September 6, 2023 • 42 mins
Join a roundtable with two prominent Central Ohio electrophysiologists, Dr. Ralph Augostini from The Ohio State University, and Dr. Anish Amin from OhioHealth, as they discuss current practices, controversies, and management strategies for patients with atrial fibrillation. They address risk factor management, the rationale for early rhythm control, and the role of left atrial appendage exclusion in these challenging patients.
This episode is dedicated to the memory of Dr. Albert Waldo, master clinician, educator, researcher, and mentor.
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Episode Transcript
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(00:11):
This is Canny Gral, president ofthe Ohio Chapter of a c c.
Before we present the newpodcast episode dealing with
cutting edge therapy of atrialarrhythmias, I just wanted to
take a moment to recognize thevery unfortunate passing of a
giant in the field of cardiologyand electrophysiology, both here
(00:35):
in Ohio and known throughoutthe.
Cardiovascular community.
We unfortunately just learnedthat Dr.
Al Waldo passed away after, uh,short illness.
Dr.
Waldo was a master clinician, hewas a researcher, he was a
master educator, and he was amentor to so many of us in the
(00:57):
cardiovascular community aroundOhio.
I have fond memories of Dr.
Waldo as a clinician inCleveland when I was a fellow.
Reading EKGs with him, uh,accompanying him on rounds and I
still refer to so many of hispearls for e k G interpretation.
Dr.
Waldo was originally from NewYork State, and after spending
(01:19):
some time training at Columbiaand Johns Hopkins, he joined the
university hospital's medicalstaff in 1986, basically to
establish the division ofelectrophysiology there.
He ended up as a professor atCase Western and clinician at,
uh, all the way until 2022 whenhe just retired a year ago at
(01:42):
the age of 85.
We all have fond memories of himas a master clinician educator
researcher as well in additionto all of his excellence
clinically.
He actually was instrumental inthe founding of the Ohio chapter
of a c c in the late 1980s, andhe also served as our second
president.
(02:03):
Uh, and so many of us who have,uh, contributed or, or benefited
from the our state chapterreally walk in his footsteps.
Therefore, we think it's veryfitting that for a podcast
episode, talking about thelatest treatment of arrhythmias
that we dedicate this.
Episode to our clinician,mentor, educator, and teacher
(02:27):
Dr.
Al Waldo.
And now for today's episode.
Kanny (02:31):
So welcome back to the Cardio Ohio podcast.
Today we're gonna have adiscussion about atrial
fibrillation, a condition youprobably occasionally see in
your own practice.
Before I introduce our twoeminent central Ohio
electrophysiologist that aregonna enlighten us on all things
af I do wanna introduce a, aspecial co-host I'd like to
(02:54):
welcome also from here incentral Ohio at Ohio State
University.
Third year fellow AndrewHornick.
Andrew (03:00):
Thanks, DRAL.
I'm honored to be here tonightfilling in the big shoes of your
usual co-host, Ben Allen Cherry,to introduce myself.
My name is Andrew Hornick.
I'm a third year cardiologyfellow at Ohio State University.
Here in Columbus.
I'm pursuing a career in generalcardiology with an interest in
sports cardiology and
Kanny (03:17):
imaging.
Andrew (03:18):
I'm excited to introduce one of our guests tonight, Dr.
Ralph Augustini, who's one ofour EP faculty here at Ohio
State.
We've been in the trenches ofinpatient consults together,
actually a few times now.
Dr.
Augustini, do you mind justtelling us briefly about where
you're from and your trainingpathway to get to O SS U
currently?
Ralph (03:35):
Sure.
I'm originally from Western NewYork.
I grew up about an hour south ofBuffalo in a large family.
I wound up making my way throughstate University of New York at
Buffalo, now the Jacobs Schoolof Medicine and did my residency
(03:58):
at the University of Michiganduring my residency.
Dr.
Topel had moved from Michigan tothe Cleveland Clinic and I
followed him there thinking Iwas gonna go into intervention.
And once I got into fellowship,I really found the intellectual
(04:18):
and variability of EP proceduresto be more enticing.
And I chose to do EP there atthe Cleveland Clinic.
I joined The practice Mid Ohio,cardiology at Ohio Health or
Riverside coming outtafellowship and then transitioned
(04:40):
to Ohio State now for 17 years.
Andrew (04:46):
Thanks, Dr.
Augustini.
We're we're glad that you'vejoined the, the good side over
at Ohio State after starting offMichigan.
Kanny (04:55):
Yeah, so I would echo that.
Welcome, Ralph.
Thanks for joining us and it'sit's been great to know you over
the years and, and practice withyou as well.
Our second guest is also aeminent electrophysiologist from
here in central Ohio.
I'd like to welcome Dr.
Anish Amin.
He's currently the chief ofelectrophysiology here at Ohio
Health.
(05:15):
He did do his medical school.
And fellowship at Ohio State.
I think finishing approximatelyin 2015, and I believe he is
just about to receive an endowedchair in electrophysiology here
at Ohio Health as well.
So Anish congratulations on thatand welcome and just let us know
a little bit about your currentclinical
Anish (05:34):
interests.
Absolutely.
Thank you, Dr.
Gral for inviting me.
And thanks Ralph for agreeingto.
With me.
As Dr.
Gral mentioned, I trained atOhio State.
In fact, Ralph trained me.
(05:55):
And so it's quite humbling to behere with him tonight.
We've had, you know, sincecoming over since finishing
Fellowship and, and starting atOhio Health, we've had
tremendous opportunities aremostly related to.
Novel energy therapies inmanaging atrial fib and as well
(06:15):
as novel device therapies forleft atrial appendage occlusion.
So to both topics that areconsistent with tonight's
conversation.
Andrew (06:25):
Awesome.
Well welcome both Dr.
Augustinian and Dr.
Amin.
It's great to have you both withus.
I think to start off thisconversation, we probably should
just dive right into one of thecore things that we always
discuss with, with atrialfibrillation, and that is when
you have a patient who's comingto your office, it's a new
diagnosis of atrialfibrillation, how do you make a
decision about pursuing either arate control or a rhythm control
(06:47):
strategy?
Dr.
Augustinian, maybe we can startwith you and, and then toss it
over to Dr.
Amin.
Ralph (06:54):
Number one, I think a, a good history.
From the patient is helpful inparticular if they're aware of
the AFib or not and also howlong it's been present.
From there, generally I wouldtake a workup including an
(07:16):
echocardiogram an E C G and someblood work to really look to
see.
If the AFib itself has had asubstantial impact on the
structural components of theheart,
Kanny (07:33):
Ralph does the pre, does the fact that the patient might
be, inpatient versus outpatientaffects, maybe how aggressive
you would be.
the incidental clinical AFib cin the office.
Do, would you treat thatdifferent than maybe someone
admitted with, with rapidventricular response and acute
symptoms?
Ralph (07:50):
I think there's a definite value to making sure
that if someone is symptomaticand or if they have a rapid
ventricular response, that theyget treated quickly.
One of the, one of the mostimportant components is.
(08:11):
Is making sure that their ratedoes not exceed 130 beats per
minute regularly, or an averagerate of 110 beats per minute on,
on a surveillance monitor suchthat they would potentially
develop a, a dilatedcardiomyopathy from tachycardia.
(08:34):
So, and also if, if they'requite.
Be more aggressive at gettingthat patient back to normal
rhythm.
Andrew (08:42):
I think that makes a lot of sense.
And Dr.
Amin, anything else you wouldkind of add as, as part of your
practice when you approach, thepatient who has new AFib and how
to manage them
Anish (08:51):
and work them up?
Yeah, I, I, I generally agree, Ithink that most programs are
gonna approach patients with aprimary consideration for
hemodynamic stability.
And so those patients that Dr.
Gral, mentioned that areinpatients admitted acutely for
(09:12):
atrial fibrillation with rapidrates, we wanna find ways to
restore sinus rhythm for thoseindividuals.
I would add that in after we'veaddressed the acute needs of the
patient.
I think we have taken anapproach that really begins to
lay the groundwork for patientsand caregivers in identifying
(09:35):
atrial fibrillation as a chronicprogressive disease.
So a disease state that.
May manifest both withintermittent, symptomatic and
asymptomatic episodes and leadto downstream heart failure
events, valvular events all ofwhich we'll need management
(09:56):
after the initial workup iscompleted with structural heart
assessment, as Dr.
Augustini referred to we also.
Want to assure that we'veaddressed stroke risk reduction
with you know Diligentconversation with the patient
(10:16):
about risk factors for stroke.
And I think we're all familiarwith the CHADS two vast scoring
system which is what we use.
We ask patients to actuallyidentify their own score so they
understand where their risk iscoming from, and then make
recommendations about both shortterm and long term
(10:36):
anticoagulation strategies asthey're applicable or
downstream.
Left atrial strategies if that'smore appropriate.
I will say that, as if we arethinking about patients who if
we're thinking about rate andrhythm control, which I think
was the original question thatyou asked.
(10:57):
I think for the newly diagnosedpatient, most of us are probably
going to at least ask patientsand Care teams to consider
rhythm control when it'sclinically appropriate.
So certainly patients in anambulatory setting on a general
(11:19):
medicine ward, it's veryappropriate to consider rhythm
strategies.
Maybe in an I C U setting, wemay say, you know, let's visit
with these folks in an whenthey're discharged and Consider
rhythm control strategies as anoutpatient when it's more
elective.
And the reason that we ask folksto to more consistently consider
(11:44):
rhythm based strategies todaythan maybe five years ago, 10
years ago, or 15 years ago, isan increasing set of data that
would suggest that rhythmpatients who undergo rhythm.
Control, whether they'reasymptomatic or symptomatic, do
demonstrate reductions in heartfailure, heart failure,
(12:08):
hospitalization, stroke, andpotentially cardiovascular
mortality.
Ralph (12:15):
we, we wind up seeing the full spectrum of what patients
present with in terms ofsymptoms or associated.
Comorbidities.
And sometimes you'll see someonewho looks perfectly fine and
they're in AFib, but they'reunaware of it.
And you get an echo and theirejection fraction is 15% and you
(12:41):
just say, how could it come tothis point?
And so at a minimum I try evena, even a what is patient
claims?
They're completely asymptomatic.
I at least try to do acardioversion to restore sinus
rhythm to see if they feel a, aclinical improvement.
So whether that be a short termepisode of AFib, Or an AFib
(13:04):
that's been persisting for 12,15 months even.
I think they deserve a shot atsinus rhythm.
So yeah, we're being much moreaggressive at rhythm control
because of the data that'semerging with composite death
(13:26):
cardiovascular events andstroke.
Anish (13:31):
Yeah, Ralph, you're highlighting that classic
patient that comes in with, youknow, tachy cardio induced
cardiomyopathy with persistentAF that's unaware of it until
their heart failure symptomswarrant the presentation.
And I think we also want to makefolks aware, Andrew, you know,
as you move into clinicalpractice, patients who will
(13:54):
present with heart failure withpreserved ejection fraction,
which is decompensated by af.
Which we know is one of theleading causes of HFpEF
decompensation.
So for the paroxysmalpopulation, certainly
recognizing the symptoms ofheart failure, de decline HFpEF
(14:17):
exacerbation when they haveparms of atrial, atrial fib is
also important.
And then I'll, I'll throw outone more consideration and maybe
get your thoughts and Dr.
Al's thoughts even on this.
Is that with the increasingprevalence of valvular disease
and the awareness that atrialfunctional Mr.
(14:38):
Mitral regurgitation, which isin fact driven by atrial
fibrillation.
Recognizing that early andunderstanding that patients who
have atrial functional Mr.
Also benefit significantly fromrhythm based strategies is
increasingly important.
(14:58):
Yeah.
Kanny (14:58):
Thanks Anisha.
That's appreciate your insighton that.
Do you think that since youtalked about you both elucidated
the, the benefits of earlyrhythm control, is there a
classic kind of patient profileyou think the general
cardiologist should be lookingfor and, and saying, this is a
patient even though this istheir index presentation of af,
(15:20):
this is a patient I might thinkof, you know, more early
considering ablation or getting,electrophysiologists involved to
at least kind of start leading'em down that pathway towards
more aggressive therapy.
Anish (15:34):
Well, I, I think it's a little bit of a loaded question,
if I'm honest with you.
I, I mean, I think that as acommunity in electrophysiology,
we wanna recognize that ablativeinterventions are more effective
earlier in the disease state.
It makes sense that they wouldbe more effective earlier in the
(15:56):
disease state because anablation is, Mechanistic and
focal.
And so if we go back to what wethink the current model of
atrial fibrillation is, which issomething that's driven by
independent triggers arisingfrom specific structures in the
left atrium, namely thepulmonary veins and the
(16:19):
posterior wall, thenintervention towards those
structures early in the diseasestate, think.
Diagnosis to intervention timethat's less than two years is
gonna be much more approachablethan seeing patients who have
long histories of atrialfibrillation refractory to
(16:41):
multiple therapies.
Just because of the inherentremodeling that occurs and the
diffuse fibrosis that occurs inthe atrium for patients that
have long histories of atrialfib.
So yes, we want to, we want toeducate both our
electrophysiology communityclinical cardiology communities,
PCPs.
(17:01):
That early referral isimportant.
Does that mean that we want totake patients who are presenting
with their first episode ofatrial fibrillation or two
episodes in two years and askthem to consider ablation?
Most people will tell youprobably not.
(17:25):
I mean, we want to help folksunderstand that there we do have
to reach a burden of events thatwill.
That will give us theopportunity to elicit a benefit
from the therapy.
And AFib ablation even intoday's day and age is not
(17:46):
without risk.
And so we have to recognizethat, you know, a one to 2%
procedural risk, which is whatis, you know, what we are seeing
in our practice in, in Columbusand in fact in most of Ohio,
but, Even higher reportedprocedural risks in, in
published studies is notsomething to take necessarily
(18:06):
lightly for a single or two orthree episodes of atrial fib.
So I think the message is, youknow, this is a chronic
progressive disease and we wantto intervene on the early end.
Ideally, when events arestarting to become increasingly
frequent.
(18:28):
And the diagnosis tointervention time is, you know,
let's say less than two years.
And by diagnosis, I mean, notthat first episode, but when
the, when the episodes arereally starting to accumulate.
I don't know.
What do you think, Ralph?
Yeah, I, I,
Ralph (18:48):
I totally agree.
I think one of the other thingsto think about too is that Early
intervention might notnecessarily be ablation.
It might be particularly here incentral Ohio weight loss so such
that you know, it, it willreduce their blood pressure, it
(19:11):
will reduce their sleep apneaand it will make any form of
therapy more effective.
And so if it's an infrequentatrial fibrillation, Event, I'm
more likely to wait on thatpatient and try to work on the
risk factors.
(19:32):
And then when things do progressor if they are failing, for
instance, an antirrhythmic drugthen move on to ablation at that
point, we don't like to see themprogress from paroxysmal to
persistent simply because weknow.
(19:55):
That that implies that there'senough fibrosis and remodeling
that's occurred that is causingthem to have that progression,
that natural progression ofdisease.
Anish (20:11):
Yeah.
I can't agree more with Ralphabout the role of risk factor
modification.
It's taken us several years inour Heart Rhythm society
guidelines to incorporate.
And strenuously identify riskfactor modification as a key
element of treating.
Atrial fibrillation.
And so weight loss is the numberone thing we can ask our
(20:35):
patients to consider.
Remember that we, we want togive them achievable targets.
So if in our program we tend tobe very discreet to patients, we
ask'em to consider a 10% weightloss.
So, you know, we're trying tomake it so that it's
approachable.
(20:55):
It's achievable.
It's not you know, somethingthat we're, that has a negative
connotation to it.
And that number is born out ofthe data outta Adelaide,
Australia where some of theearly work on weight loss and
atrial fibrillation regressionwas completed.
(21:20):
Ralph, you also mentioned sleepapnea, and I think you, you
know, maybe you're gonna bringthis up a little bit later,
Andrew, I know that we had sortof discussed this before the,
the podcast recording about,Specifically for young patients
who are otherwise healthy, theworkup.
And very often, you know, wecomplete the structural heart
evaluation, we complete an anendocrine evaluation.
(21:42):
We will often ask patients tobe, you know, acute aggressively
monitoring and managinghypertension.
Ralph, you're an expert in sleepapnea as well as
electrophysiology.
What do you think about.
Occult sleep apnea.
Are stereotypes aboutobstructive sleep apnea, the
role of central sleep apnea inarrhythmic populations?
(22:05):
Well,
Ralph (22:05):
you, you know, there's definitely a significant number
of patients who have atrialfibrillation that have sleep
disorder breathing.
And so in our clinics we'vepretty much established that
anyone who's coming in with anew diagnosis of of AFib gets at
(22:29):
least a screening questionnaireto determine if they have any,
any possible risk factors forsleep apnea or if they've had
any clinical symptoms of it.
And our referral rate.
Virtually every patient that Isee will get at least a
(22:50):
screening home sleep study todetermine if they, if they need
more aggressive treatment.
And so
Anish (23:02):
Our, our hit rate,
Ralph (23:03):
so to speak, for, for sleep apnea is about 80% for,
for AFib patients.
And so it's a virtual nobrainer.
I, I, I think it's just so muchoverlap between the disease
processes with, with obesity,hypertension, AFib, and sleep
(23:27):
apnea.
And in patients who have heartfailure in particular central
sleep apnea is quite prevalentand upwards of 50% of heart
failure patients will have someform of sleep disorder
breathing.
And there's more than half ofthose will be central apnea
(23:51):
rather than obstructive apnea.
So there's a.
A bit subgroup that really wetry to be aggressive with
screening tests in the heartfailure patients as well for an
assessment for any type of sleepdisorder breathing.
Anish (24:11):
And I think you mentioned this, so so patients who have
untreated sleep apnea, If wewere to intervene with either
drug or ablation theirdownstream one year success
rates are about half thepopulation that's treated.
Is that right, Ralph?
(24:32):
That's right.
And I think this is why it's soimportant.
Weight and sleep apnea haveclear data for the success of
intervention, whether it's drugor ablation.
Kanny (24:48):
Yeah, thanks Anisha.
Thanks for highlighting that.
I, I think that's a good takehome point is that basically
weight management and screeningfor sleep disorder breathing is
almost a mandatory part of theinitial assessment and it's
gonna guide future success aswell.
So thanks for calling that out.
I will also add Anish that wedid have Andrea on our podcast
(25:10):
last month actually, we werehighlighting, the role of apps
with innovative.
Clinics, and she's talked aboutthe AFib Walk-in AFib clinic
that you've established OhioHealth.
Several years ago she talkedabout, the success rate, but she
also highlighted how the visitsare, 50 minutes long and allow
for more in-depth discussionabout risk factor modifications.
(25:33):
So perhaps that's gonna be atrend.
And AF management is tohighlight those issues from the,
from the beginning.
We have about five to 10 minutesleft, so I wanted to make sure
we saved some room to talk alittle bit about, left atrial
appendage occlusion therapysince, this has become
widespread over the last 15years or so.
(25:54):
So I thought I'd just ask Ralph.
I think most of our cliniciansare familiar with, left atrial
appendage occlusion as a kind ofa commonplace now therapy for
patients who are intolerant orhave other reasons to not take
anticoagulation.
But as, as you know, the devicesevolved as we now have multiple
devices on the market.
(26:16):
I wanted to maybe start withyou, Ralph, and then transition
to a niche and just ask, youknow, can you like let our
clinicians know, like kind ofwhat is the typical patient
profile where they should bethinking about referral for,
device therapy versus ongoinganticoagulation?
Certainly.
Ralph (26:34):
So we really follow the publish guidelines on this.
And so we look at a CHADS VAScrisk of three or higher, or
score of three or higher, and ahas blood risk of two or higher.
(26:57):
And also in particular patientswho have had any form of
bleeding problem.
Any form of issues with anemiaparticularly in, in cancer
patients where they'reintermittently having their cell
counts dropped with therapy.
(27:20):
We look at patients who have hadthe use of warfarin with
fluctuating levels of I n r.
And difficult management becausethose patients tend to be at
higher risk than those patientswho are on the, the novel agents
because they can go high or low.
(27:42):
And with just diet dietarychanges sometimes they're quite
difficult to control.
And there are patients whosimply do not want to take an
anticoagulant.
And so those patients would alsoqualify provided that their risk
score was high enough.
(28:03):
So we've all had the patientthat comes into clinic and said,
I will not take rat poison.
Which has become less so withthe doac.
But still out there and theassociation of, of
anticoagulants they, they mayhave a family member or somebody
(28:23):
that was close to them that diedfrom an intracranial hemorrhage
and they just absolutely will,will not accept an
anticoagulant.
And so those patients are, arevery good candidates for device
occlusion of the appendage.
(28:43):
We do exclude patients who havesignificant mitral valve related
atrial fibrillation.
Kanny (28:51):
Anish how, how's the practice at Ohio Health?
Is that similar in terms ofpatient selection?
Anish (28:58):
Absolutely.
I think that the indications forleft atrial appendage have been
well described and, and as apoint of sort of logistics, I
think some of this is mandatedby C M s and the need for shared
decision making, which I thinkis why it's so important that
referring clinicians recognizethe risks and benefits of left
(29:21):
atrial appendage closure becausewe often ask for those
individuals to.
Participate in the shareddecision making with patients.
The procedures certainly havebecome increasingly safer more
convenient for the patients and,you know, in many centers
(29:42):
completed with same daydischarge.
And so there is a an in a,there's progression in the
number of patients that arereferred.
I think there.
Two clinical trials that will beupcoming.
One is called watch option,another one is called Champion
with Watchman.
(30:02):
And a third called Catalyst withamulet that are gonna be looking
to actually broaden theindication for left atrial
appendage closure.
So looking to do closure with atthe time of atrial fibrillation
ablation, which is watch option.
And then looking at.
Left atrial appendage occlusionas an alternative to
(30:24):
anticoagulation in patients thatwouldn't today qualify for
closure.
So people that are toleratinganticoagulation without issue.
Randomizing those patients tocontinue anticoagulation versus
complete closure.
That that was the premise behindChampion and Catalyst.
(30:44):
Those are, they have five-yearfollow-up.
Those results will take, youknow, seven plus years to be in
practice at this point.
But the future looks likeclosure may be a primary option
for stroke risk management.
I'll 0.11 thing out aboutclosure that I, it, and maybe
(31:05):
you were gonna ask this, it'swhat are the unresolved issues?
And, and there are several, sothe, some of the unresolved
issues are what should we beutilizing for peri procedure
imaging?
What should we be doing withpatients that have leaks of
their device?
What should we be doing withdevice related thrombosis?
(31:29):
The rates of thrombosis are, arequite low, thinking like the
three to 5% range, but dorepresent increased stroke rates
for individuals who have devicerelated thrombosis.
And the last question, andprobably the most pressing one
is how do we manage short-termanticoagulation for patients on
(31:49):
rhythm control strategies afterthey've had a closure?
So somebody gets a.
Watchman or an amulet, they haveatrial fib.
They're on aspirin as theirlong-term stroke risk reduction
with combined with the closure,and you do a cardioversion or an
ablation, what type ofanticoagulation do those
patients need?
So those are four big kind ofissues for downstream management
(32:14):
of patients with closure.
As we move beyond the populationthat's persistent AF with a
bleeding indication.
Andrew (32:21):
I think that remains one of the biggest challenges that
we see still in fellowship at,at Ohio State.
We use both CT and d e E toassess the occlusion devices.
I guess maybe for the sake oftime, if you both could just
briefly touch on what yourcurrent practices in regards to,
you know, both imaging thesedevices and then making
decisions on anticoagulation.
(32:42):
Thereafter
Ralph (32:43):
So we just published a manuscript Anish on
anticoagulation strategiesaround cardioversion in patients
with left atrial appendageocclusion, and whether that be
from surgical atrial clip orligation.
(33:05):
Whether it was from a Lariat, anamulet, or a Watchman device,
all of these patients wereincluded.
And we found that we had a verylow risk of events with a four
week strategy.
(33:27):
Anticoagulation of the patientfollowing the cardioversion if
they're, if they're sent forcardioversion.
So, so it, it was a limitedanticoagulation scheme with good
tolerance and low neurologicevent rates.
So that, that's something that,that we practice regularly now.
(33:55):
Regardless of how the appendageis occluded,
Anish (33:59):
I was teeing you up, brother.
Thank you.
Ralph (34:03):
I forgot to mention if, if the patient does have an
indication for chronicanticoagulation other than AFib,
for instance, if they've hadrecurrent D V T or they have a,
a thrombogenic genetic disorderThose patients are probably not
the best.
They're not the good candidatesfor an occlusion device as their
(34:26):
sole form of thromboticprotection, that they should
remain on an oral anticoagulantif possible.
Anish (34:35):
N now, I think Andrew, most of the time, the short-term
an Anticoagulation and platelettherapies.
The, the individual doing thecardioversion, maybe the
implanter or theelectrophysiologist is gonna own
that.
I think the question you askedabout imaging modalities pre and
post is relevant too.
You know, we want to try tominimize the amount of imaging
(34:59):
and the strain on the system forpatients who are coming through
with closure.
So We do a CT for all thepatients that can tolerate it
from a perspective of renalfunction.
And then we essentially do about50 50 implant with either T
guidance or intracardiacultrasound guidance.
(35:22):
And then we try to duplicate theimaging technique for the 45 day
follow up.
So if they, if we did a iceclosure, we'll do a ct.
At the 45 day, if we did a TEclosure, we'll do a te at five
day.
You know, there are, it's a bigconversation around what to do
(35:45):
with leaks.
'cause leaks are present and themore resolute the imaging
technique in this case ct, themore likely you are to see him.
We don't necessarily extend theanticoagulation scheme past 45
days.
If we do see a small leak, lessthan five millimeters although
(36:07):
Ralph can speak to the data thatthey've presented about leaks
less than three if he wishes to.
But I think the, at the end ofthe day, if folks, if you do see
a device related thrombus, thatpatient should be put on at
least short termanticoagulation.
So, Regardless of the imagingmodality, if you see a device
(36:27):
related thrombus, that personshould be put on at least
short-term anticoagulation.
We generally will suggest threeto six months in repeat imaging.
Ralph (36:37):
We're, we're very similar in that approach.
We pretty much have adopted CTimaging for both pre and post
testing more than t e e at thispoint.
It gives you the dimensions.
Of the left atrial appendage.
It avoids sedation for thepatient, and I think it's a more
(37:02):
comfortable and, and morethere's, there's more
information that you gather fromthe ct.
Aside from the t e e, there aresome operators that choose to
use only in echo.
With no preceding imaging.
(37:23):
I have not adopted that patternmyself at this point.
But I am using ICE with some ofthe cases where intraoperative,
t e e has increased risk.
Kanny (37:37):
Thanks.
Thank you both for the insight.
It's been very interesting tosee device therapy evolve into
the mainstream.
There's so many aspects of AF wecould keep talking about.
I, I just want to finish withone final topic because we're up
against our time and I'll throwit out to Aish first.
We, we don't have time to talkabout all the aspects of
wearables and implantableloopers.
That could be an entire.
(37:58):
Podcast by itself.
But my specific question foryou, an is, is as we've had a
proliferation of, of looprecorders and patients with
home, you know, E K G devices,whether it's Apple Watch, et
cetera, do we yet know whetherthe incidental AF that shows up
on these monitors and devicesincidentally carries the same,
(38:19):
you know, kind of prognosticsignificance?
Clinically presenting AF does.
Is that something we still haveto figure out?
And do you have any advice forclinicians, you know, who are
dealing with the, with theseresults from these devices?
Anish (38:36):
Well, it's a great question.
I, I will tell you that lastyear, I think at European
Society of Cardiology, thequestion about symptomatic AF
versus asymptomatic AF on looprecorders and stroke,
cryptogenic stroke patients wasdescribed in two different
trials with different results.
So basically saying that, Theseasymptomatic episodes maybe
(38:59):
didn't increase the e the therisk of stroke like the
symptomatic episodes did, and Idon't know if that's going to be
true for wearables as well.
I, I think that for the patientthat has a known diagnosis of
atrial fib, the wearable devicesdo provide us with a nice
(39:21):
longitudinal.
Mechanism to communicate withthe patient beyond their
symptoms.
So to have patients transmitECGs when they're having
episodes, confirming a diagnosisbefore we instruct'em to go to
utilize acute care pathways,whether that's the emergency
department in our office, AFclinic, et cetera.
(39:43):
So I think they're valuable fromthat perspective.
I also think that, you know, thenext generation of devices,
including the current AppleWatch, which allows AF burden.
Detection lets us talk topatients about that longitudinal
history of atrial fib.
So looking at somebody andsaying, Hey, when we saw you six
(40:04):
months ago, you had a 3% burdenof AFib.
Now we're seeing you, it's a 10%burden.
So your, whether your symptomsare changing or not, the disease
is changing in the backgroundand we should be managing that.
So, There is value from thatperspective.
I certainly do empathize witheverybody who has to look at all
(40:29):
the tracings because it, it, itis a little bit of a data
overload and we don't have greatways yet to not only manage the
data describe it, you know, in ausable format but also to.
Recognize the time that we'reputting in for it evaluating it.
(40:50):
So those are all things that Ithink we're, we're gonna have to
face, especially because this isjust the pinnacle.
The, I think that e c G on awearable format is easy to do
and most of us would agree withthat.
And the, you know, the evolvingdevices and we've all seen'em,
whether it's sleep metric, VOtwo.
(41:10):
You know, there are devices,especially on our implantable
loops that can monitor heartfailure.
The list is almost endless ofwhat's coming, so we're gonna
have to look at how to managethis stream of information.
Kanny (41:24):
Thanks, Anish.
That's insightful.
I think we've had an amazingdiscussion.
It's just amazing how complexthis one condition is and how it
affects so many aspects ofcardiovascular care.
And I think Andrew and I haveboth.
We've been texting each otherwith so many additional
questions and topics that we'dlike to cover.
So I would hope that maybe youguys would be willing to come
(41:45):
back.
At some point in the future andeducate us a little further, not
just on af but perhaps someother EP topics as well.
And until then, I just wannathank you both for taking the
time to educate us and and ourlisteners.
So Ralph thanks for joining us.
Ralph (42:02):
Thank you Canny.
Thank you Andrew and Anish aswell.
Anish (42:06):
Yeah.
Thank you guys.
It's a pleasure.
Ralph (42:08):
Yep.
Kanny (42:09):
And thanks Andrew for co-hosting and until our next
episode we'll be in touch.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
This is Canny Gral, president ofthe Ohio Chapter of a c c.
Before we present the newpodcast episode dealing with
cutting edge therapy of atrialarrhythmias, I just wanted to
take a moment to recognize thevery unfortunate passing of a
giant in the field of cardiologyand electrophysiology, both here
(00:35):
in Ohio and known throughoutthe.
Cardiovascular community.
We unfortunately just learnedthat Dr.
Al Waldo passed away after, uh,short illness.
Dr.
Waldo was a master clinician, hewas a researcher, he was a
master educator, and he was amentor to so many of us in the
(00:57):
cardiovascular community aroundOhio.
I have fond memories of Dr.
Waldo as a clinician inCleveland when I was a fellow.
Reading EKGs with him, uh,accompanying him on rounds and I
still refer to so many of hispearls for e k G interpretation.
Dr.
Waldo was originally from NewYork State, and after spending
(01:19):
some time training at Columbiaand Johns Hopkins, he joined the
university hospital's medicalstaff in 1986, basically to
establish the division ofelectrophysiology there.
He ended up as a professor atCase Western and clinician at,
uh, all the way until 2022 whenhe just retired a year ago at
(01:42):
the age of 85.
We all have fond memories of himas a master clinician educator
researcher as well in additionto all of his excellence
clinically.
He actually was instrumental inthe founding of the Ohio chapter
of a c c in the late 1980s, andhe also served as our second
president.
(02:03):
Uh, and so many of us who have,uh, contributed or, or benefited
from the our state chapterreally walk in his footsteps.
Therefore, we think it's veryfitting that for a podcast
episode, talking about thelatest treatment of arrhythmias
that we dedicate this.
Episode to our clinician,mentor, educator, and teacher
(02:27):
Dr.
Al Waldo.
And now for today's episode.
Kanny (02:31):
So welcome back to the Cardio Ohio podcast.
Today we're gonna have adiscussion about atrial
fibrillation, a condition youprobably occasionally see in
your own practice.
Before I introduce our twoeminent central Ohio
electrophysiologist that aregonna enlighten us on all things
af I do wanna introduce a, aspecial co-host I'd like to
(02:54):
welcome also from here incentral Ohio at Ohio State
University.
Third year fellow AndrewHornick.
Andrew (03:00):
Thanks, DRAL.
I'm honored to be here tonightfilling in the big shoes of your
usual co-host, Ben Allen Cherry,to introduce myself.
My name is Andrew Hornick.
I'm a third year cardiologyfellow at Ohio State University.
Here in Columbus.
I'm pursuing a career in generalcardiology with an interest in
sports cardiology and
Kanny (03:17):
imaging.
Andrew (03:18):
I'm excited to introduce one of our guests tonight, Dr.
Ralph Augustini, who's one ofour EP faculty here at Ohio
State.
We've been in the trenches ofinpatient consults together,
actually a few times now.
Dr.
Augustini, do you mind justtelling us briefly about where
you're from and your trainingpathway to get to O SS U
currently?
Ralph (03:35):
Sure.
I'm originally from Western NewYork.
I grew up about an hour south ofBuffalo in a large family.
I wound up making my way throughstate University of New York at
Buffalo, now the Jacobs Schoolof Medicine and did my residency
(03:58):
at the University of Michiganduring my residency.
Dr.
Topel had moved from Michigan tothe Cleveland Clinic and I
followed him there thinking Iwas gonna go into intervention.
And once I got into fellowship,I really found the intellectual
(04:18):
and variability of EP proceduresto be more enticing.
And I chose to do EP there atthe Cleveland Clinic.
I joined The practice Mid Ohio,cardiology at Ohio Health or
Riverside coming outtafellowship and then transitioned
(04:40):
to Ohio State now for 17 years.
Andrew (04:46):
Thanks, Dr.
Augustini.
We're we're glad that you'vejoined the, the good side over
at Ohio State after starting offMichigan.
Kanny (04:55):
Yeah, so I would echo that.
Welcome, Ralph.
Thanks for joining us and it'sit's been great to know you over
the years and, and practice withyou as well.
Our second guest is also aeminent electrophysiologist from
here in central Ohio.
I'd like to welcome Dr.
Anish Amin.
He's currently the chief ofelectrophysiology here at Ohio
Health.
(05:15):
He did do his medical school.
And fellowship at Ohio State.
I think finishing approximatelyin 2015, and I believe he is
just about to receive an endowedchair in electrophysiology here
at Ohio Health as well.
So Anish congratulations on thatand welcome and just let us know
a little bit about your currentclinical
Anish (05:34):
interests.
Absolutely.
Thank you, Dr.
Gral for inviting me.
And thanks Ralph for agreeingto.
With me.
As Dr.
Gral mentioned, I trained atOhio State.
In fact, Ralph trained me.
(05:55):
And so it's quite humbling to behere with him tonight.
We've had, you know, sincecoming over since finishing
Fellowship and, and starting atOhio Health, we've had
tremendous opportunities aremostly related to.
Novel energy therapies inmanaging atrial fib and as well
(06:15):
as novel device therapies forleft atrial appendage occlusion.
So to both topics that areconsistent with tonight's
conversation.
Andrew (06:25):
Awesome.
Well welcome both Dr.
Augustinian and Dr.
Amin.
It's great to have you both withus.
I think to start off thisconversation, we probably should
just dive right into one of thecore things that we always
discuss with, with atrialfibrillation, and that is when
you have a patient who's comingto your office, it's a new
diagnosis of atrialfibrillation, how do you make a
decision about pursuing either arate control or a rhythm control
(06:47):
strategy?
Dr.
Augustinian, maybe we can startwith you and, and then toss it
over to Dr.
Amin.
Ralph (06:54):
Number one, I think a, a good history.
From the patient is helpful inparticular if they're aware of
the AFib or not and also howlong it's been present.
From there, generally I wouldtake a workup including an
(07:16):
echocardiogram an E C G and someblood work to really look to
see.
If the AFib itself has had asubstantial impact on the
structural components of theheart,
Kanny (07:33):
Ralph does the pre, does the fact that the patient might
be, inpatient versus outpatientaffects, maybe how aggressive
you would be.
the incidental clinical AFib cin the office.
Do, would you treat thatdifferent than maybe someone
admitted with, with rapidventricular response and acute
symptoms?
Ralph (07:50):
I think there's a definite value to making sure
that if someone is symptomaticand or if they have a rapid
ventricular response, that theyget treated quickly.
One of the, one of the mostimportant components is.
(08:11):
Is making sure that their ratedoes not exceed 130 beats per
minute regularly, or an averagerate of 110 beats per minute on,
on a surveillance monitor suchthat they would potentially
develop a, a dilatedcardiomyopathy from tachycardia.
(08:34):
So, and also if, if they'requite.
Be more aggressive at gettingthat patient back to normal
rhythm.
Andrew (08:42):
I think that makes a lot of sense.
And Dr.
Amin, anything else you wouldkind of add as, as part of your
practice when you approach, thepatient who has new AFib and how
to manage them
Anish (08:51):
and work them up?
Yeah, I, I, I generally agree, Ithink that most programs are
gonna approach patients with aprimary consideration for
hemodynamic stability.
And so those patients that Dr.
Gral, mentioned that areinpatients admitted acutely for
(09:12):
atrial fibrillation with rapidrates, we wanna find ways to
restore sinus rhythm for thoseindividuals.
I would add that in after we'veaddressed the acute needs of the
patient.
I think we have taken anapproach that really begins to
lay the groundwork for patientsand caregivers in identifying
(09:35):
atrial fibrillation as a chronicprogressive disease.
So a disease state that.
May manifest both withintermittent, symptomatic and
asymptomatic episodes and leadto downstream heart failure
events, valvular events all ofwhich we'll need management
(09:56):
after the initial workup iscompleted with structural heart
assessment, as Dr.
Augustini referred to we also.
Want to assure that we'veaddressed stroke risk reduction
with you know Diligentconversation with the patient
(10:16):
about risk factors for stroke.
And I think we're all familiarwith the CHADS two vast scoring
system which is what we use.
We ask patients to actuallyidentify their own score so they
understand where their risk iscoming from, and then make
recommendations about both shortterm and long term
(10:36):
anticoagulation strategies asthey're applicable or
downstream.
Left atrial strategies if that'smore appropriate.
I will say that, as if we arethinking about patients who if
we're thinking about rate andrhythm control, which I think
was the original question thatyou asked.
(10:57):
I think for the newly diagnosedpatient, most of us are probably
going to at least ask patientsand Care teams to consider
rhythm control when it'sclinically appropriate.
So certainly patients in anambulatory setting on a general
(11:19):
medicine ward, it's veryappropriate to consider rhythm
strategies.
Maybe in an I C U setting, wemay say, you know, let's visit
with these folks in an whenthey're discharged and Consider
rhythm control strategies as anoutpatient when it's more
elective.
And the reason that we ask folksto to more consistently consider
(11:44):
rhythm based strategies todaythan maybe five years ago, 10
years ago, or 15 years ago, isan increasing set of data that
would suggest that rhythmpatients who undergo rhythm.
Control, whether they'reasymptomatic or symptomatic, do
demonstrate reductions in heartfailure, heart failure,
(12:08):
hospitalization, stroke, andpotentially cardiovascular
mortality.
Ralph (12:15):
we, we wind up seeing the full spectrum of what patients
present with in terms ofsymptoms or associated.
Comorbidities.
And sometimes you'll see someonewho looks perfectly fine and
they're in AFib, but they'reunaware of it.
And you get an echo and theirejection fraction is 15% and you
(12:41):
just say, how could it come tothis point?
And so at a minimum I try evena, even a what is patient
claims?
They're completely asymptomatic.
I at least try to do acardioversion to restore sinus
rhythm to see if they feel a, aclinical improvement.
So whether that be a short termepisode of AFib, Or an AFib
(13:04):
that's been persisting for 12,15 months even.
I think they deserve a shot atsinus rhythm.
So yeah, we're being much moreaggressive at rhythm control
because of the data that'semerging with composite death
(13:26):
cardiovascular events andstroke.
Anish (13:31):
Yeah, Ralph, you're highlighting that classic
patient that comes in with, youknow, tachy cardio induced
cardiomyopathy with persistentAF that's unaware of it until
their heart failure symptomswarrant the presentation.
And I think we also want to makefolks aware, Andrew, you know,
as you move into clinicalpractice, patients who will
(13:54):
present with heart failure withpreserved ejection fraction,
which is decompensated by af.
Which we know is one of theleading causes of HFpEF
decompensation.
So for the paroxysmalpopulation, certainly
recognizing the symptoms ofheart failure, de decline HFpEF
(14:17):
exacerbation when they haveparms of atrial, atrial fib is
also important.
And then I'll, I'll throw outone more consideration and maybe
get your thoughts and Dr.
Al's thoughts even on this.
Is that with the increasingprevalence of valvular disease
and the awareness that atrialfunctional Mr.
(14:38):
Mitral regurgitation, which isin fact driven by atrial
fibrillation.
Recognizing that early andunderstanding that patients who
have atrial functional Mr.
Also benefit significantly fromrhythm based strategies is
increasingly important.
(14:58):
Yeah.
Kanny (14:58):
Thanks Anisha.
That's appreciate your insighton that.
Do you think that since youtalked about you both elucidated
the, the benefits of earlyrhythm control, is there a
classic kind of patient profileyou think the general
cardiologist should be lookingfor and, and saying, this is a
patient even though this istheir index presentation of af,
(15:20):
this is a patient I might thinkof, you know, more early
considering ablation or getting,electrophysiologists involved to
at least kind of start leading'em down that pathway towards
more aggressive therapy.
Anish (15:34):
Well, I, I think it's a little bit of a loaded question,
if I'm honest with you.
I, I mean, I think that as acommunity in electrophysiology,
we wanna recognize that ablativeinterventions are more effective
earlier in the disease state.
It makes sense that they wouldbe more effective earlier in the
(15:56):
disease state because anablation is, Mechanistic and
focal.
And so if we go back to what wethink the current model of
atrial fibrillation is, which issomething that's driven by
independent triggers arisingfrom specific structures in the
left atrium, namely thepulmonary veins and the
(16:19):
posterior wall, thenintervention towards those
structures early in the diseasestate, think.
Diagnosis to intervention timethat's less than two years is
gonna be much more approachablethan seeing patients who have
long histories of atrialfibrillation refractory to
(16:41):
multiple therapies.
Just because of the inherentremodeling that occurs and the
diffuse fibrosis that occurs inthe atrium for patients that
have long histories of atrialfib.
So yes, we want to, we want toeducate both our
electrophysiology communityclinical cardiology communities,
PCPs.
(17:01):
That early referral isimportant.
Does that mean that we want totake patients who are presenting
with their first episode ofatrial fibrillation or two
episodes in two years and askthem to consider ablation?
Most people will tell youprobably not.
(17:25):
I mean, we want to help folksunderstand that there we do have
to reach a burden of events thatwill.
That will give us theopportunity to elicit a benefit
from the therapy.
And AFib ablation even intoday's day and age is not
(17:46):
without risk.
And so we have to recognizethat, you know, a one to 2%
procedural risk, which is whatis, you know, what we are seeing
in our practice in, in Columbusand in fact in most of Ohio,
but, Even higher reportedprocedural risks in, in
published studies is notsomething to take necessarily
(18:06):
lightly for a single or two orthree episodes of atrial fib.
So I think the message is, youknow, this is a chronic
progressive disease and we wantto intervene on the early end.
Ideally, when events arestarting to become increasingly
frequent.
(18:28):
And the diagnosis tointervention time is, you know,
let's say less than two years.
And by diagnosis, I mean, notthat first episode, but when
the, when the episodes arereally starting to accumulate.
I don't know.
What do you think, Ralph?
Yeah, I, I,
Ralph (18:48):
I totally agree.
I think one of the other thingsto think about too is that Early
intervention might notnecessarily be ablation.
It might be particularly here incentral Ohio weight loss so such
that you know, it, it willreduce their blood pressure, it
(19:11):
will reduce their sleep apneaand it will make any form of
therapy more effective.
And so if it's an infrequentatrial fibrillation, Event, I'm
more likely to wait on thatpatient and try to work on the
risk factors.
(19:32):
And then when things do progressor if they are failing, for
instance, an antirrhythmic drugthen move on to ablation at that
point, we don't like to see themprogress from paroxysmal to
persistent simply because weknow.
(19:55):
That that implies that there'senough fibrosis and remodeling
that's occurred that is causingthem to have that progression,
that natural progression ofdisease.
Anish (20:11):
Yeah.
I can't agree more with Ralphabout the role of risk factor
modification.
It's taken us several years inour Heart Rhythm society
guidelines to incorporate.
And strenuously identify riskfactor modification as a key
element of treating.
Atrial fibrillation.
And so weight loss is the numberone thing we can ask our
(20:35):
patients to consider.
Remember that we, we want togive them achievable targets.
So if in our program we tend tobe very discreet to patients, we
ask'em to consider a 10% weightloss.
So, you know, we're trying tomake it so that it's
approachable.
(20:55):
It's achievable.
It's not you know, somethingthat we're, that has a negative
connotation to it.
And that number is born out ofthe data outta Adelaide,
Australia where some of theearly work on weight loss and
atrial fibrillation regressionwas completed.
(21:20):
Ralph, you also mentioned sleepapnea, and I think you, you
know, maybe you're gonna bringthis up a little bit later,
Andrew, I know that we had sortof discussed this before the,
the podcast recording about,Specifically for young patients
who are otherwise healthy, theworkup.
And very often, you know, wecomplete the structural heart
evaluation, we complete an anendocrine evaluation.
(21:42):
We will often ask patients tobe, you know, acute aggressively
monitoring and managinghypertension.
Ralph, you're an expert in sleepapnea as well as
electrophysiology.
What do you think about.
Occult sleep apnea.
Are stereotypes aboutobstructive sleep apnea, the
role of central sleep apnea inarrhythmic populations?
(22:05):
Well,
Ralph (22:05):
you, you know, there's definitely a significant number
of patients who have atrialfibrillation that have sleep
disorder breathing.
And so in our clinics we'vepretty much established that
anyone who's coming in with anew diagnosis of of AFib gets at
(22:29):
least a screening questionnaireto determine if they have any,
any possible risk factors forsleep apnea or if they've had
any clinical symptoms of it.
And our referral rate.
Virtually every patient that Isee will get at least a
(22:50):
screening home sleep study todetermine if they, if they need
more aggressive treatment.
And so
Anish (23:02):
Our, our hit rate,
Ralph (23:03):
so to speak, for, for sleep apnea is about 80% for,
for AFib patients.
And so it's a virtual nobrainer.
I, I, I think it's just so muchoverlap between the disease
processes with, with obesity,hypertension, AFib, and sleep
(23:27):
apnea.
And in patients who have heartfailure in particular central
sleep apnea is quite prevalentand upwards of 50% of heart
failure patients will have someform of sleep disorder
breathing.
And there's more than half ofthose will be central apnea
(23:51):
rather than obstructive apnea.
So there's a.
A bit subgroup that really wetry to be aggressive with
screening tests in the heartfailure patients as well for an
assessment for any type of sleepdisorder breathing.
Anish (24:11):
And I think you mentioned this, so so patients who have
untreated sleep apnea, If wewere to intervene with either
drug or ablation theirdownstream one year success
rates are about half thepopulation that's treated.
Is that right, Ralph?
(24:32):
That's right.
And I think this is why it's soimportant.
Weight and sleep apnea haveclear data for the success of
intervention, whether it's drugor ablation.
Kanny (24:48):
Yeah, thanks Anisha.
Thanks for highlighting that.
I, I think that's a good takehome point is that basically
weight management and screeningfor sleep disorder breathing is
almost a mandatory part of theinitial assessment and it's
gonna guide future success aswell.
So thanks for calling that out.
I will also add Anish that wedid have Andrea on our podcast
(25:10):
last month actually, we werehighlighting, the role of apps
with innovative.
Clinics, and she's talked aboutthe AFib Walk-in AFib clinic
that you've established OhioHealth.
Several years ago she talkedabout, the success rate, but she
also highlighted how the visitsare, 50 minutes long and allow
for more in-depth discussionabout risk factor modifications.
(25:33):
So perhaps that's gonna be atrend.
And AF management is tohighlight those issues from the,
from the beginning.
We have about five to 10 minutesleft, so I wanted to make sure
we saved some room to talk alittle bit about, left atrial
appendage occlusion therapysince, this has become
widespread over the last 15years or so.
(25:54):
So I thought I'd just ask Ralph.
I think most of our cliniciansare familiar with, left atrial
appendage occlusion as a kind ofa commonplace now therapy for
patients who are intolerant orhave other reasons to not take
anticoagulation.
But as, as you know, the devicesevolved as we now have multiple
devices on the market.
(26:16):
I wanted to maybe start withyou, Ralph, and then transition
to a niche and just ask, youknow, can you like let our
clinicians know, like kind ofwhat is the typical patient
profile where they should bethinking about referral for,
device therapy versus ongoinganticoagulation?
Certainly.
Ralph (26:34):
So we really follow the publish guidelines on this.
And so we look at a CHADS VAScrisk of three or higher, or
score of three or higher, and ahas blood risk of two or higher.
(26:57):
And also in particular patientswho have had any form of
bleeding problem.
Any form of issues with anemiaparticularly in, in cancer
patients where they'reintermittently having their cell
counts dropped with therapy.
(27:20):
We look at patients who have hadthe use of warfarin with
fluctuating levels of I n r.
And difficult management becausethose patients tend to be at
higher risk than those patientswho are on the, the novel agents
because they can go high or low.
(27:42):
And with just diet dietarychanges sometimes they're quite
difficult to control.
And there are patients whosimply do not want to take an
anticoagulant.
And so those patients would alsoqualify provided that their risk
score was high enough.
(28:03):
So we've all had the patientthat comes into clinic and said,
I will not take rat poison.
Which has become less so withthe doac.
But still out there and theassociation of, of
anticoagulants they, they mayhave a family member or somebody
(28:23):
that was close to them that diedfrom an intracranial hemorrhage
and they just absolutely will,will not accept an
anticoagulant.
And so those patients are, arevery good candidates for device
occlusion of the appendage.
(28:43):
We do exclude patients who havesignificant mitral valve related
atrial fibrillation.
Kanny (28:51):
Anish how, how's the practice at Ohio Health?
Is that similar in terms ofpatient selection?
Anish (28:58):
Absolutely.
I think that the indications forleft atrial appendage have been
well described and, and as apoint of sort of logistics, I
think some of this is mandatedby C M s and the need for shared
decision making, which I thinkis why it's so important that
referring clinicians recognizethe risks and benefits of left
(29:21):
atrial appendage closure becausewe often ask for those
individuals to.
Participate in the shareddecision making with patients.
The procedures certainly havebecome increasingly safer more
convenient for the patients and,you know, in many centers
(29:42):
completed with same daydischarge.
And so there is a an in a,there's progression in the
number of patients that arereferred.
I think there.
Two clinical trials that will beupcoming.
One is called watch option,another one is called Champion
with Watchman.
(30:02):
And a third called Catalyst withamulet that are gonna be looking
to actually broaden theindication for left atrial
appendage closure.
So looking to do closure with atthe time of atrial fibrillation
ablation, which is watch option.
And then looking at.
Left atrial appendage occlusionas an alternative to
(30:24):
anticoagulation in patients thatwouldn't today qualify for
closure.
So people that are toleratinganticoagulation without issue.
Randomizing those patients tocontinue anticoagulation versus
complete closure.
That that was the premise behindChampion and Catalyst.
(30:44):
Those are, they have five-yearfollow-up.
Those results will take, youknow, seven plus years to be in
practice at this point.
But the future looks likeclosure may be a primary option
for stroke risk management.
I'll 0.11 thing out aboutclosure that I, it, and maybe
(31:05):
you were gonna ask this, it'swhat are the unresolved issues?
And, and there are several, sothe, some of the unresolved
issues are what should we beutilizing for peri procedure
imaging?
What should we be doing withpatients that have leaks of
their device?
What should we be doing withdevice related thrombosis?
(31:29):
The rates of thrombosis are, arequite low, thinking like the
three to 5% range, but dorepresent increased stroke rates
for individuals who have devicerelated thrombosis.
And the last question, andprobably the most pressing one
is how do we manage short-termanticoagulation for patients on
(31:49):
rhythm control strategies afterthey've had a closure?
So somebody gets a.
Watchman or an amulet, they haveatrial fib.
They're on aspirin as theirlong-term stroke risk reduction
with combined with the closure,and you do a cardioversion or an
ablation, what type ofanticoagulation do those
patients need?
So those are four big kind ofissues for downstream management
(32:14):
of patients with closure.
As we move beyond the populationthat's persistent AF with a
bleeding indication.
Andrew (32:21):
I think that remains one of the biggest challenges that
we see still in fellowship at,at Ohio State.
We use both CT and d e E toassess the occlusion devices.
I guess maybe for the sake oftime, if you both could just
briefly touch on what yourcurrent practices in regards to,
you know, both imaging thesedevices and then making
decisions on anticoagulation.
(32:42):
Thereafter
Ralph (32:43):
So we just published a manuscript Anish on
anticoagulation strategiesaround cardioversion in patients
with left atrial appendageocclusion, and whether that be
from surgical atrial clip orligation.
(33:05):
Whether it was from a Lariat, anamulet, or a Watchman device,
all of these patients wereincluded.
And we found that we had a verylow risk of events with a four
week strategy.
(33:27):
Anticoagulation of the patientfollowing the cardioversion if
they're, if they're sent forcardioversion.
So, so it, it was a limitedanticoagulation scheme with good
tolerance and low neurologicevent rates.
So that, that's something that,that we practice regularly now.
(33:55):
Regardless of how the appendageis occluded,
Anish (33:59):
I was teeing you up, brother.
Thank you.
Ralph (34:03):
I forgot to mention if, if the patient does have an
indication for chronicanticoagulation other than AFib,
for instance, if they've hadrecurrent D V T or they have a,
a thrombogenic genetic disorderThose patients are probably not
the best.
They're not the good candidatesfor an occlusion device as their
(34:26):
sole form of thromboticprotection, that they should
remain on an oral anticoagulantif possible.
Anish (34:35):
N now, I think Andrew, most of the time, the short-term
an Anticoagulation and platelettherapies.
The, the individual doing thecardioversion, maybe the
implanter or theelectrophysiologist is gonna own
that.
I think the question you askedabout imaging modalities pre and
post is relevant too.
You know, we want to try tominimize the amount of imaging
(34:59):
and the strain on the system forpatients who are coming through
with closure.
So We do a CT for all thepatients that can tolerate it
from a perspective of renalfunction.
And then we essentially do about50 50 implant with either T
guidance or intracardiacultrasound guidance.
(35:22):
And then we try to duplicate theimaging technique for the 45 day
follow up.
So if they, if we did a iceclosure, we'll do a ct.
At the 45 day, if we did a TEclosure, we'll do a te at five
day.
You know, there are, it's a bigconversation around what to do
(35:45):
with leaks.
'cause leaks are present and themore resolute the imaging
technique in this case ct, themore likely you are to see him.
We don't necessarily extend theanticoagulation scheme past 45
days.
If we do see a small leak, lessthan five millimeters although
(36:07):
Ralph can speak to the data thatthey've presented about leaks
less than three if he wishes to.
But I think the, at the end ofthe day, if folks, if you do see
a device related thrombus, thatpatient should be put on at
least short termanticoagulation.
So, Regardless of the imagingmodality, if you see a device
(36:27):
related thrombus, that personshould be put on at least
short-term anticoagulation.
We generally will suggest threeto six months in repeat imaging.
Ralph (36:37):
We're, we're very similar in that approach.
We pretty much have adopted CTimaging for both pre and post
testing more than t e e at thispoint.
It gives you the dimensions.
Of the left atrial appendage.
It avoids sedation for thepatient, and I think it's a more
(37:02):
comfortable and, and morethere's, there's more
information that you gather fromthe ct.
Aside from the t e e, there aresome operators that choose to
use only in echo.
With no preceding imaging.
(37:23):
I have not adopted that patternmyself at this point.
But I am using ICE with some ofthe cases where intraoperative,
t e e has increased risk.
Kanny (37:37):
Thanks.
Thank you both for the insight.
It's been very interesting tosee device therapy evolve into
the mainstream.
There's so many aspects of AF wecould keep talking about.
I, I just want to finish withone final topic because we're up
against our time and I'll throwit out to Aish first.
We, we don't have time to talkabout all the aspects of
wearables and implantableloopers.
That could be an entire.
(37:58):
Podcast by itself.
But my specific question foryou, an is, is as we've had a
proliferation of, of looprecorders and patients with
home, you know, E K G devices,whether it's Apple Watch, et
cetera, do we yet know whetherthe incidental AF that shows up
on these monitors and devicesincidentally carries the same,
(38:19):
you know, kind of prognosticsignificance?
Clinically presenting AF does.
Is that something we still haveto figure out?
And do you have any advice forclinicians, you know, who are
dealing with the, with theseresults from these devices?
Anish (38:36):
Well, it's a great question.
I, I will tell you that lastyear, I think at European
Society of Cardiology, thequestion about symptomatic AF
versus asymptomatic AF on looprecorders and stroke,
cryptogenic stroke patients wasdescribed in two different
trials with different results.
So basically saying that, Theseasymptomatic episodes maybe
(38:59):
didn't increase the e the therisk of stroke like the
symptomatic episodes did, and Idon't know if that's going to be
true for wearables as well.
I, I think that for the patientthat has a known diagnosis of
atrial fib, the wearable devicesdo provide us with a nice
(39:21):
longitudinal.
Mechanism to communicate withthe patient beyond their
symptoms.
So to have patients transmitECGs when they're having
episodes, confirming a diagnosisbefore we instruct'em to go to
utilize acute care pathways,whether that's the emergency
department in our office, AFclinic, et cetera.
(39:43):
So I think they're valuable fromthat perspective.
I also think that, you know, thenext generation of devices,
including the current AppleWatch, which allows AF burden.
Detection lets us talk topatients about that longitudinal
history of atrial fib.
So looking at somebody andsaying, Hey, when we saw you six
(40:04):
months ago, you had a 3% burdenof AFib.
Now we're seeing you, it's a 10%burden.
So your, whether your symptomsare changing or not, the disease
is changing in the backgroundand we should be managing that.
So, There is value from thatperspective.
I certainly do empathize witheverybody who has to look at all
(40:29):
the tracings because it, it, itis a little bit of a data
overload and we don't have greatways yet to not only manage the
data describe it, you know, in ausable format but also to.
Recognize the time that we'reputting in for it evaluating it.
(40:50):
So those are all things that Ithink we're, we're gonna have to
face, especially because this isjust the pinnacle.
The, I think that e c G on awearable format is easy to do
and most of us would agree withthat.
And the, you know, the evolvingdevices and we've all seen'em,
whether it's sleep metric, VOtwo.
(41:10):
You know, there are devices,especially on our implantable
loops that can monitor heartfailure.
The list is almost endless ofwhat's coming, so we're gonna
have to look at how to managethis stream of information.
Kanny (41:24):
Thanks, Anish.
That's insightful.
I think we've had an amazingdiscussion.
It's just amazing how complexthis one condition is and how it
affects so many aspects ofcardiovascular care.
And I think Andrew and I haveboth.
We've been texting each otherwith so many additional
questions and topics that we'dlike to cover.
So I would hope that maybe youguys would be willing to come
(41:45):
back.
At some point in the future andeducate us a little further, not
just on af but perhaps someother EP topics as well.
And until then, I just wannathank you both for taking the
time to educate us and and ourlisteners.
So Ralph thanks for joining us.
Ralph (42:02):
Thank you Canny.
Thank you Andrew and Anish aswell.
Anish (42:06):
Yeah.
Thank you guys.
It's a pleasure.
Ralph (42:08):
Yep.
Kanny (42:09):
And thanks Andrew for co-hosting and until our next
episode we'll be in touch.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
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