What the arrhythmia service does

One of the options for treatment of heart rhythm disorders is catheter ablation.

Catheter ablation involves placing tubes (catheters) inside the heart from the veins (usually) in the groin. This aims to deliver energy to parts of the heart upon which the heart rhythm disturbance depends, thus normalising heart rhythm.

These procedures take place here at the LGI in our state of the art EP labs (Cath labs). Procedures are commonly carried out as day case or short stay (one night) procedures.

The WYAS offer a full range of catheter ablation techniques for all cardiac rhythm disturbances.

Implantable cardiac devices can help with diagnosis of heart rhythm problems (loop recorders), treatment of slow heart rhythms (eg Pacemakers), protection against dangerously fast heart rhythms (eg defibrillators), as well as helping to improve the outlook and symptoms form diseases such as heart failure (eg cardiac resynchronisation therapy).

All these procedures are available here at the LGI delivered with a comprehensive support service provided by expert technicians, 24 hours a day, 7 days a week. Developments in the near future will include leadless pacemaker technology and options for multi-site pacing.

Leeds General Infirmary offers a comprehensive pacemaker and lead extraction service for West and North Yorkshire and Humberside.

Pacemakers and implantable cardioverter defibrillators play an important role in treatment of heart disease. Occasionally these devices need to be removed. This is a challenging and potentially high risk procedure and requires specialist expertise, tools and cardiac surgical support.

The most common reason for device extraction is infection of the device and in the majority of cases can not be cured with antibiotics. Occasionally leads fail and also need to be removed in order to re-implant new leads.

The degree of difficulty involved in the removal of leads varies and relates to the amount of scar tissue embedding the lead to the blood vessel wall. This is mainly influenced by the length of time the leads have been implanted, but is also dependent on the lead type; defibrillator leads tend to be harder to remove. In order to remove the leads it is necessary to free them from scar tissue using flexible tubes, called sheaths, to then allow direct extraction of the lead.

Leeds General Infirmary has over 15 years of expertise in this field and has all the specialist tools and experience in order to perform the procedure effectively.

The rapid access Atrial Fibrillation (AF) clinic is an option primarily for patients with a new onset of AF to be referred by their GP and seen quickly in cardiology.

Referrals are accepted from other specialities and a form for referral is available on Leeds Health Pathways. The primary focus of the clinics is stroke risk assessment and consideration for anticoagulation therapy for stroke prevention.

Patients are clinically assessed by the arrhythmia nurse specialists to:

• Confirm a diagnosis of Atrial Fibrillation
• Achieve heart rate control
• Determine suitability for restoration of normal rhythm
• Recognise significant other cardiac disease requiring further cardiologist input
• Address the risk of stroke in AF and to assess the patient’s preferences for treatment.

Following investigation with ECG and echocardiography patients undergo a comprehensive review with the arrhythmia nurses and a treatment plan is agreed and started.

There is current capacity for 15 new patients per week, so we encourage referral directly to Leeds Oral Anticoagulant Service [TO MIGRATE] to commence warfarin when a diagnosis of AF is clear without intrusive symptoms, with good heart rate control and the balance of stroke risk is clearly greater than the risk of major bleeding on anticoagulation. However demand is rising because managing AF is not always this straightforward.

Our data suggests that:

• 50% of patients require one single attendance and treatment is continued in the community
• 15% are referred on for further cardiology or EP review
• 15% are booked in for Cardioversion treatment to attempt restoration of normal heart rhythm
• 20% require follow up in the AF clinic following further investigation.

Over 90% of patients with an elevated risk for stroke in AF become established on anticoagulation from the clinic, in comparison to a national average of 53%.

We aim to see patients within two weeks

One of the main risks of AF is stroke. As the upper chamber of the heart does not contract properly, there is a risk of small clots causing blockage to blood flow in the brain. Stroke can be a major cost to quality of life, and assessment and management of stroke risk reduction is a vital part of AF management. Warfarin is the mainstay of treatment to reduce this risk of stroke, and if appropriate your medical team will recommend this agent.

For some people warfarin is not the best option and novel oral anticoagulants offer an alternative.

The Novel Oral Anticoagulant (NOAC) Clinic is run jointly between haematology and cardiology. [LINKS TO MIGRATE] The purpose of the clinic is to establish a high standard of practice in the appropriate choice and safe initiation of anticoagulation treatment. The clinic sees patients with an elevated risk for stroke in Atrial Fibrillation who are likely to benefit from anticoagulation with alternatives to warfarin. The newer anticoagulants currently include Rivaroxaban, Dabigatran and Apixaban.

The clinic is run by a consultant in haematology, senior or consultant pharmacists with a specialist interest in anticoagulation and the arrhythmia nurses.

The newer anticoagulants are not always the best option for AF and their suitability is assessed individually for each patient and discussed.

Initially, six weeks of treatment is supplied by the hospital. Either a telephone or a clinic review is conducted after four weeks to assess for adverse reactions, suspicion for blood clots or signs of bleeding problems.  Following this review, if all is well the patient’s GP is asked to continue treatment.

Most of the patients attending clinic are taking warfarin and do not yet have adequate control of the international normalisation ratio (INR). The INR  measures how long it takes your blood to clot and is generally identified in the warfarin clinics. However referrals are accepted from other sources for patients with non-valvular atrial fibrillation who may otherwise be unsuitable for warfarin.

The Left atrial appendage occlusion (LAAO) device, in trials and in practice, has proven to be an effective option in reducing the risk of AF-related stroke in AF patients for whom an oral anticoagulant such as warfarin, dabigatran or rivaroxaban, is unsafe or contraindicated.

It involves placing a small device inside the neck of the left atrial appendage, usually though a sheath delivered via a vein in the groin.

Further information is available on the AF Association website.

We have a dedicated team of arrhythmia nurse specialists. As well as running their own nationally recognised award winning AF clinics, they offer a great point of contact for our patients who have queries about there arrhythmia care, including those who have undergone procedures such as catheter ablation and cardioversion.

Some of their work includes:

• A nurse delivered rapid access clinic for the assessment and management of atrial fibrillation.
• A multidisciplinary out patient service to guide the managed introduction of the novel Direct Anticoagulant drugs.
• Direct telephone based patient support for patients.
• Support of follow up out patient review within the arrhythmia service, both in face to face consultations and through telephone follow up.
• Education and training in arrhythmia management of medical and nursing practitioners within other health care settings