0:05

Comprehensive, relevant, and insightful conversations

0:08

about health and medicine happen here.

0:11

Whenmedstarhealth dot talk

0:17

in 2020, data collected from around

0:20

the world made clear that the most common form of

0:23

an irregular heartbeat, called atrial

0:25

fibrillation, or AFib, is on the

0:28

rise. The number of

0:30

AFib cases is trending upwards by at

0:33

least 30% every 20 years.

0:37

According to the CDC, 12.1

0:40

million people will have Afib in

0:42

2030. Who among us

0:45

will be one of them? We know that atrial fibrillation

0:48

can lead to stroke. The stakes are

0:50

high. So last November, the American College of

0:53

Cardiology and the American Heart association released

0:56

guidelines to help categorize AFib and

0:59

recommend best practices for treatment.

1:03

Electrophysiologist Dr. Richard Jones from the Medster

1:06

Heart and Vascular Institute joins me today to tell

1:09

us more about those guidelines and everything listeners need

1:12

to know about afib. I'm your host, Debra Schindler.

1:16

Thank you for being here, Dr. Jones.

1:18

Glad to be here, Debra Thank you for inviting me.

1:21

Atrial fibrillation is so common that most of us,

1:24

at least most of us over the age of 45, know someone

1:27

who's experienced it or who's been treated

1:29

for it. And it can be pretty scary when you're having

1:32

symptoms. What is actually happening when a person

1:35

experiences atrial fibrillation?

1:38

Fantastic. Thank you for the question. Yeah, so, as

1:41

you mentioned, atrial fibrillation is the most common,

1:44

heart rhythm issue out there. Here in the United States and

1:46

worldwide. It's characterized

1:49

by, typically an irregular heartbeat, or an irregular heart rhythm is

1:54

how it's commonly referred to. And what's happening in

1:57

Afib is the top chambers of the heart that normally

2:00

squeeze to fill the bottom chambers. And,

2:03

the bottom chambers squeeze to the pump blood to the body.

2:06

These top chambers are quivering. They're fibrillating, they're

2:08

going 300 and 5450 beats a minute. And

2:11

kind of just chaos in these top chambers. And

2:14

that gets, transmitted to the bottom chambers as this very

2:17

irregular rhythm that people tend to feel as fast.

2:20

Palpitations, they can sometimes see on their

2:23

apple Watch or fitbit these days that the heart rate just

2:26

jumps up and kind of stays high, and it's erratic and

2:29

all over the place. And that's often a sign of

2:31

atrial fibrillation. as you mentioned, one of the

2:34

most worrisome, features of atrial fibrillation, it's

2:37

its ability to increase one's risk of

2:40

stroke. And that tends to come from those

2:43

fibrillating top chambers where blood doesn't move

2:46

well, and when blood isn't moving, well, it can form a

2:48

clot. A clot that forms in the heart can be pumped to the

2:51

brain, and that's a stroke. but that clot can really go anywhere in

2:54

the body and cause damage to any body part or organ due to

2:57

lack of blood flow wherever that clot happens to go. And so

3:00

that's why one of the first things we look at

3:03

when someone is diagnosed with atrial fibrillation is,

3:06

what is their risk of having a stroke and

3:09

afib? And that's where blood thinning medicines and things like this can

3:11

be helpful to reduce that risk.

3:14

Well, it seems that the impact of having atrial

3:17

fibrillation could really span a full spectrum,

3:20

because some people don't even realize they were in

3:22

Afib.

3:23

Absolutely. I think that's a great point, and

3:26

it always stands out to me. This patient I saw in the hospital where

3:29

I was looking at the patient, and telemetry was up above

3:32

their head, and their heart rate was going 160 beats a

3:35

minute in Afib, and I could see it on telemetry, but they had no

3:37

clue because they were looking, facing away from

3:40

the monitor. And I asked them, do you feel anything

3:43

at all? And they said, absolutely not, doc. I feel

3:46

absolutely fine. And so that's certainly one end of the spectrum

3:49

where people have no clue that they're in Afib, and they can be going

3:52

very fast, even, and have no clue.

3:54

Is it still dangerous if they don't feel it?

3:56

Sometimes, it can be even a little bit more dangerous, to be

3:59

quite honest. Because if the heart is allowed to go

4:02

unchecked for weeks and months at a time in a

4:05

very fast rhythm, at some point the heart, like any muscle,

4:08

will kind of tire out, and the heart function can actually

4:10

reduce from going so fast for so long. And

4:13

so we often see that, we refer to that as

4:16

a tachycardia induced cardiomyopathy, or

4:19

simply a weakening of the heart

4:22

due to a prolonged episode of a fast

4:24

heart rate in this atrial fibrillation. And

4:27

so it can absolutely be an issue, but

4:30

they can span from the spectrum of feeling nothing at all. To

4:33

some people, knowing the moment they go into Afib like that,

4:36

they absolutely feel it. I've had one patient describe it as a

4:39

fish flopping in their chest. Another patient, it felt

4:42

like a squirrel was running around in their chest. That's how

4:44

symptomatic they are when they're in atrial fibrillation.

4:47

Other people experience shortness of breath,

4:50

shortness of breath when they walk around a reduction

4:53

in exercise kind of capacity. Right, doc? I used

4:56

to be able to walk up this hill. I had no problems. I took my dog for a

4:59

walk every day. Now, all of a sudden, in this

5:01

Afib, I'm huffing and puffing to get up the hill.

5:04

And so that's another kind of symptom of atrial

5:07

fibrillation. Fatigue often comes, with

5:10

Afib, some people can feel the fatigue in the rhythm.

5:13

Other people describe it kind of as they break

5:16

out of afib, they can feel that fatigue. and so that can

5:19

be another common symptom of atrial fibrillation.

5:22

Feeling that a squirrel is running around on a wheel

5:24

in your heart is not something that you're likely to

5:27

not notice.

5:28

Exactly.

5:29

What should somebody do if they have that sensation? Should

5:32

they lay down? Should they not be walking the dog?

5:35

That's a great question. I mean, there are lots of ways

5:38

to approach that. I think anytime your heart rate is going fast and

5:41

sustained and you have symptoms, the safest thing is probably

5:44

to call, EMS to get immediate help.

5:46

It's a 911.

5:47

It can be. I mean, some people's heart rates get very elevated,

5:50

and depending on what other medical conditions you

5:53

have, it can be somewhat serious.

5:56

I think. If there's any time where something is sustained for long

5:58

periods of time and you're feeling short of breath or you're having chest

6:01

discomfort, anything like that, I think it's always right to just

6:04

call ems, get immediate help, get to a

6:07

hospital, and we can sort things out. Afib is not one of

6:10

these rhythms. Some people who may be listening to this may have

6:13

heard of SVT or

6:15

superventricular tachycardia, fast rhythms that come from the

6:18

top chambers of the heart that are kind of a

6:21

separate, category from atrial fibrillation. Atrial

6:23

fibrillation is also a top chamber rhythm, if you will.

6:26

but it kind of gets its own special, category with

6:29

atrial fibrillation and its cleas and atrial flutter kind

6:32

of being grouped together because they have this, increased risk

6:35

of stroke and different ways of approaching its

6:38

management. But SVT tends to be that rhythm. M where people

6:41

have heard, if you bear down, you can sometimes break out of it and things

6:43

like that. With Afib, those maneuvers don't

6:46

necessarily work so well. Oftentimes we have to

6:49

use medicines if someone stays in

6:51

sustained, fast rhythms or even procedures, like

6:54

ablation procedures, to try and kind of, control that atrial

6:57

fibrillation, if you will.

6:58

You mentioned the flutter. I want to distinguish between the

7:01

flutter and the fibrillation, what's the difference? And

7:04

is the flutter not so dangerous? It's not so risky,

7:07

or is it still just as risky?

7:09

Oh, perfect question. So, atrial flutter

7:12

is. We often refer to it as a cousin to

7:14

atrial fibrillation. They're two kind of

7:17

separate rhythms, if you will, but they tend to co occur

7:20

oftentimes. People who have atrial flutter, we will go

7:23

on 30, 50% of the time. they

7:26

will go on to develop atrial fibrillation. And in

7:29

atrial flutter, instead of that chaos that we see in the

7:32

top chambers, where the top chambers are just quivering

7:35

and going 300 and 5450 beats a minute in

7:37

chaos. In flutter, the top chamber gets stuck in a

7:40

loop, and so the top chamber tends to be going still

7:43

quite fast. 200 and 5350 beats a minute,

7:46

somewhere like that. And that loop is the difference

7:49

between the two, if you will. It's kind of a structured loop that

7:51

sometimes we have to treat. With cardioversion, we

7:54

shock people out of, which is also used for Afib or an

7:57

ablation procedure. One of the bigger differences

8:00

between atrial fibrillation and atrial flutter is it can sometimes be

8:03

difficult to control atrial flutter with

8:06

medications, meaning to slow down the rhythm

8:09

or to have people pop out of the rhythm. With what

8:12

we call anti rhythmic medicines, atrial

8:15

flutter tends to be a little bit more difficult to control as medicines,

8:18

whereas atrial fibrillation can be a little bit easier.

8:20

Both rhythms, though, is important to notice. We use

8:24

this scoring system called the chad's vas score, to look for

8:26

one's risk of stroke. That's how we risk stratify,

8:29

is use the scoring system called Chad's vasc,

8:32

and that simply stands for congestive heart failure,

8:35

hypertension, or high blood pressure. We look at age,

8:38

diabetes, history of a previous stroke, history

8:41

of a prior heart attack or other vascular disease,

8:44

and then, actually being a female gets another point as

8:47

well in the scoring system. And that's how we

8:50

determine one's need for blood thinning medicines or

8:53

other strategies to reduce one's risk of stroke. So,

8:55

both AfiB and aflutter increase the risk of stroke,

8:58

and slightly different in terms of, how we kind of manage them with

9:01

medicines and ablation and things like that. Usually someone with a

9:04

chad score of zero. We don't recommend blood

9:07

thinning medicines because oftentimes in that

9:09

situation, blood thinning medicines may have a higher

9:12

risk, whereas their stroke risk is higher than

9:15

the general population, but not so high as to warrant maybe being on

9:18

a blood thinning medicine. if you have a chad's

9:21

vascore of one, that's where we really

9:24

start having conversations with the patient about whether or not a blood

9:27

thinner makes sense with what they do and how they want

9:30

to approach things and how they approach their overall risk

9:33

for stroke. Some people are very worried about stroke,

9:36

and they want to do everything they can to reduce that risk. And so starting a blood

9:39

thinner for a chad's vascular 1 may make sense there, or we

9:42

look at other risk factors. Right. Is the top chamber of the heart very

9:45

dilated? Is there other medical comorbidities, like

9:48

chronic kidney disease or severe obesity or things like that,

9:51

that may elevate one's risk? That's outside of that scoring

9:54

system? And then generally, a chad's vascore of two or

9:57

higher is where our guidelines recommend blood

9:59

thinning medicines, for sure. The newer guidelines have made a move

10:02

to a 2% risk of annualized,

10:05

risk of stroke or more, which allows

10:08

us to take into account other risk factors outside of that

10:11

chad's vascular that may elevate one's risk for

10:14

stroke in these rhythms.

10:15

So you mentioned the svts. Is that an

10:18

arrhythmia?

10:18

It is. It's a different form of

10:21

arrhythmia. it tends to come in kind of three

10:24

main buckets, if you will. There's, ah, an atrial

10:27

tachycardia, or a little focus that starts firing fast, an

10:30

isolated little focus. There's, avnrt, or

10:33

this little loop that the heart gets stuck in right at the central

10:36

junction box between the top and bottom chambers, electrically.

10:39

And then there's AvRT, which is kind of a bigger loop

10:42

that the heart can get stuck in, which is an abnormal connection between the

10:45

top and bottom chambers, electrically. This is

10:48

different from Afib and atrial flutter in

10:51

that SVT doesn't increase one's risk for

10:53

stroke. and then when we start talking

10:56

about, medical management or even ablation

10:59

procedures, ablation tends to be much more

11:01

successful for SVT procedures, whereas

11:04

for atrial fibrillation, there's no true kind of cure

11:07

for atrial fibrillation. We use medicines, we use ablation

11:10

procedures to try and knock down the amount of AFib. One is

11:13

having, to decrease that burden, in particular, if they're very

11:16

symptomatic with Afib, or if they've had a prior reduction

11:19

in their heart squeeze, like we talked about, if they go fast and

11:22

don't know it for a while, and the heart function really

11:24

reduces, those are really reasons to really be

11:27

aggressive and try to control the amount of Afib.

11:29

You're having an irregular

11:31

heartbeat, palpitations, lightheadedness, fatigue, shortness of

11:36

breath. All could be symptoms of, Afib.

11:39

Are there others? What's the craziest one that you've heard

11:42

of?

11:42

I mean, the one that we often

11:45

find, even when patients say, I don't feel anything in Afib,

11:48

is oftentimes fatigue. Another

11:51

is this exercise intolerance. Right. I used to be able to

11:54

do this and that and not have any issues, and all of a sudden, I'm huffing and

11:57

puffing when I do it. I think those really stand out. And I

12:00

think a lot of times, if it's

12:02

unclear if someone is

12:04

having symptoms from atrial fibrillation, well,

12:07

oftentimes, that's where we may reach for a

12:09

cardioversion procedure, a procedure where

12:12

we sedate someone and make them sleepy so they don't

12:15

feel anything, and then we can shock the heart back in a normal

12:17

rhythm. Now, in normal rhythm, we can

12:20

say, well, you know, you were in Afib

12:23

then. Now you're in normal rhythm. Do you feel any

12:25

different? Oftentimes, that's where you find that the fatigue has

12:28

gone away, the shortness of breath has gone away that they didn't

12:31

realize was there, especially with exertion. Right. That shortness

12:34

of breath. And younger folks, it tends to be with exercise.

12:37

Right. I used to be able to, run 5 miles. All of a sudden.

12:40

Now I run a mile, and I'm out of breath. That's where

12:43

it really becomes evident. If it wasn't clear before, is that

12:46

juxtaposition that you're in normal rhythm now after the

12:49

cardioversion and then the weeks before you were in Afib,

12:51

how different do you feel? And that's how we kind of try to

12:54

tease out sometimes if someone truly has symptoms, because

12:57

if you have symptoms from atrial fibrillation, then that is

13:00

a class one indication to think about performing

13:03

an, ablation procedure. And in some cases,

13:06

even without trying medications, some people don't want to try

13:09

medications. In other cases, people have failed medications.

13:12

And if that's the case, then we can proceed to this

13:14

catheter ablation procedure, where we target

13:17

the most common triggers for atrial fibrillation, which tend

13:20

to come from these veins, what we call the pulmonary veins that

13:23

plug into the top chamber of the top

13:26

left part of the heart. And those pulmonary veins can

13:29

have abnormal electrical firing, and that

13:32

electrical firing can set the heart off into atrial

13:34

fibrillation. And that's the most common trigger for

13:36

Afib. It's not the only trigger for atrial fibrillation,

13:39

but it's the most common trigger for atrial fibrillation. And

13:42

that's why, when we perform a catheter ablation procedure, the idea

13:45

is to either freeze, we're using heating

13:48

energy. are the two common modalities these

13:50

days. we kind of, create

13:53

purposeful scar at the entrance of those veins with

13:56

an ablation procedure, and scar does not

13:59

conduct electricity. So now the vein can be firing

14:01

away, but the heart will never see it because it gets blocked

14:04

by this purposeful scar we've created. And that's the

14:07

idea behind a catheter ablation procedure for atrial

14:10

fibrillation.

14:11

M now, when those scars are created,

14:14

does that mean. I mean, they're not going to form

14:17

immediately when you do the procedure, right.

14:19

So the patient comes out, can they still be an

14:22

Afib after a procedure like that?

14:24

That's a wonderful question. We actually refer to the kind

14:27

of three months after an Afib ablation procedure as the

14:30

healing phase. That's when this freezing, which

14:33

we most commonly do these days, the freezing

14:36

and creating that cell death, creates inflammation in the heart

14:39

tissue itself and can actually be pro arrhythmic,

14:42

can actually sometimes cause Afib to be a little bit

14:45

more common in that healing phase. And so,

14:47

oftentimes, we'll reach for cardioversion to shock back

14:50

out if needed, or even sometimes a medication to just

14:53

help smooth over that first three months of that healing

14:56

phase. And so, oftentimes, we have folks who are already coming

14:59

into the procedure on medicines, and we'll continue those

15:02

medicines for three months, or if there is recurrence of

15:05

Afib in that healing phase, if it comes back after an

15:07

ablation, we may use an anti arrhythmic medication

15:10

to get through that healing phase, with the idea being

15:13

that hopefully, after three months, we can wean off that

15:15

medicine. Now that the heart is healed, the inflammation has

15:18

settled down, and that's when we really, truly get a good

15:21

sense of how well that procedure is going to work for that

15:24

patient. It's not truly a cure.

15:27

I certainly wish that an ablation procedure meant that Afib would

15:29

never, ever happen again, which isn't quite how

15:32

these procedures work. In part, it's because there can

15:35

be other triggers for atrial fibrillation. We're going after the most

15:38

common trigger, which is these pulmonary veins. But

15:41

sometimes the back wall can be very scarred of that top chamber, and

15:44

that can be a source of trigger, sometimes other rhythm

15:47

issues, like we talked about with svts, can actually trigger

15:50

atrial fibrillation, or there can be triggers on the right side

15:53

or this type of thing. And so, while we do

15:56

the best we can, and while ablation has come a long

15:58

way, I think it's important to think about

16:01

Afib as not truly being a cure, but that we're

16:04

managing it. Many people do remarkably well

16:07

after an Afib ablation procedure and may not have

16:10

Afib for years. But as we follow people

16:13

long term over not only one or two years, but

16:15

decades, oftentimes the Afib comes

16:18

back. So an ablation procedure isn't perfect, but I

16:21

think it's a big tool that we have in

16:24

terms of trying to manage atrial fibrillation,

16:27

to really knock down the, amount of afib that someone is

16:30

having. And newer data and the newer guidelines that you had

16:33

mentioned, make reference to that in the sense

16:35

that earlier rhythm control, trying to keep people

16:38

out of Afib earlier, tends to prevent that

16:41

progression of Afib down the road.

16:45

What kind of afib is there?

16:48

And I guess that's hand in hand with the question,

16:50

how long does Afib last? How long are

16:53

episodes? Right?

16:54

Yes, absolutely. And so we tend to

16:57

classify Afib classically in terms of

17:00

exactly that. The duration. How long does it stay?

17:03

Afib that comes and goes. We tend to refer to

17:06

that as paroxysmal atrial fibrillation, or

17:09

sometimes referred to as paf. paroxysmal

17:11

afib doesn't typically require cardioversion because

17:14

it comes and goes on its own. People pop in and out of

17:17

it. It can last for seconds, minutes,

17:20

hours, even days at a time, but people often come out of it

17:23

on their own. That's the definition of peroxysmal

17:25

atrial fibrillation. If you're in Afib for longer than

17:28

seven days at a time, then we refer to that as

17:31

persistent atrial fibrillation, and then for over a

17:34

year, long standing persistent atrial

17:36

fibrillation. And then if after a variety of

17:41

conversations and perhaps oftentimes attempts to manage

17:44

afib in some way and we can't keep it away, there's

17:47

a category called permanent atrial fibrillation, which is

17:50

just a kind of, way of stating

17:53

that we're no longer going to try and keep the afib away.

17:56

And sometimes we do that for a variety of reasons. Maybe a

17:59

couple of ablations have tried, and it doesn't work. or maybe

18:02

someone really isn't well enough for an ablation

18:04

procedure. or sometimes people, especially

18:07

in the past, really had no symptoms in Afib, and

18:10

no one worked very hard to get them out of that. it's less

18:13

likely for that type of thing to occur these days because I think we understand

18:16

that the earlier we kind of manage afib, the

18:19

less likely it is to be an ongoing issue down the

18:22

road. but that's one area where permanent atrial

18:24

fibrillation could also occur.

18:26

Clarify for me the difference between

18:28

persistent and long standing.

18:30

Persistent afib persistence just means it's been

18:33

present for seven days or more, but less

18:36

than a year. Long standing persistent is someone who's been

18:39

in a year, oftentimes even longer, of

18:42

atrial fibrillation. And the longer you're in

18:44

Afib, the more difficult it is for us to get you out of

18:47

Afib. And so I think there's been a

18:50

recognition of that, especially, since my

18:53

training has started. And we try to aggressively

18:56

kind of manage folks with, their atrial fibrillation to

18:59

try to prevent the long stream kind of, or

19:02

the downstream consequences. That is,

19:04

of the fact that the more Afib stays, the harder it is to get

19:07

you out in this type of thing.

19:09

I can't imagine being in Afib for that

19:12

length of time, years. What's the longest

19:15

case that you've ever had? And

19:18

was that patient in some kind of treatment or

19:21

just letting it go and then coming to

19:23

you years into it?

19:25

Yeah, often it's that I think,

19:28

certainly 1020 years ago, maybe there wasn't,

19:31

the ablation procedures were just kind of really

19:33

becoming a thing in the early two thousand s.

19:36

And we had medicines, and there's the

19:39

treatment strategy of where we can always put in a

19:42

pacemaker and ablate the central junction

19:45

box between the top and bottom chamber. So the top chamber is left in

19:47

Afib. The bottom chamber is now controlled by the pacemaker, which

19:50

is one way that we still use to manage atrial

19:53

fibrillation, but that may have been more commonly used, I

19:56

suppose, back in the day, but certainly people

19:59

have been in Afib for many years. I've seen people in Afib for

20:02

a decade or more. like I said, there is this

20:05

category of permanent atrial fibrillation where it was been

20:07

decided that we're just going to leave someone in Afib because they're not having

20:10

any symptoms in Afib at the time. And oftentimes

20:13

we counsel our patients, while that's okay now, if five

20:16

or ten years from now you do have issues with atrial

20:19

fibrillation, it becomes very difficult to get you out at that time. And so

20:22

nowadays, there's less permanent atrial fibrillation, typically

20:25

without some sort of attempt to get someone out of Afib,

20:28

usually, or otherwise, ah, an in depth

20:31

conversation to make sure that it's understood what permanent

20:34

atrial fibrillation means.

20:35

Okay. we wanted to talk about the guidelines today.

20:38

So what was the standard of care before the guidelines,

20:41

and what are the new guidelines now? Is that helpful?

20:44

Yeah, I mean, it was an update on the guidelines from, I

20:46

think, 2014. So it's not that we didn't have anything in place

20:49

up until now. It's just now they've kind of been

20:52

updated and revamped a little bit.

20:55

I think now there is an appreciation

20:58

that earlier management of

21:01

atrial fibrillation, meaning rhythm control, keeping people out of

21:04

Afib, prevents some of these downstream

21:06

consequences of Afib, which can include all the

21:09

symptoms we talked about that people may have. Sometimes people

21:12

in heart failure in particular, can have fluid

21:14

buildup that comes along with heart failure in Afib, can

21:17

sometimes make that much worse. so I think there's

21:20

now, with some studies that have come out over the last, I guess,

21:23

five years or so, have shown that trying to keep folks

21:26

out of Afib who have heart failure is

21:29

a worthwhile cause because the Afib often makes the heart

21:32

failure worse. and so I think there's

21:35

been a recognition that earlier

21:37

rhythm control, meaning trying to keep someone out of

21:40

Afib, is a, ah, strategy that

21:43

probably makes a lot of sense for the vast majority of

21:46

folks, especially when they're initially, diagnosed with

21:48

Afib. I think there's an appreciation that in a younger

21:51

patient, managing Afib with a rhythm control strategy,

21:54

whether it's medicines or catheter ablation, can help prevent

21:57

some of that downstream, effects of Afib, which

22:00

also means that the Afib is easier to

22:03

treat if you treat it earlier rather than let it go

22:06

and kind of run amok, and then it becomes very difficult to treat years

22:09

later.

22:09

So the new proposed classifications using

22:12

stages recognize as Afib as a disease

22:15

continuum, which is what you're describing. Why

22:18

should patients care about that?

22:20

Yeah, I think the staging system is interesting.

22:23

Right. I think they look at Afib

22:25

as kind of this, situation where

22:28

someone is at risk for Afib. Someone then

22:31

develops Afib, and we have the paroxysmol and persistent

22:34

and long standing persistent and things like that that we talked

22:37

about. And then I think they, in these most recent

22:40

guidelines, at another stage, for

22:42

someone who's had a catheter ablation procedure and doesn't seem to have much

22:45

Afib at this time. And so that's kind of, received its own

22:48

category as a population of patients that's

22:51

different from everyone else. I think the

22:54

other thing that the guidelines really focus on is that

22:57

patient who's at risk for AfiB, or

23:00

even someone with Afib, that there are a lot of

23:02

lifestyle modifications that can be beneficial

23:05

independent of medicines, independent of catheter

23:08

ablation procedures. And certainly, the combination of

23:11

everything is helpful, and those are things like

23:13

weight loss, for example. We know that people who

23:16

lose 10% of their body weight tend to have less

23:19

Afib burden. We know people who have sleep apnea

23:22

and have that treated tend to have less atrial fibrillation

23:24

burden. We know people who improve their exercise

23:27

tolerance can have less Afib. And so

23:30

all of that, I think, certainly was

23:33

better represented in these guidelines than it had been in the past.

23:36

And understanding that atrial fibrillation

23:39

is not just give medicines and perform catheter

23:41

ablation procedure, which, of course, is where I tend to, meet patients, is

23:44

when we're to that point. But even with that,

23:47

we all stress in clinic that it's important to aim

23:50

for weight loss, it's important to,

23:53

increase physical fitness, it's important to stop smoking. It's important

23:56

to control diabetes, it's important to control high

23:58

blood pressure, not only for

24:01

Afib, which is often how we're meeting

24:03

patients, of course, but I think all of that helps health in general.

24:06

So I really like that aspect of these guidelines.

24:10

Is there a standard of care for each

24:13

stage of the AFIB? Is being, reinforced

24:16

by the guidelines?

24:17

Not so much a standard of care per se. I

24:20

think what the guidelines allow us to do is to,

24:23

treat each patient individually. Right.

24:26

Every patient is going to have a, different

24:29

response to medications, every patient, in terms of

24:31

how well they respond to it, but also how much they want

24:34

to take medicine. Some patients don't want to take medications, and others

24:37

are okay with it. Some patients would rather have

24:40

a procedure than take medicines, and other patients would rather take

24:43

medicines than have a procedure. And so I think what

24:46

the guidelines do is just kind of give us a

24:49

general set of rules by which we can then go in and see a

24:52

patient and talk about kind of all of the

24:54

possibilities, and then with the information

24:57

that we bring to the table, and then the information they bring to the

25:00

table through shared decision making as we refer to it,

25:03

we come up with kind of the best treatment strategy, which

25:06

can differ for differing patients.

25:09

Everybody wants to approach things differently, and everyone can.

25:11

Who typically is an AfIB patient? Who do you

25:14

have come into your office, and how do they come to you? Do they

25:17

have to go to a cardiologist first to come to you?

25:20

Oftentimes they do, I think, because, oftentimes

25:23

they present to their primary care or to an urgent care with a little bit

25:26

of palpitation or some shortness of breath. And the

25:28

EKG shows atrial fibrillation. And usually

25:31

the first stop from there is to a cardiologist.

25:34

So many patients do, come to us via

25:37

cardiology, a little less likely directly

25:40

from primary care, but that can happen as

25:42

well. And really, it's a whole gamut of

25:45

patients who have atrial fibrillation. Right. I think we heard of, oh, I'm

25:48

blinking on the football player's name. I think it was JJ Watt who

25:51

had, a bout of atrial fibrillation within this last

25:54

year, and he was cardioverted. And this type

25:57

of. So, you know, it can happen in athletes,

26:00

it can happen in, know, distance runners and things like

26:03

that, but it tends to come hand in hand with a lot of those

26:05

things we talked about, the chad's vasque. Right? So a lot of

26:08

medical comorbidities tend to increase one's

26:11

chance of having atrial fibrillation. It also is more

26:14

common as we age, just simply as a result of

26:17

getting older. But certainly things like having

26:20

a weak heart or congestive heart failure, high blood pressure,

26:22

diabetes, having heart valve issues,

26:25

that kind of can sometimes increase the pressures

26:28

in those top chambers of the heart, can increase one's risk of

26:31

atrial fibrillation. We often see it in patients who have

26:34

kidney disease and are on hemodialysis. I

26:36

think the patient population can vary quite a bit,

26:39

actually.

26:40

You mentioned before about the smartwatches,

26:43

and I'm wondering if there is an

26:45

association with this increase, the

26:48

increase where they think every 20 years, there's a

26:51

30% increase of people who are experiencing

26:53

Afib. Does that have anything to do with us

26:56

detecting more Afib because of these

26:58

smartwatches and Fitbit?

27:01

Yeah, I think there's a lot more wearable devices out there.

27:04

Right. And to some extent, I think that's a great thing. It

27:06

allows us to sometimes catch things that we would not have caught

27:09

before. Maybe we catch it earlier, maybe we never have caught it

27:12

before, and now we're catching it on these wearable devices

27:15

like that. And I think that's part of it. I think there's also

27:18

been an increased recognition of the need to

27:21

look for and treat AFib. I think in particular in

27:24

patients who've had a prior stroke, and there's no real

27:27

smoking gun as to what caused that stroke. Atrial

27:29

fibrillation has been found to be common in that population.

27:32

And oftentimes we go really hunting for Afib, up to

27:35

and including putting in little implantable devices to see

27:38

if we can catch AFib. Not in a day or

27:41

a week in terms of monitoring, but years of monitoring.

27:44

According to Pew Research center, at least 20

27:47

smartwatches on the market now have the ability to

27:50

detect irregular heart rhythms. And both

27:53

Apple and Fitbit are currently

27:56

supporting studies of their products on the

27:58

effectiveness of using devices for monitoring.

28:01

But that's ongoing. It's not something that you would want

28:04

to use alone as a monitoring tool.

28:07

Right?

28:07

I mean, sometimes we use it, sometimes that's how it first comes to

28:10

recognition. There are these wearable devices

28:13

that allow us to catch things, like I said, that we may not have caught

28:15

before. Additionally, there are little, quite literally, mobile

28:18

ekgs that you can take, right, the cardia

28:21

mobile device, where you put your fingers on two little electrodes, and you

28:24

can get your own rhythm strip, or you put fingers on two

28:27

electrodes and then on your leg, and you can get a six lead EKG.

28:30

We use these in clinic. I have people send me these strips

28:33

quite often and wonder if they're in atrial

28:36

fibrillation or some other arrhythmia. These wearable

28:39

devices are fantastic, and that can

28:41

raise awareness and allow us to find stuff that we may not

28:44

have otherwise easily found. Oftentimes, though, there

28:47

are lots of false positives. Right. The devices and the

28:50

algorithms they use are designed to be overly

28:53

sensitive, to say that something may be irregular or an

28:56

abnormal rhythm, even though it may just turn out to be

28:59

a lot of noise or the irregularity

29:02

in the rhythm that the device wants to think is Afib may just

29:04

be an extra beat from, the top chamber of the heart, called a

29:07

Pac, or from the bottom chamber called a PVC.

29:11

And these things aren't really atrial fibrillation by any

29:14

means, but the device senses that irregularity and maybe

29:17

wants to call it Afib. So there are certainly some false

29:19

positives and a little downside. There can be a lot of extra data

29:22

that comes from that, that clinicians have to sort through. But

29:25

at the same time, I think it's an important part of our know. You know,

29:28

I certainly use it a lot when patients come

29:31

in with, Apple Watch or Fitbit data or

29:34

whatever data they have. We look at it, know, scrutinize

29:37

it together and talk about what it looks like, what it means,

29:40

and this type of thing. So I think it's certainly here to

29:43

stay, and I think it can be a valuable part of the

29:45

overall management.

29:46

Where do you go from there? Once you have that data, do you then

29:49

put the patient on some other kind of regime? What other

29:52

diagnostics are there for determining

29:54

Afib?

29:55

Yeah. No, that's fantastic. So just because the device says

29:58

it's Afib doesn't always mean it's Afib. I think that's important to

30:01

put out there. Just because a device says Afib doesn't mean you have

30:04

Afib. I think at that point, we may reach out

30:07

for, what we call a Zeo patch is often

30:10

the patch we use, although there are other ways of doing this.

30:13

But it's a little sticker that patients, wear

30:16

that can monitor their heart rate and rhythm for,

30:19

oftentimes, two weeks at a time. It can be anywhere from three

30:21

days to two weeks. But often, when we're first kind of trying

30:24

to figure out what's going on, we may reach for one of those two week

30:27

monitors.

30:28

It monitors through a sticker. Is it saving the

30:31

information on a chip?

30:33

Yeah, exactly. It's got its own little electrode there, and

30:36

it basically following, has a little ekg

30:38

that it's recording, and it stores all the data.

30:41

Oftentimes, we have patients, mail that back.

30:44

Sometimes those can actually be followed in quasi

30:47

real time where people are actually monitoring what's coming in

30:49

from those, devices.

30:51

Remote monitoring?

30:52

Well, yeah. it's called, ah, mcot m. Or

30:55

kind of a mobile telemetry kind of device where,

30:58

the company who makes the device is monitoring it

31:01

from afar and would alert a physician if

31:04

something kind of came up. But, yeah, we, you know, it's not

31:06

always that an apple Watch showing a heart rate that jumped up to

31:09

180 is diagnostic. So we have to go looking more

31:12

to see what that jump up was and what that was all about. And so

31:15

we have to go in search of kind of what that is. And usually the first step

31:18

is one of these patch. These patches.

31:21

What about that loop that you were telling me about?

31:24

Tell me about the loop.

31:25

Yeah, sometimes we reach for a loop recorder, right. If someone has

31:28

infrequent issues that we can't seem to catch on a

31:31

patch, or someone has passing out episodes

31:34

where they're occurring infrequently, and we never were

31:37

able to catch it on a patch. They didn't pass out while they were wearing the patch,

31:40

or like I alluded to before, in the situation

31:43

where someone's had a stroke and we're looking for Afib,

31:46

and the patch didn't show Afib, but that's only two weeks of monitoring.

31:49

Well, then we can put a small, little, implantable device under the

31:52

skin. It's about the size of a jumbo paperclip.

31:55

In terms of length, the width is probably a couple of those

31:57

paperclips stacked on top of each other. And we put that.

32:00

It's a simple procedure.

32:03

We make a small little incision just to the left of the

32:05

breastbone, use a lot of numbing medicine, but don't even

32:08

have to use sedation, typically, for this type of procedure. and

32:11

we're able to put this little device under the skin,

32:14

and now we can monitor the heart rate and rhythm for the next four to

32:17

five years instead of just a

32:20

matter of a couple of days or a couple of weeks.

32:22

This is an office visit. And then

32:25

you stitch it closed?

32:28

Yeah, usually. Oftentimes, we see them in clinic,

32:31

and that may become part of the treatment strategy. So

32:33

we'll see them, we'll talk about it. We'll talk about the procedure and

32:36

kind of walk them through what it will look like. And then it's

32:39

usually, at least here, performed at, Franklin Square

32:42

Union Memorial. a small little procedure, but one where you typically

32:45

go home 15 or 30 minutes afterwards, it probably takes

32:48

about 10 minutes or so to put in.

32:50

Oftentimes, you may stitch the skin together. Other times, we use

32:53

a little bit of glue or stereo strips or things of that sort. The

32:56

incision itself is quite small. It does leave a small

32:59

little scar, but quite small in terms of the grand scheme of

33:02

things. And it gives us that ability, again, to monitor things

33:05

for years at a time. And so if someone passes out

33:08

every seven months or something, now we

33:11

have something in place that will allow us to see what the heart is doing.

33:14

Right. Does the heart rate go super slow and that's why

33:17

they passed out? Does it go super fast and that's why they passed

33:19

out? it gives us that ability to monitor long

33:22

term. And then in terms of atrial fibrillation,

33:24

oftentimes we use it to monitor for Afib burden. Right.

33:27

How is someone doing after an ablation procedure? Well, now we can look

33:30

at the data and see how much Afib they've had on this loop to see

33:33

how well that ablation procedure has

33:36

worked.

33:37

What causes Afib?

33:38

Afib is kind of brought about by all

33:41

those medical conditions we've talked about

33:44

earlier that can certainly increase one's chance, but it's this

33:47

abnormal firing that we were talking about in those pulmonary

33:49

veins that seems to be the most common trigger for

33:52

atrial fibrillation. And so that electrical

33:54

firing, is what sets the heart off into afib.

33:58

If I put a pacing wire up into anyone's, heart and pace

34:01

that top chamber fast enough, I can probably put just about anyone into

34:04

atrial fibrillation. This is the heart doing it to

34:06

itself. That firing within those veins kind of sets the

34:09

heart off into Afib. And so that's kind of the cornerstone

34:12

when we perform an ablation, is to really isolate those

34:15

veins with either that heating or freezing energy, that

34:18

we talked about, in terms of kind of blocking

34:21

off that trigger.

34:22

What about genetics? Is there a genetic component?

34:26

Yeah, I think there's undoubtedly a genetic component

34:29

to Afib, and you certainly see that when you take a family history

34:31

and someone's grandma had afib and someone's mom had

34:34

afib, and here they are with Afib. So there

34:37

is a bit of a genetic component to. It's not

34:40

something we tend to test for, like other heart issues.

34:43

In particular, weak hearts. oftentimes,

34:46

as we're trying to work up why one might have a weak heart, that

34:49

tends to be an area where we use a lot of genetic testing,

34:52

a lot, because then we can look, for other family

34:55

members who may have a similar genetic mutation, if

34:57

you will. And Afib, it's not really used that much, but there is

35:00

probably undoubtedly a genetic, kind of link

35:03

there. But there's so many other things that increases

35:06

one's chance of having afib. Increased weight,

35:09

high blood pressure, diabetes, sleep apnea.

35:12

Probably certainly plays a role in all of this. Other, weakening

35:15

of the heart can play a role in one, developing Afib. Valveular

35:18

issues. These type of things certainly play a role as well, but

35:21

genetics is part of it.

35:22

As we talked about, the kinds of afib there are and the different

35:25

treatments for each kind, each

35:27

category. Paroxysmal.

35:30

Paroxysmal. Paf.

35:33

Paf, paf.

35:35

would be treatment with medication. Just

35:37

medication.

35:38

It depends. You could proceed to catheter ablation for

35:41

paroxysmal atrial fibrillation. Absolutely. No one

35:44

category prevents you from performing an ablation. Certainly

35:47

permanent means you've kind of given up on it. So you're not planning to

35:50

perform any ablation procedures. You're just going to let the Afib be

35:53

long standing, persistent, at least when I first got here

35:56

was my understanding where the hybrid procedure was playing a

35:58

role. although they may have loosened that a little bit, but I'm not.

36:01

Give us a quick, brief description of what that hybrid

36:04

procedure is for anybody who's interested.

36:07

So, a hybrid procedure is where we have

36:10

a surgeon who will perform what

36:12

we call epicardial, or on top of the heart

36:15

ablation for Afib by getting

36:17

access, to the heart, under the

36:20

breastbone. And then they're able to put a special tool back

36:23

there. And when they tunnel that tool back there,

36:25

they ablate the tissue of the

36:28

outside of the heart. And then typically what happens is we come

36:31

in as cardiac electrophysiologists and then

36:34

ablate from inside the heart and touch up any

36:37

areas where maybe they weren't able to reach

36:40

with a, surgical tool. And so

36:43

that's a procedure that, is used for long standing

36:45

persistent atrial fibrillation. And folks who have been in

36:48

Afib for a long time and has had some

36:51

success here, I must say. And so I think it's a very

36:54

reasonable procedure to discuss, and it's a.

36:57

Rather advanced treatment option. what is next? What's on the horizon for patients

37:01

with Afib?

37:02

Yeah, I think next in our world is what's

37:05

called, electroporation, or many kind of little.

37:08

We've talked about freezing and we've talked about burning kind of these

37:11

thermal energies that we use to create scar.

37:14

Now, kind of an old technology is revived in

37:16

electroporation, where we use a special catheter that

37:19

delivers these tiny little shocks. And this form of ablation

37:22

leads to, holes forming in the cells of

37:25

heart muscle. And that's how it creates scar. And

37:28

the potential benefits of Electroparation is

37:31

that it may be a little bit more selective for heart

37:33

tissue. it doesn't damage surrounding

37:36

structures. Maybe there's, some suggestion that it

37:39

can be done faster than other ablation procedures, and so it saves

37:42

some time. Most of these ablation procedures we're performing these

37:45

days are done under general anesthesia. and so anything that

37:47

saves time, I think we're all for that.

37:49

And they're not done through the open chest, correct. They're

37:52

done.

37:52

Thank you for mentioning that. You're exactly right. All of these ablation

37:55

procedures that we perform are performed through the

37:58

veins, so we get access. What I tell

38:01

patients, we put big ivs, some of them are very

38:04

large ivs, kind of the size of a jumbo straw in diameter.

38:07

But the idea, is big ivs through the vein at the top part

38:10

of the leg. and we get several of those access points

38:13

and big vein there, and that allows us to bring equipment up

38:16

to the heart through the blood vessels. So everything is done through

38:19

blood vessels, and we get up to the heart that way.

38:21

And then what's the recovery like? Patients go home

38:24

the next day.

38:25

Oftentimes actually go home the same day, believe it or not.

38:28

oftentimes go home the same day. We'll want to monitor for

38:31

several hours afterwards. So if it's late in the day, we often keep a

38:34

patient overnight, and that's not a problem. But many times can go home

38:37

the same day. Oftentimes we tell them no kind of heavy lifting

38:40

or exercise, usually for a week or two, at least seven to

38:42

ten days for sure. and that's in large

38:45

part to let those big iv sites heal up. Nowadays, we

38:48

tend to use a little bit of a collagen plug to help prevent any

38:51

sort of bleeding issues. But nevertheless, we ask patients no

38:54

heavy lifting, no kind of, structured exercise for a

38:57

week or two after the procedure. And then really they can kind of get back

39:00

to doing what they want to do at that point.

39:02

It's amazing stuff. Even just going into the

39:05

EP lab is really very,

39:08

scientific in there. Very high tech.

39:10

Yeah. Imaging, it's a really cool place to be.

39:13

Yeah. We've got a huge, large screen. We've got

39:15

multiple picture and pictures. We've got

39:17

fluoroscopy. We create 3d maps of

39:20

people's heart from within their heart with these special mapping catheters that we

39:23

have.

39:24

And how does that help? What does the 3d mapping

39:27

do?

39:27

Well, for Afib, what we're largely doing is to just

39:30

find where these veins are in

39:33

any one patient's body. And so we

39:36

create a quick little 3d map. We oftentimes get a ct

39:38

scan beforehand just so we understand what their anatomy looks

39:41

like, what their heart looks like, where their veins plug in, and

39:44

this type of thing. But in order to know where to, for

39:47

example, put that freezing balloon or where to use that heating

39:50

catheter, we create a 3d map inside the

39:53

heart using special mapping catheters prior to starting the

39:56

procedure. And so that just allows us to understand the lay of the

39:58

land, know where all the structures are, we identify structures

40:01

we want to avoid and this type of thing.

40:03

So you could actually see the electrical circuit on

40:06

your imaging, on your screen.

40:09

For Afib, we oftentimes look at

40:11

scar. So we create, what's called a voltage map, where we

40:14

look at, how healthy the tissue is.

40:17

It's judged by the amount of voltage it creates, as we're kind of

40:20

mapping along that area. And areas of scar tend to have

40:23

very low voltage. Areas of normal tissue have high

40:25

voltage, and so we can use that to

40:28

sometimes help guide our ablation procedures in

40:30

Afib. for example, not only do we go after those

40:33

veins, which is the cornerstone of any atrial fibrillation

40:36

ablation, but sometimes we go after other areas

40:38

of scarred, tissue or

40:41

in the management of atrial flutters, sometimes we have to go after

40:44

other areas of the heart as well. So it's not only kind of a

40:47

pulmonary vein kind of, ablation procedure, sometimes

40:50

we have to target other sites as well.

40:52

Is there hope, then, once a person has a treatment

40:55

done in the lab, that they won't have to be on blood thinners for the rest

40:58

of their life?

40:59

That's a great question and one that we always chat

41:02

about before proceeding with an ablation procedure. As it

41:05

stands now, there's no randomized, controlled

41:08

data that shows that performing an ablation procedure and getting your

41:11

Afib episodes down to as close to zero as

41:14

possible decreases one's risk of stroke. So whether

41:16

a patient is having an ablation procedure or

41:19

not, the use of blood thinning medicines

41:22

is always kind of guided by that Chad's

41:25

VAS score. So, in some patients

41:27

where the chad's vas score is zero or

41:30

one, we'll often start a little bit of

41:33

blood thinner beforehand, a couple of days of blood thinner

41:35

beforehand, just to make sure they may tolerate it, or

41:38

1 may choose to start it right after the ablation. No

41:41

matter what. No matter one's chad's vascore, there's

41:44

always, three month period where we tend to use a blood

41:47

thinner after the procedure. Anticoagulation,

41:50

the typical things we see on tv, Zarelto and

41:53

eloques and amperdaxin, cumin, all of these things are

41:56

the typical blood thinners we use. And so anyone who

41:58

has an Afib ablation procedure will be on,

42:01

typically right around two to three months of blood thinner.

42:04

Afterwards, no matter what their Chad's vascore is

42:07

after that time period, then the continued use

42:10

of anticoagulation is guided by that

42:12

Chad's VAS score. So if someone's chad's vascore was

42:15

high enough to warrant blood thinners before an ablation,

42:18

then even the ablation is wonderfully

42:21

successful, as oftentimes it is. And people don't have

42:24

much less Afib and much less symptoms than Afib. They still

42:27

would warrant long term, indefinite

42:29

anticoagulation based off the chad's fast score, if it was above

42:32

two or more. And so the ablation procedures,

42:35

is not a way to get rid of the blood thinning medicine.

42:38

That's a great point.

42:39

What's the final takeaway, do you think, for listeners?

42:41

What's the most important thing you hope they understand about

42:44

Afib?

42:45

Afib is truly a journey. It tends to be this

42:47

progressive kind of disease and can

42:50

come more frequently and more often and for

42:53

longer durations. And I think while there are treatments there

42:56

and can be a bit intimidating to kind

42:59

of navigate through that, I think what I want patients to know is that we're

43:02

here to kind of shepherd them through that process, through their particular

43:05

journey of atrial fibrillation.

43:06

If an ablation doesn't work or Afib comes back

43:09

after a treatment, can a patient get another procedure?

43:12

Yes. the cornerstone of that, ah, first

43:15

ablation procedure is often going after those pulmonary vein

43:18

triggers that we talked about. But if Afib comes back, we can

43:21

go after other triggers. And so, certainly, more

43:24

ablations can be helpful in that situation as

43:27

we target more tissue, more areas that could be triggering

43:29

AfiB. And so it's somewhat common to have more than

43:32

one procedure. Certainly, we hope the first procedure is the one that

43:35

is durable and provides long lasting, suppression

43:38

of AFIB. But sometimes we do have to go back, and it's certainly

43:41

possible to do more than one ablation.

43:43

And you've seen success in the second try or

43:46

maybe the third try. Third try is a charm.

43:49

Yeah. Especially in that second go,

43:52

we make sure that those veins that we tried to isolate remain

43:55

isolated. Sometimes there's a little area that maybe the balloon

43:58

didn't touch as well, or our, heating catheter didn't create

44:00

great scar. And so now that area is reconnected. So now

44:03

that vein that has that abnormal firing going

44:06

on is connected back up to the heart. And so in

44:09

particular, in that second one, and certainly any procedure that we

44:12

do afterwards, we make sure those veins are isolated,

44:15

and then we start looking for other areas.

44:17

Can you walk me through an ablation procedure?

44:20

Absolutely. So they'll arrive to our

44:22

hospital, which right now, where we're performing all this complex

44:25

heart stuff and catheter ablation procedures is at Union

44:28

memorial. And so you usually arrive an hour and a half, 2 hours

44:31

before the procedure. That allows us to get ivs

44:34

and any labs that we may need before the procedure

44:37

and for people to talk to, the patient about the procedure,

44:40

any questions to be answered, this type of thing. And then the procedure is

44:43

done in one of our sophisticated electrophysiology

44:45

labs, where we have very high, tech

44:48

equipment that allows us to perform these procedures for an

44:51

Afib ablation procedure. These days, someone

44:54

is, intubated, general, anesthesia is used, and so

44:57

they're asleep for all of this. and then while they're asleep,

45:00

we get access into the veins at the top part of the leg,

45:03

and that allows us, to put big ivs in that big

45:05

vein, and we get numerous ivs that allows

45:08

us to bring equipment up to the heart to safely perform the

45:11

procedure. And the procedure itself takes

45:14

about an hour, hour and a half or so. the total procedure

45:17

time, if you include kind of set up

45:19

and time to take down, is probably closer to two or two and a

45:22

half hours. And then they'll leave our lab and go to the

45:25

recovery area. Usually there we have them lie flat

45:28

as we just took those big ivs out. So we'll have them,

45:31

lie flat for two or 3 hours or so,

45:34

and after that, we'll have them get up and start walking around with

45:37

the help of the staff in our recovery area. And then

45:39

usually somewhere around five, 6 hours of

45:42

total time after they came out of the lab is when they can usually

45:45

go home. And so the day is a little bit long, right, a

45:48

couple of hours beforehand, several hours for the procedure,

45:51

and several more hours afterwards to recover. but most

45:54

people are able to go home the same day before you.

45:57

Take them out of the lab into recovery, is there a

46:00

way to test what you've done?

46:02

That's a great question. We look to

46:05

make sure that, what we were setting out to do, which is

46:08

oftentimes in a first time procedure to isolate those veins,

46:11

we look to make sure that that's the case, and we do so by

46:14

sophisticated mapping to show that there's no signal getting into

46:17

the vein because that area that we've just

46:19

created the scar in doesn't allow for any information, no

46:22

electrical activity to get across. sometimes we use

46:25

pacing maneuvers and things like this to show that, the work

46:28

that we did, which is to isolate those veins was done. And

46:31

so we do do that kind of testing. For every

46:34

patient who gets an AFIB ablation.

46:36

You are truly an electrician of the heart.

46:39

Yes. We've been talking with Dr. Richard

46:41

Jones, of the Medstar Heart and Vascular Institute in

46:44

Baltimore. Thank you, Dr. Jones, for sharing your expertise with

46:47

us here on MedstarHealth. Doc talk.

46:50

For more information on AFIb, go to

46:53

medstarhealth.org and put

46:55

Afib in the search box or for an

46:58

appointment with Dr. Jones, call 410-554-6727

47:06

close.