Curing atrial fibrillation

This summer, Bevan Dupre got tired of feeling like a human time bomb.

Like more than 2 million people in the United States, the Cheshire, Conn., teacher and former school administrator suffered from atrial fibrillation, a disorder in which the heart’s upper chambers quiver instead of beating effectively.

The condition, caused by a physiological short circuit in the heart’s electrical system, tends to come and go. When it came, Dupre’s heart beat so fast that even sitting in a chair made him feel as though he had just jogged several miles on a treadmill.

But while exhaustion and dizziness are the most debilitating features of atrial fibrillation, the real danger is the risk of stroke.

When the heart is not beating effectively, blood pools in the upper chambers, where it turns gooey and can form clots. Clots that remain in the heart can cause a heart attack. Those that travel into the brain can cause a stroke. The risk of stroke is seven times greater in patients who have atrial fibrillation than in people with normal heart rhythms.

To minimize the chances of stroke, doctors routinely recommend a blood thinner called Coumadin (generically known as warfarin). It is the active ingredient in rat poison and kills the pests by making them bleed internally. Needless to say, this is not an ideal treatment, but doctors recommend it and patients swallow it because, when carefully monitored, the benefits of Coumadin seem to outweigh the risks.

But not for Dupre.

He watched his mother bleed to death internally after taking Coumadin following a stroke. He is an outdoorsman and an enthusiastic bow hunter, and though he has never been cut by an arrow, he worried about the danger of uncontrolled bleeding if he were on the blood thinner and had an accident in the wilderness.

So he lived with a racing heart and the constant fear he could have a stroke at any time.

As they do with most patients with atrial fibrillation, doctors first tried to control Dupre’s fluttering heart with medication. The drugs usually do a good job slowing down the rapid heartbeat but are less successful at restoring its normal rhythm.

When the medication failed, doctors used electrical paddles to shock his heart back into rhythm. But after a few weeks of beating normally, Dupre’s heart started to flutter again.

While surgery has always been a treatment option, most patients shy away from the open-heart procedure, which requires splitting the breast bone, stopping the heart and diverting blood through a mechanical heart/lung machine.

“Most patients are not interested,” said Dr. Randall K. Wolf, director of the Center for Surgical Innovation at the University of Cincinnati. “Most patients are otherwise healthy and are not keen on open heart surgery.”

While atrial fibrillation makes patients miserable, Wolf said doctors have been at a loss on how to treat it. “The typical quote I hear is, ‘My doctor told me I just have to live with it,’ ” Wolf said.

A pioneer in robotic and minimally invasive surgery, Wolf began experimenting with new technologies that he hoped would allow him to interrupt the haywire flow of electricity in hearts such as Dupre’s without stopping the heart or opening the chest.

Heart specialists agree that recent advances in the understanding of why the heart’s electrical signals cross and where those faulty connections originate have for the first time offered hope that atrial fibrillation can be cured, rather than managed. Improvements in equipment that allows doctors to isolate and destroy the bad wires with heat or cold also make curing the condition a real possibility.

Where doctors disagree is on the best way to reach the heart to make the repairs. Now, a minimally invasive surgical approach appears to be the newest frontier. But within five years, doctors in cardiac catheterization labs across the country could be custom-targeting faulty heart wires and curing atrial fibrillation as routinely as they now unclog blocked arteries using angioplasty and stents, said Dr. Anil Bhandari, director of the electrophysiology laboratory at Good Samaritan Hospital in Los Angeles.

Two years ago, Wolf restored a patient’s heart to normal rhythm by cutting small incisions on the left and right sides of the chest near the armpit and using a tiny video camera at the tip of a scope to guide his instruments into the beating heart. Inside the heart, he used a wand superheated by radiofrequency waves, similar to microwaves, to destroy the small nerves around the pulmonary vein that can cause the irregular heart beat.

At the same time, he removed the atrial appendage, a flap of tissue left over from fetal development, which resembles an ear on the heart. The atrial appendage is believed to be the spot where 90 percent of stroke-causing blood clots originate.

Since the first operation, Wolf and his team have trained cardiac surgeons across the country to perform the procedure, known as the “Wolf Mini-Maze.” About 90 percent of 450 patients who have had the operation have been cured, Wolf said.

Many of those whose hearts remained stubbornly out of synch decided to stop taking Coumadin because the removal of the atrial appendage reduced their stroke risk so dramatically. While Wolf said he was confident those patients are safe, he said he does not have enough evidence to recommend that patients with ongoing atrial fibrillation stop taking blood thinners.

But the numbers were good enough for Dupre, who by this summer had endured one 30-hour stretch in which his heart raced and fluttered without letting up.

He was referred to Dr. Vasant Khachane, a cardiac surgeon at the Hospital of Saint Raphael in New Haven, Conn., who was trained by Wolf.

Late last month, using Wolf’s less-invasive approach, Khachane burned the trouble-causing nerves in Dupre’s heart and removed his left atrial appendage. He likened the procedure to cutting a faulty wire that is causing a light to flicker.

Khachane has performed the operation on 12 patients in New Haven and said more than half were cured. He said he is optimistic about the others, because it can take up to six months after surgery for the heart to regain its normal rhythm.

The procedure is so new that only now is it spreading into the nation’s major medical centers, such as Brigham and Women’s Hospital in Boston, Johns Hopkins in Baltimore and the University of Southern California in Los Angeles. But if its early promise holds true, some have suggested that curing atrial fibrillation could become as common as the coronary bypass operations that now repair the damaged hearts of almost 500,000 patients in the United States each year.

Dupre, 55, was in the hospital for five days after surgery and said that while painkillers kept him comfortable in the days immediately after the operation, he experienced a lot of discomfort after the epidural medicines were stopped.

So far, however, he says his heart feels good, and he has already started walking a quarter-mile a day on the treadmill at the fitness center at Cheshire Academy, where he is a history teacher.

The best part, he said, is that even if his heart starts fluttering again, he feels confident that, with his atrial appendage removed, he is no longer walking around with a stroke waiting to happen.

“The constant fear of stroke was an issue,” Dupre said. “Especially with what I went through with my mother.”