It was 2013, and Key West resident Candace Estep had been feeling fatigued and rundown for months, but was a master of ignoring the problem.
A wine representative and divorcée, she worked at home, but still managed to make it to wine events at night, tend to her adult children and her dogs and keep up her home. However, she had stopped going to her weekly yoga and Pilates classes, complaining she would get light-headed.
After returning from a business trip to Italy, Estep could not shake the fatigue she thought was jet lag. And she was starting to get short of breath.
One day, when Estep laid down in her bed to rest, she couldn’t ignore the problem any more. Suddenly, she could not breathe.
“I started crying,” said Estep, now 51. “I knew something was really wrong with me. I didn’t know if it was cancer or what, but I didn’t know it was my heart. I just couldn’t draw in any air.”
Estep made an appointment at the University of Miami Hospital with a cardiologist, Dr. Nanette Bishopric. Upon examining Estep, Bishopric could immediately tell there was a problem: Every third heartbeat was irregular. But what was causing the problem?
Bishopric sent Estep home with a halter monitor, which records every heartbeat over 24 hours. The results of the test stunned both her and her doctors.
Most heart problems are caused by the heart’s “plumbing,” that is, the arteries pumping blood away from the heart. When the public hears about heart problems, they typically think of blocked arteries, and open-heart surgery, bypasses and stents to open up the clogged arteries. But other, lesser known heart conditions are caused by the heart’s electrical system. That was the case with Estep, whose “plumbing” was perfect.
During those 24 hours she was wearing the monitor, Estep’s heart experienced more than 40,000 irregular heartbeats. A healthy person would experience just five to 10.
Rapid, irregular heartbeats aren’t fatal, but over time, they can weaken the heart and lead to heart failure. That was the case for Estep. Her heart was not properly providing oxygen to her body, which was the reason for her exhaustion. She was already in early heart failure.
“She had some cells in her heart that were firing vogue,” said Bishopric. “I call them snipers. They are beating to their own drum. At that level of extra beats, there get to be concerns.”
Both Estep and her doctor were shocked. She looked healthy and youthful, had an active life, was working, did not suffer from high blood pressure or high cholesterol, had no history of heart disease in her family and was otherwise healthy.
Bishopric referred Estep to her colleague at the University of Miami, Dr. James Coffey, a cardiac electrophysiologist, who specializes in electrical problems in the heart.
"Electrophysiology of the heart is not very well understood by the general public, but it's a huge problem," said Coffey, who estimates there are 20 to 30 cardiac electrophysiologists practicing in South Florida.
In August 2013, Coffey used UM’s 3D mapping technology to map and make images of the cells of Estep's heart to discover the source of her problem. This equipment — in existence for less than three decades —allows doctors to map exactly where the extra heartbeats are coming from. It does so through a catheter that snakes up the leg, using local anesthesia.
In real time, as doctors map the heart and discover the problem area, they use a catheter with an electrode at its tip to burn those cells that are causing the rapid heartbeat. This is a non-surgical procedure called ablation and it usually eliminates the problem.
In Estep's case, that wasn't possible. Her problem was even rarer than Coffey realized.
In the vast majority of cases, doctors usually discover one bad spot inside the heart. In Estep's case — for reasons Coffey can’t explain — there were numerous bad spots. And they were not inside the heart, but outside.
What that meant was that he was never going to be able to fix Estep's problem completely.
Luckily for Estep, Coffey had a plan in this rarest of situations to at least improve the quality of Estep's life. He had trained with a Brazilian cardiologist who invented a procedure in which doctors could pierce through the chest with a needle and enter the sac surrounding the heart before carefully burning off the bad spots outside the heart.
This procedure, however, is done with general anesthesia and considered quite risky. If the needle on the probe accidentally pierced Estep's heart, she would need emergency open heart surgery to repair it.
"With most people, it wouldn’t even be safe to try this,” said Coffey. “It's a much, much riskier procedure.
Coffey is one of the few doctors to perform this procedure.
Estep underwent the surgery in 2014 with good results. Her irregular heartbeats were reduced from more than 40,000 a day to 16,000 to 18,000. That means Estep, while not feeling 100 percent back to normal, has her energy back. She has her life back.
“I feel about 80 percent better,’’ she said. “I literally might not not be alive it if weren't for Dr. Coffey. He told me that other electrophysiologists might not take on my case and even try to fix me with ablation. Had we not persevered, I most certainly would have had heart failure eventually. So I'm deeply indebted to both my doctors. I really love them.’’