At Mount Sinai Heart, we use a variety of approaches to treating heart rhythm disorders, depending on the patient’s individual medical condition. We use medications, medical devices, and surgical procedures to treat arrhythmias.
Before proceeding with surgical interventions, we often start treating heart rhythm disorders with medication. At Mount Sinai Heart, we use several types of medications including blood-thinners and anti-arrhythmia medications.
Blood-thinners are particularly helpful in the treatment of atrial fibrillation (AFib). AFib can cause blood to stagnate, forming a clot that could travel to the brain and cause a stroke. Some people who have this condition but have a low risk of stroke, do not need a blood thinner. If you are at high risk, though, we sometimes prescribe a blood thinning medication. There are several medical options available (including warfarin/Coumadin, or one of the new medications: dabigatran/Pradaxa, rivaroxaban/Xarelto, apixaban/Eliquis, and edoxaban/Savaysa).
Anti-arrhythmia medications work on the electrical pathway to slow, speed, or regulate your heartbeat. They are especially helpful for uncomplicated abnormal heart rhythms. The goal is to lower the average heart rate to below 110 beats per minute, which is called “rate control.” Some patients remain symptomatic despite adequate control of the heart rate.
For some forms of arrhythmia, we recommend the use of an implantable device—such as a pacemaker or defibrillator—to regulate your heart's rhythm. At Mount Sinai Heart, we use transtelephonic monitoring, which are small devices that work in conjunction with a pacemaker or defibrillator to transmit your heart rhythm over the phone to your physician. These can be helpful for routine check-ups and also in case of unusual cardiac activity.
Pacemakers help if your heart beats too slowly. Often when your heart is not beating fast enough it means that your heart is not pumping enough blood throughout the body. When this happens, you might experience fatigue, weakness, lightheadedness, shortness of breath, or fainting. To treat this condition, we often recommend a pacemaker. There are several types of pacemakers available, so we can find the one that meets your needs more appropriately:
Traditional pacemakers have pulse generators, containing batteries and electronic circuitry, which send electrical pulses to the heart muscle. Doctors implant these devices under the skin, near the armpit, and connect them to the heart by tiny wires called pacing leads. These leads send the electrical pulses to the heart, causing it to contract.
Traditional pacemakers treat slow heart rhythms by regulating the right atrium and ventricle. The devices consist of a computer, electronic circuits, and a battery. To implant a pacemaker, our doctors make a small incision near the collarbone, surgically plant the devices under the skin, and connect them to the heart by tiny wires called pacing leads threaded through a large vein. Our doctors also place sensors throughout the heart's electrical pathway.
Leadless pacemakers are so small that the entire device fits in the heart, occupying less than 1cc of space. We place these devices into your heart using a non-surgical catheter approach from a puncture in a vein in the leg, as we do with other heart catheterization procedures such as electrophysiology studies. Our doctors were the first to implant leadless pacemakers in patients internationally as well as in the United States and we can discuss with you whether this is the most appropriate solution for you, based on your specific circumstances.
Biventricular pacemakers are useful if you have experienced moderate to severe heart failure and also have a poorly functioning left ventricle. We use a minimally invasive procedure to implant a biventricular pacemaker, which steadies the rhythm and speed of your heartbeat. It triggers the left and right ventricles to contract simultaneously and pump blood more effectively. This device is similar to a traditional pacemaker, but uses a third lead that focuses on the left ventricle.
We use this device in combination with a pacemaker. Internal monitoring sensors transmit information from the pacemaker to our heart team, who can then make up-to-the-minute medication adjustments. We calibrate your biventricular pacemaker to your individual needs, to provide maximum benefit.
Implantable cardioverter defibrillator (ICD) is a good option for congestive heart failure patients who also have an arrhythmia. Our electrophysiologists use ICDs to implant these devices under your skin beneath the collarbone and place a wire (called a lead) in a vein going to the heart. The device records the heart’s electrical signals, and when it detects a dangerous arrhythmia, it delivers lifesaving electrical energy directly to the heart muscle, restoring a normal heartbeat. An ICD can function as a pacemaker as well. The subcutaneous ICD (SICD), which we place entirely under the skin, does not require a lead connected to the heart. This SICD may be particularly better for younger patients as it may lead to fewer problems over time.
Laser Lead Extraction
The laser lead extraction approach may be necessary if your pacemaker or defibrillator stops working properly, if it becomes infected, or if it needs a new battery. We monitor our patients carefully and give ample time (usually three to six months) to schedule a replacement procedure. In addition, our patients typically have regular follow-up visits to check the device’s functionality and make minor adjustments without surgery.
Laser lead extraction is a minimally invasive procedure that uses a laser to deliver energy, which removes the scar tissue and allows us to remove the leads, or wires, that carry the electrical impulse from the pacemaker to your heart. We can also provide device upgrades or change out the pacemaker battery at this time, if medically indicated.
Catheter Ablation Procedures
A catheter ablation procedure uses ablation energy to scar part of the heart’s tissue, which prevents irregular impulses from traveling to the rest of your heart. We guide a catheter through the blood vessels to your heart to the source of your arrhythmia. Then we direct the energy to the part of the heart that is malfunctioning. We use this procedure, also called radiofrequency ablation, to treat atrial fibrillation and ventricular tachycardia, among other heart rhythm conditions. At Mount Sinai Heart, we can use this basic process in combination with intense freezing, lasers, and surgery. The most common procedures are:
Radiofrequency ablation is a procedure in which we manipulate catheters (long wires) through veins or arteries from the groin region to the heart in order to cauterize the abnormal tissue. We use radiofrequency catheter ablation to treat a variety of types of arrhythmias, including the typically simpler superventricular tachycardia rhythms, to the more complicated atrial fibrillation or ventricular tachycardia. Typically, a catheter ablation procedure requires an overnight stay in the hospital.
Cryoballoon catheter ablation blocks arrhythmias using cryogenics or freezing cold air to change the heart’s functioning. We direct a balloon-tipped catheter to the source of your arrhythmia, and then inflate the balloon against the problematic area, where it applies a cryo-refrigerant to freeze the tissue. Our doctors were the first ones to perform cryoballoon ablation to treat atrial fibrillation in the world, and we can talk about whether this is the most appropriate solution for you and your specific circumstances.
Left atrial appendage closures (Watchman Implantation) help patients who are unable to take blood-thinning medications, typically because they are at risk of falling or developing bleeds. In these situations, we perform a catheter procedure that isolates the area of the heart called the left atrial appendage, where clots are most likely to originate, and prevents clots from moving into the circulatory system. The left atrial appendage is a small pouch located by the left atrium. During this catheter procedure, we advance a small plug called the Watchman device using a catheter from a vein in the groin to block off the left atrial appendage.