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Melanie Cole, MS (Host): Expert Insights is an ongoing medical education podcast. The Carle division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please click on the link and complete the episode’s post-test.

Atrial fibrillation effects nearly three million people in the United States. The good news is that there's a treatment that’s proving to be very effective, and it can lead to better outcomes with patients with AFib. My guest today is Dr. Benjamin Rhee. He’s an electrophysiologist with the Carle Foundation Hospital. Dr. Rhee, tell us a little bit about AFib. What is the prevalence? Who is at risk? And in some people, they don’t know that they have it. So how is it diagnosed?

Benjamin Rhee, M.D. (Guest): Well, thanks for having me Melanie. Atrial fibrillation is the most common rhythm disturbance we see in patients. It particularly effects patients of advancing age. For example, over the age of 60, although it’s not exclusively seen in patients over the age of 60. Other risk factors that may predict appearance of atrial fibrillation might include high blood pressure, diabetes, being heavy, sleep apnea. The patients who experience atrial fibrillations are usually diagnosed at their primary care physician’s office. They may be demonstrating signs of fast heart rate or irregular heart rate picked up on physical examination. Other patients are diagnosed on the basis of an EKG, which may be ordered because of symptoms which might include palpitations, chest pain, or shortness or breath or preoperatively for other reasons.

Host: So, once it’s diagnosed, what is the first line of treatment? What would you try first?

Dr. Rhee: The focus of treatment of atrial fibrillation depends on whether patients are having symptoms or not. If they are having symptoms, then obviously we try to control those. If they are not having symptoms, we focus on treating the underlying risk factors, which involves treating them for problems with their diet, assessing their exercise regimen and seeing if that’s appropriate. We would treat any sleep apnea that might be discovered.

Once those items are treated, we focus directly on the atrial fibrillation. So, we would use medicines to help control the rapid heart rate that I mentioned earlier. We might use medications to try and keep the rhythm stable and avoid future episodes of atrial fibrillation. Although I haven’t mentioned it yet, atrial fibrillations biggest challenge is the increased risk of stroke that some patients face. So, blood thinners are generally a part of the discussion when choosing how to treat atrial fibrillation.

Host: As we’re discussing blood thinners, medications, some people don’t want to be on those for their lives or can't for one reason or another. Tell us about the Watchman Procedure and why it would be used over things such as blood thinners.

Dr. Rhee: The Watchman Procedure is a recently approved FDA device which attempts to close the part of the heart from which most blood clots form. The treatment indications right now are limited to patients who cannot safely take blood thinner. It has been shown to be at least non-inferior in trials to blood thinner in terms of preventing strokes. So, right now, this is not really an optional device for patients who choose not to be on blood thinners but is more a device to help protect patients who cannot safely take blood thinners.

Host: Explain a little bit about the procedure. This is not curative for AFib, correct? It is simply about reduction of stroke risk.

Dr. Rhee: That is correct. It is entirely appropriate that you phrased it that way. The Watchman device is only used to try and reduce the risk of stroke in patients. It does not directly treat the atrial fibrillation at all.

Host: What’s the procedure like?

Dr. Rhee: Patients are brought into the hospital and they are placed under general anesthesia. Following this, they undergo what’s called a transesophageal echocardiogram where their heart is scanned. The size of the left atrial appendage, which is the chamber of the heart in which the Watchman device is measured. The appropriate sized Watchman device is then placed in that appendage area to prevent clots from forming in there. It’s typically, from a procedural standpoint, a relatively fast procedure. Most of the time is spent in measuring the size of the chamber and assuring that the fit of the device is as good as possible. There’s not a lengthy recovery as the work is done from the leg. There’s not large incisions in the chest. One point to note is that patients do generally get placed on blood thinner for a short period of time around the time of the procedure, but generally are able to be discharged the next day with relatively small limitations.

Host: Well I'm glad you brought up the blood thinners because many people are under the assumption that after the Watchman Procedure, they do not have to be on medications for AFib anymore. Explain a little bit about how that works. Also, Dr. Rhee, who wouldn’t be a candidate. You mentioned about not wanting to use blood thinners, but some people cannot. So, who is and who isn’t a candidate for this type of procedure?

Dr. Rhee: The most common patients we refer for this procedure would be patients who have had significant gastrointestinal bleeds. For example, significant enough to require transfusion or multiple endoscopies to find the source of the bleeding. Also, patients who have had a history of bleeding intracranially would be patients that we would worry about their safety if placed on traditional blood thinners. So those are the two most common categories for patients being referred for the Watchman Procedure.

Host: And are they still on any sort of medication after the procedure?

Dr. Rhee: As I mentioned before, from a blood thinner standpoint, they would be on blood thinners for a short period of time after the procedure. As you mentioned before, these patients undergo the procedure to reduce their stroke risk. So, the medicines that they were on for their atrial fibrillation would remain in place.

Host: Tell us about some of the outcomes that you’ve seen or any patient stories where you’ve really seen that something like this has made a difference in a patient’s life.

Dr. Rhee: I think that if we were to summarize the challenges of living with atrial fibrillation, using blood thinners is a major source of dissatisfaction for many patients. They feel that they cannot go out and live their lives. They certainly feel anxious if they happen to ride a motorcycle, go skiing, go camping. Particularly before we had so many of these new oral anticoagulants, the patients who were using Warfarin also had the challenge of having to adjust their diet, being chronically monitored for the degree that the blood thinner coumadin or Warfarin was effecting their blood, and just felt uncomfortable because it was always too high or too low. They were getting calls all the time to go in for changes of the dose of their medication. So, the removal of blood thinner can dramatically increase patient’s sense of satisfaction and their quality of life.

Host: Wrap it up for us. What would you like other providers to know about atrial fibrillation and the Watchman Procedure, and when you feel it’s important that they refer?

Dr. Rhee: From an atrial fibrillation standpoint, the comments I would make are that the 2019 guidelines were just released last month updating the previous 2014 guidelines. The couple areas where I would make a comment to other providers are one, the use of aspirin has been eliminated in terms of treatment for atrial fibrillation. Previously, patients were trying to avoid anticoagulation, use aspirin, and drawing some comfort from the thought that they were getting some protection. There’s no longer any role for aspirin in the treatment for atrial fibrillations. So, patients need to decide whether they are on a formal blood thinner or they are not.

Secondly, women between the ages of 65 and 75 in the 2014 guidelines were recommended to be on blood thinner, and that is no longer necessarily the case. So, if you have patients who are specifically female gender and between the ages of 65 and 74 who don’t have other risk factors, they would no longer be recommended to be on anticoagulation. So, Watchman device is something we’re offering at Carle for the first time this year. We are excited to offer it. As noted previously, the patients are generally ones who cannot take blood thinners. If you have any, we do have a structural heart clinic that they could be referred to and we’d be happy to see them there.

The other treatments that we haven’t talked much about for atrial fibrillation are the atrial fibrillation ablation, which is increasingly shown to be effective at managing the symptoms that we mentioned earlier for treatment of atrial fibrillation. Or patients who you would consider candidates for ablation, we’d be happy to see them in the electrophysiology clinic here at Carle.

Host: Thank you so much Dr. Rhee for joining us today and telling us about this fascinating procedure. You're listening to expert insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit carleconnect.com. That’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole. Thanks for tuning in.