to a better understanding of how A-Fib signals activate in the heart. Besides making mapping and ablating A-Fib easier and more effective, ECGI with its detailed, high resolution capabilities may give us new insights into A-Fib.

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Footnote Citations    (↵ returns to text)

  1. Lee, G. et al. Epicardial wave mapping in human long-lasting persistent atrial fibrillation: transient rotational circuits, complex wavefronts, and disorganized activity. European Heart Journal (2104) 35, 86-97. Last accessed May 13, 2013, URL:http://www.ncbi.nlm.nih.gov/pubmed/23935092 doi:10.1093/eurheartj/eht267
  2. Cuculich, PS et al. Noninvasive characterization of epicardial activation in humans with diverse atrial fibrillation patterns. Circulation. 2010 Oct 5; 122(14): 1365-72. Last accessed May 13, 2013, URL: http://tinyurl.com/okp4229
  3. Non-invasive identification of stable rotors and focal sources for human atrial fibrillation: mechanistic classification of atrial fibrillation from the electrocardiogram, Europace. February 28, 2013. Last accessed May 13, 2013, URL: http://tinyurl.com/njt9zd7; doi:10.1093/europace/eut038

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