Taking it to the next level

It has been couple of tough years for Al Cheney, 75. The retired oil and gas worker’s quality of life plummeted since suffering a massive heart attack in 2017. 

Suffering with symptoms such as an irregular heart beat, swelling and difficulty breathing that made mobility difficult, Cheney was diagnosed with heart failure following the heart attack. 

He has spent a great deal of time in the hospital – often weeks at a time.  

Although Cheney’s life improved somewhat after treatment, doctors determined he needed an implantable defibrillator with a special pacemaker lead to help improve his heart function. Cheney received the defibrillator, protecting him from dangerous heart rhythms. However, his cardiac resynchronization therapy implant procedure— which involves adding a pacing lead through the coronary sinus, a special vein in the heart—was not successful because of the anatomy of his heart. 

However, in August 2019, Cheney’s physician, Dr. Jacques Rizkallah, MD, a young cardiologist who began working in Calgary in 2016, was able to overcome this using a novel technique known as Left Bundle pacing. It was the first time that this surgical technique was performed in Canada. 

Rizkallah, who received specialized training at Harvard Medical School, explains that in standard pacemaker implant procedures, doctors insert one or more pacemaker wires into the heart to activate it based on the specific needs of the patient condition. 

Although the purpose of a pacemaker is to treat patients with slow heart rates, in some rare cases, activating the heart with the pacemaker can cause it to enlarge and weaken. Known as pacemaker mediated cardiomyopathy, the condition is caused by activation of the heart out of sync. 

In the new approach, also referred to as physiologic pacing, the pacing wire is implanted in a specific part of the heart along its normal conduction system, reducing the risk of pacemaker mediated cardiomyopathy and treating heart failure in some cases.

 “This allows us to stimulate and activate the heart with the pacemaker the way it is naturally designed to be activated,” says Rizkallah. 

There are two surgical techniques involved in physiologic pacing: His bundle pacing and left bundle pacing. His bundle pacing places the pacemaker lead closer to the centre of the heart’s conduction system along the ventricular septum. 

Left Bundle pacing positions the lead in a deeper, specific location in the heart muscle that is more challenging to reach but provides a good alternative for patients in whom the HIS Bundle location isn’t technically feasible. 

Cheney notes there was significant improvement in his quality of life after the left bundle pacing procedure.  
“Everything is better,” he said. “I have nothing but good things to say about that surgery.”

Although the HIS bundle and Left Bundle pacing techniques are more technically challenging and require more time to perform than the standard pacing methods, Rizkallah is pleased with the results. 

“Persevering through these surgeries is very rewarding when we see patients benefit with improvements in their heart function,” he says. 

Radiation-free ablation
 

Rizkallah was also the first in Western Canada—and amongst the first in Canada—to perform a radiation-free complex ablation, a procedure that uses special catheters to burn or freeze circuits in the heart that cause abnormal rhythms. 

The majority of physicians rely on fluoroscopy using X-rays to visualize their tools in the heart when performing complex ablations, but this standard procedure has a potentially serious drawback. Both patients and physicians are exposed to radiation, with the amount dependent on the length of the procedure. 

Over time, the cumulative exposure increases the risk of cancer for health care providers. To shield themselves and reduce radiation exposure, physicians wear a cumbersome, lead apron weighing about 30 pounds while performing ablations. 

Not using fluoroscopy during ablations avoids all of those complications, explains Rizkallah. 

Although fluoroscopy-free ablations are performed at many centres in Canada, Rizkallah is employing it for complex procedures, such as those that require the atrial septum of the heart to be punctured to treat arrhythmias like atrial fibrillation. 

The approach uses ultrasound imaging within the heart as a guide, a method that is performed at just a few of the largest hospitals in Canada. The zero-fluoroscopy ultrasound guided technique has only been around for a couple of years and is harder to learn and implement.  

“The first case was a little nerve wracking, but exciting,” says Rizkallah. “I was fortunate to have access to the right technology at our institution, which allows us to be innovative.”

Rizkallah says his colleagues are also keen on learning the new method.

 
“I work with a great group of colleagues that are always looking to adopt innovative ways to deliver the best care to our patients.”