Keeping the Beat: Stroke and Atrial Fibrillation

Intro: MemorialCare Health System, excellence in healthcare, presents Weekly Dose of Wellness. Here's your host, Deborah Howell.

Deborah Howell (Host): Hello and welcome to the show. You're listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. I'm Deborah Howell, and today's guests are Dr. Jeffrey D. Lee, medical director of robotics and minimally invasive cardiac surgery at the MemorialCare Heart and Vascular Institute at Saddleback Memorial Medical Center. Board certified by the American Board of Thoracic Surgery and a fellow of the American College of Surgeons, Dr. Lee has been practicing cardiac and thoracic surgery for over 18 years and has performed more than 2,000 cardiac surgeries. Dr. Howard Frumin is board certified in internal medicine, cardiology, and electrophysiology. Dr. Frumin has been practicing electrophysiology for over 30 years with over 20 years in ablation. He has extensively published in electrophysiology and has participated in many national trials which have subsequently shaped the practice of electrophysiology. Today we'll be talking about strokes and keeping the beat. Welcome, doctors.

Howard Frumin, MD: Welcome, thank you.

Jeffrey Lee, MD: Thanks.

Deborah Howell (Host): Great to have both of you with us on the show today. Let's start with you, Dr. Frumin. Can you please tell us what atrial fibrillation or AFib is?

Howard Frumin, MD: Atrial fibrillation is the most common of all the arrhythmias, that irregular heart rhythms that occur in people. It's characterized by an irregular and rapid rate. And it typically becomes more frequent as we get older, but there are clusters that occur in middle age as well.

Deborah Howell (Host): Okay. And what are some of the symptoms?

Howard Frumin, MD: Well, the range of symptoms goes anywhere from no symptoms, an incidental finding when you go into the doctor, to more commonly palpitations, shortness of breath, difficulty with exercise, and occasionally, rarely, the first presenting sign is a stroke.

Deborah Howell (Host): Okay, all right. So we have the symptoms. Now how about the causes of AFib?

Howard Frumin, MD: Well, as the heart ages, scar tissue forms and the heart gets a little bit bigger. And that creates an opportunity for irregular rhythms. Sometimes they are provoked by stress, by alcohol, by excessive use of caffeine, even drugs. But sometimes it's just a natural consequence of aging and there is no cause to pinpoint.

Deborah Howell (Host): Do we have a rough percentage of people who suffer from AFib in America?

Howard Frumin, MD: It occurs in about 1% of the population at age 60, and an additional 1% every year thereafter. So if you look at an elderly population, say in the 85 range, a quarter of them will either have or have had atrial fibrillation at some point.

Deborah Howell (Host): Okay, all right. And then what are some of the consequences of AFib?

Howard Frumin, MD: Well, the main consequence is, well first consequences of course is symptoms of the palpitations and shortness of breath that I described. But the most important consequence is the risk of stroke. When the patient develops atrial fibrillation after a certain age, the upper chamber of the heart does not contract vigorously. The sluggish flow through the heart allows a little possibility of clots to form. And if the clots break free and go to the brain, that's a stroke.

Deborah Howell (Host): Yeah, okay. So that brings us to the next question, and then we'll bring Dr. Lee into the conversation. What are the goals of treatment and what are the medical treatment options?

Howard Frumin, MD: Well, goals are, number one, prevent stroke. And to prevent stroke, we use blood thinners, a variety of blood thinners. Traditionally Coumadin, but now there are three oral substitutes for Coumadin. And if thinning the blood just enough, we can reduce the risk of stroke from 6 or 7% a year to 1 or 2% per year.

Deborah Howell (Host): And how's that goal going?

Howard Frumin, MD: Well, it's going good when we treat patients, but a lot of people are left untreated, either because they're not recognized or other mitigating factors. So the penetration of treatment of all atrial fibrillations across the country is not what we want it to be.

Deborah Howell (Host): Okay, looking forward to trying to get that number better. Let's bring Dr. Lee into the conversation right now. What are some of the surgical treatment options for AFib, Dr. Lee?

Jeffrey Lee, MD: Well, at Saddleback we have designed and implemented a new program which we call the Hybrid Robotic Assisted Ablation Program. And in this minimally invasive procedure, which actually involves two minimally invasive procedures, one performed by the surgeon and one performed by the cardiologist several months later, in the surgical part, a few tiny incisions are made on the chest. A flexible catheter is wrapped around the beating heart and waves of energy are applied to the heart to prevent and treat atrial fibrillation. In addition, during this procedure, the left atrial appendage, which is known to be the source of most of the strokes when you do have a stroke from atrial fibrillation, is ligated or closed, which should help reduce the risk of stroke significantly. In a few months, our cardiology colleagues then perform a small puncture in the vein in the groin, and he checks, basically will check the ablation lines we performed at surgery several months prior, and if there are any gaps in the ablation lines, he will spot weld them.

Deborah Howell (Host): So it's definitely a team effort.

Jeffrey Lee, MD: Yes, a team effort.

Deborah Howell (Host): And what are the benefits of a hybrid robotic assisted ablation program?

Jeffrey Lee, MD: I think by working together we have been able to show an incredible amount of efficacy. It's very effective for the right patients. And there's actually published data in our literature that shows this type of hybrid approach where the surgeon will go first and then several months later the cardiologist checks what the surgeon did and reinforces any areas that may not be completely done, can really show very high levels of success in getting the patients back into sinus rhythm out of AFib, off all their drugs and off blood thinners like Coumadin.

Deborah Howell (Host): So much of medicine now is, is really looking to, you know, having everybody work together from the nurse navigator to all the physicians involved in a particular patient's milieu. So it's a wonderful day actually to be a patient.

Jeffrey Lee, MD: Absolutely.

Deborah Howell (Host): What are some of the qualifications and maybe who are some of the primary candidates to have this procedure?

Jeffrey Lee, MD: Well, this procedure is not, this program is not for everybody. Patients have to have failed medical therapy, meaning drugs, and have a significant amount of symptoms, and really be motivated to want to get out of atrial fibrillation and reduce the risk of stroke significantly like this. And we feel that the results are much better the earlier the patients are treated, so in a general sense, advice is to seek treatment early.

Deborah Howell (Host): Okay. Seek treatment early, and then someone who is researching their options on where to get their heart surgery performed and what kind of heart surgery they should have, what advice can you give to someone on where to go for this information?

Jeffrey Lee, MD: Well, like any procedure that your doctor would recommend, we personally recommend asking him specifically what kind of first-hand experience they have with the procedure. So in terms of the minimally invasive surgical procedure, which is my, my part of the hybrid program, I personally perform over 75 of these procedures. I've trained other surgeons in this technique. So I believe that having an experienced surgeon as well as an experienced cardiologist, like Dr. Frumin, is essential to obtain the great results that we're looking for.

Deborah Howell (Host): Excellent. And then from the cardiologist, does the patient return to his general physician?

Jeffrey Lee, MD: Absolutely. The idea is that they come to us with a specific problem, namely symptomatic, medically refractory AFib, which means they failed medications. They see both of us, Dr. Frumin, the cardiologist, as well as myself, the surgeon. And we come up with a plan. Those that are selected for the program have this plan where they have the surgical procedure first, the ligation of the appendage, and then several months later they get the spot welding if you will. And then after that we return the patient back to their primary care doctor or cardiologist.

Deborah Howell (Host): Dr. Frumin, would you like to jump in and add anything to that plan?

Howard Frumin, MD: No, that's basically the strategy. And there are a variety of options for ablation around the country and it's still early to tell which of the technologies will emerge. We are excited about this one for a couple technical reasons that I won't bore the readers with, but they involve our ability to get direct visual access and apply more energy than some of the catheter-based techniques. So we like it for that reason.

Deborah Howell (Host): I'd like to just elaborate on that last point just a little bit.

Howard Frumin, MD: Well, catheter-based ablation involves a catheter with a four or five-millimeter tip that goes through the vein into the heart. And we draw a line around the pulmonary veins, spot by spot by spot, like a chain of pearls. And we're using X-ray guidance and sometimes echocardiography. But we're basically working about three feet from our hands with the catheter, the tip is about three feet from our hands and we're working with an X-ray shadow to guide us. With the hybrid robotic, we actually go in and directly visualize the back of the heart. We can apply the catheter directly to it, it adheres by suction, and the burn is made in a line rather than spots and uses 70 rather than 50 degrees of temperature. So those are the technical reasons that we like it.

Deborah Howell (Host): Right, right. Oh my goodness. You know what, that last part leads me to believe that we need to have you both back and we can elaborate some more and have some more great information disseminated. Thank you so much, Dr. Frumin and Dr. Lee for being with us today.

Jeffrey Lee, MD: Thank you so much.

Howard Frumin, MD: Thank you.

Deborah Howell (Host): To listen to the podcast or for more information, please visit memorialcare.org. That's memorialcare.org. I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness brought to you by MemorialCare Health System. Have yourself a fantastic day.