Montefiore Einstein Department of Medicine

First Epicardial Ablation Performed at Weiler

Eugen Palma, MD
A complex procedure recently added to the Montefiore Einstein Center for Heart and Vascular Care's Arrhythmia Program could greatly benefit patients with heart arrhythmias throughout the Bronx and Westchester.

The procedure, a cardiac ablation performed on the epicardium (exterior heart muscle) to treat a ventricular tachycardia in a 65-year-old male patient, was accomplished by Dr. Eugen Palma with the assistance of Dr. Andrew Krumerman and Dr. Joon Kim.

Ventricular tachycardias (VTs), a type of cardiac arrhythmia (abnormal heartbeat), arise when a weakened lower left portion of the heart muscle generates an erratic electrical short circuit. This type of arrhythmia can be caused by coronary artery disease or heart attack (ischemic), or by other, often unknown reasons (nonischemic). During a VT, the heart rate accelerates to a dangerous level (as high as 250 beats per minute), which can lead to ventricular fibrillation, when the ventricles’ contraction becomes so uncoordinated that the heart muscle begins to quiver, disrupting its ability to pump oxygen-rich blood through to the body. Ventricular fibrillation can cause sudden cardiac arrest, which accounts for approximately 300,000 occurrences in the United States each year with a survival rate of only eight percent. 

VTs are generally treated with small, battery-powered electrical impulse generators known as implantable cardioverter-defibrillators (ICDs), which continually monitor the heart and deliver shocks to restore normal rhythm when tachycardia is detected. ICDs are effective in responding to VTs, but don't prevent their occurrence. Additionally, receiving an ICD shock can be painful and traumatic: "It feels like you’re getting punched in the chest," said Dr. Palma, an associate professor of clinical medicine.

A procedure known as cardiac ablation addresses arrhythmias at their source. During an ablation, a catheter is inserted into a vein in the groin. Guided by x-rays, the electrophysiologist brings the catheter through to the endocardium (inner heart), sending radiofrequency energy to heat and cauterize the cardiac tissue at the site of the short circuit. 

Short circuits can also occur in the epicardium (outer heart), but during a standard ablation procedure, the electrophysiologist’s ability to reach this area can be limited. "Thick heart muscle is difficult to burn through, even with the most powerful catheters," Dr. Palma said.

When Dr. Palma encountered this particular patient—who had been admitted to the hospital with recurring nonischemic ventricular tachycardias and who had undergone multiple ICD shocks—he decided that it was time to literally try a new treatment route. Rather than entering the cardiac region through the patient’s leg, he inserted the catheter directly through the chest wall, penetrating the pericardium (a tough, double-layered membrane surrounding the heart). This allowed him to identify and treat compromised areas of the outer heart muscle. "It's a technically demanding procedure," said Dr. Palma. "Too much and you're inside the heart, too little and you're not where you need to be. This procedure is not performed in many heart centers because of its complexity." 

The procedure—the first of its kind performed at Montefiore’s Weiler Division—went smoothly, and the patient was discharged without any further ventricular arrhythmias. Dr. Palma credited his success to careful preparation, as well as strong support from Drs. Krumerman and Kim. Dr. Krumerman has effectively performed this procedure twice before at Montefiore’s Moses Division.

Since performing its first cardiac ablation in June 2008, the Montefiore Einstein Center for Heart and Vascular Care's Arrhythmia Program has progressively expanded its range and complexity of procedures being performed in the Weiler Division. Since the Program's first atrial fibrillation ablation was performed in February 2009, Dr. Palma and colleagues have built a broad offering of highly skilled procedures (including subclavian and coronary sinus venoplasty to implant left ventricular leads for cardiac resynchronization therapy), positioning Montefiore Einstein as the premier cardiac treatment center for patients in the Bronx and Westchester, and perhaps the only center in this region to offer this caliber of cardiac treatment. 

"We are proud of our effort to provide the best cardiac care possible," said Dr. Palma. 

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