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Transcript
[00:00:08] Matthew DeVane, DO, FACC: Hi, I'm doctor Matt DeVane.
[00:00:09] Carolyn Lacey, MD, FACC: And I'm doctor Carolyn Lacey. We are cardiologists at John Muir Health and this is our podcast, Living Heart Smart.
[00:00:16] Matthew DeVane, DO, FACC: Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.
[00:00:24] Carolyn Lacey, MD, FACC: Thank you for listening and we hope you enjoy our show.
[00:00:51] Matthew DeVane, DO, FACC: Hello everybody. Welcome back to another one of our podcasts. Thanks for joining us. Today. We're going to be talking about atrial fibrillation and rhythm control when it comes to atrial fibrillation. Specifically we're going to dive into atrial fibrillation ablations what that procedure is and what you can expect. We have a guest with us today, one of our electrophysiologists from John Muir health doctor Carleton Nibley, and we're happy to have him with us today. Thank you. Thanks for being here. So first of all, Carolyn, we had this discussion beforehand. And if you can help our listeners understand, because I know the first question is what.
[00:01:27] Carolyn Lacey, MD, FACC: The heck is an Electrophysiologist?
[00:01:29] Matthew DeVane, DO, FACC: Yeah, let's start with the basics. Doctor Nibley, you are one. So why don't you tell us what an electrophysiologist is before we dive?
[00:01:35] Carolyn Lacey, MD, FACC: We also call them EPs, right?
[00:01:37] Carleton Nibley, MD: Yeah, yeah, we we're not offended if you call us EPs, but people that first meet us wonder what the background is. And we're actually cardiologists. So we go through all of the cardiology training that all other cardiologists go through. And then for some reason, we are drawn to the electrical system of the heart. The heart is not the only organ that has electrophysiology, but we seem to own that term because the heart is kind of uniquely rhythmic compared to other organs. I was compare it to an appliance that has some mechanical function and an electrical function. When you need electrical work done, you call an electrician. Everyone has a beating heart, and when there is a problem with the electrical portion of the heart you call an electrophysiologist perfect.
[00:02:24] Matthew DeVane, DO, FACC: Yes, that is a question we get often. Doctor Nibley, if you wouldn't mind just giving us. We tend to go over people's resumes a little bit. How did you end up being a cardiologist? Where did you go to school and how did you get here?
[00:02:35] Carleton Nibley, MD: Well, all of us seem to go to a lot of different places, and it's that's the fun part, I think about the dream of becoming a physician is you end up having the opportunity to go to many different schools. So I went to four different universities on my journey and it started very small. It started at Santa Clara University, and that's when I became a Californian. Um, and I was already majoring in science with an idea that I wanted to be a physician with a lot of self-doubt. And as the years progressed and there was a lot of attrition, a lot of first year college students want to be physicians. Uh, I was still standing after the first or second year.
[00:03:14] Matthew DeVane, DO, FACC: Not easy. Right?
[00:03:15] Carleton Nibley, MD: It's not easy. When I was lucky enough to be accepted to University of Southern California, USC and so stayed in California, and I went to USC. And, uh, the USC medical campus is different than the undergraduate campus, and it's located at what used to be the general hospital on the show General Hospital. That's where the medical campus is. And after four years, then you apply to residency. And if your dream is to be a cardiologist, you do internal medicine residency first. And I went to Portland, Oregon, at a school called Oregon Health Sciences University, which is the medical campus medical school for the University of Oregon. And I spent three years there doing my internal medicine training and realized that it was time to become a cardiologist. And I was very fortunate to be accepted to the Duke University cardiology program. And so I made my first foray across country to North Carolina, and I spent several years there becoming a cardiac electrophysiologist.
[00:04:18] Carolyn Lacey, MD, FACC: Did you know that even though Doctor Nibley calls his roots from California, his roots are actually from a very different place, which is my favorite place. Before he was a Californian, he was a Hawaiian, what we call.
[00:04:32] Carleton Nibley, MD: It a kama'aina, because I actually don't have any Kanaka blood.
[00:04:35] Matthew DeVane, DO, FACC: Oh that's deep. Yeah. You know the inside stories here. Okay. Yeah.
[00:04:39] Carleton Nibley, MD: No, it's true, it is true. I was born in Hawaii and I was born in Hawaii. My mother was actually born in Hawaii. Her mother and father. So we have, I think, four generations of Portuguese Americans that were well, they weren't even Americans then. They were Portuguese immigrants that went to Hawaii. And my father was from San Francisco. He went to Hawaii and married my mother, and I was born in Hawaii. But I stayed all the way through high school and spent a lot of time on the Big Island in Kona.
[00:05:05] Carolyn Lacey, MD, FACC: My favorite.
[00:05:06] Carleton Nibley, MD: Place, your favorite place in the.
[00:05:07] Carolyn Lacey, MD, FACC: World? Favorite place?
[00:05:08] Carleton Nibley, MD: And we have endless conversations about our favorite things to do and why that place resonates with so many of us.
[00:05:14] Carolyn Lacey, MD, FACC: And as much as we would love to keep talking about Hawaii, we're going to go back to AFib.
[00:05:18] Matthew DeVane, DO, FACC: Afib, our biggest concern right now. So we've had a couple episodes already about atrial fibrillation. But for people just tuning in to hear about the ablation part of it, I think a quick summary on AFib would be just. The fight right here.
[00:05:32] Carolyn Lacey, MD, FACC: We've talked about how AFib is one of the most common arrhythmias that people in the United States experience. Millions of people in the United States have it, and we have been trying to get people to understand that. It is something that is very treatable.
[00:05:48] Carleton Nibley, MD: I really tell my patients that I care about the problem of AFib for three reasons. The first one is that it's an unusual rhythm that tends to come with a risk for blood clot formation. And if you form a blood clot in the heart and the blood clot travels, there's no good place for the blood clot to go. And we think the worst place might be the brain that's a stroke. So we're very interested in AFib for that reason. Number two AFib. Once the heart learns how to do it, once it's decided it can do it, it tends to happen more and more. So if we don't do something soon, sooner rather than later, you're going to find yourself with increasingly persistent atrial fibrillation. It's there all the time, and some people are unlucky enough to have that from the from the outset. And the third issue, which is one that most people haven't really thought about, and we actually, as cardiologists, as physicians learned about more recently, which is that atrial fibrillation as it causes the heart to beat faster and irregularly, those two features, fast and irregular, tend to cause wear and tear changes in the heart, and the wear and tear manifests as weakening of the heart. We call that a cardiomyopathy. And if you get a cardiomyopathy of this type, you can end up with the thing we call congestive heart failure. And so those are the three reasons that I think we're here talking about atrial fibrillation.
[00:07:12] Carleton Nibley, MD: And from that it recognition of those three things drives the treatment discussion. And it starts so easily for me because it starts with the issue of how do we protect you from blood clots. And this series has focused a lot on the different ways that we do that, from everything from anticoagulants to treatments like the watchman device and other occlusion devices and so forth. The second issue is making sure that if you have AFib, that we're controlling how fast your heartbeat goes. And so there are medicines we use. They're simple medicines that we use to keep the heart beating a little bit slower. And if we do that now, we're protecting you from the problem of the cardiomyopathy. But what about the second problem? How do we help you to not progress and end up in persistent AFib? And there are four areas that relate to one another. The ultimate one of course is the ablation. But the first one has to be talking about lifestyle issues. And I focus a lot on things that we can do in our day to day lives to make atrial fibrillation less likely. Now, we can't reverse the aging process, but we can moderate our alcohol intake. No one should be smoking that contributes to atrial fibrillation. If you're overweight, you can work on weight loss, regular physical activity, not extremes of physical activity, but regular because that's a whole different discussion, isn't it?
[00:08:31] Matthew DeVane, DO, FACC: Doctor Ben discussed that, and.
[00:08:32] Carleton Nibley, MD: I think it's fascinating. We see young people that are doing everything right. But to excess they're running too many marathons and they're here to see me about their atrial fibrillation. But regular modulated physical exercise weight control. If you have sleep apnea, recognize that get it treated. Um, you know, these sorts of things, those things.
[00:08:51] Matthew DeVane, DO, FACC: Go hand in hand with any treatment for atrial.
[00:08:54] Carleton Nibley, MD: And any treatment of the heart. Really. Right. And then the next things are, uh, I spend some time talking about which are the use of stronger medicines, and we only have about six different, stronger medicines that might help to regulate the heartbeat. And every one of them has its limitations, but we use them and we sometimes use them in combination with the ablation. And then the final little category is when necessary, when we really need to get control of the heartbeat and where maybe we're planning the ablation or we've done the ablation. There's an early recurrence of atrial fibrillation. We do that thing called cardioversion, which sounds really well, sounds rather dramatic, like on television where we will shock the heartbeat back into normal. And I try to demystify that. I mean, I'm not a computer scientist, but my darn computer. I get that pinwheel thing, you know, the pinwheel, you can't do anything. So what do you do? You hit the reset button on the computer. Yeah. And every single time my computer comes back and I'm working again. But what I know.
[00:09:54] Matthew DeVane, DO, FACC: No damage done.
[00:09:55] Carleton Nibley, MD: No damage. Right? But I haven't fixed the computer. I've just made it so it's operating again. And I know that if I keep working on it, sooner or later the pinwheel is going to come again. So when we do these conversion procedures, we know that it's just a temporary reset that gives everyone a breather, gives us some time to plot our next intervention. So what about ablation then? You know who what? When do you decide that you should have an ablation?
[00:10:22] Matthew DeVane, DO, FACC: That's that timing is one of the biggest questions.
[00:10:25] Carleton Nibley, MD: Look, if, um, we see this someone in the holidays, they have too much alcohol, too much eggnog, and they end up in atrial fibrillation. Well, we tell that person that if they avoid that type of situation, they may actually not have further atrial fibrillation for a long period of time. So I don't think I'd recommend ablation for that person. Someone who has an obvious modifiable risk factor or an event that provoked it. Another good example is people we send for heart surgery, real heart surgery, a bypass surgery, or valve surgery. Many of those people will have atrial fibrillation afterwards. And as the heart heals from the big surgery, typically the atrial fibrillation subsides and they're back in control. So those people we probably wouldn't say should have ablation. But if there are no other modifiable risk factors or obvious precipitating event, and you realize that you've had a couple of episodes of atrial fibrillation and it's kind of out of your control at that point, the earlier you allow us to do the ablation, the higher up you go on that success, good result scale because you're dealing with the heart that doesn't want to be in atrial fibrillation, and you just have a triggering problem at that point. If we can eliminate the trigger, the rest of the heart generally wants to cooperate. But the more you allow the AFib to exist, the more the atrium changes and remodels. Then getting rid of the triggers, you're still left with a substrate that's very susceptible to further atrial fibrillation. So I say the earlier the better, with a few exceptions.
[00:12:03] Carolyn Lacey, MD, FACC: And we know that if we're able to keep people in a normal rhythm, if you have atrial fibrillation, people do better. And one of the tools that we have to do that is an ablation. And we perform that here at John Muir Health with our EPI team. Doctor Nibley is one of our electrophysiologists that performs this procedure. We have a couple other electrophysiologist, Doctor Gupta, Doctor Swan, who also perform this procedure, but we really want to make sure we dig deep into the atrial fib ablation procedure.
[00:12:32] Matthew DeVane, DO, FACC: Yeah. So Doctor Nibley, if you can just start telling us how when a patient comes to you with atrial fibrillation and wants to have the discussion, let's consider ablation therapy for AFib. This is what you do for a living. How do you go about doing that?
[00:12:46] Carleton Nibley, MD: Yeah, it's an incredible story. You know the the paradigm we use for atrial fibrillation is that atrial fibrillation tends to beget further atrial fibrillation. And the if you're in the earliest stages of the rhythm problem it starts up you feel horrible. And then if you're lucky it kind of stops and then you wait a while. It could be a day or two. It could be weeks or months. And then it happens again. And then over time it becomes more and more frequent and the episodes tend to become more prolonged. Now there are some unlucky people that may be listening. Their very first episode of atrial fibrillation is sustained and it's not stopping, and they feel horrible. And we've learned over the years that if you can take steps to maintain normal rhythm at that person's outcome in general is going to be better. Now, there are some there are some exceptions to that. I mean, there are people who live a long, healthy life with atrial fibrillation, but it still requires appropriate medical supervision. But for those where we believe there's an opportunity to restore normal rhythm and maintain normal rhythm, we often come to a recommendation for ablation. And I stopped there because ablation is a word. And like other words, in electrophysiology, we claim it as our own. But ablation is done for a variety of things. You for a woman who has a uterine fibroid, you can do a uterine ablation.
[00:14:14] Carleton Nibley, MD: Ablation was an idea that if you have a wire touching the abnormal tissue, if you could deliver some energy source to the tissue, that you could eliminate that electrically active tissue and restore normal rhythm. And so early ablation about 30 years ago was one of the reasons that I decided to devote my life to electrophysiology. In about 1998, uh, a group in France had the idea that we might be able to ablate atrial fibrillation. So they asked a fundamental question how does atrial fibrillation begin in the heart? And what they found is that atrial fibrillation tends to begin in one area of the heart, from person to person to person. And that was a revolutionary finding as we were already active in ablation work. Now we had a target, and that target turned out to be in the left atrium in an area called the pulmonary veins. And those are the veins, the vascular structures bringing blood back from the lungs into the left side of the heart. There are four of them, but basically we know where they are. We had the tools to do ablation, and we just needed a way to get over there and start to create small burn marks to eliminate that electrically active tissue that was promoting atrial fibrillation. Now, when.
[00:15:35] Carolyn Lacey, MD, FACC: You're a patient, though, you're coming to the cath lab and you're you've decided you're going to have an ablation. How do you describe that to the patient when you're seeing them?
[00:15:45] Carleton Nibley, MD: Well, the ablation procedure is actually a very safe procedure. And that's just been demonstrated now in our hands over the past 20 years as we've been working on atrial fibrillation ablation. And I think that's the most important thing is that people come into the room to have their procedure and know that all of the different safety precautions are in place, that they can feel confident that they're going to come out of that room feeling as good or better than when they came in a little sleepy after anesthesia. So although this procedure is generally considered to be a kind of painless procedure, I mean, you're laying on a table in a room, but we still use general anesthesia, and we use general anesthesia so a person doesn't suddenly move when we're working on the heart. But if you were wide awake, you probably wouldn't even know that we were doing the procedure. That's amazing. And that is amazing. There are only a few areas where you have some sensitivity and we stay away from those areas. But so the procedure you're laying there asleep and we enter the veins of the leg and we place a catheter into the heart. So the veins of the leg bring blood directly to the heart. So we're exactly where we need to be. And we move one catheter over to the left atrium again. That's the place where those four pulmonary veins are. And then we determine what catheter would be best to create a lesion. A mark that would eliminate those electrical potentials that cause the atrial fibrillation. That's the ablation part.
[00:17:16] Carolyn Lacey, MD, FACC: And then when you when you start talking about the energy energy source that you use, I know that there's a few types of energy. And I know that I get asked that by my patients before they come over to see the Electrophysiologist. What kind of energy do you use? And honestly, how do you decide what kind you're going to use? What what sort of decision making processes do you go through there? Yeah, what.
[00:17:38] Carleton Nibley, MD: A great question. So we know there are a variety of energy sources that can be used to make changes in in heart tissue. But in the early days we really had we relied on one energy source and that was radio waves, radio waves, just, uh, high frequency alternating current. And it would cause a very small heat burn cautery to the tissue. And so that type of ablation is, uh, delivered through a very fine tipped, uh, wire or catheter, and it creates a little spot lesion. I was compared to a match. So you get a very small, very discreet burn. Kind of like a match head would burn your tissue. Well, that's a small mark. And in atrial fibrillation ablation, we have to make, uh, circular marks around those vein structures. So in the early days of ablation, we use radio waves. And some still do for the basic AFib ablation. But it's it's kind of tedious. I compare it to tattooing. So you're basically tattooing in a circular way around these structures. But about 12 years ago the engineers looked at what we were doing and they said, you know, you need a tool that can deliver a circular mark around that vein structure faster and more effectively. And they devised a balloon catheter. And once we enter the vein, you touch a button on the console and the little balloon inflates and it fits perfectly into that vein opening.
[00:19:05] Carleton Nibley, MD: Once you have that ball in the socket, the balloon in the vein, we hit a second button, and we have to deliver some type of energy that would travel through a balloon. And it turned out that if you freeze. Cold enough, you create a freeze mode. Okay. And again, this is so many wonderful analogies what we do, but I love comparing it to a block of dry ice. Sure. And you know that if you touch it you can only touch it for a few moments. Then you have to take your finger away. And if you don't, not only is it going to feel more like a burn than something very cold, but it will. It will burn your skin. Using freezing energy, a freeze burn. And then after four minutes, the freezing stops and the balloon deflates and you move on to the next one. But it's about 30 minutes worth of freezing and you're done. And that's a lot different than when we were using radio waves for this particular type of play. You can choose your energy source. Most of us in this area use the freezing balloon, because it seems to be a tool that was ideally suited for this particular type of ablation. Others rely on radio waves because they are just used to it, and there's some newer, interesting energy sources that may be worth mentioning too.
[00:20:17] Matthew DeVane, DO, FACC: Yeah, please. If there's something on the horizon, I'd love to hear about it.
[00:20:20] Carleton Nibley, MD: Well, we're already getting questions about something called pulsed field ablation, and it's simply a different energy source that is deployed through a, a catheter that goes to that same area of the heart. And rather than being a balloon or a simple pointed catheter, it has multiple electrodes on it. And it creates a circular lesion by virtue of having multiple electrodes. And this type of energy is more of a we call it electroporation, where it is a high voltage energy source that has a particular predilection for disrupting cardiac myocytes at that particular frequency and that particular voltage. And it's fast. And the tool is again made to create a circular mark. Pulsed field ablation is something that everyone is interested in as yet another way to do the same thing. The other point I'll make, which I think is really interesting, is that everyone wants to do the procedure as quickly as possible so that your time in the room, your time under anesthesia, your time on the table is as short as possible. Sure. And write. Our ablation currently is about a one hour ablation procedure.
[00:21:42] Carolyn Lacey, MD, FACC: So you've done that part of the procedure. After you've finished your ablation what do you do. What does the patient do. You just do you just take everything out and you're done. Do you wait to see how the electrical signal travels? What do you do there?
[00:21:57] Carleton Nibley, MD: Right. So the goal is to isolate electrically isolate those four areas. And once you've done that the ablation is effectively over. And you know it takes about an hour as I mentioned. So we can quickly go back and look at the earlier areas that we worked on, see that they're still nicely isolated. And at that point everything is removed. So the little tubes that we use to slide these catheters into the heart, they're removed. The tubes are the largest tube we use is probably the size of your average drinking straw. When you remember when we used to have plastic straws, not so much anymore. Um, the your average plastic drinking straw, if you were to use that as a tube to enter a vein, we can slide catheters through that. So we remove those tubes. And now it's really important to have that individual lay still flat, be monitored to make sure that there's no bleeding, just the same way you would if you had blood drawn from your arm, that you look at that area, you put a cotton ball in that area, we apply a little pressure and make sure that there's no bleeding from the vein entry sites. And typically that requires several hours of resting and the nurses will be monitoring that person. Many people will spend the night on occasion. If you have a morning procedure, you'd be released that afternoon, and by the next day you're up moving around pretty normally, right? And we generally recommend no exercise for several days. I recommend no exercise, no vigorous exercise for a week. And that's not really because of the heart. That's because we want those areas where we enter the veins to heal up nicely.
[00:23:32] Matthew DeVane, DO, FACC: Okay, that's a good description of the procedure. We're always weighing the benefits and the risks of everything we do. So when we're sending you over a patient to consider atrial fibrillation ablation, can you tell us what you discuss with the patients are as to what the risk of the procedures are.
[00:23:48] Carleton Nibley, MD: And one of the most incredible things about this procedure, as it turns out, is, is the overall safety of the procedure. And we know that with now 20 years of experience doing atrial fibrillation ablation, and I speak for myself, but also my colleagues and laboratories that do this around the world, some of the things that could happen, but again, they're exceedingly rare, is a catheter could perforate the heart tissue. And that would be a situation where you push on the wall of the heart and the wall of. Heart tissue may be thinned. And if you detect that, then you stop the procedure and you manage that, usually with a drain placed, uh, under the breastbone to drain any blood that may be accumulating around the heart. In this area that we're ablating, especially when we use the freezing balloon. There are nerve fibers that actually help us with breathing the diaphragm. It's called the phrenic nerve. So we monitor that. And if we see the phrenic nerve getting cold, then we stop the freezing. And generally we've around the world and in our experience there really are not permanent nerve injuries. If you intervene quickly and you stop freezing and we monitor the temperature of the esophagus, and what we find is that freezing in that area is generally very well tolerated. And if we see a drop in the temperature, uh, a few degrees will typically stop the freezing and then we can do more short freezes in order to achieve our objective without causing the esophagus to get very cold. We've learned and we've learned over the last many years that a person having the AFib ablation should be on their selected anticoagulant or blood thinner, if you will. And we don't stop the anticoagulant for this procedure, you can actually have your ablation with no interruption of your blood thinner. And by doing that, we've essentially minimized the risk of nearly eliminated the risk that you might have a blood clot form.
[00:25:41] Matthew DeVane, DO, FACC: I think in general, I tell my patients this is a very low risk procedure, you know.
[00:25:46] Carleton Nibley, MD: And I like to say that actually the biggest risk of the procedure doesn't relate to the safety, but it relates to the fact that in this type of ablation, for a problem that is generally related to wear and tear on the heart tissue, aging, other modifiable risk factors, some not modifiable, that it doesn't work every single time. And that's very different for us as electrophysiologists than ablation for the simpler rhythms that we learn to do early on. Um, other rhythms that involve a spot ablation where they tend never to recur again.
[00:26:22] Matthew DeVane, DO, FACC: So, yeah, I think when you're what you're talking about is the risk are very low. But the biggest risk that probably keeps you awake is it may not work. The first you can.
[00:26:31] Carleton Nibley, MD: Do a perfect atrial fibrillation ablation. And there is such a thing. We do it routinely. It's quick. It's everything is laid out well. You're so proud of the lesions. And that person who has who you've achieved, everything you set out to achieve goes on to have more atrial fibrillation. And there and we understand their reasons for that. But you can't predict in advance. With any reliability who those individuals will be.
[00:26:57] Matthew DeVane, DO, FACC: So big picture speaking. What do you tell your patients? The chance of success of this ablation procedure will be I.
[00:27:05] Carleton Nibley, MD: I say two things. I say that just sort of overall doing a cryoballoon vein isolation ablation. As the first procedure for someone with atrial fibrillation. Overall, it's about 80% at one year. That is, eight out of ten at the end of a year will not be having detectable atrial fibrillation. But what I what I also say, the second thing I say is that let's talk about you as an individual. And so my number may be even better for a 45 or 50 year old man or woman who's in the earliest stages of atrial fibrillation, who's modifying some risk factors compared to someone who may be older, who is now persistently in atrial fibrillation and has been that way for many months or longer, where the atrium is actually started to stretch and our ability to eliminate AFib in that individual, the number will be lower. And so I try to give that person their number based on many people that have the sort of matched issues to what they're what we're confronting with that person.
[00:28:14] Carolyn Lacey, MD, FACC: I think that it's really important. We've talked about this in other episodes where we talk about that nothing we do really cures the atrial fibrillation. This is another tool in our armamentarium to really help prevent how long it is before people have more atrial fibrillation.
[00:28:37] Carleton Nibley, MD: Yeah, I think that's accurate. And it's it's hard for us. So it's been very difficult as we tackle a problem that's related to the aging process, to wear and tear on the heart, to sort of, um, temper our expectations and to convey an idea that what we're really trying to do is push back on this problem the way that you would for many age related problems, to kind of tamp it down, to let a person live longer, feeling more normal, to be in control of whatever problem it is we're dealing with, whether it's pain in the knee or, you know, digestive problems. But yeah, invariably, if we're lucky, we get older. And in that case, the likelihood that there could be further changes in the heart leading to atrial fibrillation, that push continues to exist.
[00:29:26] Carolyn Lacey, MD, FACC: Do you ever offer a repeat atrial fibrillation ablation to patients?
[00:29:33] Carleton Nibley, MD: We do. Again it's it's an admission that the problem is difficult to completely solve. We solve it most of the time and those are easy ones. We've solved it so we don't hear from those happy individuals again. But a sizable number have further arrhythmia symptoms. And one of the things we'll offer is a repeat ablation. And so there's a whole new quandary that we face on the repeat Ablations what more should you do? And that's an area of active interest. And no one has really figured out on a repeat ablation when all four vein areas look beautifully ablated from the first procedure, what exactly you should do on the repeat so it gets very artistic, are among electrophysiologists, and we each have our idea of what may help the most.
[00:30:25] Matthew DeVane, DO, FACC: Well, I think what we're talking about here is trying to give our patients the best quality of life they can. And each reverberation causes so many symptoms. The stroke risk we've talked about before. So when you talk about 8,680% success rates, many of those 20% patients still have less AFib than they did before. Symptoms are improved. They're just not gone completely. Is that most of the 20% that are still remaining? Yes.
[00:30:53] Carleton Nibley, MD: And I try to remember to say that that if you're in the unlucky 20% where there's still some AFib in general, it's under better control, it's more manageable, it's responding better to medications. But there are occasions where there's something about the ablation. Yeah, where a person either has the perception or the reality that they're actually having more atrial fibrillation or fluttering rhythms than they did before. And now we're really challenged because we've we've provided a treatment that has helped most of the individuals. But when when somehow that situation feels worse afterwards, then we really have to double down and figure out the best way to solve that problem.
[00:31:38] Matthew DeVane, DO, FACC: That's a tough one. That's a tough one.
[00:31:39] Carolyn Lacey, MD, FACC: That has to be extremely.
[00:31:42] Matthew DeVane, DO, FACC: Well, I think again, when we're talking, this procedure is not going to save lives. So the main reason we're doing this is it going to prolong lives. I mean, am I right in saying that, Karl is it or this is a procedure done to to prove symptoms keep you out of the hospital. Less medications hopefully, but not life saving. Is that safe to say or.
[00:32:02] Carleton Nibley, MD: Yeah, that's a really big question. So I think that rhythm control and what we mean by that is keeping you in normal rhythm has dividends that do translate into improved survival. Now the ablation itself is not sort of a life saving procedure, but in some cases it feels that way. And I think the data support that. And there are other data to say that that maintaining normal rhythm, I think just conveys other health benefits for individuals. You know, I think the biggest surprise in my career, as we're on this journey in medicine, specializing, I find it interest in arrhythmia work. And at the end of all of that, I find myself being an atrial fibrillation specialist. And if you had asked me when I started in medical school and became aware of that rhythm diagnosis, of all the millions of diagnoses that were offered to think about and learn about, there's just no way in the world I would have predicted that. And it turns out to be an incredibly challenging, incredibly rewarding calling because it's so incredibly prevalent. It's such a prevalent problem. And as our population ages, more and more of us will be face to face with this issue. And, um, there are just some of us who have been picked. Yeah, to take this on as our life calling.
[00:33:29] Matthew DeVane, DO, FACC: It's a fascinating journey. And just to see, because there's still so much we don't understand. I mean, I try to think where we're going to be in 20 years and the things we're doing now will be obsolete when it comes to atrial fibrillation.
[00:33:40] Carleton Nibley, MD: Absolutely.
[00:33:41] Carolyn Lacey, MD, FACC: Doctor Nibley, this was excellent. This was such a good overview of what patients can expect during ablation, how we use ablation as a tool in our AFib journey. I'm going to ask you a question that I ask everybody that comes on the show. There's this saying that, you know, we all know the apple a day. It keeps the doctor away. And when you think about what the proverbial apple is, what is that for you? What would you think is the best way to keep yourself healthy throughout the course of your life?
[00:34:14] Carleton Nibley, MD: Well, I think we've learned this. The experiment, the American experiment is that as we use technology to help us manufacture abundant quantities of food, we find ourselves being overfed and not just overfed, but we're overfed. Foods that have been overly processed and engineered kind of reminds me of the astronauts in Tang in place of orange juice. And there are a million other examples of that that we grew up with. And if we can find a way to get back to eating whole foods, the idea of organic foods, which I rejected initially as a physician, but now understand what I was, they were trying to tell me and work on controlling our calorie intake and and thinking about how the calories that we consume are fueling all of the cells in our body. If we focus on that, then we can avoid that classic triad the metabolic syndrome, the high blood pressure, the diabetes, and then the vascular disease, the obesity and everything that comes with it that we spend so much time as, as cardiologists. So it's it's to me, it's the fuel. And the apple a day is kind of sort of the simplified version of that. You know, to me it's going back to basics. It's really sourcing my food, trying to find the the best examples, knowing where the food comes from. So a lot of that is really, you know, um, um, eat whole.
[00:35:45] Matthew DeVane, DO, FACC: Foods, eat less. I mean, I think we're just overeating and eating the wrong stuff. Right?
[00:35:50] Carolyn Lacey, MD, FACC: There it is.
[00:35:51] Matthew DeVane, DO, FACC: I love your apple.
[00:35:52] Carleton Nibley, MD: I think that's my apple a day.
[00:35:53] Matthew DeVane, DO, FACC: That's perfect. Thank you so much for being here with us today, Carl.
[00:35:56] Carleton Nibley, MD: It's so much fun. Yeah, I could talk about atrial fibrillation all day. Well, wait a second, I do. And then you'll be back on the doc again.
[00:36:04] Matthew DeVane, DO, FACC: All right. Thank you, thank you. This is Doctor Matt DeVane and on behalf of my co-host, Doctor Carolyn Lacey and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.
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