Bringing Innovative EP Treatments to Iowa Patients: EPLD Speaks with Kamran Toluie, MD

In July of 2000, when I first joined my group Cardiologists PC in Cedar Rapids, except for pacer and ICD implants that were also performed at St Luke s Hospital, all of the electrophysiology procedures were performed exclusively at Mercy Hospital s single-plane EP lab. Through the support of my partners and of the CEO at Mercy Hospital, Mr. James Tinker, Mercy s EP lab very quickly became one of the most advanced EP labs in the country. Shortly after my arrival, Mercy Hospital built and purchased at our request a brand new biplane Siemens EP lab. The first Biosense Webster magnetic mapping system (CARTO) in the state of Iowa was also purchased and installed in year 2000. Later, the first phased array intracardiac echocardiography equipment (Acuson) in the state was installed at Mercy. Having a biplane lab, the Biosense Webster system, and intracardiac echocardiography made ablation of complicated EP procedures like atrial tachycardia, ventricular tachycardia (VT) and pulmonary vein isolation much easier. I performed the first successful ventricular tachycardia (VT) ablation in Cedar Rapids in August of 2000. Ventricular tachycardia ablation in patients with structurally normal hearts, especially RVOT VT, can be very safely and easily performed with a cure rate of more than 95%. Also, ablation of scar-related VT is a critical electrophysiology procedure for patients with frequent ICD shocks due to recurrent sustained ventricular tachycardias refractory to medical therapy. Ablation of idiopathic and scar-related ventricular tachycardias are as important today as they were 5 years ago. With the help of these Biosense Webster mapping systems, the ventricular tachycardia of a significant number of patients with unmappable VT can also be cured or controlled with ablation. In 2001, we were among the first who performed biventricular pacing in the state of Iowa. As part of my training at the University of Pennsylvania, we were involved with the original INSYNC trial as well as other cardiac resynchronization trials. My prior experience made me very comfortable offering the procedure to select heart failure candidates after the hospital s IRB approval of our study. Cardiac resynchronization therapy is currently approved by the FDA and has a class IIa indication for patients with class 3-4 chronic heart failure (CHF) on optimized medical therapy and underlying BBB and QRS duration of > 130 ms. Cardiac resynchronization is probably the most important breakthrough in the management of symptomatic CHF patients since beta blockers. Currently, in our practice, biventricular pacemakers account for about 20% of our resynchronization patients. After the MADIT II results and also considering the preliminary results of the COMPANION trial, it seems that this number would most likely go to an even lower percentage, as the vast majority of these patients would be candidates for biventricular ICDs. As I mentioned above, the majority of patients who need cardiac resynchronization therapy have a current indication for either secondary or prophylactic ICD implantation. There are also some patients who already have a defibrillator but continue to struggle with CHF. These patients have underlying bundle branch block (BBB) and are candidates for an upgrade to the biventricular (BIV) ICD. One of the limitations of current BIV ICD systems, in addition to cost, is the size of the device and the number of leads that may be of concern in some elderly cachetic heart failure patients. However, BIV ICDs significantly improve patients symptoms and decrease the hospital admissions and decrease mortality. I learned the technique during my fellowship (1998-2000) at the University of Pennsylvania. My mentor was Dr. Francis Marchlinski, the Director of Electrophysiology at PENN, who has been a pioneer in the field. There were no complications during that first procedure. The patient, who prior to the procedure had very frequent symptomatic atrial fibrillation episodes refractory to medical therapy, remained free of atrial fibrillation and off any antiarrhythmics for about 9 months post-ablation. His coumadin was stopped about 3 months after the procedure. He did have one recurrence of atrial fibrillation 9 months post-ablation, but has had no recurrences since then. There were no guidelines for performing trans-septal puncture at any of the hospitals in town as this procedure was not offered at the time. I had reviewed the guidelines of some of the hospitals that were performing the procedure nationally and developed a guideline that was later approved by my group and other local cardiologists. This guideline was then taken to the internal medicine section of both hospitals and after approval of the credentials committee was taken to the hospital board for final approval. It finally did happen. We were the first community hospital in the world who used the catheter for mapping the pulmonary vein with St Jude s Spiral HP catheter. This catheter was used previously in three university hospitals in Germany, France and New York. I found the St. Jude s Spiral HP catheter very helpful during pulmonary vein mapping. The catheter comes with a tip straightener that makes insertion of the catheter in the trans-septal sheath much easier. Also, compared to the previous version of the Spiral catheter, this catheter has a deflectable shaft that makes placement of the catheter in the pulmonary vein much easier and less dependent on the manipulation of the guiding sheath. In addition, the catheter has 20 electrodes that makes mapping of the vein easier. The electrograms are very sharp and nicely defined, most likely because of the decreased inter-electrode distance between pairs. Since we started performing pulmonary vein isolation for atrial fibrillation, St. Jude representatives have been present during many of our ablation procedures. They were very interested in our technique and have offered us the opportunity to be a visiting center for electrophysiologists who are interested in learning the technique of trans-septal puncture. At this center, electrophysiologists can also learn the practical aspects of atrial fibrillation ablation, including the use of phased array intracardiac echocardiography and 3-dimensional electroanatomical mapping. I graduated from Tabriz University Medical School in Iran in 1985. After completing my internal medicine residency at State University of New York in Brooklyn, I performed my cardiology fellowship at MetroHealth/Mt. Sinai Medical centers in Cleveland, Ohio. After completing my cardiology fellowship, I did two years of dedicated electrophysiology fellowship under the directorship of Dr. Francis Marchlinski at the University of Pennsylvania. During my internal medicine residency, I was involved with multiple EP research projects with Dr. Nabil El-Sherif and Dr. Turitto. The more I got involved in EP and its inherent challenges, the more interested I became. Dr. Lee Biblo, who was the Chief of Cardiology at MetroHealth, also had a very strong and supportive role in having me pursue a career in EP. At Cardiologists PC, we are a group of 10 cardiologists and 2 electrophysiologists. Typically, I am in the lab all day, about 2-3 days a week. The other days, I am either at the office seeing new patients, doing follow-up visits, or I am on-call at the hospital for the group. In average, I perform about 500 procedures per year including pacers, ICDs, BIV pacers and ICDs, and different ablations including AVNRT,AVRT, atrial flutter, atrial tachycardia, ventricular tachycardia and atrial fibrillation ablation. Currently we perform up to 4 pulmonary vein isolation procedures per month. The success rate of the procedure is around 70%. We have not had any major complications from trans-septal punctures or pulmonary vein ablations. In two patients, we noticed during the procedure the presence of the thrombus on the catheter in the left atrium by intracardiac echocardiography. In both patients, the catheter and sheath were pulled back to the right atrium, and new transseptal punctures and sheaths were introduced. However, neither had any cardioembolic events. We also routinely perform 3-month follow-up chest CT scans to exclude pulmonary vein stenosis. I doubt that medication for treatment of atrial fibrillation will become obsolete. Currently we perform atrial fibrillation ablation only in those patients with very symptomatic episodes of atrial fibrillation who have failed membrane active antiarrhythmics, and who have paroxysmal or persistent atrial fibrillation. At this time, we do not offer pulmonary vein isolation in patients with chronic or asymptomatic atrial fibrillation. We are also very closely collaborating with our Department of Cardiothoracic Surgery for developing a protocol for performing pulmonary vein isolation with RF or cryo intraoperatively for patients with atrial fibrillation who undergo open-heart surgery. We are considering endocardial ablation for patients who undergo valve surgery, and epicardial ablation for patients undergoing CABG. We have dedicated research EP nurses at both hospitals and are currently involved with several research projects. These projects are both industry-sponsored and in-house projects. At this time, our major concern is performing curative ablation quickly, safely and effectively for the most common arrhythmia: atrial fibrillation. Developments in catheter technology and energy delivery, as well as our further understanding of the mechanisms of initiation and perpetuation of AF may allow us to perform this procedure much more quickly and with a higher cure rate close to that of atrial flutter ablation. Currently, there are a lot of asymptomatic patients who would like to have the procedure done; these patients hope to eliminate long-term anticoagulation or use of antiarrhythmics. When we reach that safety and efficacy, a much broader group of patients would benefit from the procedure.