good evening and welcome to the night show our guest position tonight is actor chris bonnet we're happy to have you here chris welcome on our topic will be cardiac arrhythmias and atrial fibrillation welcome chris electrophysiology i think probably the easiest way to think about it is dr burke he's a plumber and i'm the electrician of the heart the heart electrically has a top chamber called the atrium that has a little pacemaker in it that is why our heart speed is fifty sixty  minute that impulse is transmitted from the top chamber through the conducting wiring of the heart to the bottom chamber and it beats so a normally beating heart beats like this again i'm a cardiologist that specializes in the electrical conducting clinic one day a month in in canada for guys seeing patients with electro physiologic issues cardiac arrhythmias pacemakers to further later we will see those people and follow up beginning next month they as a cardiologist electrophysiologist it's a very common problem because your cell phone are doing a very good job in keeping people alive a long time by the time you hit sixty one to two percent of the american population will have the tool for relation by the time you hit seventy or three to four percent by the time you hit eighty one in ten americans will have a tool for violation again i like to use this little model your heart in normal rhythm beats like that atrial fibrillation is when you're talking for the atrium instead of being organized so instead of a nice regular fifty sixty seventy beats a minute the top chamber for relates much faster hundreds of beats per minute and this can often be transmitted to the lower chamber to cause palpitations light headedness dizziness a lot of r symptoms and the other concern with atrial fibrillation has instead of this normal organized rhythm it's a regularity can lead to clots coming out stroke is the biggest concern so people with a tool for a relation have an increased incidence of stroke that we try to prevent it can be what we call lone l o n e a tool for relation we tend to see in younger healthy people i see a lot of people referred in with we're going to talk about the risk factors but no risk factors for rachel from elation it just occurs can't tell them why but it's there the standard risk factors that we often think about are high blood pressure prior pressure in the heart causes stretch on the atrium stretch of the atrium leads to the irregularity for violation thyroid disease high thyroid hyperthyroidism is a common cause of  so any patient that would come in with nuance that a tool for relation we always get a blood test to make sure the thyroid is not abnormal coronary disease blockages in your heart prior heart attacks heart failure dilated hearts there's a lot of causes but those are some of the age sixty and it's up to ten percent at eighty so it's very common as you age and as well as electrophysiologist chris i'm curious a lot of times as a cardiologist i'll take care of the easy atrial fibrillation or control the heart there are so well treatment options again eighty percent i have three partners at allegheny general eighty percent of our business coming in as a tool for violation it's a very common problem a while and when i meet with someone or any new patient there are several treatment options the first is what they call a rate controls tragedy where you're going to have some major from elation we're going to try to keep your rate in a normal range seventy eighty ninety beats per minute and then talk about the clot risk as well so there's always the ra issue and then do you need to be on warfare and do you need to be on this new medication do you need to be on aspirin how do we try to make sure you don't have a stroke in a tool for evolution when you have the boss so that's called a rate control then there is the rhythm control where and the rate control we use those patients the patients we talk to about that strategy is the ones that have a little bit of help potations but the h r for a relation is not a major disruption of their life they can live with it some people have patients you know just can't live with the arrhythmia they feel miserable they say dr burkley i can't live in this my life is miserable my heart is palpitating i don't feel well i just can't go on to do whatever it takes and those people we adopt what we call a rhythm controls tragedy so we're going to try to keep you in normal rhythm  see how you do on those drugs we start with those drugs because they tend to have minimal side effects be well tolerated if you can't tolerate those if you are having a lot of fibrillation it's not working very well for those drugs well then step up in potency will go to the next treatment medications are stronger medicines that are very potent that will try to keep you normal rhythm but as you know the best medicine we have m yoder own successor one year is about sixty five percent so good medicine but not great medicine and the stronger the medicine the more side effects sam yoder own commonly used drug but a lot of side effects going to affect the liver lungs so you're always weighing symptoms or the patient want to keep your normal rhythm but what's this drug the side effect profile we certainly don't want to develop the significant side effects from the drugs and then the third is an invasive approach called ablation and what that is is again just a little i like these little simplified we said the top chamber for blades but when you look at the mechanism of atrial fibrillation there are four veins that come from the lungs here's your lungs are four veins the plug back into the left atrium the left side of the heart and most atrial fibrillation starts right where the your relation right with the veins plug into the heart so here's your a t m here's where the veins plug into right here you get what they call triggered activity early potentials to start the a fib procedure we do one of my partners dr beldin trained at the cleveland clinic and does this procedure where will stick catheters through the bone in your leg up into your heart your s completely out and he'll go up and around each of those veins he will do and then circling burn all the way around is called a pulmonary brain isolation procedure he's attempting to isolate so here's where the a fib starts and we're going to put an electric line i select line all the way around there so the tip can't get to the heart he does that on all four pulmonary veins so you know it's a big procedure so he has a catheter in there burn burn burn all the way around and basically forms a scar and prevents electrical activity across that left in fear pulmonary vein so hold do that to look for any other substrate other areas of a tool for ablation starting and try to burn those and then he'll pull the catheters out look for any other activity so it's a fairly big procedure cure rates are good not great is about seventy percent to get to that seventy percent we do the first procedure coming out looks good but as those scar lines heal up you'll get some leaks through so you're doing good two three four six months out you go back  back in put the catheters in look for that leak through and do a redo procedure so again to get to that seventy percent cure rate about one to one third of the patients will need to redo procedure and then there's always potential complications what would be the drugs we will offer the procedure to we've done them on eighty year olds realizing that the longer you've been in it the bigger your atrium is to lower the success rate but still even in difficult cases of price to at least a forty or fifty percent success rate  prognosis for the electrophysiologist with that the long term prognosis even with this ablation many times they'll just go into it later on for again the the cure rate we quote is about seventy percent and we again this is a fairly new procedure is along with data it's somewhere in the six to seven a year range so you know seventy percent again very symptomatic patients will take that and run with that we have done two three you know up to four perceivers on some patients are very symptomatic because they feel great and then if a recurrence they say doctors tried again as you said the surgical we are now looking at combining one of our surgeons dr maraca dex to do he was trained in the surgical approach he can do a combined pro pro choice us where blood can stagnate clot when he does the surgical approach he can go in and actually clip that off and there's a lot of research going on right now if you click that off do you need to be on war for long term wise because the biggest thing that anyone with a job for a relational war for and they don't like the medication because blood thinner you need at least a monthly blood test to look for a number there's a number called the i n r that needs to be two point zero to three point zero to try to prevent six the stroke risk because you know on warfarin should be careful to vegetarians can eat lots of green leafy vegetables it makes the numbers fluctuate makes your blood stew then and so we are now looking at the surge and some combine what we call trans venus and surgical approaches to some higher more difficult patients patients with prior valves surgeries and things looking to see if usually on war for an anti rhythmic drug it's three months we see him back in clinic if they're doing well at three months we will get rid of the anti rhythmic drug and see how they do on our front alone at six months if they're doing well we put a monitor on use we have wear for two weeks to make sure they're not having silent recurrences and if things look good on that monitor we get rid of the we're friends they all have a big smile is leaving the door because they don't longer you know and we put them on a baby aspirin a day and hopefully they're cured so it's six months they would be able to come off all the symptomatic with a rapid heart rate it goes up to one sixty one seventy and it's very difficult to control the heart rate and and that's the heart rate control and then the blood center the other the other question i had is there's not everybody if you come in to you as a young by structurally normal no blockages no muscle dysfunction no weakness or cardium opting of alveolar disease no the current recommendations for low nature for relation would be aspirin alone ok the problem is if you have lone even you have a normal heart and been in it for a week or two and we want to try to get you back in normal rhythm we still were usually put you on war front are there again this newer medication projects are to big a trend because to get you from a tool for relation back to normal rhythm there's a little bit of a clot risk normal rhythm once and with minimal drugs and basically say see how you do because some people i mean a lot of the low nature for relations will be young people drank a little too much the night before young kids studying for exams drank too much gout caffeine coffee you know there are days when we know those are always to study for exams and to basically have a have a trigger to get him back in so we would start him on a war friend after the blood has been adequately thinned to a cardioversion put him to sleep shock the heart back into the normal rhythm and then  watch how they do stop the war from a couple weeks later and then just see how they do on maybe a baby aspirin alone realizing there's a good chance it's going to come back but don't intervene until it comes back again and then you take a more aggressive approach the second time around you mention the cardio version that's it's an interesting thing before a lot of patients i never never heard of the car dealers and it's basically the same procedure you see on t v where they say clear except this is a very very controlled situation the patients awake very to put them to sleep and only takes a minute a shot them and they wake up it's basically stops the heart for just a few seconds was not so much starts but the i remember that again getting back to this little simple matic diagram your heart's fibrillating you put patch fibrillation that's occurring allows the normal pacer to come back up as you said the patient is asleep you do want to get him deep enough because it does hurt and it's actually interesting ten fifteen years ago we did a lot of research thought was pacemaker putting up on the shoulder through a vein in the heart into the atrium where the thought when you went in for ablation you could activate it or come in and and let the electrophysiologist activate it the problem with that is it hurt and we could not get low enough energies and the thought of a patient putting say ok i made a film i'm going to shock myself back in that just never work very well and and it just so the a told a further later pretty much a thing of its past its prime and probably won't see much of it in the future but it was a thought from a lot of the companies in the better minds could we make an implantable to firm later so that when you went in you could just activate it on your own but we could never get the energy low enough to be painless to the to the patient so it sort of went by its wayside we started out training nearly twenty years ago more than twenty years ago things have really taken taken we remember being trained in that it was basically black box medicine but patients live in nice long lives now with the help of twenty five years later we're sitting here talking about all these a lot of things we've lived through these advances a pacemaker is fairly simple i think we just talk about that you have some type of rhythm problem worry that your top chamber your own beat is going to slow what they call heart block all the pacemaker does is make sure you don't go too slow so if your heart is slowing down it looks and says your heart's fifty five i think you set the little computer at sixty on the patient at sixty carli painless the next  in the bottom chamber we knew that external cardioversion work for sudden death what we did would implant a pacemaker deferrable later on what a difference later was it not only will pace which is painless for slow heart beats it will shock so just like you see patients get a shock from the paramedics it will give a shock internally gives a big jolt but the options of being dead or dying suddenly saw two or three patients that day that would have been dead without the device they were at home had the arrhythmia got shocked their family saw them pass out they wake up ten seconds later jump and they're alive so the technology that we've seen over the twenty five years we've been doing this it's it's amazing it's amazing how well it works it works to save lives occasionally we run into a problem because the that  were later how it knows to shock is based basically based on a fast heart rate occasionally they'll have a fast heart rate but not a lethal rhythm and it will go off inappropriately but it's appropriate for the different bladder it's just it's doing the right thing but  so it's a pacemaker deferrable later and again with this third lead is sort of the cadillac not only would pace shock the heart for better rid me but it tries to improve in recent criticised the heart so people with bad heart failure who have fluid accumulation shortness of breath about two thirds will benefit some significantly and feel much better with less heart failure symptoms in the in the in the arrhythmia so there we would we solved all  t usually it's at least the bottom chamber some have a top chamber the simulator and it's amazing how much is save lives not now i guess ideal like you mentioned before i'm a plumber and i see i get called in our gently for my cardinal functions and that someone has damage to the heart they're prone to a rhythmic afterwards if they have a bad rhythm during the heart attack there's no no guarantee whether they'll have a rhythm yet later on and that's why might get a bit simpler so anyway well we're getting close to the end here and yeah i want to thank you for joining us you're welcome and the technology certainly is evolving again we talked a little bit before the show there's actually for people like you said who had arrhythmia for the first four to six weeks after you know before we determine whether you need the implantable to for a player you are at least protected at home it gives you the patient and their families a lot of you know  you don't win the old days we would actually test if there was a bad rhythm nowadays they put it in that's what we've got in the old days it was called secondary prevention and we started twenty years ago in his field you had to have died suddenly to have an arrhythmia to get a different letter but now as you say we moved into primary prevention we tried to find out people who are risk and put the device in i talk to a lot of patients that you know have been without a figure layers for a long period of time and now their criteria change and i have to discuss i said well you fall in  the in the the group that need it so anyway chris i think we're coming to an end here i want to thank candace berger hospital and allegheny general hospital for sponsoring this and as well as peter's high school and our staff here and of you of course for