Just when news in medicine seems all bad there comes some gratification in the lab…
The patient calls and says her heart rate has been 120 beats per minute for a couple of weeks. There is progressive shortness of breath, increased fatigue and now some swelling. Similar symptoms that were present four years ago when a valve was repaired with open heart surgery. An ECG from the internist shows a “funny looking” rapid heart rate from the top chamber of the heart. The ultrasound sadly reveals a weakened heart muscle – a cardiomyopathy.
The arrhythmia is atrial flutter which is acquired as a result of numerous birthdays and prior heart valve disease. But the ECG pattern (like a fingerprint) and the prior heart surgery suggests an atypical variant. Undoubtedly, the sustained rapid heart beat is responsible for these classic symptoms of congestive heart failure as well as the weakened heart muscle.
In the electrophysiology lab, after placement of two catheters it is obvious that the origin of the atrial flutter is form the left side of the heart. More than ninety percent of atrial flutter is from the right atrium and is ablated easily with low risk and usually under an hour. This left sided atrial flutter is many fold more complicated and much riskier to fix.
Ten years ago there would have been no consideration of chasing this. Often ineffective medicines would have been the only option. Five years ago things were a bit better and maybe a University center might have attempted a curative ablation, but success rates were still low. The current state of the art is much improved. After the many advances in catheter and mapping system technology (requiring millions in investment by my hospital) and our five year atrial fibrillation ablation experience the thoughts went something like this: “it is left sided, let’s go see what we can do.” After about 30 minutes or so of mapping with state of the art tools, a familiarity with the anatomy and 15 years of “learning while burning” the tachycardia was narrowed down to the left sided pulmonary vein orifices and ablation terminated the tachycardia – a cure. When after hours in the EP lab the incessant mind numbing tachycardia finally stops during a burn, the technician next to me whispers to herself, “oh my.”
A triumph. For just a precious few moments after the termination of tachycardia there were flashbacks. Like the weekend of “camping” in the Hobart College biology building from Friday to Sunday night studying for Cell biology, Organic chemistry and Calculus final exams. Or those med student (“learner”) days on clinical rotations back in Hartford CT, running around hoping for more disease to present itself. Then the IU medical center where one could alternate between the formalness of the University hospital, the rawness of the county (Wishard) hospital and the stoicism of the veterans at the Indy VAMC.
Like Santiago, the journey was beautiful but the treasure of terminating the tachycardia was grand as well.
In the grand scheme of things, curing a complicated tachycardia is a small victory. Building schools in Pakistan it is not, but for the moment, gone are the CPT codes, the worry of “reform,” and the stress of a new practice. Being a doctor was fun. Grin.
Now how do I do all those codes?