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 Innovations in Heart Care and Research

Unique Collaboration Tackles Difficult Cases, Produces Life-Changing Results

Naomi Kertesz, MD, Director of Electrophysiology and Pacing at The Heart Center at Nationwide Children's Hospital and Steven Kalbfleisch, MD, Medical Director, Cardiac Electrophysiology at Ohio State’s Heart and Vascular Center.

Adult Congenital Electrophysiology Combines Adult and Pediatric Expertise

Seeking treatment for a complex arrhythmia problem, a 35-year-old woman with adult congenital heart disease (CHD) traveled from her home in Houston, Texas, all the way to Columbus, Ohio, where her physician at Nationwide Children's Hospital combined expertise with an adult electrophysiologist at Ohio State's Heart and Vascular Center to cross a baffle in her heart constructed during pediatric surgery and successfully complete a complex ablation.

One of Few Adult/Pediatric EP Partnerships in U.S.

The procedure is one of several performed this past year through a unique collaboration co-led by Adult Electrophysiologist Steven Kalbfleisch, MD, and Pediatric Electrophysiologist Naomi Kertesz, MD. Their Adult Congenital Electrophysiology collaboration is one of only a few in the country to merge pediatric and adult electrophysiology skills in treating arrhythmias and performing lead extractions in adults with CHD.

"It's rare to have pediatric and adult EPs working together. We have two nationally ranked hospitals actively fostering collaboration among specialists for best outcomes for patients," Dr. Kertesz says.

The physicians spend clinic time together seeing patients and sharing their unique perspectives. They discuss whether the patient would benefit most from medication, a device or ablation.

"We complement each other," Dr. Kalbfleisch explains. "Adult electrophysiologists have a lot of experience with complex ablations such as atrial fibrillation and atrial flutters, and the pediatric electrophysiologists have a better understanding of the complex anatomy and natural history of the congenital abnormality."

Co-led by Drs. Kertesz and Kalbfleisch, other members of the team include adult EPs, pediatric interventional cardiologists who help them reach hard-to-access areas of the heart during complex ablations, and pediatric and adult cardiologists who assist with echocardiograms. Dr. Kalbfleisch's partner works with Dr. Kertesz to perform lead extractions so stents can be inserted into narrowed vessels.

The physicians perform EP procedures at both Ohio State's Richard M. Ross Heart Hospital and Nationwide Children's Hospital, depending on which venue is likely to provide the most optimal care for the patient.

Broader Understanding Yields Better Results

The collaboration evolved with encouragement from Curt Daniels, MD, director of the Columbus Ohio Adolescent/Adult Congenital Heart Disease (COACH) program, which serves patients at both Ohio State's Ross Heart Hospital and Nationwide Children's Hospital. Dr. Daniels frequently consulted adult or pediatric EPs, but he rarely had the benefit of their synergistic approach to patient care.

Dr. Kertesz comments, "We have patients come to us whose cases have failed because the doctors weren't ablating in the correct place, or they couldn't get to the correct place because they weren't familiar with the anatomy. We're drawing on expertise of both the pediatric and adult side to help the patient."

Case Study

The 35-year-old woman from Texas is one of more than a million American adults living with CHD.

Dr. Kertesz had first seen the patient during the 1990s and had treated her for arrhythmias. The arrhythmias had been managed with a pacemaker and medications, but symptoms worsened during the spring of 2013. When an ablation attempt failed in Houston and doctors there suggested a new regimen of medications, the patient sought Dr. Kertesz's assistance.

Drs. Kertesz and Kalbfleisch agreed to make another attempt to do an ablation. The patient arrived in June 2013 for a six-hour procedure at Ohio State’s Ross Heart Hospital. With the help of a pediatric interventional cardiologist, they reached both sides of the Mustard baffle constructed during the patient’s childhood to redirect blood flow. The EPs used radiofrequency energy to modify the conduction system tissue to eliminate her arrhythmia.

"She had a very unusual form of atrioventricular node re-entry, which required an approach entirely different from the typical approach." Dr. Kertesz explains. "Without an understanding of her anatomy and without an understanding of the arrhythmias common in this type of heart disease, one would have significant difficulty in trying to take care of this patient's arrhythmia."

Dr. Kertesz continues, "We couldn't completely get rid of the rhythm, but we were able to identify much better what it was. Rather than being on four medicines, the patient is now on one and feels much better than she ever has."

While the initial procedure was performed at Ohio State, subsequent procedures have been performed at Nationwide Children's Hospital. The team chooses the location for each procedure based on the specific needs of each patient and procedure.

Improving Outcomes

"We are succeeding with patients who have had other treatment attempts and failed," Dr. Kertesz says.

As Dr. Kalbfleisch further explains, "Rhythm problems such as atrial flutter and atrial tachycardia are difficult even with normal patients. For congenital patients, it's much more difficult. A typical success rate would be 60 to 70 percent for a person with CHD versus 80 to 90 percent for a normal heart. With this dedicated program, we can be much more successful."

He expects increased collaboration and volume as the collaboration enters its second year.

"Bringing expertise from all of these different areas enhances the quality of patient care and patient outcomes," he adds.

The success of this collaboration has set the stage for other partnerships. Pediatric and adult interventionists are working on valve problems collaboratively, and plans to create a combined genetic arrhythmia collaboration are under way/under discussion.

To learn more, visit: NationwideChildrens.org/HeartCenter or call 614-293-ROSS (7677).

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