At Vassar Brothers Medical Center, electrophysiologic expertise and multidisciplinary diagnostic and therapeutic capabilities come together in an Arrhythmia Center that is unmatched in the Mid-Hudson Valley and northwestern Connecticut.
Vassar Brothers Medical Center boasts a trailblazing history of heart rhythm disorder care in the Mid-Hudson Valley. It is home to the region’s first and only fully equipped electrophysiology laboratory. Vassar Brothers Medical Center introduced the left atrial appendage occlusion device to the area and remains the only local facility to offer it. In 2017, clinicians there implanted the region’s first transcatheter leadless pacemaker, a potentially game-changing device that could usher in a new era of miniature, minimally invasive pacing systems. Now, the Arrhythmia Center offers diagnosis and treatment of every type of arrhythmia — a level of comprehensiveness that allows Mid-Hudson Valley residents to remain close to home for the same sophisticated care they would otherwise have to travel to large, urban centers to the north and south to receive.
Detecting Abnormal Rhythms
For all patients with suspected arrhythmia, the diagnostic process begins with a thorough history.
“In many cases, electrophysiologists can obtain 90 to 95 percent of the information they need to make a diagnosis simply by talking with patients,” says John Respass, MD, FACC, cardiac electrophysiologist at Vassar Brothers Medical Center. “Next, we typically ask patients to have an electrocardiogram, and then, depending on the frequency of symptoms, to wear a heart rhythm monitor for 24 hours to one month or receive an implanted monitor to determine symptom-to-rhythm correlation.”
The Arrhythmia Center offers a variety of noninvasive evaluations, including several types of echocardiography and stress testing, as well as a comprehensive range of electrophysiologic tests, which clinicians perform in Vassar Brothers Medical Center’s two electrophysiology laboratories.
Vassar Brothers Medical Center was an early adopter of intracardiac ultrasound and continues to use it to outstanding effect.
Sankar Varanasi, MD, FACC, FHRS, CCDS, performs an ablation procedure with remote navigation system at Vassar Brothers Medical Center.
“During electrophysiologic studies or procedures, physicians need to know which part of the heart they are in and ensure they are not close to critical structures to avoid causing inadvertent damage,” says Sankar Varanasi, MD, FACC, FHRS, CCDS, Director of Clinical Cardiac Electrophysiology at Vassar Brothers Medical Center. “Traditionally, fluoroscopy acted as a guide. During long procedures, however, exposure increases, and fluoroscopic radiation has been associated with skin damage. Using ultrasound is safer for patients because it doesn’t involve radiation, and the images ultrasound produces are significantly more detailed than those of X-ray fluoroscopy. Specialized mapping software facilitates reduction in fluoroscopic exposure.”
“Our ability to offer the full range of invasive electrophysiologic evaluations and interventions is atypical for the region,” says Sarah Levin, MD, FACC, cardiac electrophysiologist at Vassar Brothers Medical Center. “We have cardiac mapping capabilities that allow us to make 3D electroanatomic maps of the heart, which we can then manipulate in space to exactly elucidate the mechanism of patients’ arrhythmias.”
Electroanatomic mapping works by using small patches placed on a patient’s skin to create a mini-GPS field inside the individual, according to Dr. Respass. With that navigational framework in place, the electrophysiologist can use information from CT or ultrasound studies to create a 3D image of the patient’s heart that allows for catheter-based radiofrequency ablation of areas that give rise to abnormal rhythms, without the need to expose patients to radiation from conventional imaging studies.
Mark Difalco, Cardiovascular Technologist, and Dr. Varanasi perform an ablation in the electrophysiology lab at Vassar Brothers Medical Center.
In most cases, diagnosis and ablation take place during the same procedure. Electroanatomic mapping allows an electrophysiologist to visualize the location of catheters in the heart, and a complementary technology — robotic magnetic navigation — allows the physician to maneuver the catheters with robotically controlled tableside magnets rather than by hand. The catheters have magnets embedded in their tips. This lends an extra level of precision to cardiac ablation. Vassar Brothers Medical Center’s electrophysiology lab is equipped with robotic magnetic navigation, and it’s one of fewer than 10 such labs in New York state to be outfitted with that technology, according to Dr. Varanasi.
Ablation: Treating Arrhythmia at the Source
Treatment for arrhythmia may begin with behavioral modification, such as stress reduction, or antiarrhythmic medications. For individuals with certain types of arrhythmia, including atrial fibrillation, ventricular tachycardia, AV nodal reentrant tachycardia, atrial tachycardia and Wolff-Parkinson-White syndrome, ablation may be appropriate if conservative measures are insufficient or if patients experience side effects from or prefer not to take medications. Vassar Brothers Medical Center is the only center in the Mid-Hudson Valley that performs ablation for atrial fibrillation and ventricular tachycardia, according to Dr. Respass.
“During ablation, we use a specially designed catheter to deliver radiofrequency waves that cause controlled damage to tissue in the heart so targeted abnormal electrical circuits can no longer function,” Dr. Varanasi says. “We advance small electrodes through veins in the groin to the heart, where we provoke the arrhythmia to identify the abnormal circuits. That’s when the electroanatomic 3D mapping system comes in handy. Once we make the diagnosis, we may use robotic magnetic navigation coupled with 3D mapping to gently guide the ablation catheter to the area of interest, and then we deliver the ablative energy with careful monitoring.”
“Vassar Brothers Medical Center offers comprehensive diagnostic and treatment services for arrhythmia and has an excellent track record of safe procedures, including a low rate of complications, over the past decade.”
— John Respass, MD, FACC, cardiac electrophysiologist at Vassar Brothers Medical Center
John Respass, MD, FACC, talks with a patient to gather information that will aid in making a diagnosis.
To destroy cardiac tissue that gives rise to atrial fibrillation, Dr. Levin says, electrophysiologists use another type of ablation: pulmonary vein isolation.
“The pulmonary veins transport oxygenated blood from the lungs to the left atrium of the heart, and sleeves of atrial tissue can grow up into these veins,” she explains. “In patients with atrial fibrillation that comes and goes, abnormal electrical signals issue from these veins and trigger the arrhythmia. By manipulating the ablation catheter throughout the left atrium and making wide, encircling lesions around the veins, we can wall them off from the rest of the atrium, which is effective in preventing those abnormal pulmonary vein potentials from developing and triggering atrial fibrillation. Ablation can be extremely effective for treating atrial fibrillation. We perform the procedure with patients under anesthesia, and they typically return home the next day.”
Comprehensive Therapeutic Technologies
Left atrial appendage occlusion device
Vassar Brothers Medical Center has long been a leader in offering the latest device therapies to patients in the Mid-Hudson Valley. After the FDA approved the left atrial appendage occlusion device for patients with nonvalvular atrial fibrillation in 2015, the Arrhythmia Center began offering it to individuals who are at risk of stroke but cannot take anticoagulants safely. Atrial fibrillation can cause blood to pool and clot in the left atrial appendage, from which clots can travel to the cerebral arteries.
“Individuals with nonvalvular atrial fibrillation may be unable to take blood thinners for a variety of reasons, such as comorbid conditions or interactions with other medications,” Dr. Varanasi says. “For them, the left atrial appendage occlusion device is a valuable option. We perform a minimally invasive, catheter-based procedure to plug the left atrial appendage with the device. Within weeks to months, the body lines the device with tissue, and it becomes part of the heart.”
Transcatheter leadless pacemaker
Last year, Vassar Brothers Medical Center continued its tradition of early adoption of innovative device therapies when it became the first facility in the Mid-Hudson Valley to offer implantation of a transcatheter leadless pacemaker for bradyarrhythmia, or slow heart rate. Unlike a conventional pacemaker, which requires an incision and creation of a pocket beneath the skin in which the device resides, the leadless pacemaker, an approximately 1-inch capsule, is placed directly into the right ventricle of the heart using a catheter inserted through a puncture in a vein in the groin. Unencumbered by external wiring, patients avoid dislodgement, malfunction of the wires and other lead-related complications that can occur with conventional pacemakers.
Erin Gillen, DNP, FNP, ANP-BC, CCDS, monitors a patient’s device at the Device Clinic.
“The leadless pacemaker offers tremendous benefits in terms of ease of postoperative care,” Dr. Levin says. “With a typical pacemaker, patients face a seven- to 10-day moratorium on showering because of the risk of infection, and a four-week restriction on use of the arm through which the pacemaker was placed. With the leadless pacemaker, patients complete six to eight hours of bed rest after placement, and that’s it — they don’t have any other restrictions. There is no visible, external sign of a pacemaker and no issue with skin thinning over a typical pacemaker site.”
Eligibility for the leadless pacemaker is limited to a small class of patients, Dr. Levin says, but she envisions many more individuals benefiting from it and subsequent iterations in the future.
“Right now, the leadless pacemaker is applicable to about 10 percent of people who need pacemakers because it can provide pacing support in just one chamber of the heart, and most people need more support than that,” she says. “The most exciting thing is this technology is a jumping-off point for a wave of new devices in the future.”
The Arrhythmia Center also offers other device therapies, including:
- Conventional, lead-equipped pacemakers implanted through a vein in the shoulder for patients with slow heart rates.
- Implantable cardioverter defibrillators — also placed through a vein in the shoulder — for individuals with ventricular fibrillation and other conditions involving rapid heart rates.
- Implantable loop recorders for long-term heart rhythm monitoring.
Cardiac resynchronization therapy, another type of device therapy available at the Arrhythmia Center, can improve heart function in individuals with congestive heart failure.
“A key part of our patient-centered approach at the Arrhythmia Center is providing the best, most advanced treatment options in the Mid-Hudson Valley so patients don’t have to seek them elsewhere. That is why we were the first in our region to offer the left atrial appendage occlusion device and the transcatheter leadless pacemaker.”
— Sankar Varanasi, MD, FACC, FHRS, CCDS, Director of Clinical Cardiac Electrophysiology at Vassar Brothers Medical Center
“Cardiac resynchronization therapy devices are, predominantly, defibrillators, but they can also be pacemakers,” Dr. Varanasi says. “They are designed to make the heart’s electrical function similar to its natural activation. Loss of synchronicity can lead to heart failure, and in these patients, cardiac resynchronization therapy can improve heart failure symptoms by correcting the heart’s rhythm and provide lifesaving defibrillation, if necessary.”
“Atrial fibrillation is a significant problem in the Mid-Hudson Valley. That is why, earlier this year, we created a comprehensive atrial fibrillation program at Vassar Brothers Medical Center so patients can visit one facility for all of the services they need without having to travel far from where they live and work.”
— Sarah Levin, MD, FACC, cardiac electrophysiologist at Vassar Brothers Medical Center
Dr. Respass and Jennifer Schmidt, FNP-C, review a patient’s device interrogation.
Prioritizing Minimally Invasive Therapies
Achieving better outcomes via less invasive means is not just an aspiration at Vassar Brothers Medical Center, it is a reality. Electrophysiologists perform almost all treatments in a minimally invasive manner, according to Dr. Varanasi, and patients rarely spend more than 24 hours recovering in the hospital, whether they have undergone ablation or device implantation. The electrophysiology team is working to convert certain procedures into same-day treatments.
Team members from the Arrhythmia Center at Vassar Brother Medical Center
“Ours is a full-service Arrhythmia Center that is wholly dedicated to providing leading-edge care to the communities we serve,” Dr. Varanasi says. “We’re excited about imminent innovations that have the potential to further enhance our ability to improve patients’ lives.”
For more information about arrhythmia diagnosis and treatment at Vassar Brothers Medical Center, visit healthquest.org/arrhythmia.