All Things Afib

In this episode, I speak with Dr. Vinay Badhwar, an internationally recognized master cardiac valve surgeon, and an expert in complex mitral valve repair, atrial fibrillation surgery, minimally invasive valve surgery, and robotic surgery. The main topic under discussion is Dr. Vinay’s paper, “Robotic-assisted Cryothermic Cox Maze for Persistent Atrial Fibrillation: Longitudinal Follow-up” by Badhwar et al. Key points from the paper: Objectives Surgical ablation of atrial fibrillation (AF) is recommended as a stand-alone therapy for patients refractory to medical or catheter-based treatment, or as a concomitant therapy when associated with structural disease. We report a single-therapy robotic approach to the Cox Maze with longitudinal follow-up. Methods Consecutive patients who underwent robotic biatrial cryothermic Cox Maze for nonparoxysmal AF between November 2016 and January 2022 were examined at 1, 2, 3, 6, 9, 12, 18, 24, 36, 48, and 60 months. Freedom from atrial tachyarrhythmias (ATA) was assessed with 24-hour continuous ECG or pacemaker interrogation in all patients after 6 months. Mean follow-up was 17 ± 14.5 months (Range 1-60 months). Time to event analysis with competing risks was used to determine risk-adjusted associations with late outcomes. Results Patients (n=135) had a median AF duration of 4.0 years [IQR 0.8-7.0], with 29.6% failing one or more catheter ablations. Stand-alone Maze was performed in 25.2%, while 61.4% underwent concomitant robotic mitral valve (MV) surgery, 7.4% tricuspid valve repair, and 4.4% aortic valve replacement (AVR). No patients were discharged in AF. There were 3 operative mortalities (2.2%), none in stand-alone patients. One patient required catheter ablation at 8 months postoperatively, and one had a non-embolic stroke at 18 months. There were 9 late deaths. Freedom from ATA and anti-arrhythmic drugs (AAD) at 9, 12, 18, 24, 36, and 48 months was 97.0%, 96.7%, 98.1%, 97.1%, and 100%, respectively. Lower ejection fraction and need for concomitant MV replacement and/or AVR were independently associated with worse survival. Conclusions For persistent AF, robotic biatrial cryothermic Cox Maze offered greater than 90% 1-year longitudinal freedom from stroke, oral anticoagulation, repeat ablation, and recurrent AF without the need for AAD. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: ● How Dr. Badhwar began using robotics ● Robotic surgery has been around for a long time ● The increasingly common “one and done” procedure, patients request ● Some of the patient profiles in the study ● Robotic advantages ● Patient safety is #1 ● Dr. Badhwar takes us through precise step-by-step robotic procedures ● Phrenic issues can be avoided ● Full flow and drainage ● Is the process for mitral the same? ● Using anti-coags after surgery - the controversy ● Training available for robotics ● LAA and the LAAOS III study ● Level A evidence, the future guidelines, always consider LAA! ● Honor the evidence…. Resources: Dr. Vinay Badhwar LinkedIn Dr. Badhwar’s Paper Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Dr. Thomas Michael Tadros returns to the podcast to discuss the DECAAF II Randomized Clinical Trial. As a Board-certified Cardiologist and EP, Dr. Tadros’ gives us the pros and cons and takeaways from this study, that advances AFib knowledge within our specialty. The study, “Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The DECAAF II Randomized Clinical Trial” was authored by Marrouche, Wazni, McGann et al and just released in June 2022 by JAMA. Key points from the paper: ● Question: Among patients with persistent atrial fibrillation (AF), does the addition of magnetic resonance imaging (MRI)-guided fibrosis ablation to conventional catheter ablation affect atrial arrhythmia recurrence? ● Findings: In this randomized clinical trial that included 843 patients with persistent AF, there was no significant difference in atrial arrhythmia recurrence in the MRI-guided fibrosis ablation group compared with the pulmonary vein isolation only group (hazard ratio, 0.95). ● Meaning: Findings do not support the use of MRI-guided fibrosis ablation for the treatment of persistent atrial fibrillation. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: ● Persistent vs. Paroxysmal Afib and background on the DECAAF I study ● Using MRIs to identify fibrosis prior to ablation ● Follow-up testing showed no differences - 43-46% of patients had a recurrence of AFib ● Patients were all approximately one year out from their diagnosis ● Even in patients with only 7 days of Afib, there was significant fibrosis – due to history of hypertension? ● Interstitial vs. replacement fibrosis ● Stroke incidence and mortality after the procedure ● Epicardial procedures - does this study impact? ● Where do we go with the data from this study? Does it impact practice? ● Scalability of this data/study/impact ● Overall these studies continue to be extremely relevant Resources: DECAAF II Study in JAMA Dr. Thomas Michael Tadros at Brigham and Women's Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Show Notes - All Things Afib - Episode 17 (16) - Medicare Cuts!!!! with Dr. Brett Gidney Medicare is slashing reimbursement for AFib procedures during a time of record-setting inflation and an increasing number of patients (currently 6 million) suffering from AFib. From an RVU (Relative Value Unit) of 26.44 in 2021, the payment is being reduced by FORTY PERCENT to 15.88 in 2023. AFib is becoming more and more widespread, in fact, there are predicted to be 20 Million AFib patients by 2050. Afib can often be fixed very easily, REDUCING the burden on the healthcare system, as likelihood of stroke, dementia, and other morbidities are reduced by AFib management. There are only 1500 EPs in the U.S. right now, and Medicare cuts are actually DE-INCENTIVIZING more doctors from entering this specialty, because they cannot get fairly compensated for their work. Did you know Medicare pays the same amount for an EP to sit in their office and read 3 echocardiograms, as they would get to do a complex AFib procedure/operation?! Join me and my guest Dr. Brett Gidney to discuss how and why these cuts are happening, and what you can do today to join the fight to reform these Medicare payments. Dr. Brett Gidney is a cardiac electrophysiologist leading the charge to reform Medicare payments to EPs. He practices throughout the central coast of California from Thousand Oaks up to Santa Maria. He is board certified in clinical cardiac electrophysiology focusing on complex cardiac arrhythmia management. Dr. Gidney spends the majority of his time in the hospital setting performing procedures, such as cardiac ablation, to treat abnormal heart rhythms. He is particularly interested in very low or no radiation exposure facilitated by 3D mapping and ultrasound technologies. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: ● Dr. Brett Gidney introduction ● The reduction of RVUs– 2021 to 2023 – reduced 40% - bundling/cuts ● EP is a tiny specialty, only 1500 in the US today ● AFib procedures REDUCE the burden on the system ● Who is advocating for these cuts? The RUC and it’s role ● Affect on caseloads/day to day practice ● De-valuing physician services vs. equipment costs ● Will this be the spark that leads to the formation of lobbying groups? ● 501(c)6 vs. 501(c)3 ● Reduced access to underserved populations ● The EPAdvocacy.org foundation will soon be up and running ● Reach out to your congressperson and senator, let them know we need reform! Resources: Dr. Brett Gidney LinkedIn Dr. Brett Gidney Twitter Find Your Representatives Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Show Notes - All Things Afib - CAST-AF 2022 with Dr. Bradley Knight So many legends in the AFib world are excited about the upcoming Catheter and Surgical Therapies for Atrial Fibrillation (CAST AF) Conference happening at the end of August in Chicago. Here to speak with me about some of the sessions is my esteemed guest Dr. Bradley Knight, Director of Cardiac Electrophysiology, Bluhm Cardiovascular Institute of Northwestern at Northwestern Medicine. We’ll discuss some of what you’ll see and hear at this world-class conference, happening Friday and Saturday, August 26-27 at the Radisson Blu Aqua in Chicago, IL. The talks scheduled are only 10-15 minutes each, with plenty of time built in for questions and discussion after each section. From AI to PFA, wearables, and other forward-looking AFib topics, presenters and technology, register now to attend and get intense, high-yield information, theories, and technology that you can put into practice the very next day you return to work! Dr. Knight is the Chester C. and Deborah M. Cooley Distinguished Professor of Cardiology at Northwestern University, and has been the Director of the Heart Rhythm Program at the BCVI, since November 1, 2009. He earned his BS in Public Health/Biostatistics at the University of North Carolina in Chapel Hill, and his MD at the Ohio State University. After completing his training in Medicine, Cardiology, and Cardiac Electrophysiology at the University of Michigan, he joined the Michigan faculty in 1997. He later served as the Director of Cardiac Electrophysiology at the University of Chicago from 2002 to 2009. As the Medical Director of Cardiac Electrophysiology at Northwestern Medicine, Dr. Knight remains clinically active with a broad range of clinical and research interests in the field of Heart Rhythm Disorders. These interests range from catheter ablation for complex arrhythmias, such as atrial fibrillation, to fundamental issues related to the basic mechanisms of various types of arrhythmias, and the use of imaging in the electrophysiology laboratory to guide ablation procedures and device implantation. He is involved in several multi-center clinical trials that are evaluating novel ablation tools and implantable devices, including the cryoballoon for pulmonary vein isolation, the totally subcutaneous implantable defibrillator, and left atrial appendage occlusion devices. He has coauthored over 300 scientific papers and is on the editorial board of several high-impact medical journals. He has served on the ABIM CCEP Exam Writing Committee for ten years, and is the Editor-in-Chief of the Journal of Cardiovascular Electrophysiology (JCE) and EPLab Digest. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: This may be the best conference happening in the world today Focus on interventional therapies Structure of the conference, short and intense for high-yield information The collaborative methods in practice at Northwestern Hot Topic: Pulse Field Ablation and it’s many advantages Talking tech: Devices and wearables The new approaches - using anticoags, closing the left atriral appendage, LAOS III and reducing stroke risks Training programs at Northwestern – new opportunities The differences in training from only ten years ago are staggering Register to attend today! Resources: Dr. Bradley Knight LinkedIn Dr. Bradley Knight Twitter CATH AF 2022 Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Show Notes - All Things Afib - Episode 15: Dementia and Atrial Fibrillation with Dr. Jared Bunch As doctors, we often don’t ask our patients (or their spouses) about “memory issues” or other signs of dementia, related to AFib. We usually ask about stroke, clots, and other heart functions but neglect to ask about the brain. My guest today is Dr. T. Jared Bunch, Head of Section for Heart Rythm Services at the University of Utah. Dr. Bunch specializes in the diagnosis and management of heart rhythm disorders. His current research involves defining mechanisms underlying the association between atrial fibrillation and dementia. He looks at therapeutic opportunities to lower the risk of cognitive decline, the integration of wearable and implantable devices to improve early diagnosis and treatment of arrhythmias, and improving mapping and catheter ablation of arrhythmias. Dr. Bunch is a section editor for Current Cardiology Risk Reports, Heart Rhythm Journal, and a guest editor for American Heart Journal. He is on the editorial boards of the Heart Rhythm Journal, Journal of Cardiovascular Electrophysiology, Heart, American Heart Journal, JACC electrophysiology, and the Journal of Innovations in Cardiac Rhythm Management. In addition, he is a Professor of Medicine at the University of Utah and Editor-in-chief of the Heart Rhythm Society. Join us for a discussion on the alarming connection between AFib and dementia, how to manage AFib and also assist in preventing brain decline, and the many exciting studies and trials, books and articles about the relationship between the two. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: Dr. T Jared Bunch intro and background What is dementia? Why should we care about its relation to AFib? An AFib/Dementia story– the salesman with AFib and “senior moments” Many times doctors neglect to ask patients about dementia and memory issues – only ask about stroke, clots, etc. Microbleeds, microclots, and hypoperfusion Assessing risk through blood panels The concussion/afib trial The magnitude of risk for dementia is higher in younger patients – ages 60-70 vs. 70-90 The impact of wearables and the Heartline Trial Benefits of anticoagulants Appendage management, AFib, and dementia CHADS VASC scores and AFib/dementia What other tests/scores do you look at? The AFib Cure book and Dr. John Day Closing words: for anyone listening– Be your own advocate, ask questions, join the AFib online community, and find a doctor who will answer your questions/knows about AFib. There are treatments and ways to address Afib. Resources: Dr. T. Jared Bunch LinkedIn Dr. Bunch Publications Join the Heartline Trial/Apple Watch The Afib Cure Book StopAFib.org Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Show Notes - All Things Afib - Episode 14 - Tachycardia Mediated Cardiomyopathy - Dr. Ali Khiabani from Washington University in St. Louis Today I’m speaking with Dr. Ali Khiabani, MD, MHA who is currently a fifth-year post-graduate student at Washington University under the tutelage of Dr. Ralph Damiano Jr., one of the world’s leading Cox-Maze surgeons who himself trained under Dr. Cox. Dr. Khiabani and Dr. Damiano have recently co-authored an important paper on the long-term outcomes of the Cox-Maze IV and today we’re going to discuss all the important findings in that paper. The paper’s abstract reads: Surgical ablation of atrial fibrillation (AF) is indicated both in patients with AF undergoing concomitant cardiac surgery and in those who have not responded to medical and/or catheter-based ablation therapy. This study examined our long-term outcomes following the Cox-Maze IV procedure (CMP-IV). And the conclusion states: The CMP-IV had an excellent long-term efficacy at maintaining sinus rhythm. At late follow-up, the results of the CMP-IV remained superior to those reported for catheter ablation and other forms of surgical ablation for AF. Age, left atrial size, and nonparoxysmal AF were the most relevant predictors of late recurrence. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: You have written some impressive papers – can you tell us a little about this paper? Some important elements in the research: Patient selection was key All underwent MRI’s to determine fibrosis levels 37 patients total Class III or IV EF Median follow up was 22 mos. All had significant improvements It’s not necessary to restore 100% sinus rhythm all the time– what were your statistics? Any additional points you’d like to share regarding this paper? Switching gears –tell us about your training with Dr. Damiano How many procedures until you were comfortable? What’s next for you with your training or research? Closing words: for anyone listening– the lesion set in this Bi-Atrial Maze procedure is the most robust method available today for patients with stand-alone AFib Resources: Dr. Ali Khiabani at Wash U. Wash U. Article about the Study Link to Study Abstract Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Some high-level takeaways from the paper: Early initiation of rhythm-control therapy conveys a clear clinical benefit in patients with recently diagnosed atrial fibrillation (AF) Based on trial results, rhythm-control therapy should be offered to all patients with recently diagnosed AF and cardiovascular risk factors, including those who present without AF-related symptoms, in addition to anticoagulation, rate control, and therapy of concomitant conditions Early initiation of rhythm-control therapy, before AF-induced atrial damage (atrial cardiopathy or atrial structural remodelling) has irreversibly damaged the atria, could be more effective and safer than the current symptom-based—and therefore delayed—approach to rhythm-control therapy. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: What was the purpose and background of this paper? How realistic is the patient population, compared to your practice? Figure 1- Meds vs. Ablation, your thoughts? Is a figure of 20% of patients treated with Amiodarone normal? What is your opinion on the long-term outcomes in this study? Afib and cognitive decline/dementia This study will change how we practice– it’s a game-changer What protocols do you recommend for your patients that come in earlier and earlier for AFib? The Mobile Cardiac Telemetry (MCT) monitor vs. others How smartwatches are raising patient awareness around AFib, and many times are useful tools in cardiac monitoring Tadros reiterates just how important this study is for all of us Resources: The EAST-AFNET 4 Study Dr. Thomas Michael Tadros at Brigham and Women's Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

My guest for this episode is Dr. Ashkan Ehdaie, an Electrophysiologist at Cedars-Sinai Medical Center in Los Angeles. Dr. Ehdaie is currently an Assistant Professor of Cardiology and Associate Director of the Clinical Cardiac Electrophysiology Fellowship Training Program. I interview Dr. Ehdaie about the different types of Vtach, the risks and outcomes associated with treating each type, and we dig into some of the protocols used for various scenarios where Vtach requires treatment, both medically and surgically. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: How is Vtach different from supraventricular tachycardia? What are the different types of Vtach? What is the conversation when a patient is diagnosed with Idiopathic Vtach? Where is the threshold between treating with meds or ablation? Why does malignant Vtach occur? Monomorphic vs. polymorphic The medications that can cause polymorphic Vtach Patient follow up procedures and the LifeVest We do imaging for Afib at a certain time post-procedure, when do you do it for Vtach? What is the success rate when treating with ablation? How much Vtach is too much? A study focusing on reviving tissue, instead of destroying it with ablation What else should our listeners know? “That Vtach is not one-dimensional, it has many presentations and complications.” Resources: Dr. Ashkan Ehdaie Cedars-Sinai Dr. Ashkan Ehdaie LinkedIn Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Is one glass of red wine a day an acceptable amount of alcohol for patients diagnosed with AFib? Is heavy drinking associated with an increase in AFib intensity or frequency? Until quite recently, the thinking around AFib was that you either have it or you don’t. But just as the medical community realized several decades ago that diet/lifestyle and alcohol consumption were important factors in coronary heart disease and MI, we are now seeing research results pointing to alcohol and other lifestyle choices having a causal effect on Afib. In this episode, I speak with Dr. Gregory Marcus about all things alcohol and AFib. Dr. Marcus is Associate Chief of Cardiology for Research at UC San Francisco Health. His particular research interests include cardiovascular effects of alcohol and caffeine and other common, modifiable, lifestyle factors. More recently, as one of the leaders of the Health eHeart Study and the NIH-funded Eureka platform, Dr. Marcus' interests have included mobile health technology and leveraging devices, sensors, mobile apps, and the internet to conduct clinical research more efficiently and to understand "real-time" and "real life" effects on patients. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: Gregory Marcus– background and research focus “Holiday Heart” – the anecdotal evidence of cardiac incidents following excess alcohol DIfficulties of studying alcohol and AFib– self-reporting, etc. A study of dry vs. wet counties in Texas What are the numbers– drinks vs. timeline of AFib episodes? Research found a median 4 hours between consuming alcohol and AFib occurrences We as surgeons don’t often discuss reducing alcohol after ablation Any correlation between amount of alcohol and length of AFib incidents? We hear about moderate consumption (one drink per day) being part of healthy heart/reduction of MI’s and coronary disease– how does that apply to AFib? We are just now considering lifestyle/diet/alcohol in relation to AFib, the way we looked at it with MI’s and coronary disease 20-30 years ago. Last words– moderation is always key, and abstinence is probably best Resources: Dr. Gregory Marcus LinkedIn Dr. Gregory Marcus at UCSF Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

My guest today is Dr. Christian Shults, the Co-Director of Aortic Surgery, the Director of Surgical Ablation, and the Director of Innovation at Medstar Heart and Vascular Institute in Washington DC. In addition to coronary bypass and valve surgery, Dr. Shults has developed significant expertise in complex open and endovascular aortic surgery, as well as transcatheter valve therapy and minimally invasive surgical treatment for atrial fibrillation. Dr. Shults consistently embraces new technology and innovation to safely deliver life-altering therapies in the least invasive way possible. Join us for a discussion around Dr. Shults’ algorithm for when to use TT vs. Convergent, the technical details of how he performs procedures such as the Convergent and the Cox Maze IV, his personal ablation protocols and technique, and more. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: Tell us a little about your practice at Medstar? How do you decide between TT vs. Convergent? Is there a cutoff you observe, or is it just a general impression How durable have you found the posterior wall ablation to be? Have you found a difference in stroke outcomes with only posterior wall ablation vs. left atrial appendage management? Shults walks us through his steps for the Convergent procedure What is your follow-up protocol at Medstar? The Cox-Maze IV and Dr. Shults’ preferences for the procedure Final words? “Become an expert in AFib!” Resources: Dr. Christian Shults LinkedIn Dr. Christian Shults at Medstar Email Dr. Shults with questions or to inquire about a fellowship Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Attention all providers: This episode may be one of the most important and valuable discussions you will hear all year. Get ready to have many of your preconceptions challenged and your understanding considerably deepened– about what your patients experience before, during, and after their AFib diagnosis and treatment. My illuminating discussion today is with Ms. Mellanie True Hills, who was herself a patient suffering with AFib. She got treatment, is AFib free, and now advocates for others through her important patient-focused work and education with StopAFib.org– of which she is the Founder and CEO. Mellanie speaks openly about her personal nightmare with AFib, how urgent it is for the medical community and other AFib patients to get up to speed on the best ways to deal with AFib, and some interesting and exciting new paths that AFib research may take with an unusual, but necessary, focus on “patient-initiated research.” I implore you to listen closely to this entire episode, all the way through, and recommend it to your fellow medical professionals. The insight into the patient experience will help all of us become better providers for our patients. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: Mellanie relates her personal fight with AFib prior to her procedure in 2005 The insidious ways that AFib hijacks your life physically, emotionally, professionally, and even financially Does Mellanie see different concerns from AFib sufferers now, vs. when she first began? Doctors need to spend much more time with AFib patients– in a one-two meeting that allows them time for the diagnosis to sink in Is stroke still the top concern for people you speak to? The troubling stats on patients that are being treated by generalists, and not referred to, or treated by, AFib specialists Digital tools- The Watchman and Amulet AFIb patients, in general, may not be being treated soon enough before scar tissue complicates treatment The importance of providers listening to and understanding patient’s “values and preferences,” which may be different from what we imagine We talk a lot about patient-centered care, but Mellanie has opened our eyes to many opportunities for vast improvements around the treatment of AFib Resources: StopAFib.org Website StopAFib Library of Conferences, Webinars, Master Classes Mellanie True Hills Website Mellanie True Hills on LinkedIn Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Today I’m speaking with Dr. Thomas A. Dewland, an EP with a focus on atrial fibrillation epidemiology (the study of which populations are affected by certain diseases and why). His goal is to identify ways to prevent atrial fibrillation before it occurs. Dewland earned his medical degree at the Yale School of Medicine. Currently at UC San Francisco, he has authored over 80 peer-reviewed papers. I recently listened to a symposium where Dr. Dewland spoke about the topic of “How much Afib is enough…” and so today we will be discussing it in depth. Join us as we cover the use of monitoring devices (both implantable and non) to detect AFib and the widely varying thresholds that doctors feel is enough to refer their patients to an EP for further treatment or consult. We will dig into: using anti-coagulants, when left atrial appendage management is indicated, and what the future of monitoring looks like - with the constant improvement and ease of use in newer monitoring devices. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: A patient comes in with AFib detected by their Apple watch– what do you do? If a patient has a 10 second AFib occurence, what is your device of choice to monitor them for more AFib? What is the threshold you use to determine if a patient should receive an implantable loop recorder? The availability of low cost home monitoring such as the KardiaMobile CHADVASC scores as an indicator for anticoagulants and/or further monitoring What are your thoughts on surgically managing the left atrial appendage if a patient is low risk? The incomplete closure of the left atrial appendage is worse than not closing it at all, so know if your skills are up to it We need to see the results of the two trials that are underway– in one to two years they will be published. Tech is improving to the point that we’re seeing AFib everywhere– is it a pathology or is it simply a bio marker of aging? Resources: Dr. Thomas Dewland at UCSF KardiaMobile Device - personal EKG Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

Have you wondered about the pros and cons of using cryoablation or a cryoballoon therapy to manage AFib? Join me for a fascinating discussion with Dr. Arash Aryana about the approaches available, and the varying successes of outcomes that EPs can achieve using cryoablation alone or in combination with other modalities. Dr. Aryana is a cardiac electrophysiologist located in Sacramento. Currently practicing at Mercy Medical Group, Dr. Aryana received his training at Massachusetts General Hospital/Harvard Medical School, Boston. Dr. Aryana joined Regional Cardiology Associates in 2008 and Mercy Medical Group in 2015. He specializes in the management of cardiac arrhythmias including both clinical and interventional therapies such as catheter ablation and cardiac rhythm device implantation. With nearly 100 peer-reviewed articles under his belt, Dr. Aryana is the current principal investigator for the PIVoTAL-IDE study on cryoballoon treatment, which we will be discussing later in this episode. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: Introduction and background – Dr. Aryana How did cryo become a modality for the endocardial space What percentage of procedures use cryo vs. a cryo/AF hybrid currently? Is cryo becoming more popular? What are the advantages of cryo vs. PFA (pulse-field ablation)? Aryana’s Journal of Innovations article on cryoballoon ablation How does cryo fit with intentional left atrial appendage ligation? Using cryo for the ligament or Vein of Marshall (VOM) Even the best surgeons are not 100% successful with ablation, how do you treat with cryoablation after those failures? Why is your upcoming PIVoTAL-IDE study on cryoballoon treatment so important? How the study invites more scrutiny with certain methodologies When is this study projected to be finished? The other exciting clinical trial– the CryoICE Atricure study Resources: Dr. Arash Aryana at Mercy Medical PIVoTAL-IDE Study Journal of Innovations Article: Rationale and Outcomes of Cryoballoon Ablation of the Left Atrial Posterior Wall in Conjunction with Pulmonary Vein Isolation Study: AtriCure CryoICE Lesions for Persistent and Long-standing Persistent Atrial Fibrillation Treatment (ICE-AFIB) Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel