Treatments & Devices
Treatments
The underlying cause of an arrhythmia provides the basis for selecting the best treatment. Treatments fall into several main categories along a continuum from the least to most invasive. In general, the least invasive treatment that effectively controls the arrhythmia is the treatment of choice. Options include lifestyle changes, medication, devices, ablation procedures, and surgery, including the implantation of pacemakers and defibrillators.
Lifestyle Changes
Medications
Electronic Devices
Cardioversion
Catheter Ablation
Surgery
Treatment Decisions
Lifestyle Changes
Since other heart disorders increase the risk of developing arrhythmias, lifestyle changes often are recommended. In addition, improving health can lesson the symptoms of arrhythmias and other heart disorders as well as prove beneficial to overall patient health.
Medications
Medications can control abnormal heart rhythms or treat related conditions such as high blood pressure, coronary artery disease, heart failure and heart attack. Drugs also may be administered to reduce the risk of blood clots in patients with certain types of arrhythmias.
Learn more about medications that treat heart rhythm disorders.
Cardioversion
Cardioversion is a brief procedure where an electrical shock is delivered to the heart to convert an abnormal heart rhythm back to a normal rhythm.
Catheter Ablation
Catheter ablation is a procedure where one or more flexible, thin tubes (catheters) are guided via x-ray into the blood vessels and directed to the heart muscle. A burst of radiofrequency energy destroys very small areas of tissue that give rise to abnormal electrical signals.
Catheter Ablation for Atrial Fibrillation
The Arrhythmia Institute at St. Luke's-Roosevelt Hospital participated in a live webcast of a catheter ablation, a new treatment for atrial fibrillation.
Surgery
Although surgery is sometimes used to treat abnormal heart rhythms, it is more commonly elected to treat other cardiac problems, such as coronary artery disease and heart failure. Correcting these conditions may reduce the likelihood of arrhythmias.
Treatment Decisions
The first step in treating any arrhythmia is determining the underlying cause of the problem. Then, patients and clinicians can discuss treatment options factoring in the circumstances of each individual case. The following are some of the considerations when determining appropriate treatment:
- The nature and severity of the heart rhythm disorder and its symptoms
- Underlying diseases and other conditions that contribute to the disorder or affect the patient's health or quality of life
- The patient's age, overall health and personal and family medical history
- Medications and other therapies that the patient may be using for other conditions
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Devices
Electronic Devices
By delivering a controlled electric shock to the heart, defibrillators or cardioverters “shock” the heart back into a normal heart rhythm. Sometimes the devices are external, such as in an emergency situation. Often, the electronics are implanted in the patient’s chest.
- Implanted Cardioverter Defibrillators (ICDs). ICDs are 99 percent effective in stopping life-threatening arrhythmias and are the most successful therapy to treat ventricular fibrillation, the major cause of sudden cardiac death. ICDs continuously monitor the heart rhythm, automatically function as pacemakers for heart rates that are too slow, and deliver life-saving shocks if a dangerously fast heart rhythm is detected.
- Pacemakers. Devices that “pace” the heart rate when it is too slow (bradycardia) can take over for the heart’s natural pacemaker, the sinoatrial node, when it is functioning improperly. Pacemakers monitor and regulate the rhythm of the heart and transmit electrical impulses to stimulate the heart if it is beating too slowly.
- Cardiac Resynchronization Therapy (CRT) for Congestive Heart Failure Devices for Heart Failure The U.S. Food and Drug Administration (FDA) recently approved a special type of pacemaker for certain patients with heart failure. In Cardiac Resynchronization Therapy, an implanted device paces both the left and right ventricles (lower chambers) of the heart simultaneously. This resynchronizes muscle contractions and improves the efficiency of the weakened heart.
The Arrhythmia Service of St. Luke's-Roosevelt Hospital has become the first center in New York City to have the Spectranetics Laser Sheath” with the CVX-300 Excimer Laser for the removal of chronic pacemaker and defibrillator leads. This laser catheter, which obliterates the scar tissue binding these leads, represents a significant advance in lead removal technology making extraction procedures safer and easier to perform. This technology has become available to the Arrhythmia Service through its participation in the Pacing Lead Explant with Excimer Sheath (PLEXES) Trial.
Cardiac Lead Removal
A cardiac lead is a flexible wire, coated with insulation that connects a pacemaker or implantable cardioverter defibrillator (ICD) to the interior of the heart. Removal of the lead may be necessary under certain circumstances. Cardiac Lead Removal is often referred to as lead extraction.
A key challenge in removing a pacemaker or defribrillator lead from the heart is overcoming the fibrous tissue that grows around around the lead around the lead and adheres to it. The Spectranetics Laser Sheath (SLS II®) delivers ultraviolet light generated by the Spectranetics Excimer Laser system to free leads from this binding tissue.
A ring of laser energy gently breaks down the scar tissue into particles that are easily absorbed into the blood stream. This process frees the lead from the binding tissue and enables the physician to remove the lead in a controlled fashion.
Why do Cardiac Leads need to be taken out?
- The lead is damaged
- The lead requires more energy to function than the device (pacemaker or ICD) is able to deliver
- There is an infection at the implant site of the lead
- The lead is interfering with blood flow back to the heart
The Lead Removal Procedure
The laser is calibrated before the start of the procedure. An incision is made and the old device is removed. According to the size of the leads, an appropriate lead locking stylet is advanced to the tip of the lead and a suture string is deployed on the outer surface. The laser is deployed over the sheath and under fluoroscopic guidance, binding sites are ablated using short bursts of laser energy. Traction–countertraction is employed to remove the last embedded portion of the lead and if indicated, a new system can be re-implanted immediately after extraction. Major complications rarely occur with this technique, and include tamponade, hemothorax, pulmonary embolism, lead migration and death.
Image courtesy of The Spectranetics Corporation ©
Outcomes
Laser-assisted lead extraction has been shown to be highly successful with a low procedural complication rate. One of the largest initial studies was reported in 2000; this study examined 1684 patients who underwent lead extraction at one of 89 centers. Laser lead extraction was successful in 93% of cases, with a complication rate of 2%.
The PLEXUS trial compared laser assisted extraction with standard extraction. In 301 patients, complete lead removal was achieved in 94% with the Laser as opposed to only 64% in the standard group; the major complication rate was 1.96%.
A larger study has recently reported on the safety and efficacy of laser extraction in a more contemporary period. The LEXICON study, reported in early 2010, evaluated 1449 patients who underwent laser lead extraction and reported a clinical success rate of 97.7%, a complete lead removal rate of 96.5%, and a major complication rate of only 1.4%.
Source: © Heart Rhythm Society
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