MedStar Health DocTalk

Pulsed Field Ablation for Treating AFib

Sunjeet Sidhu, MD Season 5 Episode 3

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A groundbreaking innovation is making waves for the approximate six million Americans who suffer with atrial fibrillation (AFib). It’s called pulsed field ablation. In our latest podcast episode, host Debra Schindler talks with Dr. Sunjeet Sidhu, a renowned cardiac electrophysiologist at MedStar Health, to explore the intricacies and benefits of this safer, faster, cutting-edge treatment.

 The number of those suffering with AFib, may even be an underestimate, but statistics show they are steadily increasing due to factors such as an aging population and the obesity epidemic. Traditionally, AFIB treatment involved thermal ablation methods, which, although effective, posed risks of collateral damage to surrounding tissues. Enter pulsed field ablation, a technique that uses ultra-short electrical pulses to target and destroy abnormal heart tissue without harming nearby structures. This method is not only safer but also more efficient, reducing procedure times significantly.

 Dr. Sidhu explains how pulsed field ablation works by creating a scar tissue barrier, effectively isolating the problematic areas of the heart that trigger AFIB. Unlike thermal ablation, which relies on heating or freezing tissues, pulsed field ablation uses electroporation to disrupt cell membranes, leading to cell death and scar formation. The heart cells are particularly sensitive to this type of injury, allowing for precise targeting without affecting surrounding tissues.

 The benefits of pulsed field ablation are manifold. Patients experience shorter procedure times, reduced anesthesia exposure, and fewer complications. Dr. Sidhu shares his firsthand experiences, noting a significant improvement in patient outcomes and satisfaction. He recounts a heartwarming story of a young mother who, after undergoing the procedure, was able to regain her quality of life and engage in activities with her children without the debilitating effects of AFIB.

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

>> Debra Schindler:

Comprehensive, relevant and insightful conversations about health and medicine happen here when MedStar Healthth doc talk. These are real conversations with physician experts from around the largest healthare system in the Maryland D.C. region. For decades, cardiac electrophysiologists have been looking for better ways to treat atrial fibrillation, a condition affecting millions of people worldwide. Traditional treatments are effective, but could come with risks. Collateral damage to healthy tissues, for example. But now there is an exciting new option for treating afib. It called post Field Ablation, an exciting new technology that uses ultra short electrical pulses to target and destroy abnormal heart tissue, causing irregular heart rhythms without harming nearby structures. How does it work? What does it mean for those who suffer with afib? And what are the risks today? Well explore those questions and more with MedStar Health cardiac electrophysiologist, Dr. Sunjee Sidu. Im, your host, Debra Schindler. Dr. Sudu, welcome back to Doctalk.

>> Speaker B:

Thank you for having me.

>> Debra Schindler:

It's really hard to believe, that Doc Talk is in its fifth season. You have been back a couple of times with us. We're always glad about that. One of the most popular podcasts that we've done through the years in terms of downloads is the atrial fibrillation episode I recorded with you in season two. To what do you attribute the interest in afib?

>> Speaker B:

Yeah, I'm not surprised. You know, atrial fibrillation is a very common problem. It affects somewhere on the order of 6 million Americans. With those numbers just going up over time. Know some of that's linked to the aging population, some of that's linked to the fact that we're living longer. Some of that's linked to the obesity epidemic. But either way, AFIB is getting more and more common and there's a lot of people suffering with it. And so I'm not surprised that many people have turned to this podcast to hear more about it.

>> Debra Schindler:

I suspect those not numbers, maybe even modest because some people don't realize that they have aib.

>> Speaker B:

Yeah, it's hard to really get a sense of how many people have AFIB that'undiagnosed. There are s some models that suggest that somewhere in the order of a half million Americans have AFIB that don't know about it. You know, some more AFIB is being detected by some of these technologies like patients, Apple watches and SmartW watches and blood pressure devices that detect AFIB or cardiom mobiles. And so we're seeing more and more of it, but in general it's just a very common problem.

>> Debra Schindler:

So let's Clarify what AFIB is and how people would know that they have it. How is it diagnosed?

>> Speaker B:

Yeah, so atrial fibrillation is an irregular rythm in the upper chamber of the heart, whereas normal rhythm, what we call sinus rhythm, originates from a structure in the heart called the sinus node. And the heart beats in a very organized, regular fashion from top to bottom. With atrial fibrillation, the upper chambers of the heart are go chaotic, irregular activity, where they're essentially quivering at somewhere between 300 to 500 beats per minute. And sometimes that results in the bottom chamber, the heart beating fast. Sometimes it results in the heart functioning less well. And so the symptoms can vary quite a bit. Some patients know it the second they go into afib. They feel their heart beating irregular, they feel their heart beating fast. They get chest pain, they get lightheaded, they get dizzy, they increase urination, shortness of breath. There's many symptoms that people experience with atrial fibrillation. Other patients have less, less sort of aggressive less, are less aware of their afib. You know, they may just feel like they're more tired. They may blame it on aging. You know, sometimes it's their spouse who notices that they're just not as active as they used to. They're taking more napss. They're just much more fatigued when they're in atrial fibrillation because their hearts beating less efficiently. And there are even some that have no symptoms at all. Hard to believe, but there are some that have no symptoms.

>> Debra Schindler:

We know that it does affect the quality of life, but it's also very risky for stroke. And that's the main concern, would you.

>> Speaker B:

Say, you know, atrial fibrillation, increases the patient's stroke risk by about three to five times as compared to someone who doesn't have afib. So there's definitely a significant component of AFIB that we worry about because of the risk of stroke. And some patients are diagnosed only after they've had a stroke from afib. The other reasons we worry about atrial fibrillation include increasing risks for heart failure, increasing risk for dementia, effects on quality of life, increased healthcare utilization, like going to the hospital or going urgent care, ER visits. It generally is just a very bothersome diagnosis and can really affect patients quality of life and their trajectory as well.

>> Debra Schindler:

What are the traditional treatment options for afib and how effective are they?

>> Speaker B:

Yeah, so whenever we see someone who has atrial fibrillation, we go through a whole valuation of that patient in terms of the risk factors, what might be driving their afib, and then ultimately, how do we go about treating their afib? So when I see a new patient of atrial fibrillation, you know, often I want to get an echocardiogram. I want to understand how their heart functions, whether or not they have any valve problems. I want to understand if they have high blood pressure issues, issues with diabetes. We want to look for issues with sleep, for example. Sleep apnea can be a driver for atrial fibrillation. We want to look at things like alcohol use because that can trigger afib. smoking can be a big driver for atrial fibrillation. Physical inactivity can be a big driver for afib. So we want to evaluate lots of things to understand how can we prevent AFIB progression, how can we sort of halt AFIB in its tracks. Then we get to the treatment phase of afib, where we're discussing patients risks of stroke, whether or not they need to be on a blood thinner to help reduce their of stroke, whether or not they need to consider other alternatives to blood thinner, like devices like the watchman device, the amulet device. We talk about how we manage their heart rhythm, whether that be with things like cardioversion, electrical shocks, the heart to get them back to normal rhythm, whether it be medications, of which we have a whole slew of medications as means to try to control their heart rhythm, or whether it be an AFIB ablation. And that's part of what we're here to talk about todayct.

>> Debra Schindler:

Okay, so explain what the ablation is in the traditional or the standard sense.

>> Speaker B:

So ablation is a bit of a grab bag term, but when we talk about atrial fibrillation, ablation, the typical approach we take for atrial fibrillation is targeting these structures in the back of the heart called the pulmonary veins. Those seem to be the main triggers for afib. For most patients who have atrial fibrillation, not the only triggers, but seem to be the main target. And so for decades, we've been doing what's called pulmonary vein isolation. What we do is we electrically isolate that vein tissue from the rest of the heart, knowing that the triggers for AFIB lie somewhere between where the myocardium, the muscle cells of the heart, interface with the vein cells of the pulmonary veins. And that's what we've been doing really since the 1990s. What's changed or, you know, the way that we've been doing it so far has largely been with these technologies called thermal ablation. We either heat up the tissue or freeze the tissue. The exciting new player in the field, with the first clinical trials being conducted around 2020 2021. And now with reaching FDA approval over the last year, has been what's called pulsed field ablation.

>> Debra Schindler:

Let me pause you. What does freezing the tissue or heating the tissue do to it, and how does that effectively stop atrialfibrillation?

>> Speaker B:

Yeah, so what it does with either freezing, heating, or pulse f ablation is you're creating a small area of scar, a small area of the heart that's becoming inactive, that can no longer act to trigger atrial fibrillation. So with heating and freezing, we're either burning the tissue, in the case of the radio frequency ablation, or freezing, were causing those cells to essentially go through a freeze thaw cycle where they basically burst. you know, the salt cells are mostly fluid, and so they basically burst and those cell tissue is replaced with scar. The concerns we've had with the thermal ablation technologies has been with radio frequencies. Some of it is, it's time intensive, but also that you can have injury to surrounding tissue because when you heat up something or when you cool something, well, that your neighbor gets hot or cooled, respectively. Right. And so when you do this ablation inside the heart, where we would like to have is isolated injury to just those cells that we're trying to treat. But what we end up having is risk to surrounding tissue. And so the things, you know, surrounding the heart include injury to the nerve. So there's a phrenic nerve that goes down to the controlled breathing to control the diaphragm that that can be injured. In about 1 in 100 patients, we can see injury to, the vein itself. So some patients will get what's called pulmonary vein stenosis, where the vein starts to squeeze, close off slightly, which can result in decreased blood flow from the lungs back into the heart, which can cause symptoms. And we can even get the dreaded complication of injury to the esophagus. And that can be quite serious because if you get a severe enough injury to the esophagus, it can be deadly.

>> Debra Schindler:

When these things happen during an ablation procedure, do you know it right away or do you have to wait for it to sort of reveal itself?

>> Speaker B:

Yeah, there are some risks that are some side effects and concerns we see during the procedure itself. Those are relatively rare. These risks that we're seeing in terms of esophageal injury. Pulmonary vein stenosis, or even injury of the phrenic nerve can be long, longer term concerns, and some of them can present weeks later, especially in terms of the risk of injury to the esophagus.

>> Debra Schindler:

Which brings us to pulsed field ablation. Why is this so exciting and how does it differ?

>> Speaker B:

Yeah, so pulsed field ablation is a different way to treat the tissue. So rather than heating or cooling, we are shocking the tissue. We're delivering, you know, somewhere around 1,000 to 3,000 volts of electricity to the tissue over a very, very brief period. and what that does, it causes a phenomenon called electroporation. It makes all the cell membranes more porous. It sort of opens up the pores of the cells and where the cell membrane can regulate lots of things, including, you know, what ions are outside the cell and what ions are inside the cell which is responsible for, you know, how the heart beats. When you open up those cell membranes and you cause all these changes between how proteins and ions go through the cells, it can cause those cells to burst and die and eventually create that scar. So as a result of the electroporation, we're creating that same scar. And you could say, well, why is that different than thermal ablation? We basically rely on the fact that the heart cells are particularly sensitive to this type of injury, whereas their surrounding tissue is not. Now, a lot of research has gone into that. They've tuned how these waveforms are delivered. You know, how frequent the pulses are, how long the pulses are that you're shocking for. And so they've. Each company has come up with their own secret sauce as to how to treat those cells without creating injury to the surrounding nerve cells, the surrounding vein cells, the surrounding esophagus.

>> Debra Schindler:

So in both the standard ablation and the pulse field ablation, the goal is to create a scar tissue.

>> Speaker B:

Correct.

>> Debra Schindler:

And how is that affected? What is behind that?

>> Speaker B:

Yeah, so the idea behind it is that we want to create this scar tissue to serve as kind of like an electrical fence between the remainder of the heart and the part of the heart that's driving the afib, the part of the body or the interface between the heart and the vein that seems to be the main driver for affib. Now, there are other areas that you can treat for atrial fibrillation as well, including the back wall of the heart called the postior wall ablation, and other areas as well. But the mainstay of treatment is what's called pulmonary vein isolation. And so that's where I think about creating this barrier between the remainder of the heart that we want to leave in normal rhythm and the part of the heart that might be triggering afib.

>> Debra Schindler:

How long does it take for it to Be effective once you've done the procedure?

>> Speaker B:

Yeah. So, I mean, generally we can see effects right away. Right. You see patients that come in afib, you treat their atrial fibrillation, and they're no longer in afib. Right. You would consider that as treatment right away. But in general, what I tell my patients is we expect about a period of about one to three months where they might experience some atrial fibrillation. You know, we create inflammation when we do the procedure that might trigger more afib during that healing phase. So I usually tell patients to keep in mind that they might experience some afib in that first month or even that first three months. And then after three months is we really see the durable effect from the procedure itself.

>> Debra Schindler:

How long is host field ablation been available?

>> Speaker B:

So, believe it or not, the first sort of treatment using electroporation was done back in the 80s. Right. And this type of technology has been used a lot for gene therapy, has been used a lot in the oncology space. But in terms of it being used particularly for cardiac ablation in a really, really robust and sort of a widespread way, you know, the first in man studies from these technologies, maybe around the 20 teens or so, the first sort of clinical trials around starting around 2015. It got approval in Europe in 2021, and then the approval of the United States. FDA approval was late 2023, early 2024. In that time period when they last look, sometime last year, about 40,000 patients or more have been treated already with pulse field ablation.

>> Debra Schindler:

In your experience Now, I don't want to really sort of date this podcast because your numbers, if people listen, a month from now versus a year from now, the number is going to be dramatically different. But where do you think we are right now in terms of how many cases that you've done? To speak from your experience?

>> Speaker B:

Yeah, it's a great question. So I will tell you that, you know, we got pulse field ablation several months ago and it has really changed our practice. We've entirely switched for traditionallation for afib, from our previous ablation strategy of radio frequency and cryo balloon ablation, the heating and freezing, respectively. Entirely two pulse fieldl ablation.

>> Debra Schindler:

Wow.

>> Speaker B:

I mean, it was almost overnight that we got the cathet on our hands and we've switched to this new technology.

>> Debra Schindler:

I was going to ask who gets the standard treatment and who gets the new way, but you're not even doing the old way anymore. What made you completely jump in with both feet?

>> Speaker B:

Yeah, good, great question. So it's not that we're not using the old technologies. You know, still, radio frequency has its role, cryo has role. There are other ablation technologies that have their role as well. But for patients who have a standard afiblation PFA or pulse field ablation has really taken over for our lab and for many labs. We've seen these findings in Europe because they had the catheter first. And the same thing has happened to us as well. The difference between our current pulse field ablation technologies and what may be in the future versus radio frequency. With pulse field ablation, you're targeting a wide area. The current catheters that we have available right now are designed to treat those pulmonary veins. They're specifically designed to treat those particular areas in the heart, and they do so quite quickly. Whereas radio frequency, it's more of like a pinpoint strike. So I can direct my catheter directly to a spot. So if someone comes to me with a different type of arrhythmia, for example, atrial flutter, SVT, PVCs, ventricular tachycardia, well, in those cases, we're more looking for a pinpoint strike to a particular area. We're not treating the pulmonary veins in those cases. I'll reach out to our other ablation technologies to do that pinpoint strike, whereas in pulse field ablation, we're targeting a wide area. And so that wide area approach works very well for our AFIB patients. And so that's the difference in where we use both technologies respectively.

>> Debra Schindler:

So walk me through the experience. If I had to get this treatment done today, what would happen? Is it a, is it a one day stay or am I in the hospital for a couple of days and I assume the patient is under general anesthesia?

>> Speaker B:

Yeah, it's a great question. So in terms of the experience that patients have with afibrilation, you know, prior to the procedure, they're obviously coming to us for a consultation leading up to the procedure. We're doing the workup that might include an echocardiogram, some blood work. Sometimes we'll get a CT scan to better understand the structure of their heart. We'll then bring them to the procedural area. The procedure is done under general anesthesia. It's done through the femoral veins. So the vein, the legs. So we get access to the vein and the leg, we go up into the heart, we do our ablation time.

>> Debra Schindler:

no chest cutting.

>> Speaker B:

Correct. There's no incisions, there's no open heart procedures. We go up all through a small vein. So a small pinhole in the Vein on both sides. Usually the procedure from when I get access to when I take everything out somewhere in the order of about 40 minutes, sometimes less, sometimes more, Depending on what we're doing or the complexity of the case. The patient is then woken up in the lab, they come out to our recovery area where they stay with us for an additional four to six hours, and they're home that same day.

>> Debra Schindler:

Wow.

>> Speaker B:

Not all places are doing general anesthesia. So there are patients who can have the procedure done under conscious sedation. So they're not, you know, under general anesthesia with a breathing tube, but rather under twilight sedation. That has not been our practice yet. You know, with the previous technologies, we'using a lot of general anesthesia. So we're still doing general anesthesia now, but there are places particularly more so in Europe, but now in the United States, as while they're doing some cases with conscious sedation and has been able to be done safely with consciousation,

>> Debra Schindler:

Put me out, put me out. I have to be all the way out.

>> Speaker B:

That is often the experience or often the comment my patients telling me as.

>> Debra Schindler:

Well, is there pain through this procedure?

>> Speaker B:

Yeah, it's a good question. So the pain that people experience, obviously you're going to experience some discomfort from the puncture sites in the leg. Some patients will experience some discomfort from the breathing tube itself.

>> Debra Schindler:

So a sore throat, do you numb the puncture site?

>> Speaker B:

Yeah, we do numb the puncture site. So they don't feel it at the time of the procedure. It's after the procedure they feel some mild discomfort of that site.

>> Debra Schindler:

Do you'll close it up with a couple stitches or how does that work?

>> Speaker B:

So sometimes everyone's a little bit different in terms of how they manage their puncture sites in the vein. We here are often using a closure device called Vasade that helps to prevent bleeding. It leaves behind a small plug of collagen, kind of the same stuff lip filler is made out of that sits underneath the skin, dissolves on its own after a few weeks, and just really helps people get out of bed quicker and be in less pain from obviously being in bed because it's not comfortable to lay flat in a hospital bed for hours, an hour. The other discomfort that people can experience in the chest, sometimes patients will feel like a dull ache in the chest, lasts a few days and goes away. And that's pretty much it. You know, it's not the kind of incisional pain you'd experience from open heart surgery or other types of surgery. It's sort of A dull ache in the chest that most of my patients will tell me they have, but for a few days only.

>> Debra Schindler:

And once they go home, what's the expectation in terms of their activity? Are they able to walk around or be active? Drive? Can they drive?

>> Speaker B:

Yeah, they can drive. Usually I tell patients they probably won't feel up to it either because of the anesthesia or the procedure itself the next day, but usually two days later, they're up moving around, driving. We ask that patients limit their strenuous exercise or activity for a few weeks just to prevent the risk of bleeding from those puncture sites in the leg that are freshly healed. But after that, they're back to all their normal activities.

>> Debra Schindler:

Have you had any cases where, it wasn't effective, where it just didn't work?

>> Speaker B:

Yeah. So to get to the effectiveness question, with AFIB ablation, whether it be with the thermal ablation technologies or with pulse field, there isn't really a cure forhm. When we talk about atrial fibrillation, I sort of think of it as if we are putting afibin remission. So usually the way I couch the discussion with patients is that we can get the afib under better control. For some patients, that means no afib. And so to put that in numbers, we expect about 70% or so of patients who have paroxysmal afib mean AFIB that comes and goes, no episode lasting more than seven days. That about 70% of those patients, they will have no episode of AFIB lasting more than 30 seconds at one year, from the procedure. Now, if someone who's having hours and hours of afib several times a day tells me that they had a 32nd episode of afib, they may not feel all that bad about it because that's much better than they were before. So, you know, some studies have looked at, well, let's use a different marker. Let's use the burden of AFIB of less than 0.1%, which is, you know, 1.4 minutes of afib over the course of, you time period. And they've looked at that marker and said, well, how many patients can we hit that mark? Because those are the patients that come to the hospital less, have less need for medicines that do quite well. And what we can tell patients is that with pulse field ablation, we expect about 80% of those patients will have less than 0.1% burden of VIB. If they had paroxysmal afib coming in versus with our old thermal ablation technologies, that number was closer to about 72, 73%. So there is some improved efficacy in reducing the burden of AFIB with pulse field ablation. The other things getting to a question you asked earlier, what are the differences, you know, between the two procedures? So some of it, there might be a signal for improved efficacy. I think more studies need to be done as well as the fact that you got to think about the fact that we're using a first generation technology as opposed to, you know, a technology that's been around for a while. But even still, the data is quite impressive. There's improved safety. As we alluded to earlier. We don't see those concerns for phrenic nerve injury, esophageal injury, palmr vein stenosis. Just does not happen with pfa. And then the other part to it is actually the procedure is more efficient. So there's about a 40% depending on the study. You look at reduction in the time of the procedure with pulse F ablation. To give you my own personal experience, the previous technology I would use often was called Cryl. In ablation, the freezing technology was doing those cases in about 60 minutes from when I got access to the vein to when I took everything out. With pulse field ablation, that number is closer to 35 to 45 minutes.

>> Debra Schindler:

Oh, that is significantly less.

>> Speaker B:

Significantly less time in terms of experience for the patient. So less time under anesthesia, less time on the table. So that's obviously improvement for that individual patient. But then if you think about all the patients we have to take care of with this rising epidemic of afib, that does allow us to treat more patients who have atrial fibrillation and get them feeling better.

>> Debra Schindler:

Why is it so much quicker? That's a good half hour difference.

>> Speaker B:

Some of it is how the technology works. Right. So with our to give cryo as example, with a cryoablation lesion, you know, I'm doing two freezes per vein. Each of those freezes takes three to four minutes. And then I'm doing that for all four veins on average. Right. So that takes time versus with pulse field ablation, we're giving eight pulses per vein, with each of those pulses taking seconds. So it's a vast difference in terms of the time it takes to treat each vein and move on with the procedure.

>> Debra Schindler:

Are you able to actually look at the vein while you're doing that? I mean, how do you see it?

>> Speaker B:

Yeah. So, again, everyone's different, but the way we do the procedure, we use a few different guiding options. For us, the one thing that we use is X ray. That's been around for a long time. We monitor the whole procedure with X ray to see where we are in the heart, where our wires are going, where our catheter is. We use a electro anatomic mapping system which uses essentially magnets to help us understand where we are in the heart. We can actually generate a 3D map of the structure that we're dealing with with that system. We also use intracardiac echo, so that uses ultrasound that bounces off the tissue and allows us to see inside the heart where we are, where the veins are, where the wire is, to make sure that we're having good contact with our catheter to the tissue, to make sure that we're giving effective lesions. So we use all three of these modalities continuously throughout the whole procedure to make the procedure quick, effective and safe.

>> Debra Schindler:

It sounds so complicated for something that can happen in 30 minutes. It really does. It's very impressive.

>> Speaker B:

It takes a lot of training to get there.

>> Debra Schindler:

Who's been your youngest patient, would you say?

>> Speaker B:

The youngest patient who I traded for atrial fibrillation, I believe was 20 at the time of his afib ablation. That's quite uncommon. that's pretty much an outlier with someone who had afib after Covid. The oldest patient whom I've treated with atrial fibrillation at the time of their procedure was 87 when he had his afibrilation. So there's a big gamut of patients who get afib treatment.

>> Debra Schindler:

Are there specific patient groups for whom pulse field ablation is particularly beneficial or not recommended?

>> Speaker B:

Yeah, there isn't any patients in particular that I would say are not recommended for pulse field ablation. Al be approved for what's called paroxysmal afib for patients AF that comes and goes. That's true for also the thermal ablation technologies. So with any patient, we sort of go through what are the risks and benefits for each ablation technology and how to best treat that patient. So there isn't any particular one? I'd say yeah, it's better for this patient versus worse for this patient. And there isn't really any particular patient who I'd say it's not indicated now. There isn't yet any data for patients who have what's called long standing afib, meaning they've been stuck in afib for over a year with pulse field ablation. Those patients. Currently we're sending for a different FDA approved treatment strategy that we do here at Medstall called hybrid ablation, which is a combined procedure we do with Our cardiac surgeon, where we do an ablation both on the outside wall of the heart and the inside wall of the heart. But I expect that it's only a matter of time before pulse field ablation is used for those patients too. So those studies are coming, and I think it's. It's rapidly changing. I mean, think every week there's probably a new study published on, pulse fuel ablation.

>> Debra Schindler:

It seems like that would be a first step rather than go to the hybrid. Yeah, why not knock it out, right. To see if it works.

>> Speaker B:

Well, I think that needs to be studied. Right. And so those are the things that are going to be done. And, and we'get more, more data as time goes on to understand what's the best way to treat these patients as we get these new technologies in our hands.

>> Debra Schindler:

The electrical part of the heart is really so complicated to understand, I think for most of us lay people. Do you have a difficult time sometimes explaining it to your patients?

>> Speaker B:

You know, I think of the heart kind of as a house. Right. There's the plumbing, there's the electrical, there's the pumping component of the heart, and sor. So they all work together. But if you sort of divide the things into separate buckets, it can sometimes be easier to understand as to why the electrical system might be on the fritz. And that is often the case with afib. Now, that may be driven by other problems of the heart. Right. So for patients who have valvular heart disease who have a leak in one of their valves, or for those patients who have a weakening of their heart muscle, a cardiomyopathy, whether it be from an old heart attack or whether it be from a genetic cause or something else, those may drive the AFib, in which case I'm often referring those patients to my colleagues and, you know, our advanced heart failure team to optimize their heart function, maybe I'm referring them to our structural heart team to help with their valveular heart disease, because that might be the actual driver for their afib. It might not be a primary electrical problem. So, with every consultation, we're trying to get to the bottom of what's the driver for that patient. And thankfully, I've got a lot of, you know, experienced and excellent colleagues that I can send my patients to to help with whatever the driver their AFIB might be.

>> Debra Schindler:

If a patient has AFIB or suspect they have afib and they want to ask their physician about it, what do you recommend that they ask? What should they ask their doctor?

>> Speaker B:

Yeah. So atrial fibrillation can be diagnosed in a myriads of way. Right? So some patients are those that show up to the er, they're severely symptomatic, they feel their heart racing. Those patients often come, come to usite quick, quite quickly, right? You know, they need help, and they need help quick because they are quite symptomatic. Other patients now are diagnosing their afib on their apple watch, right? They're getting an alert for an irregular heart rhythm notification. They go to their primary care doctor, they get some electroardiogram or they get a heart monitor. They're told, yes, you have afib. And there are other patients who find it for their routine physical. They go to their, they go for surgical clearance for, let's say, a colonoscopy, and they find out, oh, I have afib. And then what we do with those patients sort of depends, right? So with every patient, we're evaluating the risk for stroke, right? Because at the end of the day, stroke is a huge thing that affects that patient's quality of life. And so we want to make sure they're protected from stroke. We want to make sure they don't have another driver for the afib. And so that's the key here, is that we need to really understand who has afib, and how we can best manage their risk factors in terms of stroke risk, the drivers for afib, and then go from there.

>> Debra Schindler:

In terms of treatment, can a patient have ablation twice?

>> Speaker B:

Yeah, some patients do need more than one ablation, and particularly those patients who have more difficult to control afib, those patients who are in afib continuously, what's called persistent afib, sometimes they do need more than one ablation. I, often quote patients about a 1 in 5 chance that they may need more than one ablation. Sometimes that's because the ablation that was done has healed up a little bit. Right? So they, we go in, we do the ablation, we electrically isolate these pulmonary veins, and some patients have recurrence. We go back in and their veins have reconnected, right? They're no longer isolated. And sometimes it means we have to touch up those areas. Now, we are hopeful that pulse field ablation will see that last. Right. Some of the initial clinical trials, we saw some excellent numbers for durability of our pulmonary vein isolation with pulse field ablation. We're all really excited about that as a potential benefit for our patients. But there are some patients who need other ablations because their afib is just more progressed and we need to go back in.

>> Debra Schindler:

How long do you usually have them wait before they come in for follow up.

>> Speaker B:

So usually and everyone's practice a little bit different. We usually have patients come back about four weeks after their visit, after their afibiblation to understand, you know, how are they're doing after their procedure, make sure they're not having any complications, make sure they're doing well. We then will have patients come back at three to six months to see if there are any medicines that we can take them off of. Right. Often these patients come to their afiblation and they've been trialed on one or two different antirhythmic drug medications before they even came to see us. And so we'll see if their afib is excellently controlled. Do they still need to be on these medicines that may have other side effects, that may have potential long term side effects? Can we come off those medicines? So we'll usually see them three to six months later and then farther follow up just depends on how they're doing and what their status of their afib was. And we just sort of take it from there and individualize their care depending.

>> Debra Schindler:

On where they are, what's been their reaction when they come back for their follow up. What do they usually tell you? Are they happy doct do?

>> Speaker B:

Yeah, I think patients are doing quite well. I think, you know, we've been definitely seeing, and this is anecdotal, but I've definitely been seeing patients complain of discomfort in their chest a lot less with the pulse FL ablation as compared to the other thermal technologies. So patients generally tell me that they're doing quite well, that they're feeling well, they feel better after theiribrilation because they're not having constant afib or frequent episodes of atrial fibrillation. And they often thank me to say that, you know, they've got their life back, they're back to doing the things that they want to do.

>> Debra Schindler:

Has there been anyone who wasn't happy?

>> Speaker B:

I mean, look, sometimes patients have difficult to control afib and they come back and they still have more afib. sometimes that means we're putting them on medicine. Sometimes that means we're trying medical, you know, drug therapy, cardioversions, another ablation procedure. It's rare, but some patients do have complications from afibrilation and they, they have to be managed right. obviously, you know, some of those complications are less with the pulse field ablation. Whereas in the past, you know, I'm sure every doctor will can tell you who does afibrilation. They've had a Patient who's had injury to their phrenic nerve. Right. It's rare OCC in 1 in 100 patients, but it can be quite symptomatic. Right. Those patients have shortness of breath with any exertion. Right. They feel uncomfortable laying flat because their diaphragm may not move as well on the right side. And sometimes that means they need even more treatment for that.

>> Debra Schindler:

Is that correctable?

>> Speaker B:

It often resolves on its own. but in some patients, you know, not hasn't happened to any of my patients. But for some patients it means that they need to go for surgical plication of their diaphragm or some patients need pacemakers so their diaphragm. I mean, there's all sorts of treatments that can be done. But ultimately, you know, one of the things that we don't see anymore with pulse field ablation are those kinds of complications that, that can really affect patients quality of life, even though they're rare. Right. You know, if you have one, you never want to have another.

>> Debra Schindler:

Absolutely. So what would you say are the takeaways people should know about post field ablation?

>> Speaker B:

That there are a lot of exciting treatments for atrial fibrillation that patients don't need to deal with their afib in silenced, that we have ways to try to get them out of afib or at least manage their atrial fibrillation. That pulse field ablation, an exciting new technology that we're really just understanding how well it can be used to treat our patients, including improvements in efficacy, improvements in time in the lab, improvements in time under anesthesia, and in terms of safety from the procedure. And that there are a lot of different ways that we can treat patients.

>> Debra Schindler:

Afib, can it get better? PAF field ablation?

>> Speaker B:

Yeah. So there are a lot of interest in pulse field ablation. Every, every company is trying to come up with their own new catheter. So right now there are currently three FDA approved catheters from different companies to treat AFIB using pulse F ablation. There are a whole different slew of products that are on sort of each company's bench to try to come out next, whether that be trying to deliver pulse field ablation to specific areas, trying to introduce pulse field ablation into the ventricle. Right. So one of the areas that we try to treat for patients who have arrhythmias in the bottom chamber called ventricular tachycardia. So we have challenges in giving effective lesions there, giving deep enough lesions there. Those procedures can often take a long time. With our current Technologies radio frequency ablation, because we need to spend time in each spot to give an effective lesion. And we can often spend 30, 40 minutes of just doing RF ablation, radiofrequency ablation, which means long procedure times for that patient that could be effectively cut in half with pfa once we have a catheter that can be used in the ventricle. Now, our current catheters are not designed for that, but there are catheters coming that may change how we treat other arrhythmias, not just atrial fibrillation. So there's lots of things coming. There are new upgrades, you know, how to make the catheter more efficient, more data to receive from the cathet are incorporating with our mapping systems better. So, you know, everyone's iterating on their catheters. I would say that pulse field ablation has somewhat been a revolution in afhiib ablation treatment and how we do, ablation in general. And I think it's only the start for what's coming.

>> Debra Schindler:

More stuff on the horizon.

>> Speaker B:

Oh, yeah, there's always new things coming. And there's a lot of smart people putting a lot of effort in this because as I said earlier, AFIB is very, very common. Six million Americans, likely 50 million people worldwide, have AFIB. AFIB is the most common rhythm problem that we deal with worldwide. And so there's a lot of research going into how can we help these patients.

>> Debra Schindler:

You must feel very satisfied with your career decision.

>> Speaker B:

Oh, yeah, it's been great. I mean, can we can really help people and on a selfish side, it's fun playing with new toys, but yeah, it's, it's very satisfying to be able to help patients who have been suffering with AFIB and tell them we have a way to make them feel.

>> Debra Schindler:

Better and have them come back in and tell you how wonderful they feel.

>> Speaker B:

Oh, yeah, yeah, it's wonderful every, every time you can get a patient back to doing the things that you love, That's a plus in my book.

>> Debra Schindler:

Do any patients come to mind when you say that? You know, a patient coming back in and just being really happy with the outcome?

>> Speaker B:

Yeah. Recently I had a patient who just came to see me after her procedure a few weeks ago. Young mom. She was in her 40s and she had young kids and was very, very debilitated by her arrhythmia. Every time she'd exert herself, every time she'd go after to run after her kids, she'd get episodes of arrhythmia, caused her to stop doing what she was doing. It was really affecting her quality of life. I brought her for an ablation a few months ago. She came to me for a follow up and she thanked me for being able to play with her kids again. So that was the one that probably comes to mind first.

>> Debra Schindler:

Definitely life changing for her.

>> Speaker B:

Oh yeah, absolutely. Absolutely.

>> Debra Schindler:

Well, I'm glad that you're in the field that you are. Thank you.

>> Speaker B:

Of course. My pleasure.

>> Debra Schindler:

We've been talking with Dr. Sunjeeitidu, a cardiac electrophysiologist at MedStar Health. Thank you for sharing your expertise with us again.

>> Speaker B:

Win doctalk thank you for having me.

>> Debra Schindler:

If you would like to listen to Dr. Sdou's previous doct talk episode about atrial fibrillation, go to tinyurl.com allab about afib or you can find it on YouTube by searching medstarhealth doctalk aphid if you're in the Baltimore area and would like to make an appointment with Dr. Siddou, call 410-554-6727.

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