Award-winning Orlando cardiologist Dr. Sambit Mondal talks with the Opportunist’s Managing Editor Leslie Stone about the groundbreaking work his practice is doing in the diagnosis and treatment of cardiovascular diseases, his focus on electrophysiology and the reward of giving his patients a new lease on life.
Sambit Mondal, M.D., is Board Certified in Cardiovascular Diseases, Internal Medicine and Cardiac Electrophysiology and has practiced medicine since 2004. As the only electrophysiologist among the physicians at Orlando Heart Specialists, his primary focus is on the pursuit of heart rhythm disorders, better known as cardiac arrhythmia. His innovative ablative therapy offers a potential cure for issues around tachycardia—a heart rate that exceeds normal range—and has improved lives by eradicating crippling symptoms in countless patients.
Orlando Heart Specialists is among a select group of cardiology practices in the nation—and the only cardiology practice in Florida—that have achieved the Bridges to Excellence® Cardiology Practice Recognition for meeting rigorous thresholds established by the American College of Cardiology and Bridges to Excellence®. Additionally, Orlando Heart Specialists was the recipient of the 2012 Florida Health Care Coalition’s Community Quality Award and, in December 2012, the practice was featured in Orlando magazine’s Best Doctors® and Top Doctors lists and named Orlando’s Finest Doctors in the practice of cardiology.
Opportunist: According to the Centers for Disease Control and Prevention, CDC, heart disease is the leading cause of death for both men and women. What typically goes wrong with the heart?
Dr. Mondal: There are four chambers of the heart. Although each one functions independently, if something goes wrong in one chamber it will adversely affect the others. A patient may have a valve problem, a ‘plumbing’ problem or an electrical problem. When someone has a heart attack it is a ‘plumbing’ problem—due to a blockage or clogged artery. Electrical problems are the worst. Congestive heart failure is an electrical problem, and cardiac arrest is an electrical problem that must be fixed immediately. Diagnosing and treating electrical problems is my specialty.
Opportunist: What motivated you to become a cardiologist?
Dr. Mondal: I initially wanted to become a cardiothoracic surgeon, but toward the end of my medical school years I spent some time with a cardiologist who was involved in interventional cardiology and that experience left me thinking: OK that seems like a branch of medicine that I would like to pursue.
Opportunist: How does interventional cardiology differ from general cardiology?
Dr. Mondal: It’s a branch of cardiology that deals specifically with catheter based treatments such as balloon stents, etc. That looked pretty cool to me at the time, so I went into internal medicine and practiced in New York for a few years. From there I was accepted into a cardiology fellowship program at the University of Miami in 2002 and got the chance to participate in some interventional work where I would scrub in and help with acute heart attacks and things of that nature. It was very interesting and challenging; however, I was surprised that it didn’t pique my interest as much as I thought it would. By the end of my second year I was introduced to cardiac electrophysiology, which is the study and treatment of the electrical properties of the heart. I will never forget my first day in the electrophysiology lab because I could not understand a single thing. I was baffled and wondered what my colleagues were seeing that I wasn’t because it just whizzed past you—it was nothing like an EKG—and I found that amazing.
Opportunist: What role does electrophysiology play in cardiology?
Dr. Mondal: It involves the measurement of voltage change or electric current and is not as visual as interventional cardiology where you insert a catheter into the heart to see where a blockage exists. The electrical currents pass by at about eight times the speed at which your eyes are trained to see, and it requires recording data from one side of the heart and then another and placing it within a 3D pattern of the heart from which you extrapolate the circuitry. The amount of technology that goes into an electrophysiology lab is worth seeing. If you ever go into an electrophysiology cockpit you will recognize the mapping system, the recording system and the fluoroscopy that we use. These three techniques combined allow us to see what is going on with the heart and to see where we can eliminate the problem. I came home thinking I don’t know what’s going on and I don’t know what they’re seeing, but at the same time I was gravitating toward it because I found it extremely challenging and I like a challenge. Finally, by the third or fourth day, all the pieces fell into place and I figured out how the jigsaw puzzle was playing out. We are taught to read EKGs as students and internists and then when you become a cardiologist you learn to see more things, but with electrophysiology you aren’t just seeing 3D images—you are trying to figure out how the electrical patterns are moving within the heart. It is way beyond the general cardiologist’s level of interpreting heart rhythms—we are able to interpret phases in the cell activation cycle that might be getting blocked. It’s a lot more mentally challenging and it requires all the skills required for interventional cardiology as well as extraordinary mental focus, which I found extremely interesting. I was sold on this facet of cardiology and so, after six years of concentrating on the interventional aspect, I switched to electrophysiology and I haven’t looked back. I have been practicing cardiac electrophysiology for about seven years now and I am in love with it.
Opportunist: Please tell us about the heart’s internal electrical system and what happens when it goes haywire.
Dr. Mondal: The heart’s internal electrical system controls the rate and rhythm at which the heart beats. That electrical signal travels from the top to the bottom of the heart, and as it travels it causes the heart to contract and pump blood. When it isn’t working properly, congestive heart failure can occur.
There are many things we can do from the heart failure standpoint to improve the quality of life in an individual and make them feel human again and also save their lives if they go into cardiac arrest. Our goal is to keep them from being admitted into the hospital and living life there, not to mention the huge costs benefits. Implanting a defibrillator is one way in which we can prevent cardiac arrest. It’s a metal device that sits on the upper chest. It’s not a pacemaker—it not only sets the pace of the heart but it can also shock the patient’s heart if cardiac arrest is about to occur. And it allows us to monitor a patient and see how he is doing at home. We can determine how many hours he is walking around, if he has received any life-saving shocks from the defibrillator, if fluid is accumulating in the body and a diuretic must be prescribed to alleviate that, or if he is going into heart failure. This information lets us intervene before the patient gets to the point where he must be admitted to the hospital. The patient could be sitting in Timbuktu and as long as he has an Internet connection we can monitor his situation remotely. Heart failure is just one aspect of my disease management. There are many rhythm disturbances that can occur in the heart and cause short circuits in multiple locations. When they do, quality of life goes down the drain. We also do pacemakers for less severe cases, and Bi-ventricular Implantable Cardioverter Defibrillators (ICDs) for severe cases of congestive heart failure.
Opportunist: What other kinds of disturbances can occur?
Dr. Mondal: Palpitations are a rhythm issue. The heart beats fast and the electrical system short circuits and the patient starts having symptoms of fatigue or loss of quality of life. They get up in the morning and by 10:30 a.m. they are moping round and want to go back to bed or they might go into cardiac arrest.
Atrial fibrillation, or A-fib, is the most common cardiac arrhythmia and it is often associated with heart palpitations, fainting, and chest pain or, in worse case scenarios, congestive heart failure. Palpitations and fatigue also put people at risk for stroke.
Opportunist: How prevalent is A-fib and what causes it?
Dr. Mondal: As we grow older and live longer A-fib is more common and we are going to see more of this. It’s the most rapidly increasing diagnosis in our country and it affects about 2.6 million people every year.
Alcohol is the biggest trigger for A-fib. That includes wine, beer and alcohol of any kind. Wine is quite often reported to be good for health but that’s mostly for plumbing problems. A-fib isn’t usually not a disease of the young, but it can happen in young people. ‘Holiday heart’ is the term that is used when it occurs in an otherwise healthy individual. This typically happens after a drinking binge. The electrical system short circuits and makes the chamber beat as much as 500 times per minute. It’s not life threatening but exhibits almost the same physiology. It’s like a bag of worms because it’s beating so fast that the current cannot travel properly and it can become incapacitating. Quite often, people don’t recognize it. A patient might think I’m 72 and that’s why I am so tired, but it’s more than that. If I ask you if you could do the same things today that you’ve done in the last two years with the same amount of energy could you say yes? Someone with A-fib would say ‘no.’ It’s that simple because when you have A-fib it’s sucking the energy out of you very slowly. Symptoms are quite subtle sometimes and present themselves as mostly fatigue and exercise intolerance. A-fib is such an important factor of a disabling stroke. Take a walk through the Neuro-ICU of any hospital and you will see that nearly one-fourth of the patients have an A-fib diagnosis. Also, patients with a history of heart attack or bypass surgery and those who are older or who have high blood pressure, diabetes or are genetically predisposed [to heart disease] run a higher risk of A-fib. It’s a very disabling disease, not just from the standpoint of stroke but from the loss of day-to-day quality of life.
Opportunist: Is a heart murmur considered a rhythm disorder?
Dr. Mondal: No, a heart murmur is actually a valve problem. But a valve problem can lead to electrical problems. Leakiness of the left upper and left lower chambers of the heart, for example, can lead to problems in the left upper chamber. They are all interlinked in some fashion or another.
Opportunist: Please tell us about your innovative ablation procedure.
Dr. Mondal: Ablation is the biggest part of my work and the most satisfying. It is what drives me. What we do is take these A-fib patients into the electrophysiology lab and induce a rhythm disturbance—for which they are symptomatic—in a controlled setting. Then we use a mapping system and pacing maneuvers to discover where the short circuit is and we use ablation to not only trap it but to destroy it so it doesn’t come back to bother us. We can map the short circuit within a millimeter space. Mapping is two-fold. One kind of mapping system uses a magnetic system like a GPS within the heart. It has a magnetic field and the catheter tip is magnetically enabled. We affix six patches on the body and use this mapping system to reveal the circuitry of the patient’s heart. Imagine I have blinded you and you do not know what the door looks like. The mapping system pinpoints the problem and my catheter lets me connect these dots and make a door out of it. I cannot see these structures visually but when I use the mapping system I can find them. Imagine a 3D point in a room and we have no way of telling you where it is. If I have a beam of light telling me where it crisscrosses, I can find it. As my fidelity goes up and touches more and more spaces, I can connect the dots and figure out what the surface of the heart looks like. As we induce the arrhythmia we are collecting information that tells us if we are cold, warm, hot, hotter, and closer and closer to the bad circuit. The mapping system lets us locate the bad circuits that we need to ablate. It’s a very precise space and we can potentially achieve a cure for the rhythm disturbance. Most of what we do in medicine suppresses the problem but doesn’t eliminate it. Take diabetes for example. We have suppressed the problem and controlled it, but we have not cured it. Rhythm disturbances in the heart can be located and eliminated. We can tell the patient they will never have the problem again. There are very few things in medicine that can achieve a cure like you can with electrophysiology. If one of my patients has a heart attack and I have to call in my plumbing partners, they will insert a balloon or a stent but they cannot tell the patient they will never have a heart attack again.
Ablation for A-fib is going to change the landscape for how we treat everything. Up until this time, it was a fairly difficult problem to treat. Cardiothoracic atrial fibrillation has been treated since the late seventies and early eighties when Dr. James Cox out of St. Louis developed the procedure. He would make slices around the heart and sew it back up to interrupt disturbances such as common arrhythmia of the heart. Ablation has barely existed for barely a decade and there are centers that specialize in this now. It has become more commonplace in the last five or six years. Florida Hospital Orlando and Orlando Regional Medical Center do a fairly good job in targeting this particular problem, and there are centers across the country that have recognized themselves as centers that attract physicians to come and do their work. There are many things in the pipeline now and technology is being developed that will allow us to better understand the heart and make us much more effective at performing ablations and even allow us to occlude the left atrial appendage and prevent strokes. Research is being done and new things are being developed to not only predict worsening, but also to improve the autonomic nervous system that affects the heart. The yin and yang is in perfect balance and when heart failure occurs that system goes out of balance. Lots of studies are going on in the last year or so that are helping us to determine if we can effectuate and change heart failure status. There are also strides being made in the ablation area involving other technologies like lasers and high frequency ultrasound and microwaves and studies on cryosurgery—to see if they do a better job than ablation. There is a massive amount of interest in trying to figure out the mechanics in which A-fib perpetuates itself.
Opportunist: Can you share some of your success stories?
Dr. Mondal: Yes. Just this week, I saw a patient whose defibrillator saved him from fatal cardiac arrest. He awoke feeling OK, with a normal heart rate, and then things went awry and he was heading into cardiac arrest. After his defibrillator kicked in he was remarkably able to drive in to the office to see me, and we were able to access his records wirelessly and print them out and analyze them.
Opportunist: How was that possible?
Dr. Mondal: He simply stood beside the wireless unit in our office and it ‘uploaded’ his record. Then I was able to print it out and pinpoint exactly where he got into trouble. He will always need a defibrillator but it’s better than going into cardiac arrest and hoping the ambulance arrives in time to save him.
About two years ago I saw a young 57- year-old man diagnosed with heart failure. Throughout our treatment we have encouraged him to exercise and change his diet and do this and that and, yes, he still needs defibrillation, but his heart function has improved. In fact, it’s almost 35 percent better now. We hope to improve it to the point where he doesn’t need defibrillation at all.
I saw a young lady who was suffering with palpitations. Whenever she drank coffee or ate chocolate or exerted herself the slightest bit, her heart rate would jump to 250 beats per minute. So I took her into the lab and diagnosed her short circuit. Then I went in and ablated it and her chances of ever having this problem again are less than 2 percent. She was on two different medications and we were able to stop those as well. I saw her a month later and she remained OK, so I told her ‘Go live your life. You don’t need me anymore’ and she was thrilled.
Opportunist: In addition to the groundbreaking work you are doing in cardiac care, what else do you believe sets your practice apart?
Dr. Mondal: Our practice was among the first cardiology practices recognized by the American Heart Association as the premier group in the country that is practicing medicine that is way ahead of its time. It’s a rare distinction having been conferred upon us. We don’t boast about it but at one time we had six out of the 17 physicians around the country in this elite group of physicians.
Our philosophy in practicing medicine, and especially cardiology, is to only do what is necessary. When everybody else is trying to do more procedures we are striving to do less. If a procedure isn’t necessary, we don’t do it. If it ain’t broke, don’t fix it! If a procedure is necessary, however, we will do it and, yes, we are very good at it. What we can wait on we will wait on. We don’t do testing just for the sake of testing. Before we subject a patient to testing we ask how much it’s going to affect the person long term and what will be the outcome for their life.
We believe that much of the ‘common sense medicine’ has been lost and we want to bring it back. In other words, there are ways and means of using common sense practicing guidelines that will allow you to achieve the same things by doing less. Consequently, we can deliver the same or better care at one-fifth the price. If all of us would practice medicine this way the cost of medicine would go down for everyone. Our cost of care per person, per month for any disease state is about one-half to one-fifth of any competing group within the Central Florida area—keeping the same outcomes or, in some instances, better outcomes.
Opportunist: Are you a proponent of prescribing medication when necessary?
Dr. Mondal: Yes, of course. Medication is often needed to support the quality of life and avoid future bad outcomes and prevent death. Many of our patients with congestive heart failure are on ACE [angiotensin-converting enzyme] inhibitors and, if not, there is a reason why. We strive to stay above the national standards and we follow the guidelines of whatever medicines are necessary to a T. We don’t like unnecessary medications and we don’t practice polypharmacy, which is the prescribing of too many medications for the same thing. We are also very cost conscious and if we can achieve the same results without expensive drugs we will go to generics. Sometimes expensive drugs are better and have better delivery systems, and when that is the case we will have a frank discussion with a patient and say ‘Hey this is a drug that is more expensive but it works better’ and we prescribe it accordingly.
Opportunist: What do you enjoy most about your work?
Dr. Mondal: The knowledge of electrophysiology that I have, which lets me go in and fix a problem that makes a difference in a patient’s life. When a patient tells me ‘Thank you … you have given me my life back’ it makes it all worthwhile. I haven’t just saved a life; I have improved the quality of somebody’s life.
My colleague Dr. Nandkishore Ranadive is giving a lecture outside in the waiting room right now. He’s just sitting there among the patients and talking with them about things like what they can do to improve their diet and what they can do about exercise. If you didn’t know he was a physician, you’d think he was a patient himself. People read so many health claims on the Internet and get advice from friends and family, such as ‘is ginger good for my health?’ or ‘should I eliminate this food or that food from my diet,’ that it is good for the physician to actually interpret these claims and provide factual data to prove or disprove it. He does this almost every Monday for whoever wants to stop by, and he covers any topic they want to talk about. One day he grabbed me and we sat and talked with patients about defibrillation. Today he is talking about diet. One day I caught him answering common questions that patients have about vitamins and other things that quite often go unanswered, such as what is going on with their blood pressure and things of that nature. We are very big on cardio rehab and how doing simple things like walking around can improve your heart function.
Leslie Stone is an award-winning writer/editor with more than two decades of experience covering business, finance and lifestyle issues for newspapers, magazines and online publications. Originally from Virginia, she currently resides in Florida. Follow her on Twitter at @les7989.