Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Procedures for treating and preventing atrial fibrillation
After successful cardioversion many patients (up to 75%) may experience
recurrence of atrial fibrillation within 12 months. Therefore, many patients will need long-term
treatment with medications to prevent a recurrence of atrial fibrillation; however, medication(s)
are effective only 50%-75% of the time in preventing recurrence. Moreover, many
patients cannot tolerate the side effects of long-term medication. For these
reasons, several procedures have been developed to treat and prevent recurrence
of atrial fibrillation; they include:
Ablation of the AV node with implantation of a
pacemaker
Implantation of a pacemaker
Implantation of an atrial defibrillator
Maze procedure
Isolation of the pulmonary vein
Ablation of the AV node with implantation of a pacemaker. Ablation of
the AV node is a procedure that destroys the AV node so that the atrial
electrical discharges cannot pass through the AV node to activate the
ventricles. The procedure usually is performed in a cardiac catheterization unit
or an electrophysiology unit of a hospital.
1) Procedure. For ablation of the AV node, patients are given a local
anesthetic to minimize pain and are mildly sedated with intravenous medications.
Using x-ray guidance, a wire (catheter) is inserted through a vein in the groin
to reach the heart. Electrical recordings from inside the heart help to locate
the AV node. The AV node is destroyed (ablated) using heat delivered by the
catheter. After successful ablation of the AV node, electrical discharges from
the atria can no longer reach the ventricles. Destruction of the AV node
(whether by catheter ablation or by disease that occurs with age) can lead to an
excessively slow rate of ventricular contractions (slow heart rate). Therefore,
a pacemaker is implanted in order to provide the heart with a minimum safe heart
rate.
2) Benefits of ablation of the AV node. The benefits of ablation of
the AV node and implantation of a pacemaker include:
resumption of a regular heart rate (even though a
pacemaker may be determining the heart rate)
relief from palpitations, fainting, dizziness, and
shortness of breath
ability to stop medications and avoid their potentially serious side
effects
3) Risks of ablation of the AV node. Potential complications of
ablation of the AV node and permanent implantation of a pacemaker
include bleeding, infection, heart attack, stroke, introduction of air into the space
between the lung and chest wall, and death. Still, this technique has helped
many patients with severe symptoms to live normally.
4) Candidates for ablation of the AV node. Candidates for ablation of the AV
node are patients with atrial fibrillation who respond poorly to both chemical and electrical
cardioversion. These patients experience repeated relapses of atrial
fibrillation, often with
rapid rates of ventricular contractions despite medications. Ablation also may
be an option for patients who develop serious side effects from the medications
that are used for treating and preventing atrial fibrillation.
5) Limitations of ablation of the AV node. Ablation of the AV node only
controls the rate with which the ventricles beat. It does not convert atrial
fibrillation to
normal rhythm. Therefore, blood clots still can form in the atria and patients
are still at risk of strokes. Thus, there is a need for long-term
anticoagulation in addition to the permanent pacemaker.
Pacemakers. Permanent pacemakers are battery-operated devices
that generate electrical discharges that cause the heart to beat more rapidly
when the heart is beating too slowly. Recent studies suggest that some patients
with recurrent paroxysmal atrial fibrillation can benefit from the implantation of a
permanent pacemaker. Although the reasons for this benefit are unknown, regular
electrical pulses from the pacemakers may prevent the recurrence of atrial
fibrillation. Furthermore,
newer pacemakers that can stimulate two different sites within the atria (dual
site atrial pacing) may be even more effective than standard pacemakers in
preventing atrial fibrillation. Nevertheless, permanent pacemaker implantation cannot be
considered as standard non-medication treatment for atrial fibrillation.
Implantable atrial defibrillators. Implantable atrial defibrillators
can detect and convert atrial fibrillation back to a normal rhythm by using high-energy shocks.
By detecting atrial fibrillation and terminating it quickly, doctors hope that these devices will
prevent recurrences of atrial fibrillation over the long term.
Atrial defibrillators are surgically implanted within the chest under local
anesthesia. These devices deliver high-energy shocks to the heart that are
somewhat painful. Atrial defibrillators are not useful in patients with chronic
sustained atrial fibrillation and are suitable only for patients with infrequent episodic attacks
of atrial fibrillation.
Maze procedure. Many doctors believe that the atria cannot fibrillate
if they are sectioned into small pieces so that the conduction of the electrical
current through the atria is interrupted. During the Maze procedure, numerous
incisions are made in the atria to control the irregular heartbeat and restore a
regular rhythm to the heart.
1) Procedure. The Maze
procedure is most commonly performed via open-heart surgery.
Some electrophysiologists (doctors specially trained to treat abnormalities
of rhythm) are now attempting to perform the Maze procedure using
catheters inside the heart that are passed through a vein in the groin
without open-heart surgery. Unfortunately, the success rate using the catheter
is below 50% and complications (such as strokes) may occur.
2) Effectiveness of the Maze procedure. The Maze procedure done
surgically (using open heart surgery) has been reported to correct atrial
fibrillation in
90-99% of patients. Only 15-20% of the patients need a pacemaker after
surgery, and there is only a 30% chance of requiring long-term medications to
maintain a normal rhythm.
3) Risks of the Maze procedure. The surgical maze procedure involves
open-heart surgery and the pumping of blood by an external bypass pump while
the surgery is performed, much like patients undergoing cardiac bypass
surgery. The complications are not insignificant and include stroke, bleeding,
infection, and death. Therefore, doctors usually do not recommend a surgical
Maze procedure for the treatment of atrial fibrillation unless the patient is undergoing
open-heart surgery for another condition (such as for coronary artery bypass
or replacement or repair of a diseased heart valve).
Low blood pressure, also referred to as hypotension, is blood pressure that is so low that it causes symptoms or signs due to the low flow of blood through the arteries and veins. Some of the symptoms of low blood pressure include light-headedness, dizziness, or even fainting if not enough blood is getting to the brain. Diseases and medications can also cause low blood pressure. When the flow of blood is too low to deliver enough oxygen and nutrients to vital organs such as the brain, heart, and kidneys; the organs do not function normally and may be permanently damaged.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
An arrhythmia is an abnormal heart rhythm. With an arrhythmia, the heartbeats may be irregular or too slow (bradycardia), to rapid (tachycardia), or too early. When a single heartbeat occurs earlier than normal, it is called a prmature contraction.
Hyperthyroidism is an excess of thyroid hormone resulting from an overactive thyroid gland. Symptoms can include increased heart rate, weight
loss, depression, and cognitive slowing. Treatment is by medication, the use of
radioactive iodine, thyroid surgery, or reducing the dose of thyroid hormone.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
COPD (chronic obstructive pulmonary disease) is a disorder that persistently obstructs bronchial airflow. COPD mainly involves three related conditions, chronic bronchitis, chronic asthma, and emphysema. Symptoms of COPD include chronic cough, shortness of breath, frequent respiratory infections, wheezing, morning headaches, and pulmonary hypertension. Treatment of COPD is focused on the related condition(s).
Mitral valve prolapse (MVP) is also also known as "click murmur syndrome" and "Barlow's syndrome." Mitral valve prolapse is the most common heart valve abnormality. Signs and symptoms of mitral valve prolapse include: fatigue, palpitations, chest pain, anxiety, and migraine headaches. Echocardiography is the most useful test for mitral valve prolapse. Most patients do not need any treatment, however, patients with severe prolapse may need treatment.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Pulmonary edema (swelling or fluid in the lungs) can either be caused by cardiogenic causes (congestive heart failure, heart attacks, abnormal heart valves) or noncardiogenic causes such as ARDS, kidney failure, high altitude, pneumothorax, pleural effusion, aspirin overdose, pulmonary embolism, and infections. The treatment of pulmonary edema depends on the cause of the condition.
Pericarditis is the inflammation of the pericardial sac that surrounds the heart. The causes of pericarditis include injury from heart attack, heart surgery, trauma; viral or fungal infection, HIV, tumors, mixed connective tissue disease, metabolic disease, medication reactions, or idiopathic. Treatment for pericarditis is generally medication, however, sometimes surgery is necessary.
When a portion of the brain loses blood supply, through a blood clot or embolus, a transient ischemic attack (TIA, mini-stroke) may occur. If the symptoms do not resolve, a stroke most likely has occurred. Symptoms of TIA include: confusion, weakness, lethargy, and loss of function to one side of the body. Risk factors for TIA include vascular disease, smoking, high blood pressure, high cholesterol, and diabetes. Treatment depends upon the severity of the TIA, and whether it resolves.
Rheumatic fever is a disease that sometimes occurs after a group A streptococcal infection of the throat. Symptoms and signs include carditis, polyarthritis, Aschoff bodies, rash, Sydenham's chorea, and fever. Treatment for rheumatic fever involves eliminating the bacteria with penicillin, erythromycin, or azithromycin. Further treatment focuses on alleviating the symptoms brought on by the body's immunologic response to the bacteria.
Heart attacks are the major causes of unexpected, sudden death among men and women. A heart attack is also a significant cause of heart failure. Learn the risk factors for heart attack such as high blood pressure, diabetes, and other heart conditions. Lowering your risk factor, lifestyle changes, and in some cases medication are the most effective way of preventing a heart attack.
Stroke is the third leading killer in the United States. Some of the warning signs of stroke include sudden confusion, trouble seeing with one or both eyes, dizziness, loss of balance, and more. Stroke prevention and reatable risk factors for stroke include lowering high blood pressure, quit smoking, heart disease, diabetes control and prevention.
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