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Atrial Fibrillation & New Orleans’ Top Hospitals

Getting the irregular problem regular: A Q&A with cardiologist Dr. James McKinnie

Bryan Tarnowski Photograph

(page 1 of 2)

Any condition that causes a heart to beat too slow, too fast or with irregularity is termed an arrhythmia. When the heart’s electrical conduction system goes astray, the four chambers of the heart don’t expand and contract in concert causing the heart to be a less effective pump.

Dr. James McKinnie lives and breathes arrhythmias. He got hooked on heartbeats one summer during high school after scoring a summer job as an orderly at West Jefferson Medical Center. He began watching the heart monitors in the coronary care unit and became fascinated by the various changes in rhythm patients had after heart attacks.

His fascination launched his career. As had become the increasing norm even before Hurricane Katrina, McKinnie left New Orleans after medical school to pursue specialized training. And, as is also common, he returned to New Orleans to practice. He joined the faculty at Louisiana State University and migrated to Tulane Medical School for a spell. McKinnie is a board-certified cardiologist with a specialty in electrophysiology and is now ensconced in heart rhythm disturbances at both East Jefferson and West Jefferson Medical centers.

It has been my impression through the years that the busier the physician, the easier they are to track down. McKinnie’s answering service found him one Saturday morning within minutes of my call. He emailed me responses to dozens of questions on atrial fibrillation, the most common arrhythmia of them all, which I summarized and edited.

What is atrial fibrillation? An irregularity in the heart rate that physicians have long called an irregular irregularity. This disordered electrical activation of the heart causes blood to stagnate and form clots in the thin-walled left atrium of the heart. Clinically, there are several outcomes from no symptoms to incapacitating complications caused by decreased blood flow or breaking off of pieces of clot that cause havoc in the arterial circulation.

What causes atrial fibrillation? Any condition that enlarges the atrium or inflames the atrial tissues can cause atrial fibrillation. These include hypertension, diabetes mellitus, coronary artery disease, thyroid disorders and advancing age. A multitude of other triggers include caffeine, alcohol, nasal decongestants and sleep apnea. The increasing use of highly caffeinated energy drinks may also be playing a role in increased prevalence of atrial fibrillation.

What are the symptoms? About a third of folks with atrial fibrillation have no symptoms, the silent variety. Others may experience varying degrees of palpitations, shortness of breath, weakness, dizziness, confusion and even chest pain. Often patients experience atrial fibrillation as a “come and go” phenomenon termed paroxysmal. When atrial fibrillation doesn’t convert spontaneously it’s persistent. And atrial fibrillation that persists for more than several months is called chronic.

Is atrial fibrillation a killer? Rarely alone. Atrial fibrillation is important clinically because of its strong association with stroke and heart failure.

How is atrial fibrillation diagnosed? An irregular pulse detected incidentally during a physical examination is a tip-off. It takes an electrocardiogram (EKG) or some other monitoring device to confirm the diagnosis.

True or false: Are atrial fibrillation diagnoses on the rise? True. There is a strong link between aging and the prevalence of atrial fibrillation. Predicted population demographics suggest there will be more and more atrial fibrillation diagnoses as our country ages.

Why does the incidence of atrial fibrillation seem to increase with age? Increasing age is linked to deposition of increased deposits of certain tissue in the atrial walls. This increased collagen deposition can result in unstable patterns of activation in the atria increasing the susceptibility to atrial fibrillation. In addition, chronic inflammation from any cause can play a contributory role.

Will atrial fibrillation go away on its own? If atrial fibrillation is due to some precipitating cause such as heavy caffeine or alcohol intake or thyroid dysfunction treatment of these underlying conditions may result in resolution of the atrial fibrillation. More commonly, atrial fibrillation is a chronic relapsing disease and requires long term management.

Ablation sounds like some religious term. How does this seek and destroy mission work?  Catheter ablation is a viable treatment option for patients with symptomatic atrial fibrillation not controlled by medications. We thread flexible catheters usually from the femoral vein toward the heart. Using electrical impulses we locate what’s usually a tiny area of tissue in the heart or pulmonary arteries producing the faulty electrical signals and zap those cells.

How successful is catheter ablation? My own current experience with atrial fibrillation ablation dates to 2004. Many of those early patients have had no recurrent atrial fibrillation. Typically the success rate of catheter ablation with a single procedure is about 60 percent with success rates increasing if the procedure is repeated a second or third time.

I hear about freezing and radiofrequency forms of ablation. Which is better? The original technique utilized a ≠≠ generator to create a series of encircling lesions around the pulmonary veins. An alternative strategy is to create this series of lesions involves the use of a specially designed refrigerant balloon.

The latter seems to be safer and is the preferred technique in our laboratory.

What are those possible adverse effects? Any procedure in which catheters are threaded inside the heart carries the risk of death and stroke. Overall these procedures carry a risk of unexpected death in 1 in 5,000 cases. Strokes can also occur. The wall of the nearby esophagus might be damaged. And, it’s important to remember that this procedure doesn’t always work. Failure rates range between 25 and 40 percent.

Why did cardiac electrophysiologists like you start treating atrial fibrillation? The increasing complexity of long term antiarrhythmic drug therapy coupled with adverse effects of antiarrhythmic drugs like amiodarone prompted primary care physicians and general cardiologists to seek non-pharmacologic methods, such as catheter and surgical ablations.




Getting into a rhythm
“For me having a normal heart rate is the difference between a bumpy ride in a Jeep and the smooth glide of a Cadillac,” says Jose Torres. “I first woke up feeling funny and with palpitations about 10 years ago.”

An emergency room physician diagnosed atrial fibrillation when Torres was in his 40s. He became a regular with his cardiologist, but the irregular heart rhythm kept coming and going in spite of numerous medications. Finally he listened to his wife, a nurse at East Jefferson Medical Center, and made an appointment to see Dr. McKinnie.

Last November McKinnie threaded a small caliber catheter through a large vein in Torres’ leg until the tip was inside the heart. First, McKinnie found the small area of aberrant cells causing the recurrent atrial fibrillization. Then he zapped them, a procedure called a radiofrequency.

“Dr. McKinnie is optimistic that my regular rhythm will be permanent. I have already stopped three medications I was having to take previously,” says Torres. And Torres knows the importance of regular rhythm. He was a sales director at the House of Blues for 10 years and has just helped open the doors of The Little Gem Saloon on North Rampart Street, an eagerly anticipated opening at the site of an important New Orleans jazz landmark.
 

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