Shooting for the Stars
15-year-old Leah is a high-level basketball player at the top of her game as a rising junior on one of Pennsylvania's best high school teams, Bethlehem Catholic High School. At one particularly intense game, as she was running down the court, she felt her heart racing and a tightness in her chest. Her mom, Maria, tried to get Leah to come out of the game, but Leah waved her off and downplayed the symptoms.
Concerned, Maria took Leah to her general pediatrician and explained what had occurred. Her pediatrician immediately referred Leah to a cardiologist and restricted Leah’s activities. Leah’s cardiologist performed numerous tests, including an electrocardiogram (EKG) and echocardiogram, neither of which detected anything abnormal. He gave her a Holter monitor, a small, wearable device that records the heart's rhythm and is used to spot irregularities, to wear for several days. During her next basketball game, Leah wore the monitor at her doctor's insistence. After helping her team to an overtime win, Leah went into cardiac distress in the locker room, experiencing a racing heart, lightheadedness, and chest pain that made it hard to breathe. Her heart rate and pressure were fluctuating wildly.
“We found out later from the Holter monitor data that her heart rate went up to 260 and that she was in atrial fibrillation (AFib) with supraventricular tachycardia (SVT). She could have died,” Maria said. SVT is a fast or erratic heartbeat affecting the heart's upper chambers.
EMTs arrived and took Leah to St. Christopher’s Hospital for Children. At first, the Emergency Department staff was unable to get an accurate reading of her heart, as the AFib episodes were coming and going.
“They said they had to give her medicine to slow her heart so they could get a reading,” Maria recalled. “I was terrified and praying to Jesus, but just before they pushed the meds into the IV, her heart rate dropped to 99 so they could do the reading without it.” The test confirmed that Leah was in AFib.
It is extremely rare for a healthy 15-year-old to have atrial fibrillation, and genetic testing ruled out an inherited condition. Leah was admitted to St. Christopher’s Pediatric Intensive Care Unit (PICU), where the physician started Leah on several medications to slow her heart rate and control her heart rhythm, but the medications did not work. Leah’s care team told Maria they would have to perform electrical cardioversion, a treatment that uses one or more quick electric shocks to relax her overactive heart.
The critical care team shocked Leah’s heart twice but could not get it back into a regular rhythm. They reached out to Nandini Madan, MD, Section Chief of the Heart Center and Director of the Electrophysiology and Exercise Laboratory at St. Christopher’s. Dr. Madan was boarding a plane for a family vacation but took the time to consult with the team on a different course of medication. The new medication worked, and Leah was discharged two days later and cleared to play basketball again.
Leah did not experience any issues for two weeks; then, another AFib episode struck during basketball practice. She was rushed to a local hospital and taken by air transport to St. Christopher’s PICU, where the Critical Care staff was able to control her symptoms with different medication.
“After our second ICU visit, I wanted a second opinion and took Leah to another children’s hospital,” Maria recalled. “The doctor was nice enough, but when we met with Dr. Madan again, I instantly decided we were staying with Dr. Madan without a doubt in my mind. She knew Leah, and she had stepped in while on vacation. I was taken aback by how much she cared. Dr. Madan asked Leah about her goals in school and sports and explained the treatment options in detail, including ablation. We were so grateful that Dr. Madan was willing to try managing her condition with medicine because Leah wanted to play college basketball, and it was possible that if they performed an ablation, she might only be able to perform at 80%.”
Ablation is a procedure to treat AFib that uses heat or cold energy to create tiny scars in the heart. This helps to break up or insulate the faulty signals that cause irregular heartbeats and can help the heart maintain a normal heart rhythm. A cardiologist commonly uses thin, flexible tubes called catheters to perform an ablation. The catheters are placed in blood vessels and guided to the heart.
Leah continued to see Dr. Madan at St. Christopher’s Heart Center’s outpatient clinic, where Dr. Madan could closely monitor her care. With extensive expertise in sports cardiology and knowing the potential risks facing a high-level athlete, Dr. Madan consulted with her peers who worked with collegiate and NBA players.
“She had been having these arrhythmias for some time, so for me, there were three key things,” Dr. Madan said. “Most important was to make a diagnosis – it was not clear if her arrhythmia was coming from multiple locations in her heart, and there was the AFib, which is far more common with older people but has been seen in young patients who are very accomplished athletes. Second, I wanted to develop a plan of care that would allow her to continue playing. And third, was to prevent her from having to go to the hospital every month in distress.”
It eventually became clear that Leah would need ablation therapy, and Dr. Madan explained the procedure to Leah and her parents. She also told them that she had arranged for an experienced adult electrophysiologist to be on standby during the procedure. Adult and pediatric electrophysiologists sometimes work together to provide the best care for teenagers or young adults.
“No other hospital could get an adult and pediatric electrophysiologist in the cardiac catheterization lab at the same time as we could, which was best for Leah,” Dr. Madan said. “I had colleagues willing to come to perform Leah’s procedure with me, but I had to figure out how I could get them credentialed at St. Christopher’s within two weeks.”
Maria works in a physician’s office, so she understood the hurdles they faced in having another provider credentialed so quickly to participate in the procedure. “Dr. Madan moved mountains to make this happen,” she said.
It proved to be a team effort.
“We are a small hospital compared to others, so we provide personalized care, not just for the physicians but the whole staff,” Dr. Madan explained. “St. Christopher’s Administration supported me every step of the way and helped me get the adult electrophysiologist credentialed. Maria’s insurance also required additional clearance on the day of the procedure. With guidance from Sherree Wagner, Heart Center Practice Manager, I went to our chief financial officer. I explained that I had the adult electrophysiologist onsite and ready to go and that Leah needed this procedure now, so he gave the green light. I am not sure that would have happened anywhere else. I am incredibly grateful to St. Christopher’s, not only my Cath Lab team, but to administration, the credentialing team, and everyone else who played a role in ensuring Leah received the best care.”
The procedure went well, though Dr. Madan could not guarantee that the AFib would not return. “Leah wasn’t in consistent tachycardia, so we couldn’t be sure we found all the misfiring areas, but it was enough to map and ablate 95% of her heart. We implanted a loop recorder to monitor her heartbeat for several years.”
Maria says Leah’s care was a miracle. “It was the grace of God that put Dr. Madan in our path. Everyone at St. Christopher’s was just really wonderful and supportive, but Dr. Madan, without a doubt, is the best. She has a passion for not only treating the ailment, but she truly cares about the whole child and their goals. Dr. Madan continually spoke to Leah’s pediatrician while she was an inpatient and after she was discharged to ensure they were on the same page for the best possible care for her. Dr. Madan is so uplifting, encouraging, confident, and intelligent. Finding a physician so dedicated to putting all the pieces together is rare. What we were going through – from the difficulty of diagnosis to getting approval for the adult electrophysiologist to the insurance problem – Dr. Madan and the St. Christopher’s Heart Center staff were on top of everything.”
Now 16, Leah is doing well and treating her condition with low-dose medication. Division One college basketball scouts are already courting her, so a college scholarship and even higher levels of basketball may be in her future.