Accessory pathway ablation

Just thought I’d put out a post from my work last week. A woman in her 30’s had been getting palpitations. They were much worse during her pregnancy, but continued even after delivery. We had caught a supra-ventricular tachycardia (SVT) on ECG monitoring.

I did an Electrophysiology study to assess the heart’s wiring system. I passed 4 wires through the veins at the top of the leg up into the heart, under local anaesthetic. It was easy to set off the SVT and there was evidence of an extra pathway (called an accessory pathway) on the left side of the heart.

I did a puncture across the atrial septum to get access to the left atrium. We set up to use a 3D anatomical mapping system (Carto) to localise the pathway. I then delivered a series of ablation lesions to get rid of the pathway and terminate the tachycardia. This should be enough to fix the problem and prevent future episodes.

The video shows the map that we created, using the open window mapping method. The heart was being paced from the right ventricle and electricity is passing from the ventricle (in red) up into the atrium (in magenta). The white line shows the mitral annulus (where early meets late signals) and the colours reveal the wave front passing through the accessory pathway.

A series of lesions here abolished conducting through the pathway and terminated the tachycardia. The lesions are shown as the red points, with the catheters visible on the shell.

The diagnosis was not Wolff-Parkinson-White syndrome as the resting ECG was normal. This is explained by the fact that this accessory pathway did not conduct antegradely from the left atrium to the left ventricle, but only conducted backwards from the left ventricle to the atrium. This was sufficient to allow atrio-ventricular re-entry tachycardia with a circuit down the normal conduction system and back up the accessory pathway.

The ablation was performed under sedation and with painkillers. Whilst the total procedure time was a few hours, the ablation time was only 4 minutes. This is definitely a case where the adage “measure twice, cut once” is important! The pathway fibres did seem to fan out so a few lesions were required.

If you have palpitations it is worth getting it checked out. There may be nothing serious, but it can be something like this which can be sorted out. Monitoring your own heart rhythm using a Smartwatch pulse monitoring or indeed the ability to capture your own ECG.

Palpitations – should I be worried

Palpitations are one of the commonest things that people come and see me about.

I have written a guide with 10 things you need to know before you call the doctor – when you need to worry and when you can relax. Fill in your details below to get your free copy.

A palpitation is being aware of your heartbeat. It doesn’t have to mean that anything is wrong and most people are aware of their heartbeat at some point or other, even if it is just with exercise or if lying in bed quietly at night and the loudest thing is your heart.

Sometimes people find they are aware of their heartbeat at other times and that the speed or rhythm of the heart is different to normal. This can be worrying.

The commonest cause of palpitations is the occasional ectopic beat. These tend to come in either single beats or a few beats clustered together. The classical description is someone who says that they are aware that their heart skips a beat every now and again. It is often more prevalent when you are not doing very much because that is when your mind can be free to concentrate on these sensations.

The reason it feels as if the heart is skipping a beat is the extra beat usually comes at an earlier time than the normal beat would be expected. At this point the heart would not have had enough time to fill properly and therefore the amount of blood ejected in that heartbeat is low. There is a compensatory pause before the next normal heartbeat and this means that the heart has had more time to fill and therefore when it beats with that normal heartbeat, it tends to be stronger and therefore it feels as if it is a really strong beat, so this is why people tend to say that their heart has missed a beat because they do not feel the extrasystole but they feel the harder normal beat after the extrasystole. It is completely normal to have a few of these every day.

Nobody really knows what tends to bring them on but there does seem to be some association with stress and certainly it is well recognised that people can become more aware of them during stressful periods in their lives and even after the stressor has gone, then the recurrence of these extrasystoles can be quite uncomfortable partly because it is associated with the feelings of stress that make them noticeable in the first place. The important thing is to make sure that there are not too many of them because very high numbers of these extra beats for example more than 20,000 a day are associated with heart failure.

It is also worth testing to make sure that there are not any other rhythm problems. Atrial fibrillation is probably the commonest rhythm problem overall and this is associated with the heart beating irregularly. These episodes tend to be sustained over a longer period. It is worth picking up as its treatment is quite different. There are also other sustained rhythm problems which are regular such as supraventricular tachycardias or ventricular tachycardias and again these are worth picking up because the treatment is different, they can be associated with other heart disease and they can be treated with drugs and/or ablation treatment.

If someone does have common or garden palpitations/extrasystoles, then I usually try reassuring them in the first instance and hopefully that can be enough to make sure that no one is worried about it. Drugs such as beta blockers or calcium channel blockers can be helpful if they remain bothersome but these are used for symptom relief only. For those people who have so many extra beats that heart failure is an issue (usually where every 5th beat is an extra beat or more), ablation can be performed but in order to map these in the catheter laboratory they need to be happening very frequently.

So I hope that is some useful information on palpitations for you. If you have any further questions, please do not hesitate to get in touch by calling me on 01634 510 521 or emailing so that we can make an appointment and get you checked out.

Is Wearable Tech Any Better Than Feeling Your Own Pulse?

Is this the best thing since sliced bread?

Well yes and no. There’s an awful lot of hype, and Silicon Valley methods – move fast and break things – is not really the way medicine works.

As Doctors, we’re very sceptical and want assurance that something works before we recommend it.

But wearable tech has great promise, and now is getting good data.

I have always believed in the concept of empowering patients to be involved in making choices about their health and one of my core values is that ‘better information leads to better decisions and healthier patients’.

I am happy to work with my patients and utilise technology to collaborate and monitor their condition. I’m already starting to see patients who have self diagnosed atrial fibrillation on their smart watch. But not everyone has a smart watch, and wouldn’t it be great if you could have something that worked with your phone?

Apps like Fibricheck use the camera to look for atrial fibrillation. It tracks the pulse using a similar technology to heart rate monitors on watches and if your pulse is irregular it will alert you to atrial fibrillation.

I can honestly say I was very sceptical when I first saw these at conferences back in 2013. Sounded great, but was it better than feeling your own pulse? Certainly that’s not a comparison that the manufacturers make, but I wonder if its simpler to learn to check your pulse every now and then?

How do you feel your pulse?

I tell people to check their pulse at the wrist. Turn it so that your palm is facing up. See the tendons in the middle of your wrist. Place three fingers next to the tendons on the thumbward side.

You should feel a regular pulse about once per second. Feel if it is regular or not. You can count your pulse rate by counting the pulsations over 15 seconds and multiplying by 4 to get the beats per minute. If its irregular or fast (over 100 beats per minute) or slow (less than 50bpm) it’s worth getting checked out.

You can certainly get a lot of information by simply feeling your pulse, but it can be a bit subjective and it is not always the easiest thing to do.

I have embraced the use of wearable technology and I encourage my patients to use it and will help and support them to find the right tech for them.

The Next Level – ECG recording

The mainstream devices that monitor heart rate and rhythm are widely available and I have also been recommending ECG (electrocardiogram) machines for some years.

The Kardia by AliveCor is a fantastic little device which has been around for nearly a decade and takes things one step further. It can record a 1 lead or 6 lead ECG (depending on the model). You can also access ECGs in a watch such as the Apple Watch or Withings Smartwatch.

Of course, these are no substitute for an assessment by a doctor as there is a lot more to diagnosing heart problems than simply looking at your heart rate or ECG, but wearable tech can be very powerful when used in conjunction with your doctor.

If you are worried about any symptoms or signs of heart problems, then you should consult your GP (or you can make an appointment to come and see me) to get checked out.

Once you have a baseline diagnosis, this is when the wearable tech comes in.

The ‘Healthy Heart WhatsApp Group’

I have a ‘Healthy Heart WhatsApp group’ that I set up for my patients to give an opportunity to get help and advice without necessarily having to come back to the clinic to see me.

I think that this is the future and technology is only going to get more advanced in what it can tell us about the functioning of our bodies.

I am looking forward to embracing new innovations and working with my patients to give the most streamlined and accessible service that will be beneficial to all.


When should I use my private insurance?

The NHS is amazing at emergency care.

You can have a heart attack and your heart arteries could be unblocked within 2 hours.

But when it comes to less urgent things the delays can be intolerable.

I’ve seen a patient today who was admitted to hospital in March with a very fast heart rate causing poor heart function but he is still waiting for his treatment.

I saw him last week as he was fed up and he’s had his ablation treatment this week, restoring normal rhythm and hopefully heart function.

If you have insurance please do use it for things like this.

You get treatment quicker and in a more pleasant environment

You also take some of the burden off the NHS which means that more patients get treated.


Covid Vaccine side effects

Should I get the Covid vaccine? Will it cause trouble. I felt rubbish after the first jab, should I have the second dose?

I get asked this all the time.

From a numbers perspective it’s clear – Covid can be a nasty disease and the risk of being severely ill with it is much higher than the vaccine for all adults.

But many people say they feel terrible after the jab. How much of this is a “Nocebo” effect is hard to tell. People almost expect bad things which means they are more likely to feel bad things have happened due to the vaccine.

We can see the same with Statin drugs and if you’re interested I’d check out the Samson trial.

So whilst bad things do happen with the vaccine they are rare. As a cardiologist I have seen reports of myocarditis in young people after the Covid vaccine. This is currently under investigation.

The difficult thing is always knowing if this is coincidence or if there’s a causal relationship.

If you’ve had a bad experience with the first jab should you get the second?

There’s no good way to answer that. Some people have been asking me to test for antibodies – but this is an area where it pays to know what your testing. Many antibody tests look for the Antibodies to the N protein. This is produced by infection, but not by vaccines as these make the body produce antibodies to the spike protein. So know what you’re being tested for!

Intuitively antibody production should reflect immunity but the immune system also has a cellular response.

While the UK experience shows that a single jab has some effect, it seems to be less effective against the new delta variant so it is important to get both jabs to be fully protected.

The importance of CPR

Seeing Christian Eriksen collapse on the pitch during the Euro 2020 football match was a shock.

I’ve refrained on posting about him until we knew he was ok, but I think this does have important lessons to share.

It’s fantastic that he has made a recovery and has made it home.

This shows you how important quick and effective CPR, cardio-pulmonary resuscitation is. The medics on pitch started CPR within 2 minutes and he was defibrillated within 5 minutes.

Even in the last week, I’ve seen someone in their 30’s who didn’t get CPR or defibrillation so quickly and they have yet to wake up.

So what do you do if you see someone collapse in front of you?

Make sure it’s safe to approach, then check if their conscious and breathing. Shout for help. CPR starts with ensuring the airway is clear, putting someone on their back and starting chest compressions.

Find an automatic external defibrillator (AED). If you pass through train stations or leisure centres, or work in an office or building site regularly keep an eye out for where these are kept.

They are great little machines that talk you through what you have to do – open up the box, get the pads out, where to stick them and what to do. They can and do save lives. St John’s Ambulance have got a good video.

Hopefully we will continue to see these AED’s in more places, perhaps on every football pitch or sports ground. Please do take up CPR training if you can – these courses are often run through your employer or St John’s ambulance.

5 Reasons Why You Should Keep In Touch – The Importance Of Follow Up

One of the founding values that I have built my practice on, is that I believe in treating patients as a whole, rather than a result on a piece of paper like an ECG or a scan.

The sort of problems that I deal with – chest pain, palpitations and shortness of breath, can be caused by a variety of issues, not only with your heart

…it may be a problem with your lungs

…or the muscles around your ribs

…and it may be stress related or have an emotional element

Furthermore, it can be a combination of these things.

We are very good these days at pinpointing the location of the trouble, especially when it comes to ruling out anything serious, but tests are only a snapshot of what is going on and things can and do develop over time. 

There are several reasons that I always offer my patients a follow up appointment* and whether or not you take it, I am keen to point out that you can get in touch and book in to see me without having to go through your GP if you are ever worried or have questions.

• REASON 1 – Peace of mind

There is a significant psychological element to anything to do with your heart and many of my patients are reassured when the tests come back negative and there is nothing sinister to find, however, they still like to come back for regular check-ups for peace of mind.  

When I see patients in the NHS, or for insured patients, I am often encouraged to discharge them back to their GP, but this has never sat comfortably with me, so in my own Private Practice, I like all my patients to know that I am always there for them at the end of the phone.

• REASON 2 – Things change

When I see a patient in the clinic, I will examine them and may perform tests, but these will only give me a picture of what is going on in that moment in time

…. and things change.

Just because your heart is in a normal rhythm when the ECG was done, does not mean it will always be that way.  

A normal blood test is reassuring, but the levels could start to change at any time and if we are not keeping an eye on them, there is a possibility things could be missed.

Furthermore, your symptoms may change

…things may get worse, or you may start experiencing something different.

It is important not to ‘leave it and hope it gets better’

It may be nothing, or it may be something, but it is important to get it checked out and if you have a follow up appointment, then that can be an ideal time to go over everything

…in fact, if things change significantly, then don’t wait for your follow up appointment, but get in touch and I will be happy to bring your appointment forward.

• REASON 3 – To monitor the effects of treatment

Medicine is not a precise science and it is essential to monitor the effects of any treatment or intervention.  Sometimes things may need to be tweaked to optimise the benefits and to limit the side effects.

All treatments will have some degree of potential side effects and some treatments are more effective in certain patients than others.

We need to keep an eye on how things are going, to make sure that everything is optimised.  This might mean that we may need to change the dose or type of treatment your are receiving and it may mean stopping or starting a treatment.

Many cardiologists rely on your GP to monitor the effects of treatment, which is perfectly acceptable

…but I like to give my patients the option to come and see me, to take the pressure off the GP service and to give a level of continuity of care.

• REASON 4 – New treatments are always coming out

Medical advancements and research is a continuously ongoing field and a large part of my job is keeping up to date with the latest developments.

This is one of the benefits of being a cardiologist who specialises in rhythm disorders, because I can be at the forefront of any new technologies.

For example, in the last 5 years there have been 2 new drugs for heart failure so if you want state of the art care it is worth checking in with me once in a while.

• REASON 5 – Maintain awareness of your heart health

I find that patients who come back to see me regularly at the clinic are more aware of their symptoms and tend to look after themselves well.

It is not all about taking tablets or having a medical intervention, as lifestyle changes can have a profound effect on your risk of heart disease.

Being aware of the need to maintain a balanced diet and a healthy weight.  Stopping smoking and being mindful of the need to reduce stress can have as much of an effect on your heart health than medication (and more!)

So, you see, there are several reasons for you to keep in touch and come back to the clinic for a follow up appointment.

If you don’t already have a follow up appointment and would like to arrange one, feel free to get in touch by phone on 01634 510 521 or email: , or you can get message me on our new WhatsApp number, 07878 214940.

*insurance companies will often only cover a limited number of follow up appointments, but I offer a self-pay service where you can ‘pay as you go’ for follow up appointments not covered by your insurance

If I have an AF ablation without insurance, why is it so expensive?

So you’ve got Atrial fibrillation (AF) and you’ve considered your options for treatment – a lifestyle approach, medications, or an ablation.

You’ve decided that the best solution for you is an AF ablation.  You may be having this paid for by insurance, but more and more patients are saving on insurance premiums and deciding to pay for it themselves.

We offer self-pay packages for patients who are not insured and this is a growing part of the market and can offer more flexibility and choice.

If you do choose to go down the self-pay route, you may ask ‘why is this an expensive procedure?’

Like anything in life, we have to weigh up the cost of something against the benefits it can provide.

When it comes to your heart health, AF ablation can be the most effective way to ensure the heart beats effectively in selected groups of patients.

While it may seem like a large up-front cost, the benefits or reverting your heart in to a normal rhythm almost immediately, compared with the alternative of having a lifetime of medication can be hard to measure in terms of monetary value.

Not only is there the constant reminder that you need to take your medication, but there are also risks and side-effects of the medication, that should not be overlooked.

Of course, there are risks with ablation too, but it is usually a one-off procedure and could result in you not needing any medication to maintain your heart in a healthy heart beat rhythm.

Studies have shown that, in the right patient, AF ablation can be not only the most successful and in the long-term, safest way to treat your AF, but it is also the most cost-effective, when everything is considered.

…but even if you have accepted that it is the best way to treat your AF, then you may be wondering,

‘how do they justify the cost?’

Well, people are always surprised by how many people are involved in this procedure.

We have arrhythmia nurses to help smooth the process and counselling before and after the procedure.  In the room itself there is a scrub nurse to assist, a running nurse to get equipment, a radiographer to operate the X-ray machinery, a cardiac physiologist to operate the ablation equipment as well as the Anaesthetist and his assistant.  Afterwards there are the nurses in the recovery department, as well as the ward staff – nurses, ward clerk, porters, cleaners and so on.

The equipment costs are also significant.  A purpose-built catheter lab costs over a million pounds to build.  It needs to be lined with lead to prevent X-ray radiation leaking out, as well as meet operating room standards of cleanliness.  This includes filtered air at a higher pressure than outside so air flows out of the operating room at all times to minimise the chance of germs coming in.  The operating table needs to be able to take the weight of the patient and ancillary equipment, be able to be manoeuvred in the room to assist with procedures and be transparent to X-rays.  The X-ray equipment needs to move around the patient and be very sensitive to help up see the catheters inside the body.

We also use 3D mapping systems which cost over £100,000.  These act like a GPS system to localise catheters inside the heart and allow us to map the veins and additional connections.  The consumables for these systems are expensive – the conducting patches that are stuck to your back cost around £500 alone. 

The freezing console and the Radiofrequency consoles are of the order of £50,000 each and these enable the ablation to be performed.  The individual catheters that are placed in the heart and do the ablation are single use and cost over £1000 each.  There are also other diagnostic catheters – up to 4 used for each case.

We also use specialised custom sheaths which are often deflectable to help guide the catheters.  These are again single use.

The ultrasound machine costs a £100000 and the probe itself is £10,000!

So there’s a lot of kit and people involved which makes it amongst the most expensive health-care procedures you can have done, and probably the most expensive in which you don’t actually get a prosthesis or device implanted.

Is it worth it?  Well, the procedure has come on tremendously in the past decade as the kit has improved.  We are on the 3rd generation of cooling balloons, the RF catheters can now sense the contact force making ablation more effective and safer, and the mapping systems are getting better resolution all the time.  We may not be able to cure atrial fibrillation yet, but we can certainly improve symptoms for the majority of patients using this technique.

I am a cardiologist with a special interest in AF and electrophysiology, so I am able to offer the whole range of treatments for AF, including ablation.

If you want more information or would like to set up a free call to discuss your problems, please get in touch (link to contact page) and I would be happy to help.


Are we going to have a second wave of Covid?

I was asked this by one of my patients last night.

Simple question, difficult to answer.

We are all seeing in the media that the number of infections is rising steadily, but overall numbers are much lower than earlier in the pandemic. They also seem to be geographically concentrated in the north west, north east and the midlands. Infections in London and Kent are still low, and there aren’t many suspected cases in the hospitals.

It seems obvious that as children return to school, parents will return to work and fatigue about social distancing sets in, numbers of infections will go up.

We seem to be entering an endemic phase – we’re going to have to learn to live with this, and I think life is going to change. It’s quite possible that “Christmas will be cancelled” and holidays abroad next year may well be disrupted.

What does this mean for Cardiology services? I think remote visits are here to stay, and there’s going to be a much greater focus on patient self monitoring. Already we’re seeing patients being asked to check their own blood pressure and weight. Self-recorded ECG’s are becoming indispensable in the treatment of patients with rhythm problems. In terms of procedures, we are having to be much more organised than before to ensure that elective wards are Covid free. This means patients needing to self isolate for 14 days before major procedures, and 3 days before minor procedures and Covid testing all patients 3 days beforehand.

The focus has to be on delivering safe services for those who need them, but clearly capacity is down because of the extra cleaning and social distancing required between patients.

I think we will see a second wave, but this isn’t going to be tsunami of the first wave, and we are in a much better place to cope with it second time round.

Ever wondered what all those letters after a doctors name mean?

Here’s a potted guide. The letters themselves are called postnomials. They are qualifications and can indicate membership or fellowship of an organisation that can award them.

MBBS – Bachelor of Medicine, Bachelor of Surgery. This is the degree issued by most medical schools in the UK after 5 years of medical training at University.

MBChB – Bachelor of Medicine, Bachelor of Chirugery (another term for surgery). Some medical schools in the UK issue this degree.

BSc – Bachelor of Science. This is a undergraduate degree (meaning that you do not need a degree already before you can enrol) which takes 3 years at University. A BSc in certain subjects can be obtained by an additional year taken half way through medical school training.

MD – Doctor of Medicine. In Britain this is a postgraduate research degree (meaning you need to already have a degree before you can enrol) which requires 2 years of full time study and the writing of a thesis. In the USA, this is the basic degree in medicine. In India, this is a postgraduate taught degree, rather than a research degree.

PhD – Doctor of Philosophy. Some doctors undertake a PhD, usually a 3 year research degree.

MRCP – Member of the Royal College of Physicians. Membership is awarded after passing a postgraduate exam. All doctors specialising in internal medicine must pass this exam before entering subspecialty training eg in Cardiology.

FRCP – Fellow of the Royal College of Physicians. Members of the Royal College of Physicians can be elected to become a fellow if they have distinguished themselves in the field of medicine. Not all Consultants are invited to become fellows.

FHRS – Fellow of the Heart Rhythm Society. Fellowship of this US based organisation is offered to those who have extensive training and specialise in heart rhythm disorders.

CCDSCertified Cardiac Device Specialist. This is a qualification offered by the International Board of Heart Rhythm Examiners. This requires evidence of completing training in pacemaker and defibrillator therapies, followed by a 5 hour exam, which is valid for 10 years. I recertified in 2019.

CEPS-AC. Certified Electrophysiology Specialist in Adult Cardiology. This qualification is awarded by the International Board of Heart Rhythm Examiners and again lasts 10 years.

CCT – Certificate of completion of training. This is awarded to doctors when they have completed their training and are eligible to enter the GMC Specialist register or the GP register. All permanent Consultant appointments require entry on the GMC Specialist register, though locum Consultants may not be on the Specialist register. The letters CCT are not recognised as a postnomial and are therefore not usually used.

There are a whole host of other qualifications for doctors in different fields. 

Surgeons for example have MRCS and FRCS, Membership and Fellowship of the Royal College of Surgeons, which is awarded after passing a postgraduate exam. For some reason in the UK this means that they are addressed as Mister / Miss / Mrs rather than Doctor. They don’t do this in other countries.

General Practitioners also have the MRCGP (Membership of the Royal College of General Practitioners) exam and can do other qualifications in many specialties, for example Obstetrics and Gynaecology (DRCOG).

Universities also have titles such as Professor / Reader / Senior Lecturer and these reflect teaching or research roles.

My qualifications include MBBS(Hons). Hons is short for honours. These were awarded because I graduated in the top 10% of my year at Medical school. I also did an additional Bachelors of science degree (BSc) in Neuroscience. After qualifying I passed the MRCP exam in 2003. I was awarded an MD(Res) in 2016 with King’s College London for echo imaging to research the effect of pacing on heart function. I also passed both the IBHRE exams in pacing and electrophysiology. I retook the pacing exam in 2019 after 10 years, I scored in the top 1% so have been invited to be an IBHRE ambassador and mentor for other candidates. I was elected a Fellow of the Royal College of Physicians in 2018 as recognition of my research, teaching and my work on College committees. I was elected a Fellow of the Heart Rhythm Society as I have exemplified my commitment to Cardiac Electrophysiology.