Understanding Electrophysiology

Pacemakers, defibrillators and Afib are just a few terms related to electrical activity in the heart. Specialists called Electrophysiologists are specially trained to diagnose and treat irregular heart rhythms. Advanced Practice Provider Bryce Yantis tells us more about this interesting and growing specialty of medicine.

Transcript

A heart that beats too slow, to fast or not consistently is not a good thing, but the good news is the specialists in electrophysiology at Sarah Bush Lincoln have a variety of medications, devices and procedures to fix irregular heart rhythms. Advanced Practice Provider Bryce Yantis tells us more about this interesting and growing specialty of medicine. He’ll share his extensive knowledge and experience with us and spotlight some exciting new procedures available at Sarah Bush Lincoln for treating EP issues, including pulse field ablation for Afib. Stay with us more after this break.

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Welcome to Health Styles. This is your host, Lori Banks. And I'm sitting here today with Bryce Yantis. He is an advanced practice provider at Sarah Bush Lincoln.

Bryce, thanks for coming to the podcast. Yeah. Thanks so much for having me. And you are relatively new to Sarah Bush Lincoln. We met just now a couple of weeks ago for the first time, just a couple months. I've started here and, I'm excited to be able to give back to the community and provide some education. Good.

Well, before we get into the topic of electrophysiology, tell everyone about your medical background and your practice here at Sarah Bush Lincoln. Sure. So I was raised local. I was, raised in Arthur, Illinois, went to high school in Arthur, graduated there. And my journey took me down to Southern Illinois Edwardsville when I obtained my Bachelor of Science in Nursing, I worked in South County, Saint Louis for about a year or so, my last year of nursing school and a little bit closer to graduation than I transitioned up to a hospital system up here. I worked there for four years at the bedside in cardiac med surge was very fortunate to be approached by one of my physicians, who later became one of my, attending and supervising physicians, who was a cardiology electrophysiologist and encouraged me to go back into, advanced practice school. So I went to nurse practitioner school at Olivet Nazarene. I did family training because it was the most marketable, so I had more opportunities after graduation. From that, I was able to sign with a cardiology group, and I worked there for an additional seven more years. I worked in general cardiology for about a year and a half after that year, and a half, that same physician had approached me and wanted me to spend more time with electrophysiology. So then I kind of sought a sub specialized, you could say, into electrophysiology. And it's different than with nurse practitioners and physicians, you know, physicians, they have all of this, you know, interns and residencies and fellowships and very stringent, time consuming medical training. And for nurse practitioners were it's more on the job. So I was, you know, taught by those three providers who are all amazing, electrophysiologist and was very fortunate and I would not be the provider I am today without them.

In addition to their support, electrophysiology is very industry driven. So we can get into the specifics about the procedures that we do. But pacemakers, defibrillators, ablations etc.. So all of those companies who perform those services with the physician are big into education and have provided a lot of education for myself over these past, you know, almost ten years.

So I was fortunate enough that there was an opportunity to come down here to Sarah Bush to start this program with, wonderful EP Doctor Labedi, who, who will be a great asset to this organization. So I hope, yeah, I hope that kind of understands my background. I currently live in Tuscola. I volunteer for our local fire department to give back to the community, so I'm hoping to continue that in this role.

Oh that's wonderful. So when you look back, you were doing cardiology. What kind of drew you to electrophysiology? 

I didn't understand it. And a lot of people don't, which is why we're doing this podcast. That's right. So it's one of those it's so focused. You know, the way I equate it is, you know, in with the brain, you have a neurology urologist and you have a neurosurgeon. And we'll think of like electrophysiologist as like the neurosurgeon of neurology. So they are so honed in and they have such a stringent, you know, education. And it's so specific into the electrical system, you know, altering and modifying the electrical system with either devices or medications or just understanding what is going on. So it's just such a vast field. And if you look at medicine as a whole, it's a relatively new field, you know, late 90s, you know, early 2000s is when things first started, you know, kicking off with electrophysiology. There's, you know, a lot of great textbooks out there and highlight some of these wonderful, brilliant minds in electrophysiology. And so understanding it and also the physicians that I was going to be able to work with was a big draw, too. They were, you know, all three wonderful guys. And I was able to really, you know, go under their wing and learn this field. And it's something that continues to be intellectually stimulating. You, you think you know a lot and then you are humbled very quickly, which is good and it is a good thing. So what's then the difference between what a cardiologist does and an electrophysiologist. So if you think about their pathway through school, you know, a cardiologist goes typically to an internal medicine program and then ends up in a cardiology fellowship. So an Electrophysiologist does all that and then goes to another 2 to 3 years after that into electrophysiology. Some cardiologists can implant pacemakers because it's under their scope of practice, as long as they're trained. Electrophysiologist kind of take that one next step and they focus. You know, different programs do different things. They focus on, you know, more complex procedures. Ablations, these pacemakers, defibrillators, different types, what they mean, looking at how different extra electrical pathways, other, gene mutations, other, you know, risks of, of sudden cardiac death. So it's almost like that, that next step as far as looking at the electrical system specifically.

So what kind of conditions does an EP treat. 

So all of various types of conditions, you know, anything from, you know, slow heartbeats, bradycardia, heart block with pacemakers. There are certain incidents where a patient who has congestive heart failure needs a defibrillator. There are atrial fibrillation, for which we can provide medications or ablation to help alleviate or reduce some of those symptoms. You know, atrial flutter, super ventricular tachycardia, which is kind of a very generic diagnosis. AFib and atrial flutter also fall into a consideration of SVT. But there are other more specific types, you know, AVR, TAVR, all these other different types of tachycardia is that, you know, as an EP, they're able to figure out what exactly is going on, either by the surface EKG, presenting symptoms. History is big, or during those complex ablations procedures. And even more so they can treat, you know, ventricular arrhythmias, you know, whether that be skipped extra beats, PVCs, ventricular tachycardia, with defibrillators or medications. And, that's kind of a good, good roundabout way of those different procedures that they can and will treat. But the a lot of them also may treat other things. If I my previous practice, they had patients that they had seen for many years and they managed coronary disease not as much anymore because times have changed and the need for electrophysiology has grown so dramatically, dramatically. So that that is they can they can treat anything but specifically heart rhythms. 

Okay. So this is all related. If you you help manage or fix things when the heart is not beating, it's either beating too fast or too slow or not enough. Correct. Or abnormally abnormally not. Not the way it should. Yes. 

So is there a certain age range when these kinds of conditions start to present themselves in people.

 Yes. Great question. So I think different conditions can present at all areas of life, all age ranges. You know our these are super ventricular tachycardia. So fast heartbeats originating from the, the upper part. They often present with the younger patients, you know, even you know, those are the patients that have had, you know, that kind of quickening, that feeling palpitations, feeling of fast heartbeat, all their lives. And then it becomes, becomes worse and, manifests itself over time. But you also have that same condition in, you know, 60, 70 year olds.

Atrial fibrillation is becoming a more common abnormal heartbeat. That has been a big focus in electrophysiology as far as our treatment strategy. And, you know, we are seeing that in patients in their 20s and 30s. Also, I think my general colleagues can attest to that. Patients are having heart attacks. Youngers are having heart failure younger. There are also other conditions that we're starting to learn about, that are affecting younger population mitral annular disjunction, which has an increased risk of sudden cardiac death, and all these other valvular issues that, you know, main because imaging techniques and other, diagnostics are improving so much, we're able to find out more as to why patients have these abnormal heartbeats, whether they're life threatening or not. 

So when we hear that story of a high school basketball player collapsing on the basketball court, was that probably an EP related thing going on?

It is suggestive of that, absolutely. Whether that's a hypertrophic cardiomyopathy or some other type of congenital abnormality. Yeah. A lot of times these young individuals have a structural or a tissue make up of their heart that is abnormal, that leads to electrical problems. So those are the patients that have, you know, very bad, life threatening heart rhythms that need to be, you know, resuscitated with either CPR and shocking the heart. And depending on what those strips and what is found out about that patient, they may end up needing a defibrillator, to help prevent that from happening again. 

So if someone's at home listening, how would they know if they had an EP problem?

Like, other than my heart rate's really fast, or I feel like I'm going to pass out because it's really slow. And that's. Yes. And a lot of times these screening ways, you know, nowadays, our wearable technology has become so, monumental in our management as far as it may not give me the diagnosis right away, but it is starting to clue patients into, hey, maybe something is up, but I think it's always important to talk about those concerns with your primary care provider. And preliminary testing can be done. And if other abnormal heartbeats or there's concern that maybe something electrical is going on be referred to, you know, either our general cardiology colleagues, they do a wonderful job about doing that initial diagnosis. And management. And if these other issues need more complex management, then that's when they come to electrophysiology. You know, we, I think the screening tools are great.,Also the heart to heart in those types of things, but also family history. Right. That that's big. As far as, you know, understanding, you know, family history of sudden cardiac death before the age of 40 or 50. So you have that, personal history. You know, that's an important thing to tell your primary care provider and get started on the right pathway so workup can be done.

So if your Apple Watch indicates something not right, go to your primary care. 

Yeah. No I think it's a big yes. Absolutely. Because they can you know at least start that preliminary workup. And and then if they feel that hey that I have a lot of concerns, you know, we're more than happy to see them over in the cardiology clinic. You know, again, these tools are good. But again, they're tools. So sometimes they're not as accurate as or specific as detection is what we would like. So you know, providers can review the strips from the Apple Watch. Or there's another device, Cardia, which, patients can often purchase if they're having, you know, quickening of heart sensation or palpitations or other concerning heart symptoms to check the electrical signal. But then the provider can also interpret those. So the tools, the tool. But it's up to the provider to be able to provide that diagnosis or discuss about further workup. So what are the common diagnostic tests that you do when someone comes in with a potential epi issue? I'm very fortunate. Most of the time the workups done. So that's that's where I give credit to primary care. And my general colleagues, they do a good job of getting that baseline testing of an EKG. You know, an echocardiogram, which is an ultrasound of the heart looking at the valves in the walls and the chambers, and then also sometimes doing a stress test that may some conditions and EPI may not have concerns of a heart blockage. Just not all EPI conditions are related to a heart blockage. But if we choose to pursue medical therapy, it actually allows us to do certain medical therapy. If we have proven that you don't have any heart blockages. So it's not so much as a direct cause, but it also allows us to understand, what exactly is going on with the plumbing. And then oftentimes patients either have a wearable heart monitor that they've done. They sometimes they have a loop recorder that's implanted, which is a tiny monitor underneath the skin and monitors the heart's electrical signal 24 hours a day, 52 weeks a year. And so sometimes we detect abnormalities with that. So those are those are some of the preliminary testing that we see.

So you go through the testing now it's determined they need some sort of treatment. So we've got medication. We've got devices and we've got procedures. So walk us through what options we offer here at Sarah Bush Lincoln.

We operate based on the American Heart Association and the Heart Rhythm Society guidelines. So when we talk about those, you have your class one or class two way to be in class three. So class one means you should do it. It's just like going into your primary care office and then taking a blood pressure that you should do that. So again, if a patient suffers from super ventricular tachycardia and we believe we know kind of where it's coming from, you know ablation is is a class one indication for that specific heart rhythm if it meets this criteria. So what that involves is a procedure will be take you to our lab. We start an IV in the arm. We drape you with a blue drape, and we kind of, give you some sedation to relax. We numb up the groin area of the right groin, and we take our tools or catheters up into the heart. Essentially, Doctor Labedi draws a 3D shell of the heart, and then you have all these stickers and patches on you that allow us to kind of track the electrical system. Think of it as if you're in a dark room and somebody's speaking and you can't see and somebody speaking from across the room, and all of a sudden they say one word or two words or five words, and we're trying to hone in where the source or where that area of abnormal electrical signal is coming from. And once we're able to identify it, as long as it's not near any other important structures of the electricity system of the heart, we apply heat or other energy to help kill those cells that are causing the problem. They're not causing any other, you know, main function of the heart. It's just causing the issue because you're not in that abnormal heartbeat all the time. So that's kind of an ablation for SVT. A-fib is very similarly, except atrial fibrillation. Number one is a non life threatening heartbeat. It comes from the left upper chamber most commonly around the pulmonary veins. So as the heart grows in utero actually cells are displaced into these pulmonary veins. And over time they become electrically active. So these electrical signals come from the lungs to do the veins into the left upper chamber through the opening of those veins. So again, Doctor Labedi would go in and essentially the same preparation as the other ablation SVT, only this one's done under general anesthesia, just because the nature of the, procedure, he goes into the left side of the heart, and then he is able to cauterize, freeze, or provide some other energy, something called pulsed field ablation, which is kind of the up and coming source of, of doing the job. And he, it energizes that, vein and heats it up or he freezes it, or he uses pulsed field ablation to isolate those veins electrically. Basically, you're putting up a roadblock so that electrical signal can come down into the left upper chamber of the left atrium, but it actually doesn't make it all the way into the heart, causing the issue. So again, those are kind of ablations in a nutshell. There are some patients who have what we call tacky Brady syndrome. So atrial fibrillation with fast heartbeats. And then when you give them medications to prevent the heartbeat being fast. So you slow it down, it goes too slow. So you put in a pacemaker to allow the heartbeat to not go less than 60. But the pacemaker does not do anything for the fast heartbeat. The heart can still go as fast as it once. So that's where we lean on specific type of medications. Something is called antiarrhythmic drugs, meaning they change the electrical properties of the heart, preventing these abnormal heartbeats. That's to where there's not, unfortunately, not too many options for that. There's only about 4 or 5, but I think it depends on patient a patient basis. So those are kind of our variety of treatment options for a variety of, of arrhythmia issues. Other issues that we do. You know, certain patients need a defibrillator to protect them from life threatening heart rhythms. So you look at either primary prevention or secondary prevention. Primary prevention meaning, hey, you're at risk. We should put this in so you don't go down or have a cardiac arrest or secondary prevention. Hey, you had a cardiac arrest. Now we want to make sure that you you don't have another one who needs CPR again. So that's part of it. And there are some conditions to where there's different types of defibrillators that can help heart function and all these other things, but those are very case specific.

So what are some of I mean obviously you can die sudden cardiac death if your heart quits beating, or you know, you've got this crazy heart rhythm, but other than than that, what are some other long-term complications if people don't get these things treated? 

So a great question. And things have evolved over time. I believe it was in the early 2000 there was the Affirm and Irish trial. I believe that we're looking at atrial fibrillation and the rate versus rhythm control. So again, two strategies to managing AFib, accepting that it's going to happen and ensuring the heart rates are under control, or fixing the issue and trying to correct the heartbeat back to normal rhythm. Now that being said, there is no cure for AFib. So if somebody ever tells you I can cure your AFib, I would maybe reconsider that. But we help reduce how often it's going to recur. And some patients do very well. Ten plus years I've had patients do extremely well. It will recur at some point. You know, the biggest risk factor for AFib is age. I tell my patients with the heart rhythm, there's two things that are going to happen if we all lived long enough. Number one, you're bound to have AFib. Number two, you're bound to have a pacemaker. We all live to be 120. We're all going to probably end up with both of those conditions at some point. Well, recently over the past 2 or 3 years, there's been some new trials that have come out and easy AF net and Scad have, and a couple other trials that looked at the benefit of maintaining a normal heartbeat for as long as possible. So what it found is that restoration of a normal heartbeat improved morbidity and mortality in certain patient populations. It also reduced the recurrence of heart failure in admissions. So we've really tuned in to aggressively treating those AFib patients or these other tachycardia or extra beat patients because of the long-term implications that sometimes atrial fibrillation in some patients can cause congestive heart failure. So you have to be very aggressive in treating AFib to help prevent, that heart failure recurrence. Because if you maintain a normal heartbeat, a lot of times their heart function does return to normal and get better. So, yeah, we've really shifted our focus into, it's it's there. But we're really just give you some simple medications and make sure the heart rate's under control versus now, you know, ablation is now a class one indication for atrial fibrillation.

Okay, so you said you cannot cure AFib. Correct. Are there other EP conditions that can't be cured but managed? 

Yeah, I think a lot. You know SVT depends on the type. A typical atrial flutter which comes from a specific area of the heart. Those are some of the few conditions, if the ablation is done, that we can say, yes, you know, they're 95, 97% of the time. They never return. There are those one off situations where a redo procedure may need to be done because, you know, the body's smart, it likes to grow back those areas. And so sometimes those electrical signals are electrical pathways reconnect. But again, that's, you know, 2 to 3% of the time extra beats oftentimes are a benign condition that are medically managed or, you know, cycle socially managed. A lot of patients just want reassurance, you know? Yes, I know you can feel your heart skipping a beat, but guess what? We did the monitor. It was happened 2% of the time. It's not life threatening. It's more bothersome and annoying. Just provide you reassurance that this is something that we can watch. If those extra beats from the bottom chamber start to get in that ten, 12, 15% of the time, then we start looking to other other medical therapies. But again, they can still come back and sometimes they come back from different areas to you may not only have one area of the heart that's causing the problem. So a lot of those, you know, we kind of manage manage medically in mind monitor.

 So I had this question does heart disease and epi related conditions go hand in hand. They have heart disease. You're going to have this. 

Yeah. And it's not it's not guaranteed that you're going to have it. But it definitely increases your risk. Whether that be you know you've had heart blockages instance. Right. So whenever I tell patients about the heart, I divided into three different categories. Structure and function is one, plumbing is one, electrical is one. And they all interrelate. You have heart valve problems that can lead to, changes in tissues in the heart, which can lead to electrical problems. So yes, they all go hand in hand, you know, especially in our patients who have had really significant heart attacks, their heart function, their heart muscle is very affected. They end up having congestive heart failure. Those are the patients that we end up implanting defibrillators because they're at high risk to have sudden cardiac death. Okay. 

So can we, do anything to prevent EP related issues? I think I know the answer to this question of the hour. 

And, you know, I know I'm sure patients are tired of hearing it, but it's going to be the same thing that's been taught for the past 20 years. You know, diet plus 20 years, plus diet, exercise, smoking cessation. They say 10% body weight reduction can reduce your AFib burden by. But I believe it's up to 40 or 50%. You know, it's it's the simple things and it's it's harder to do those things because they take more work. Portion control, increasing our exercise. And again, those are just as beneficial to the electrical system as they are to any other system in the heart. That being said, you can't fix your genetics. So even if I've had very healthy patients, marathon runners, and they still develop AFib, you know, there was an exercise paradox that was taught. There was probably in the 70s, 80s, maybe even earlier than that, that they thought exercise was bad. Well, there is that happy medium because we find that these these patients that do these very extreme, you know, 100 mile runs, that their heart is in great shape per se, but their upper chambers are so dilated and so large that they end up having electrical issues because of that. So again, you know, 40 to 60 minutes, 2 to 3 times a week, modern intensity exercise, that'll do the job. 

Okay. So Bryce, tell me, what is, what is your role here in the EPI program? You've got two doctors. Yep. And you. And then we will have another mid-level provider coming, I think, at the end of the year.

So we have a full-fledged electrophysiology program. So what's your role with patients? Yeah. If we're fortunate enough that, you know, in the area took a hit with some changing in hospital regimes. But I think our area definitely benefited from that as far as providers that we were able to get, you know, we were very fortunate. Doctor Kocherli has joined the electrophysiology team part time and he will be servicing patients in Tuscola. I believe it's Wednesdays all day, Thursdays half day. And then he'll be doing procedures on Friday. So we're able to have five day coverage of procedures and call for electrophysiology, which is wonderful. So those patients who may be come in more urgently, they need a pacemaker while we can do it now here in house, we don't have to ship them out. So my role specifically is I'm kind of the support system, so I'm the one that really helps them with whatever they need. I'm kind of that utility player that team player. So if they need help seeing patients in the office, if they need help, you know, following up with patients afterwards, since I've kind of started before them, I've kind of helped build a population and build their schedule with patients who I really do think need earlier intervention, and then I can help see those patients. Postoperatively. But I'm still helping out our general cardiology colleagues and seeing follow ups or acute visits or what have you. But specifically for EAP, I will help, you know, just make sure that this program is successful in whatever way that they feel is necessary. I do my own little bedside procedures. I implant loop recorders. There may be some more expensive procedures in the future, but for right now it's office visits, inpatient consults, follow ups, and just otherwise just being around for whatever they need to make this program successful and

We had the pleasure of actually meeting Doctor Labedi earlier this week. And he he made a very good point. He said when people have maybe an epi issue and they think, oh my gosh, I have to go 2 or 3 hours away, I don't have people to take me there, etc. they put it off and then by the time they come and see someone like you, it's their their disease is much more advanced.

So the hope is, is because this service services available locally is that you'll be able to catch those issues early and be able to help more people. Most definitely. And especially when it comes to AFib, the AFib causes more AFib. So the longer people stay in AFib or have a-fib issues, the more prevalent it becomes and sometimes it becomes harder to restore that normal heartbeat. So yes, earlier intervention is better. Again, we are so happy to be able to provide this service for this area because it is such a growing need. And with Sarah, which is outreach as to how many counties they service, and just the vast square miles that are covered under this, it's it's really going to be a good, good thing for the community. And, and I think we will notice a direct impact almost immediately.

Well Bryce, this has been really informative. I want to thank you for taking time to chat with us today and let, let us know more about what you do and what electrophysiology is.

Absolutely. Thank you so much.

Like Bryce said, the same things that keep you healthy overall also keep your heart strong—things like eating well, staying active, keeping a healthy weight, and quitting smoking if you need to. And if something doesn’t feel quite right, or your smartwatch gives you an alert, don’t wait—check in with your primary care provider.

Thanks so much for listening to Health Styles! Just a quick reminder: everything we share here is for information only and not meant to replace medical advice. Be sure to hit subscribe so you don’t miss our next episode and leave as a review and a comment!  For more information about the EP program at Sarah Bush Lincoln head to our website at Sarahbush.org. That’s Sarah with an H. Until then, take care of yourself and have a great day.