Offer at Valley Regional Arrhythmia Center
Regional Arrhythmia Center offers a comprehensive approach to
managing patients with cardiac arrhythmias. In addition to
providing both inpatient and outpatient consultation, we have
several active clinics following pacemaker and defibrillator
patients. Our physicians perform an entire range of inpatient and
outpatient diagnostic and therapeutic procedures.
Consultation and Second Opinion
Cardiac Electrophysiologists are available for
an initial consultation and for a second opinion consultation
regarding any aspect of arrhythmias management. We understand
that many patients have invested a significant amount of their time,
energy, and even money in setting up and coming in for a
consultation. We further realize that for most patients, the
purpose of their consultation is to "get some answers."
Therefore, our philosophy on office consultation is very simple; we
"tell it as it is." We will analyze your complex medical
history and distill it down to simple and understandable terms
relevant to your arrhythmia. We are committed to giving you an honest and
straight-forward opinion about your condition and lay out all reasonable treatment options.
A question that frequently comes up is whether a
patient needs a "referral" to see a specialist. The general
rule is that consultations do require the referral from your primary
physician, but patients may also initiate the request for a second
opinion consultation. Please keep in mind that for certain insurances, especially an
HMO, a "referral" is mandatory for any type of specialist
visit. If unsure, please check with your insurance before
making the appointment.
In order for your visit to be most productive and
worthwhile, having your medical records available at the time of
your first visit is critically important.
Please refer to the section on "preparing
for your first visit."
pacemaker is a
complicated electronic medical device that requires close follow-up.
For optimal performance of the device, fine-tuning on a long-term
and on-going basis is mandatory. In general, a pacemaker
should be checked in the office at least once or twice a year, and more frequently
immediately after initial implantation or toward the end of its battery life.
At each pacemaker clinic visit,
the pacemaker is "interrogated" by the programmer (see picture
below). The programmer uses a "wand" that communicates
with your pacemaker over radiofrequency signals. This can be
done without you undressing, as long as the wand is within a few
inches of the pacemaker. Newer generations of defibrillator
(see next section) but not pacemakers can be "interrogated" using
wireless technology, without the wand.
for a Pacemaker Clinic appointment.
With each interrogation, the information from the
pacemaker is downloaded into the programmer for your physician to
review. The status of the pacemaker battery is evaluated, as well as the
integrity of the electrodes (the "wires"). Pacing and
sensing thresholds, or the ability for the pacemaker to "capture"
the heart and to "see" the underlying heartbeats,
are carefully evaluated at each follow-up.
The output of the pacemaker
and the "sensing" level are then "adjusted" in order to provide the best
combination of patient safety and battery longevity.
One needs to keep in mind that
these "thresholds" for a given pacemaker or a given patient can be
dynamic and may change over time, thus the need for continued
long-term follow-up. For some patients whose pacing threshold
had increased above and beyond the setting of the pacemaker may
experience symptoms due to pacemaker pacing ineffectively, or not at
all. Many patients who never been enrolled in a pacemaker
clinic may still have their pacemakers programmed at the "out-of-the-box"
setting (the original manufacturer default setting), which can lead to premature battery depletion and
additional unnecessary surgery.
Modern pacemakers also have a great deal of
diagnostic features which can help your physician detect potential pacemaker or arrhythmia problems.
Examples of problems that can be identified during such visits
include malfunction of the electrodes, premature depletion of the
batteries, unexpected irregular
heartbeats, or worsening congestive heart failure. These
information are usually recorded in the memory of the pacemaker
which can then be "downloaded" by your physician in the
follow-up. These data can give your physician important
insights into the integrity of the pacemaker and the health of your heart,
helping him or her
render timely treatment for your heart as needed.
Another important reason for following up in pacemaker clinic is
that from time to time, there may be unexpected malfunction of
pacemakers that lead to "recall"
of the affected units by the manufacturer. Information on such
issues can be quickly disseminated to patients who maintain regular
contact with the pacemaker clinic. Those that are lost to
follow-up may not receive these critical information.
There are pacemaker clinics that are attended by
nurse practitioners and physician assistants, many of whom are very
well trained and perfectly capable of handling all pacemaker related
issues. At Valley Regional Arrhythmia Center, however, we
believe that physicians should be present at the time of the visit
in order to give the best services to our patients. Our
pacemaker clinic is always attended by our physicians in conjunction
with other ancillary service personnel (except in the case of
unscheduled or emergency visits). There are several advantages
to our system. The first is that any problem that is
identified during the follow-up visit will have the immediate
attention of our physicians, who can then make immediate decision
and make any necessary changes to the setting of the pacemaker.
Second, our physicians can evaluate the patient for medical issues
that requires immediate attention, above and beyond those associated
with the pacemaker, without the need to make another consultation
Just like a pacemaker, a defibrillator is a
very complex electronic machinery that
requires regular follow-up evaluation. The follow-up
requirement for a defibrillator is even more vigorous than that of a
pacemaker because of its more complex functions and the fact that
patients who need a defibrillator are in general much sicker and
have more medical problems. The result is that more potential
problems can occur and can be readily picked up at the time of
A defibrillator follow-up is usually twice a year
to four times a year. At each visit, the defibrillator is
"interrogated" by the programmer (see picture below) through a wand
or via wireless technology. Battery status, electrode
integrity, pacing and sensing thresholds, along with the entire
range of diagnostic information are determined just like those
for a pacemaker (please refer to the section on
pacemaker clinic for details on
these). In addition, specific attention is given to the
recording of potentially life-threatening arrhythmias and the
presence or absence of a defibrillator intervention for such
for a Defibrillator Clinic appointment.
The diagnostic and recording capabilities of a
defibrillator is even more comprehensive and complicated than those of a pacemaker.
The defibrillator memory can give a precise date and time of nearly
events that have occurred since the last clinic visit, and can provide long-term trends of many parameters pertaining to
the functionality of the defibrillator and even the well-being of the
patient. These important data are downloaded at each office
visit to help your physician better manage your arrhythmia and heart
Like the pacemaker, a defibrillator should not be
programmed to the "out-of-the-box" setting in the long
term, as this can lead to premature battery depletion.
Instead, careful fine-tuning is necessary for each individual
patient, in order to achieve the optimal performances of the device. Inadequate defibrillator
programming can lead not only to premature battery depletion, but
also inappropriate defibrillator shocks and sometimes even failure
of the defibrillator to perform some of its most important function,
i.e., resuscitation of the heart. It is important to note that
programming of the defibrillator should only be done under the
direct supervision of a physician.
Just like the
pacemaker clinic, a defibrillator
clinic can help inform patients of critical updates about their
devices, including the issue manufacturer "recall."
At Valley Regional Arrhythmia Center, the
defibrillator clinic is attended by our Electrophysiologists, just
like the pacemaker clinic. At each visit, not only do
we check the mechanical function of the defibrillator, we also
provide medical evaluation for the patient as a whole. Any medical decision about
the care of the defibrillator or the treatment of of the patient can
be made at that visit without the need for a return consultation visit.
Certain models of pacemaker and defibrillator are
capable of so-called "remote monitoring," or "home monitoring."
This service generally utilizes some type of wireless technology to download
the information from the pacemaker or defibrillator and transmit it over a phone line
or even wirelessly to a
remote secure website run by the manufacturer. This
information can be downloaded and
viewed by you physician. This type of remote monitoring may be ideal for patients with
transportation difficulties. However, one should keep in mind
that home-monitoring is for diagnostic purposes only. Any intervention
(changes to the setting of the device) still requires a visit to the office.
We at Valley Regional Arrhythmia Center provide
home monitoring clinic for patients wishing to enroll this type of
service. Downloaded information is reviewed by the physician
and steps are taken to have patient evaluated as the need arises.
Coumadin (or Warfarin) is an important
anti-coagulant (blood-thinner) that helps prevent the
formation of blood clot in certain types of condition
that predispose the patient to
thrombosis (blood clot). The most common indications for
Coumadin are atrial fibrillation and valve replacement.
Long-term monitoring of the status of
anti-coagulation is of paramount importance because levels that are
too high or too low can both be dangerous. Furthermore, level
of anti-coagulation (how thin or thick the blood is) can vary from
day to day and from week to week, even though a
patient may be taking the exact same dosage of coumadin. This is because many factors
can influence the level of anti-coagulation, including variation in the
diet, differences in the absorption of coumadin, and potential
drug-to-drug interaction from other concurrent medications.
Therefore, close monitoring is mandatory.
Monitoring of the level of anti-coagulation is done through
a test called
Pro-Thrombin time, or "Pro-Time" or "PT" for short. Most people
today refer to the test as INR (International Ratio). An INR
that is too high indicates that the blood
is "too thinned" and can patient may bleed. On the other hand, an INR that is too low
means the blood is "too thick" and this can be
accompanied by blood clot formation.
Valley Regional Arrhythmia Center provides the
service of INR evaluation in our Coumadin Clinic for the benefit of patients with atrial
fibrillation or other conditions that require
anti-coagulation. While many other offices utilize the laboratory to perform INR, which requires a phlebotomy (blood draw
through a needle in the vein) and
has a turn-around time
of up to 1 day, we perform INR with a finger prick and the results are
available within 5 minutes. The decision
on whether to change the dosage of Coumadin or to stay the same can be
made in one setting without the need for repeated messaging and "phone-tagging."
Office Procedures: Valley Regional
Arrhythmia Center offers a comprehensive array of office-based
diagnostic procedures for the evaluation and treatment of patients
with arrhythmias. The following are brief descriptions of the tests
we offer. Please click on the
links to see detailed descriptions of each procedure.
Electrocardiogram (EKG): a simple recording of your heart
rhythm, usually with 12 electrodes.
a 24-hour continuous recording of your heart rhythm, usually with 3
Event monitor: a 30-day long-term,
Tilt table study:
a non-invasive test for the diagnosis of fainting.
Exercise Treadmill Test:
a treadmill test to assess for
underlying coronary heart disease.
Stress Echocardiogram: an exercise
treadmill which involves additional imaging with
a non-invasive ultrasonic imaging
study of the heart.
Our physicians are affiliated with most area hospitals and can
perform a wide range of procedures for all kinds of arrhythmias.
are brief descriptions of the procedures we routinely perform. Please
the links to see detailed descriptions of each procedure.
an outpatient treatment to
"shock" and restore normal rhythm of the heart.
(PM): an implantable electronic device that
helps regulate heartbeat.
Cardioverter-Defibrillator (ICD or AICD):
an implantable pacemaker with defibrillation
Implantable Loop Recorder:
an implantable long-term event monitor.
Electrophysiology Study (EPS):
an invasive diagnostic test for arrhythmias.
Radiofrequency Ablation (RFA):
an invasive, curative procedure for arrhythmias.
Mapping (Electro-Anatomic Mapping):
a new computerized mapping technique used to help localize
Fibrillation Ablation: a curative
procedure for atrial fibrillation.
For Frequently Asked Questions (FAQ) about these procedures, follow this
Electronic Medical Records (EMR)
Valley Regional Arrhythmia Center utilizes
paperless Computerized Electronic Medical Records. This
improves efficiency in the running of the office and drastically
reduces the chance of human error in appointments, record keeping,
and medication prescription.
is a board-certified Pediatric Neurologist with an active
Pediatric Neurology practice at this office. She sees children
with all forms of neurological disorders. She is the Vice
President of Valley Regional Arrhythmia Center.
for an appointment to see Dr. Tseng-Ong for neurology consultation.