A unit in Cape Town established itself as the leader in the field of cryo-balloon ablation therapy for atrial fibrillation in the Middle East/Africa region when Dr Razeen Gopal, Cardiac Electrophysiologist, and his team at the Cape Town Atrial Fibrillation Centre at Mediclinic Panorama hospital, performed their 300th cryo-balloon ablation procedure to treat Atrial Fibrillation earlier this year.
Heart rhythm disorder
Dr Gopal confirms: “This is by far one of the largest cohorts of atrial fibrillation patients treated with cryo-balloon therapy in South Africa and across the Middle East /Africa region. I believe our team has been successful in changing lives and giving our patients back the type of lifestyle they are now able to enjoy.”
What marks this achievement as even more special, is the fact that it was achieved within the short span of four years and by a single operator, (and despite the fact that the overwhelming majority of Dr Gopal’s ablations are in fact performed with radio-frequency ablation, which is thermal cauterisation, with him averaging at least 300 cases per year since the laboratories inception), while in the USA and Europe this was most often achieved by a full team of electrophysiologists within a unit.
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Atrial Fibrillation (or AF) is the most common heart rhythm disorder and affects one in eight people over the age of 60, but increasingly also affects younger people. Its incidence usually increases with age.
AF is an irregular heart rhythm that affects the upper chambers (atria) of the heart. Due to extra electrical signals entering particularly the left upper chamber, the atria may contract at a fast, but chaotic rate of 600–900 beats per minute, instead of regular 60–90 beats per minute.
This quivering form of contractile dysfunction, instead of normal synchronous beating, may result in the turbulent flow of blood in these upper chambers, leading to pooling and clotting due to the slow flow, and resulting in catastrophic stroke.
Improved quality of life
Cryo-balloon ablation revolutionised the early treatment of atrial fibrillation, being the only single shot technology with proven efficacy and safety and is now used universally in the management of both paroxysmal and persistent AF (the pulmonary vein is isolated with a single contiguous lesion instead of a myriad of multiple point ablation lesions).
The technology has the added advantage of hardly, if ever, causing additional rhythm disturbances as a consequence of lesion formation, as in the case of radio-frequency ablation. Dr Gopal feels this is a huge step forward as these post-ablation arrhythmias related to scaring from heat energy, may be the bane of the existence of any electrophysiologist, often being very difficult to localise and cure. In the interim newer generations of anti-clotting medications also have emerged in the battle against stroke. Currently, studies have shown that early ablation treatment leads to better long-term results and improved quality of life.
Treating AF is important because:
- Untreated AF leads to an elevated (up to 5 – 10 times higher) risk of stroke, since a blood clot from the atria may lodge in the brain. This risk is elevated particularly in people with a history of stroke, diabetes, hypertension or those older than 65 years;
- If the irregular heart rhythm continues on a permanent basis in a rapid and uncontrolled fashion (known as persistent AF) it can lead to heart failure, since the pumping chambers (ventricles) cannot contract effectively at a constant high rate;
- Untreated AF may eventually lead to changes in the heart’s electrical architecture, resulting in worsening of irregular heart rhythms.
AF is associated with symptoms of fatigue, shortness of breath, listlessness, palpitations, chest discomfort, fainting and lightheadedness and deleteriously affects quality of life.
Nico Barnard, a previous patient of Dr Gopal can testify to the success of the cryo-balloon ablation procedure, “I have a big fruit farm which is my livelihood and I had heart rhythm problems which were being managed by medication taken on a daily basis. Unfortunately my heart rhythm got out of control and I tired easily. At times I battled to breathe. I was referred to Dr Gopal who confirmed that I had atrial fibrillation and he performed the cryo-balloon ablation procedure.
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"Since then I have the ability to deal with the many challenges that come with farming.” Heinrich Pieterse, another patient of Dr Gopal, confirms the change in lifestyle, “I enjoy golf and I am now able to fully participate without the problems I had before. I am also able to coach rugby and run with the team as they train.” Both these patients have had their procedures several years ago and have been off medication since.
Cryo-balloon catheter ablation is a minimally invasive procedure during which the pulmonary veins are electrically isolated from the left atrium to terminate abnormal electrical circuits. Approximately 75% of patients with paroxysmal (intermittent) AF stop taking anti-arrhythmia medication (while anti-clotting medication remains recommended depending on their risk) within one year post-procedure, while 60% of patients with persistent AF recover from AF after a series of ablations.
These success rates achieved at Dr Gopal’s unit compare well with the very best internationally.
Key opinion leader
The successful team headed by Dr Gopal includes specialist cardiac anaesthesiologists, clinical technologists, dedicated cathlab staff and radiographers and specialist arrhythmia nurses, integral to the follow up of patients as well as the co-ordination and maintenance of the AF ablation programme which has seen resounding success.
Dr Gopal himself is an interventional cardiologist who has studied in South Africa, Belgium and England. He has a passion for teaching, runs a national ECG teaching programme for general practitioners and ICU staff and is involved in convening the institutions cardiac imaging meeting.
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He is also employed as a proctor by both ablation as well as cardiac rhythm device management industries, frequently lecturing both medical students, internists and cardiologists in training (locally and from outside the borders of South Africa).
He has been invited to teach cardiac ablation therapies in the Middle East, various African countries as well as the Indian Ocean islands. He has also served as a key opinion leader in cryo-balloon ablation therapy in the UAE.
The Cape Town Atrial Fibrillation Centre regularly host eminent specialists from abroad. Despite his hectic schedule Dr Gopal tries his utmost to find time to publish and commit to research.
While in London at St Bartholomews and Oxford (John Radcliffe) hospitals, Dr Gopal initially performed catheter ablation for AF using radio-frequency (thermal) energy and cryo (intense cold) energy and began performing these procedures (being the first in using the latest versions of the technology in the emerging market region) and in South Africa during 2012.
At the Cape Town AF Centre, situated at Mediclinic Panorama cryo-balloon ablation is most often used to treat both paroxysmal and persistent AF, while radio-frequency ablation is used to treat children with heart rhythm disorders, all other heart rhythm disorders in adults, as well as a percentage of cases of resistant AF.
Coronary artery disease (CAD)