2020 Virtual Cardiovascular Evening Symposium: Structural Heart and EP Updates
Originally Broadcast: Wednesday, October 28, 2020
being president of M. H. I is a true blessing. E. Get to help create a new environment for people to be helped by our teams for those people that come to us when they need us and to create that environment that's gonna bring them to care that they deserve a cover of five state area and 36 different communities in that region. We work with a great group of doctors. We have 55 cardiologists that cover the full spectrum of cardiology, as well as seven cardiothoracic surgeons and eight vascular surgeons. So we have 70 physicians that are working to care for you that have a whole range of expertise. E think There are a number of reasons patients should consider choosing mh I for the care one. We're providing cutting edge care every day for our patients to. We're evaluating the quality of that care, making sure that we provide the best care to every patient and every encounter, and three were trying to do that in an efficient way that provides benefit to the patient in the system. We're really evaluating all aspects of our care to achieve the best outcomes at the lowest cost for our patients for patients coming to see us at Minneapolis Heart Institute. Our data warehouse capabilities allow us to improve the care of cardiovascular patients through fewer days in the hospital. Fewer re admissions, particularly for heart failure patients, improve care, coordination and improving the quality of their cardiovascular care by leveraging the data warehouse resource is that we have throughout the system most of the time in previous institutions, I look in the operating room and I get a sense of what my day is gonna look like and what I have to pay more attention to, based on the people who are there here. The quality of the individuals and the team members from all walks of specialties and subspecialties is so high it doesn't even cross my mind. I walk in there, I know I'm gonna have a good day. The reason that I practice Minneapolis Heart Institute Abbott Northwestern Hospital is because everybody there is constantly pushing the envelope, striving for not just excellence, but to be at the very cutting edge of what's next and what's best. My partners that I work with our national and international experts in every field of cardiovascular medicine a Z look to the future. The goal is really gonna be providing people with the care that they need right where they are. And that's really what tell a heart gets at is we can provide specialty expertise even to the level of an advanced heart failure Dr. Or an electrical cardiologists to a person in their own community. But they can see the top of the line best cardiologists that they need right at home. Having a tool that allows you to know exactly where that person should be is really gonna be powerful Going forward. Vascular is a unique surgical specialty in that they become our patients for life and thes air people we follow throughout the course of their post operative care. And so I think those personal relationships and that trust that you develop with the patient and their family is often the most rewarding aspect of our practice. It's more than just the therapies that we can provide, but it's the patient taking an active role in their own care. I think increasingly we understand that good diet is important, focusing on riel foods or not processed food focusing on fruits and vegetables, and not eating too much, paying attention to portion sizes and then finally, activity. So we're looking for patients to be active, moving 30 minutes five times a week and moving enough that they couldn't sing a song while they're doing it. They need to be active short sentences because they're working hard. If you're having symptoms that you are concerned might be related to a heart attack. Don't wait. Get it checked out a soon as possible. And if it's new and it's not going away, that's what 911 is for. Ambulances are made to bring people with that situation directly to the hospital. Don't wait. I like to tell people to live life in moderation. The only thing that I would say not too moderate on is smoking. But aside from that, live your life. Just don't overdo it. Even the future of MH I is incredibly bright way all know that health care is moving very quickly. Way have to keep up with all the technology and the latest and greatest science to deliver to our patients. At the same time, we want to keep that caring touch and be the patient's advocate on the person that they want to come to because they feel safe and cared for. Yeah. Good evening on. Welcome to the C V Symposium on Minneapolis Heart Institute. It's my true honor tonight to be your host. Thistle is, ah, new venture for us. We have hundreds of cardiovascular talks per year that we do for our community. And, uh, this is, uh, now, ah, new venture into the virtual world. And we're really pleased Toe Thio have this and have this reach. There are five states represented and over 150 participants tonight. So I hope everyone's had a wonderful day at work and that they can sit back and enjoy the wonderful, um, presentations we have for you tonight. Ah, I'm gonna see if I can advance. Here we go. So my name is Bill Qazi. Honest, um, electro physiologist And I'm also blessed to be the president of the Minneapolis Heart Institute. And we have to tremendous speakers tonight that I always learned something from every day I I walked past them in the hallways, but they're they're just tremendous speakers on a national and international level that that's Paul Suraj and Johnson K. But I'll introduce them individually later. Um, just a few brief comments about our group. The Minneapolis Heart Institute, is a collection of cardiologists, cardiac surgeons and vascular surgeons, along with nurse practitioners and P A s, and nurses and staff that will provide tremendous care toe a broad area not only in Minneapolis but across the state and the five state region. Thes numbers represent the Minneapolis Heart Institute at Abbot, but recently we've also merged with our partners in the Lina in Saint Paul on Do we currently have close to 130 physicians? Onda Uh, roughly 70 advanced practice providers. We have a lot of employees. We see a lot of patients in a lot of clinics throughout the state and western Wisconsin Dakota's and we practiced the entire breath of the cardiovascular world. That's from prevention all the way through transplant and everything in between. And you'll learn about our approach to valvular heart disease and arrhythmia care today. Um, just because we do ah lot and these are big numbers. Um, I hope, as the video, it was suggested that we still have that personal way. Care for patients one at a time, and help them feel safe and cared for and get the care that they deserve. And also the partnership that we have with our referring community that you hear from us. And we have that touch with you, that we're partners in the care of these precious, precious patients that we get to care for the Minneapolis Her institute has a philosophy of delivering care where the patients live, everything we can do locally we try to do locally. This represents again 35 sites where we're closer to 50 now with our our partners in ST Paul on Beacon. See that we touch a lot of areas in the metro of the Twin Cities, but we go to remote places as well. We've been doing, um, tele visits for many years. Um, and we'll continue. Obviously, the pandemics change that for all of us, but our philosophy of caring for patients where they live is critical. We don't want to bring people to Minneapolis or the same Paul unless they need a procedure or an operation that they can't get locally. So we try to provide all our expertise and testing to the best of our ability and all these locations. One way to bring service to our partners. You all the referring community is a practice we call cardiology curbside. We pride ourselves in wanting to serve. And one way to do that is by providing a cardiologists toe. Answer your phone calls every day. Monday through Friday, at least. And so I'll let you know an easy way. Get this. But this is ah, phone number that everyone in this broadcast can call tomorrow at 7. 30 in the morning. And you call and have a question. The question. I have a patient with symptoms. What do I do? Have a patient who is in the hospital and they're not doing as well as we think or hope. How do I manage this? I have an E k g. Can you look at it for me? I have an echo. Can you look at it for me? What test? Should I order? What stress test? How doe. I approach this. How do I transfer patient? All those questions could be answered through this service. And we will try our best to actually manage that patient with you where they where they are in your office or in the hospitals that you practice that there's no price for this. We want to make good partnerships with with caring for the patients that you all have entrusted us with. So call this number cardiology curbside tomorrow. Give it a try. Our goal there is to have, um, deliver what the patient needs and what you need to care for them. An easy way to access cardiology Curbside is through our app. So if you go to the APP store, it's M h I. If you just type in mh I, it will be the first thing that comes up. Mh i. It's slash a n w, but it'll come up. It's free on it. We have tremendous number of resource is we have anti coagulation questions answered with How do I manage this person's dough? Ac going to surgery? I have a patient with a certain symptom. What test should I get? What kind of stress test should I get? What about statin therapy? Chest pain? All our protocols are on there and they get updated. In addition, we have emergency protocols. What do I do if someone has an s t elevation and my a triple a shock all those things are on there. But what I emphasize is that there's a button on there on the bottom and it says Call cardiology curbside. So you don't have to memorize any numbers. My kids say, Why do we memorize any numbers any day? Isn't there something I could touch on my phone? So this APP gives you the button to push, and it will connect us, connect you to a cardiologists waiting Thio, answer your question on any of these issues or anything else s O I. I urge you toe to explore the the APP. It's been downloaded many thousands of times in multiple countries, actually, and we don't discriminate whether you're in our network or outside of our network or competitive across the street. You can use this this service. Um, we're partner tonight on in our Siris of CD symposiums with broadcast Met and they've been able to reach out the five state region. And that's why we have so many wonderful participants tonight over 150 I welcome you to explore their website. We have many resource is on there and talks by our physicians that are incredibly useful and well presented. So broadcast met our partners tonight. Thank you. And then this is Ah, a list of things coming up in future podcast David Hurl which test when Monju pie palpitations as television in my prevention veins All the things that I know a zone electro physiologist I know nothing about anymore and as an administrator, I know even less so These air wonderful people giving practical talks, um that are, you know, filled with pearls to take care of our patients. Upcoming Virtual CD symposiums November David Hurl will host vascular surgery and heart failure updates and in December, prevention and surgery CT surgery therapies for heart disease again great speakers and welcome you to sign up for all of those on DSI. Emmy is provided. Let's see, I can advance here. Um, obviously, we have disclosures tonight and we have nothing to disclose. The speakers will reveal their own disclosures as they go. The first speaker I'm gonna introduce is Doctor Paul Saraya. Dr. Sarah Gia trained at the Mayo Clinic and, um became one of the youngest, if not the youngest full professor at Mayo Clinic. When we went out and recruited him. I'm forgetting now, but maybe 78 years ago, maybe longer. Probably closer to 10. Um, Paul serves as our section head for interventional cardiology and a Xanthi head in the chair of our valve science center. In our research are Paul is a national and international expert on Val your heart disease and perky Tania's therapies and has really revolutionized the field. Um, he's not only incredible, uh, physician and innovator. He's also an incredible leader for us, and, ah, wonderful teacher. And I know you're going to enjoy his his talk. So with that, Dr Soraya, thank you very much, Bill. Really appreciate the kind introduction, and I hope all of you are doing very well out there. Uh, it has become a virtual world, and certainly I will look forward to the time that we could get together again. Really, really soon. Um, I've been asked to give you an update on structural heart disease on there. Just a few messages that I want to go over and hopefully highlights some of the some of the innovations that we've been working on and how these innovations can really, uh, affect your practice and benefit your patient's. So when we look at innovation in cardiovascular disease and particularly structural heart world. It really used to be mostly about tavern. This is an example of a tavern that was done actually almost 10 years ago where a valve is passed through a film or arty in in a matter of about 20 minutes. We could take a council white valve that looks like this and and and plant a new valve and do it in ways that really are just quite remarkable. I'm sorry about the slide advance here. I'm just gonna go back here and just to give you an idea of how this can really affect our patients, the patient on the right here is a woman who is 104 years old. Andi and her name is Pat. And she had tavern Don. And you might ask, Well, why would you do ah procedure in 104 year old woman? And this woman said that she just had to go kayaking again. And this is her kayaking after her tavern was done and she lived another three years and without the procedure she shouldn't have Certainly wouldn't live mere months. But this just gives you an idea of how the world has really quite evolved and falling on that. I'm just gonna talk about a few patients to highlight what's even more new with regards to the structural heart world. And the first patient is this 80 year old woman who came to see us with severe dystonia and had preserved ejecta fraction. And this is something that we can really offer your practice and your patients because she had unexplained shortness of breath. I'll readily admit this is not the same 80 year old woman that I just introduced here, and that's because this is I didn't have a video of her. But just as an example, this is another person who is doing this supplying bike exercise, and what we're doing is we're measuring the pressures in the patient's heart and lungs, while we're also doing anaerobic assessments and also simultaneous echo. And this type of information is really helpful because you can do things like look at pressures here and diagnosis with relative certainty as to what the cause of a patient's shortness of breath this. So here in the left hand side, you could see that this is patient one, and this is the wedge pressure or left at your pressure, and here you can see it's pretty normal at rest. But then, with exercise, the wedge pressure goes up essentially triples and value. And this patient here clearly has Beth Beth. Well, how about this patient? This is a different patient, and here this is a patient again. Same scenario pressures air normal at rest. But here, with exercise, they don't increase to more than 15 to 20 millimeters of mercury, and the patient becomes anaerobic for other reasons, as we can tell from the video to measurements. So patient number two unfortunately sorry, my mouse here, Just go back here. So patient number two has non cardiac shortness of breath, and so we can help differentiate and diagnosis because of Disney, with quite a degree of certainty for these patients, who have uncertain causes of the shortness of breath. And then for those patients who are found a half half, half or even half breath, we can do things to alleviate the left atrium hypertension that can happen in these patients. And this is a first and human experience of a technology that we've been leading the way in the national investigator for this technology is called Thea Outflow Study, and this is an example of how it's done. We go through the neck, we come down to the coronary Sinus and essentially across from the corners Sinus into the left atrium to create a shunt that offloads the left eight your hypertension that occurs in these patients who, when they're exercising, and this video place for a little while. So in the interest of time, I'm going to try Thio. Skip ahead here, but you get the idea of how this stent is placed. This is an example. This is a picture from an animal of how it looks in the corny Sinus. And then I'm going to show you the results of this 80 year old woman. This is again a large sheet places their internal jugular vein. We cross into the left atrium using the corner Sinuses, a conduit within. Place a stent here from the corner Sinus into the left atrium and then access Apapa valve. For patients who have heart failure, this is a transit stop to echo. You could see on three D here in the bottom left hand side. This is a stent and then here with color. You could see the flow through that stent. Now, this first patient that we treated she is the first of three s so far. And she now is almost two years out. And quite amazingly, she's gone from class three to being asymptomatic. She's doing really, really quite well. So this is a study. The device is called the root device. It's part of the awful study. We're looking for patients with Hef path for Hef breath Essentially, those who are having Disney A. That is not due to other causes or is due to heart failure. And I just asked you because I'm quite certain many of you have patients with Disney A. And if you do, please let us know we're happy to evaluate and treat them accordingly. So how about this patient? This is a 79 year old man with heart failure and severe Maher, and he come to see us with findings have reduced ejection fraction of 30%. Now many of you are aware of our trans catheter mitral valve program, in which we use a mitral clip to put the anterior and posterior leaflets of the mitral valve together. And by doing that we create leaflet opposition that recreates this quotation to reduce mitral valve regurgitation. And this is really not that new. It's been around in the United States since 2013 for patients who are at high risk with degenerative M R. But most recently there has been a really compelling data for patients who have m R. That is due to a secondary cause, and this is that data. This is the co op study, which was published in the new Androgel Medicine about two years ago. And what This shows that in patients who have heart failure with reduced ejection fraction trans catheter repair with mitral clip reduce the risk of heart fair hospitalization quite considerably as well as we. There was a significant reduction in mortality, and when you look at the effects of this device in this part of this patient population, it was really incredible because the number needed to treat to prevent one heart failure. Hospitalization was three, and the number needed to treat to prevent one death was only six. In other words, single digit and aunties, which is actually better than aspirin, is better than beta blockers ITT's better than some other device therapy. It's really, really quite remarkable. And if you wonder how this works well, why would a patient with heart failure and reduce eject traction tolerate or benefit from having a clip place? So here's how it is. This is that patients 79 years old. This is the tea, and you can see here this is micro fabric vegetation, this flame that is regurgitating intellect, a trim, that's all micro vegetation. And this is a direct measurement of the left. Eight. Your pressure before we start here in the lower left hand side. This is the placement of the clip, and you can see here with elimination off that much about reputation on the lower right hand side, the left eight. Your pressure becomes normal, and this is how this procedure saves lives. So we now treat thes patients quite routinely, is part of our practice because it is lifesaving, and certainly there is a new experience that is required for this procedure. This is a paper that we published last year in the journal Jack Interventions, and what this shows is that when you look at the sequence of procedures here on the X axis. The success rates here on the Y Axis increase, and they continue to increase throughout. The experience on that's important because we want to try to get as close to what we could do with surgery as what we could do with a chance catheter standpoint. And it's generally around 200 cases of Mawr that you get surgical like results. Now, in that vein, I'm just gonna go back one slide here There is a repair and mark trial, and this is the new expansion of our TransCanada's microbe. All therapy were now offering micro clip and a randomized fashion for patients who are at intermediate surgical risk age. 75 Years of Asia older and this is a random ization versus micro valve surgery. We started rolling these patients. We certainly we'll look forward to having patients be treated like more trans Catholic therapy, uh, for their micro fabric vegetation. And for those patients who can't have trans catheter repair, there still is three option of trans catheter mitral valve replacement. This is an example of a patient who we did a first in the world experience for treating severe Mac, you can see here in the top. There's a severe much about regurgitation, and this is the 10 dine Val, which reap place to a small their economy between the ribs. This is the Mac beforehand. And then on the right hand side here, lower right inside. You can see this is on Foss view of the tendon valve inside the severe Mac, and this is now in a pivotal clinical trial that we're leading. We have been planted over 20 patients in this trial. The results have been excellent, and we certainly welcome your referrals for those patients. Now, the final type of patient I wanna call your attention to is this patient. She's a 74 year old woman with fatigue and lower extremity Dema, and this is a patient who will often sneak under the radar in your clinical practice because they have severe TR. Severe TR is one of those, uh, lesions that is easily to miss. Easy to miss because it often responds to diabetic therapy and patients can have minimal symptoms, including mild fatigue and lower extremely Dema for many, many decades. And so this is an example off patient in whom became symptomatic with TR and hear the TR is actually quite torrential. This is, Ah, way of looking at the natural history of these patients with t R. And as I mentioned, they could go a number of years with diabetic therapy. But what really eyes believed to be present more and more is that the impairment and survive before these patients begins, even when they have moderate disease, it starts to accelerate when they have severe disease. But the diabetics that we give these patients can often match a mask the impairment that they have. And pretty soon they could develop already failure, which really is a late phenomenon for these patients. There are different categories of TR now that go beyond severe. There's massive and there's torrential and these patients, it's a very steep curve in terms of their impairment. It's very steep of both ways and in terms of the survival Onley. 10% of people who have severe TR live at our live at 10 years, so the rate of death for these patients is about 10% per year. What we now have try customer valve repair system. This is a similar to what we do for the mitral side. It's been specifically designed to treat patients with severe tr, and this is an example of how it's done here in the top left. This is that patient that I showed you earlier. These are images taken from a trance gastric view looking directly at the tri customer valve here, where my hand is is the answer. CEPAL area appears posterior Most of the TR. Here's an hour septal on the top right here. This is a bow tie that's created by placement of two clips, and you can see what was torrential trackless travel. Vegetation is now mild, and these procedures now for the track cancer about take no more than 40 or 45 minutes, and the patients could go home the very next day. We published the initial experience on this and the land set, and it's been quite remarkable even for those patients who have torrential TR. I put in there that the curve is steep both ways because even the ones who are torrential could benefit from this therapy. This is an example. About 80% of the patients are anyway H a class two or one at 30 days, and the average K, C. C Q score for these patients is over 15 16 points, and I have the pleasure of being the national P I for the to eliminate pivotal study. Uh, this is being run out of our center. On another partner of ours is David Adams out of New York, and this is the first pivotal clinical trial ever to be done in patients with track us about regurgitation, and it's a really exciting to be part of this. We implanted the first in the world this past August, and it was a cell of celebration here, off of sorts here on it made some headlines, and so we look forward to seeing those patients with T. R. I want to thank your thank you all for your attention. My key points are really think about those patients with Disney, uh, and how we can diagnose the cause of Disney A and treat shortness of breath in new ways. Think of trans catheter, micro repairs and life saving therapy, especially for those patients with reduce subject fraction. And we're now studying this therapy and low risk patients, and there's a lot more innovation now towards track us about regurgitation, and this is just the start of it. And you're gonna be hearing more about these innovations for a long time coming. I'd be happy to address any questions, as you would like, Paul. Thank you. That was a fantastic talk is always and I know you kinda leave it to the interventional cardiologists to say our our MP's go to 11. Um, by going beyond severe, too massive, um, and torrential, Uh, you know, I, uh, I have a question in there. A couple online. One question I have is we all in our practice have patients who have a moderate valvular disease on these eco reports. Sometimes they say moderate. Sometimes they say, moderate to severe. Our patients are elderly, and you know, it's hard to sort out their symptoms. And I'm just raising my hand. I feel stupid bothering you with referring patients when they're only moderate or moderate severe. And I don't know if I'm taking care of them in the best way or not. It's easy for me to feel stupid. When do you want to see these patients? When should we refer these patients? Do we wait for them to get, uh, you know, dilated cardiomyopathy? These do we wait for them to get super severe symptoms? When do you want to see? Well, it's a great question because in the world of valve disease, the number one criteria of number one question we always ask, This is surgery or transparent therapy indicated for this patient, and it used to be a really late phenomenon in terms of recommending therapy. In other words, we would wait until the Eric Snow Sis's critically severe waiting to over 50 cal various less than 500.7 before intervening. But that's because those therapies at that time, you know, 15 to 20 years ago were risky propositions on nowadays. Because we have a lower risk procedures, including many that could be done with the catheter, we tend to intervene earlier rather than later. We have a number of studies that are looking at treating asymptomatic patients for patients who have modern disease. What I would recommend is that if there any doubt is any doubt about the severity, we'd be happy to see them. And the reason why there's been so much new attention on T R is because TR is a great example of a valve disease been that's been underestimated for years. If you just think about the human dynamics, the human annex of the right side or one quarter of the left side. So if you use a traditional measures of severity from the left side and applying to the right side, you're gonna be underestimated. Severity by 1/4. I mean sorry by 75% because it will be a one quarter of the left side. So there, there, there's it's a whole new field, and we're always happy to see patients. And if the question is easy to answer, well, easy answer easily for you. If there's something needs to be done, will certainly be able to do that for you, too. Great. Thank you. And I could just say from personal experience, uh, referring the first several patients thio Paul and his team. Then you learn a lot by their recommendations in your communication back. And now you know, now you know how to manage other patients and when to send those to. So thank you, Paul. Have a couple questions online. And then one, um uh, that will call on. So the first question is when you showed that bike stress tests in the cath lab question is, how are you measuring pressure during that exercise? Yeah, great question. So for that patient, there's a swan catheter that's been placed to the right into our jugular vein on that pressure. And that catheter is passed out to the pulmonary artery and its used to go into the West position and also the pulmonary artery thio. Look at whether or not there's severe former hypertension with exercise. That's really cool and great data to help that patient. Um, next question is, um, what do you use as criteria when you're determining whether to repair a valve or replace it? That's a great question to you know, a prosthesis always has some risk because of prosthesis can become infected or can degenerate with time. So in general, we try to repair a valve first, especially for a mitral valve, and we look at the leaflets. We look at how close they are to being able to be put back together. The way I often describe it. Thio patient and their family is nature created leaflets to fold in hands like a prayer. They're supposed to come together on def. They can't be folded like a prayer. It's unlikely to be repairable, so sometimes they're thick there, calcified their short or they're absent. And in those patients were replaced about mhm. Um, let's try calling on Ah, live audio question. Eso If our partners can a mute this participant, Go ahead and ask your question. Yeah, okay, so while we're waiting on that, let's take another question and then we'll have doctors a cave come up. So, um, would you consider try custard valve clip for severe TR related to a defibrillator Lee on? I guess I'd say a pacemaker leads it as well. Yeah, so that's a great question. Eso we will if the pacemaker defibrillator defibrillator leader. It's not holding open the septal leaflet, which is the most common corporate on for that. You know, I have my colleagues to thank because building John can speak to this, but their experience with extraction is absolutely extraordinary. And so if it leads in the way, we'll consider extracting it. If it's not in the way in terms of how much tether Yuras, we do dio trans catheter, track us about repair. Great. Um, in the interest of time, there's some more questions We'll try to get them to them after the next speaker. But in the interest of time, I'm gonna move us on. Paul, thank you so much and hang tight because we might have some questions at the end for you, too. Our next speaker is Dr Johnson Cabe, uh, doctors. Cave is originally from Virginia, and it is training at the Cleveland Clinic. And, um, I had heard so much about doctors a cave over years and years that he was one of the most fabulous Cleveland clinic docks ever. I was tired of hearing about it and we, um, reached out and we were blessed and fortunate to be able to recruit doctors a cabe tow our practice doctors. A cave is an electro physiologist, Um, and Justin, outstanding physician. And just like Dr Suraj, a great teacher, great speaker. And I can honestly say they're both incredible people. And so it's an honor. Thio, have doctors a cave tonight, join our symposium and talk to us about some advances in heart rhythm management job. Great. Thank you so much, Bill. It's a pleasure to be invited to participate. And thanks to all of you for your participation, I have the honor of presenting Tonight a little bit about advances in electrophysiology and heart rhythm management at the Minneapolis Heart Institute. And it's a big topic. I tried Thio cover really only two things, but in the interest of time, I'm just going to move right along. And if I can make the slides go, that would be good. Here we go. That was not there we go. So I think we'll discuss, um what I thought I do. Since we talk so much about so many of these topics, I thought I'd give you a little window into what it's like to actually work in the lab and perform a catheter ablation for one of your patients. Eso We'll talk a little bit about the underpinnings of catheter ablation and go in the lab, and I'll show you what the technologies are. Hopefully, if Aiken teach enough people Thio Oblate a fib. I won't have Thio spend my entire career doing it myself, so we'll see how it goes, I think. Well, look at imaging technologies and I'll show you those the approach to anti coagulation I was going to try to cover, but it's really short, long topic for such a short period of time. And I looked at the MH I Ap last night, and it covers this topic and calculation in atrial fibrillation and the use of the new anticoagulants. So well, I thought, Well, I'm gonna pass on that. And then I want to show you a few approaches to pacing that are really new over the past year or two and dramatically changing the face of plain old vanilla dual chamber pacemaker king. So with that, I'll move along, You know, in this cove it pandemic. We've had so many changes in our lives and and, as you all know, sometimes you get it more than you wanted when you ask for something. And we've spent a lot of time at home with our families. My family wanted a puppy, so we tried to find a lapdog, and I found a good deal on a dog that was raised with toxins. But I ended up getting more than I asked for because this dog was a great Dane and she's been a beautiful addition to our family. So you may end up getting more than you asked for tonight with with our presentation, uh, about these arrhythmias. But first I did want to give you my list of important approaches to managing the stresses of this incredible pandemic that we find ourselves in. And I think among all the things that we do in our day, we need to support each other as practitioners and providers and its human beings, because the stresses of what we've undertaken be care for this population during the pandemic have been profound. And I would say the last thing that I've just added to my list is Thio Take a moment and right Ah, quick, thank you. Note updating an old mentor or ah, former teacher about how things turned out for you and how you've done it. It profoundly changes, Um, their their day and they'll get in touch with you. Um, and it's a really neat thing. So let's move on. We're gonna work on the anatomy a little bit. This is, of course, the Frank Netter Classic Frank Netter drawing of the Surgeons view of the heart with that that Ronald cut away and we'll work really on the electrical aspects of the heart. So let's just show you a few teaser pictures. Of course, the electrical activation of the heart on the surface, E k g and what we study when we're working inside the heart with atrial activation the activation of the hiss bundle potential, which is this, uh, infra nodal connection to the bundles and then activation of the ventricular of my cardi. Um, the result of ordered electrical activity of the heart is a profound and elegant pump function with this four chambered pump that when it operates in synchrony, is incredibly efficient. And if I'll run through these, I'm giving you all of these slides because I think if you would like to look back at them in the future, you'll have all this refer to. But I'm gonna move through pretty quickly. All this to say when we talk about arrhythmias. If if you saw an Olympic athlete like Michael Phelps uh, try toe win a gold medal with atrial fib Relation. Um, you would never have heard of Michael Phelps. So the ordered activation of the heart makes it profoundly efficient. When people have arrhythmias, it loses so much of that efficiency that they become symptomatic. And it's a real problem, though the cardiac arrhythmia is that we'll talk about our an abnormal activation sequence of the heart chambers or an activation of the of the heart beats themselves and there could be symptoms or problems, and some are are asymptomatic. And there are many things that contribute to these arrhythmias, and I'll highlight them here and you can review them. I mentioned hydroxy cork win because it did cause some headaches for us early in the pandemic and the last probably the most important cause of arrhythmias is aging there at the bottom, and the only example of that that I could think of was getting older. But I did want to talk about atrial fib relation, and the burden of atrial fibrillation has been significant. You all see it every day in your practice, and you know how much it impacts our patient population on our our patients individually, with symptoms of, uh, palpitations and limitation and functional status decline that's become so important in their lives. And we all know how to recognize it with chaotic atrial activity on the surface. CCG tracing Andi in the intra cardiac electro grams you see here these air recordings from inside the heart during atrial fib, relation just profound electrical disarray that drives the heart very rapidly. Um, I've listed some substrates for atrial fibrillation and causes here that you can review. Hopefully, you'll have access to these slides in the future. But I did want to move towards, uh, the underpinnings for catheter ablation, and you can see here the Kochs Maze procedure from the 19 seventies, which is really this is a poster view of the left atrium here, and the surgeons would cut the atrium apart and then sew it back together and use those scars to help maintain an organized electrical rhythm after surgery. And that was effective. Thio degree on get still used today with more modern technologies. Back in 2000 to 2003 people were putting catheters into the heart and blading within the pulmonary veins when they recognized that the initiators for, uh for atrial fib relation our focal a topic. Drivers that fire rapidly within the pulmonary veins and people first went into the veins and a bladed, and then eventually got into the veins and a bladed in a circumferential fashion to tryto electrically exclude the the ah abnormal electrical substrate that's in the pulmonary veins from disturbing atrial rhythm, and that was effective to a degree. But a bleeding inside the veins resulted in catastrophic scar tissue formation that ultimately, as you can see on these angiograms, denotes the pulmonary veins and obstructed outflow of blood from the lungs back into the heart. So wide areas circumferential ablation came along and you can see here, um, ablation lesion sets around this virtual rendering of the left side of pulmonary veins and every year, the right side of pulmonary veins, excluding any electrical substrate within any of the pulmonary veins. And that was much more effective and eliminated the problem, or at least mitigated the problem of pulmonary vein stenosis. And you can see here I've drawn you this picture. Here's a catheter recording inside the pulmonary vein after a successful circumferential lesions that has excluded this electrically active tissue in the veins from disturbing atrial rhythm. And you can see here on these inter cardiac recordings, the patient is in Sinus rhythm, undisturbed and beautiful, elegant Sinus rhythm. And yet on these electrodes, which are these circumferential electrodes inside the pulmonary vein here is a staccato 20 or 30 beat run of a rapid ECT API, which previously would have initiated a disturbance of the atrial rhythm and caused atrial fib relation. And now this electrical activity is excluded from the the atrium itself by the ablation lesion set, and the patient remains in Sinus rhythm undisturbed. So that's how we got to catheter ablation. This study was performed that this was called the Raft Trial, Um, in 2000 and 2002 at the Cleveland Clinic. While I was there, um published essentially atrial fibrillation ablation as a first line treatment because it resulted in a more effective elimination of patients atrial fibrillation at one year than anti arrhythmic drug therapy. And so that's where atrial fib relation began as trying to mitigate people's symptomatic atrial fib relation. And I'll fast forward 20 years. Here's a study that we published, um, in 2019 looking at patients who underwent a very modern catheter ablation procedure with a very modern up to the minute mapping system to identify the drivers for, um, persistent atrial fib relation, showing great success. So what patients go through. They undergo a general anesthesia and spend the night in the hospital after the procedure. The procedures, done through three small accesses in the femoral veins under lots of local anesthetic. In general anesthesia, we use multiple image ing technologies, and our catheters can sense the contact force. They can tell us how hard repressing when we're touching tissue inside the heart. Onda. Help us minimize the need for repeat ablation by maximizing the chance that we deliver effective lesions upfront. And we have new mapping technologies that help us identify locations within the atrium that are driving atrial fib. Relation. Another technology that's revolutionized this procedure is CT angiography. When we can perform a C T scan with a modern scanner 192 slice scanner very rapidly and obtain, uh, you know, up to the minute images of the patients left atrium. This is a scan through the left atrium showing you the pulmonary veins. This is a unique scan in which this patient actually has a common inferior pulmonary vein. In other words, if you look right here, you'll see the patients to lung's air connected to each other by these this pulmonary vein that has a single trunk entering into the left atrium unique finding. But ultimately we can download the data set from our C T scanner into our mapping system, and that helps us guide our procedure when we start the procedure in the right atrium and I've drawn you a schematic of the right atrium from the side view. Here is the Super Vienna Kaveh inferior vena cava and the right atrium, and this is using intra cardiac echo to identify the floor of the right atrium. This patients in typical atrial flutter. As you can see on the left, there's counterclockwise rotation of a very rapid propagation around the tri customer. Dominant results in atrial flutter when we have laid the floor of the right atrium from the tri custard valve. The doctor, Sara Joe, was intending to fix way a blade all the way back across the floor here and when we've completed a line of burns across the floor and up the ridge here and on this membrane and eliminate any electrical activity from crossing that floor and we terminate the flutter and the patient goes back to Sinus rhythm. After that, we turn our attention to the inter atrial septum and cross the septum. Um, this is an intra cardiac echo, with our ultrasound being looking through the fossil of Alice in the inter atrial septum from the right atrium here to the left atrium. And this is a 71 centimeters deal, uh, trans septal needle, that impressing against the fossil Vallis under ultrasound guidance, and we can advance the needle across. You can see here that the needle tip there's just a little bit of either the needles pulled back. This is a plastic sheet that's across there now and then we advance, um, are, uh, shaped sheath across and we're into the left atrium, and now we can begin mapping the left atrium. So now we transition from an ultrasound guided procedure to a three dimensional mapping guided procedure. And this is the This is the three dimensional rendering of the patients left atrium that you saw on the C T scan. And what you see here is this pen Tariq catheter with five franz or electrodes on each front gently moving around the atrium like like a firm like the front of a firm. And as it goes, it's collecting electrical data. And so now, instead of just the an atomic information, we have physiologic information about the electrical substrate here and you and see, the color spectrum is rendering voltage that we're recording on all those locations. And I think we're up Thio 4000 points that have been analyzed in this map and we'll continue until we have a complete three dimensional rendering of the left atrium and evaluate the patient's electrical substrate thereafter. Now, I told you I was going to show you ah, rendering of the electrical substrate and I want to warn you, it can cause a seizure activity. In fact, the whole thing looks like a porcupine having a seizure, because this is these pylons that you can see on the rendered on the map and show us the amplitude of the electrical signal we recorded in that location and the frequency. And so we'll analyze this map, uh, to look for areas of high frequency and low amplitude as those areas. Maybe, uh, maybe driving atrial fibrillation once it's been initiated, um, from the pulmonary veins. And so when you put a catheter like that on the poster of all of the left atrium during atrial fibrillation, this is what it looks like. This is incredibly rapid electrical disarray. And as you see on the surface, E k G. It looks more organized. You might say this looks like flutter on the surface, E k g. But of course, that's a filtered phenomenon, as this much rapid signal is transmitted through the body of the atrium. It's filtered, and it looks slower and slower as you get to the surface electro grams. But we do our ablation and, as we identify as we isolate the pulmonary veins, and then we identify targets outside the pulmonary veins that are perpetuating a fib you'll see slowing of the atrial cycle. And finally it will terminate. And now we have electrical silence before the first beat of Sinus rhythm. Once again, it's a really a kind of a profound moment when you achieve that. And here's the same view of the posterior wall that you saw before. Only now we're in Sinus rhythm, and we've got to completely organized left atrium. There is the lesion set from that atrium that we way had a bladed, and you can see um, the colored the segments are excluded from disturbing. The atrial rhythm in the atrium remains a normal rhythm. Here's a Here's a catheter that's inside that left superior pulmonary vein after electrical isolation and within about two minutes after this patient was returned to Sinus rhythm after years in atrial fib. Relation, this is what they're pulmonary vein did, and you see it was much more comfortable going back to fib relation. This patient, uh, was probably so still doing this years after their ablation, but they remain in Sinus rhythm, so that's the goal of our procedure. And it's a very effective and very helpful in really a profound benefit, as it obvious the need for anti arrhythmic drug therapy and rate controlling therapy and in the selected patients, potentially, it will obviate the need for anti coagulation, depending upon their risk. So who's a candidate for catheter ablation of atrial fib? Relation? I would tell you that patients with symptomatic paroxysmal atrial fib relation patients who failed great control patients who failed anti arrhythmic drug therapy and who still have symptoms. Patients, even if they're minimally symptomatic if they have attack a cardio mediated cardiomyopathy associated with their a trail for relations in patients who have to discontinue necessary anti arrhythmic drug therapy so that they can take other medical therapy. Sometimes those drugs interact with one another and we can work around other devices that have been implanted. Certain valves, uh, being a cable filters, SD patches, you name it, and we kind of find a way around it and get to where we need to go to fix the patient's problem. So that's my spiel about catheter ablation of atrial fibrillation, and I just wanted to cover in a couple of minutes some really interesting stuff about pacing the right ventricle, which we have for many years tried to avoid because we know that pacing the right ventricle in patients with heart block, um, can contribute to left ventricular systolic dysfunction. I had a mentor one time named Bruce Stamler, who's a case now in Cleveland, he said. There's no worse place to pace the heart than the right ventricular apex, and that was true. It induces dissing pretty. That's no different than the left bundle branch block that we often try to correct in patients who have diabetic cardiomyopathy. And I've entered, you know, suggested some studies that suggested that and and ultimately ah, lot has been of effort has been expended in trying Thio identify ways of mitigating the detrimental effect of right ventricular myocardial pacing. His bundle pacing was described years ago in 1978. We do it all the time when we're in the lab with catheters, but we haven't had leads and delivery equipment, uh, to deliver those leads that allow us to reliably pace the hiss bundle and utilize the patient's own intrinsic conduction system with pacing technology. Until more recently. And since we've been doing that, we found there's observation of studies that show hey, we we can we can normalize left ventricular activation by recruiting the left bundle. Even if the person has had left bundle branch block for 30 years, We can pace the left bundle more distantly within the ventricle within the septum and use it to re synchronize the left ventricle, um, and normalize ventricular activation sequence and even normalized ventricular function. So there are concepts called selective. His bundle pacing was very interesting. You actually implant a pacing lead directly into the hiss bundle that the structure I showed you at the beginning, and you can see here in this patient, um, normal intrinsic conduction in a patient who is requiring pacing for perhaps intermittent a B block or advanced second gravy block And when you pace you get a cure s complex that's identical to their intrinsic. And that means you are pasting their his bundle. Well, uh, we've achieved that and over the past several years have found that perhaps non selective, his bundle pacing is better. And so we're using this alternate technology that allows us to pace near the his bundle. But not not not solely that his bundle and, um you know, looking at these drawings, you can see well, the target for his bundle pacing is right here. Um, but on the other side of the Internet, real septum or inter ventricular septum, the left bundle divides into multiple branches. And so if you can sort of drill a lead through the septum and into any of this network, you can send your signal anta great down the fiber that you recruited and then retrograde down all the other fibers and you get a relatively normal appearing cure s complex. Here's the curious complex of someone who got selective his bundle pacing straight into there proximal his bundle, and they have a very normal looking cure s complex. And I was incredibly proud of this. E k G when we implanted this and I'll tell you how that goes down the road. Here's what I do now this is non selective, this bundle pace and you can see the pace QRS complexes still very narrow. It's like 100 18 milliseconds, which there's no way you can achieve a curious complex that narrow without recruiting the intrinsic conduction system. But you also have pre excited the Maya cardi, um, adjacent to the conduction system. So even if there's some drug that kills there for Kinji System, you're still activating their my cardio and you'll still have pacing capture. Um ah. Final quick topic is normalizing left bundle branch block with this pacing strategy and you can see in this patient we have an intrinsic your s complex and sweep speeds wider than a normally cagey. But this is 153 millisecond left bundle branch block that's been present for years. And when we implanted a lead into the conduction system a little bit distal to the hiss itself. But in the left bundle across the septum, we got a very narrow QRs complex with the stem artifact here to measure to the end of the cure s 135 milliseconds. But because we paste into the hiss the stem to the onset of curious complexes 22 this person's curious complex is 113 milliseconds. Looks very normal. Ended up getting a vibe ventricular device, but it zone, additionally, that we may find is not necessary in the future. This is just a schematic showing you on ablation catheter touching the proximal bundle of hiss. And here's how far into the ventricle we are with our pacing lead and still pacing in this location, we achieved a cure s complex of 113 milliseconds. So we're, well remote from the very proximal conduction. And I'll show you how that comes into play in just a moment. This made the person's heart very happy in this situation. And Paul, you'll recognize the tabard device. Um, this is a This is a trans catheter delivered aortic valve. Um uh, within the outflow tract of the left ventricle and it's essentially created a direct injury to the left bundle branch. Uh uh, with the stress of this valve and we were able to correct the left bundle branch block created by the stress of the valve by pacing directly into the left bundle thereafter, and this person had a curious complex of 142 milliseconds with left bundle branch block after tavern and prolonging a V interval suggestive of a B nodal injury or proximal hiss injury also. And we put our facing, uh lead into the left bundle and we resulted a curious complex of this one again. 113 milliseconds. Really good result. This is just, ah study. Looking at this pacing strategy versus by ventricular pacing showing really benefit normalization of left ventricular systolic function with the F going from 30 to 56 with NYC class going from 2.8 to 1 so similar to buy ventricular pacing So a riel innovation in a much simpler pacing system that shows dramatic promise. And I think you know, we're really, um, uh, pushing the limits of of plain old vanilla dual chamber pacing with a new strategy recruiting the patient's intrinsic conduction system, which may have been dormant for decades. I've been back normalized left bundle after 30 years of clinical left bundle branch block. So I wanted to cover those couple things, and then I'll stop and we can answer questions. But I'm just really excited that you got Teoh. See what I wanted to show you. But maybe you got to see more, uh, what I wanted to show you then what you are looking for. I'm living that at my house, as you can see. Thank you so much for your attention. I sure appreciate your participation. And please be safe and strong during this really trying time. Yeah. Thank you. As always, A tremendous talk. And, um, I'm an electro physiologist, but they don't let me near electrophysiology anymore. So I always learn a lot. And I would suggest that we need to borrow from the lexicon of the interventionists. I think those potentials that you showed in the pulmonary vein during atrial fib relation Those were torrential to steal from Paul. So we're falling behind. We can't We can't fall behind. Um, it was a really, um it was It was opposed on our chat and question. Answer as a simple question. But it's not a simple question. It's a really incredibly important question. And that is rate versus rhythm control for atrial fib. relation. Should we should we try to maintain people in Sinus rhythm the way they were born? Or can we just control the rate of the response? Central formulation And it kind of gets to Who should we? Oblate? What do you think, John? You don't want to take that one. You want me to take it? Well, you know, I'm the host tonight, so I got it. I got it. I think it's a fantastic question. When I was a chief resident and internal medicine in 2000 and three, the Affirm trial was published, and I thought, finally, this question has been answered. And then I read the trial, and, having interacted with the people that ran the trial over the years, realized that trial did not answer the question. And it's been a burning question ever since. The problems we have with rate control and anti coagulation are simple, and that is that the drugs we have that are available to achieve adequate rate control and to cause the same symptoms that people get when their rate is uncontrolled and that is still ties them causes swelling and fatigue, and, uh, beta blockers cause fatigue and depression. and, um, a variety of other problems. And so if you give enough of those drugs to suppress our A V nodal conduction, especially in young patients, and we see people were 50 who do not want to be taking those drugs or 60 or 70 or 80 you name it. You know you give people enough, they don't they're not happy. And so rate control on any calculation is entirely appropriate for a subset of patients who have minimal symptoms from their arrhythmia and who have, uh, adequate rate control with preserved ventricular function on a well tolerated medical regimen. If you can achieve that and the patients happy with that approach, that's a fantastic approach. But it's a small subset of patients because we have other patients who are profoundly symptomatic and when they're symptomatic, it doesn't matter to them that you've controlled their rate because they have irregularity. They have breathlessness, they have fatigue. And you know we have patients. We've all seen who have a 20 minute episode of atrial fib relation, which is symptomatic, and then they have 24 hours of fatigue afterwards. And if you just give that person beta blockers for their weekly episode of a fib. They have all of the adverse effects of the beta blocker every day, and it only helped them when they were out of rhythm. So for a variety of reasons, rate control alone is not adequate for the entire A fib population. It works perfectly for some subset of patient. And then there's anti anti arrhythmic drug therapy, which, um, over the past 30 years really hasn't moved very far. We've had one new anti arrhythmic called Dronett Iran, which, um, sadly was less effective, more expensive and not not super helpful. So, using the same standard set of anti arrhythmic we've had since the 19 eighties and early 19 nineties, we haven't achieved the same freedom from atrial fib relation as we did in the early days of atrial fibrillation ablation, as you saw in the raft trial in 2003 on DSO. If you give patients anti arrhythmic drugs and randomize them drugs or ablation, it's the ablation group that remains in Sinus rhythm at a higher rate a year later, so it's still a difficult question, and it ultimately the answer is it depends on what works for the particular patient great answer. Jonah and I completely agree, I would add, And I know you're being humble. First of all, the studies of rate control, they did show that rate control is an excellent therapy and doesn't have an adverse effect on duration of life or quality of life. But those studies were done in patients in their seventies, and they're relatively asymptomatic. As you pointed out, uh, you know, younger patients, even patients in their seventies, deserve a discussion. And I don't do this procedure anymore. So I'm gonna say you all do such a great job managing that patient and all the options for them. Um, that is just Ah, it's a wonderful, uh, kind of a no brainer to refer those a fit patients to you and your colleagues to take care of them. And the procedural, uh, risk and the procedural discomfort and recovery is there so optimized Now patients just fly through this thing and get just great great care. So, um, so I think that's the right approach. In the interest of time, we promised that we have people freed up by 7. 15 were fallen short. I'm gonna summarize tonight. Please join us for future CV symposiums that were listed. We welcome you all to join us for all those topics. Um, number three, um, grab our app. It's free and it's really useful. And I'll tell you, I'm a I'm still board certified, but you fall behind on all these new therapies and how to take care of manage all these patients. And I use that app all the time for things outside of my specialty. Onda Fourth, use that app in that button for curbside cardiology. Give us a call with your questions about patient care, how to take care of the patient in your office or in the hospital, or somebody coming up or results that you got that you'd like us toe help you interpret will be more than happy to partner. And I and I just love that term because it truly is a partnership of taking care of patients together with that Thank you for joining us tonight. Have Ah, wonderful recipe Evening. God, bus and stay safe. Take care
