Maggie McKay (Host): How much do you know about electrophysiology and treating AFib or atrial fibrillation? Today, we'll find out about the advancements in treating arrhythmias with cardiologist Dr. Ayhan Yoruk, who specializes in complex ablations for AFib and more. Welcome to Wise and Well presented by Community Memorial Healthcare. I'm your host, Maggie McKay. Dr. Yoruk, thank you so much for being here today.

Ayhan Yoruk, MD: Thank you so much for having me, Maggie.

Host: Let's start with your education, training, and experience. Tell us about that.

Ayhan Yoruk, MD: So, it's a long road to get to where I am now. I'm born and raised in New York, went to Cornell for undergrad. I was at Columbia for a master's program in public health. I met my wife there. Went to George Washington University in Washington, D.C. where we trained together for medicine.

Yes, a long road and a long time together, so we know each other quite well.

And then I found myself back home in Rochester, New York, where I was born and raised, did my cardiology fellowship there. And then my wife's from actually from California, so she gave me an ultimatum. I chose to follow my wife. And we moved to California, where I did my training in cardiac electrophysiology at University of California, San Francisco, up north at UCSF.

And now I'm here in beautiful Ventura in Ventura County, practicing, Clinical Cardiac Electrophysiology.

Host: Oh, it's so beautiful, Ventura. I love it. How does your education and experience impact the care that you provide to your patients?

Ayhan Yoruk, MD: Well, it allows us to feel very confident in how we approach our patients. It's not just, hey, you have an arrhythmia. It's a complex milieu of things. Most of these patients have multiple co-morbities. They may have multiple factors, risk factors that go into atrial fibrillation or any of these cardiac arrhythmias.

They may include sleep apnea, high blood pressure, stressors in life. Drug intake, other medicines that they may be on. So it's quite a complex combination of things. And it's nice to have such an extensive background, not just in medicine and cardiology, but also electrophysiology to approach these patients.

Host: And what exactly is electrophysiology and how has it evolved in the last, say, 10 years?

Ayhan Yoruk, MD: Well, it's funny you say that I actually happened to train with Dr. Scheinman, one of the pioneers of the field up at UCSF. he was the first person actually to perform an ablation procedure in humans in the world. So that was at UCSF. But it's come a long way since then. Technology has changed.

Medications have changed. Our knowledge in the pathophysiology of arrhythmias has changed. And the more we know, the better we can treat it. It's not just treating too, it's how to prevent it. So the more knowledge we know, the better. So you asked an interesting question, how has it changed?

It's constantly changing. And that's what attracted me to the field of electrophysiology. It's the one field where the technology for treatment and therapies of our patients are constantly changing. The type of energy we use to perform the ablations, the type of catheters, the type of mapping systems, it's constantly evolving and that's what makes it so exciting.

Host: And what is AFib and what are the symptoms?

Ayhan Yoruk, MD: AFib is a very common arrhythmia. We're learning and more about it. Common risk factors of AFib include things we may not even think about. Sleep apnea is one of them. So if you snore at night, that's a big risk factor for AFib that we don't know about. Obesity is another one. High blood pressure. Just any sort of cardiomyopathy or heart failure or any heart disease. These are just a few of many risk factors for AFib. And what is it? AFib, I like to say it's dancing of the heart. The top chambers of the heart are dancing around, they're moving very irregularly and fast.

And sometimes when this happens, blood pools up, it can pool up, cause a clot or a thrombus or, a collection of blood that formalizes into a clot, which can unfortunately dislodge and cause a stroke. And that's why we really care about AFib. It's not just how it makes you feel, the symptoms you may have from it, but the damage it can do and one of them is unfortunately a stroke.

And the type of stroke AFib can cause are the types that are devastating. It's usually five times more deadly and more debilitating than any other type of stroke. That's one thing. And then common symptoms you asked, atrial fibrillation, symptoms may include chest palpitations, feeling lightheaded, feeling dizzy, feeling race of heart, fluttering sensation like a butterfly's in your chest.

You may feel tired. You may feel fatigued. These are just some of the many symptoms you may feel. But interestingly, not everyone has symptoms. Some people may not even feel it. That's what makes this kind of a a bit more scary. It's not always so evident you may have AFib. If you have risk factors for AFib, I definitely encourage you to get screened or talk to your physician about atrial fibrillation.

Sometimes people just may have it in their sleep and they may not even know. And that's the scary thing about AFib. If we don't pick it up, if we don't learn more about it, if we're not on the lookout for it, it can sneak up on us and cause major issues in our life. Quality of life and stroke is, uh, again, a big issue.

Host: I was going to ask you next. How does AFib negatively impact the lives of your patients?

Ayhan Yoruk, MD: Oh, there's many studies have shown, definitely, impacts the quality of one's life. Just the symptoms I mentioned alone can really impact people's life. It's even shown to, uh, lead to depression. There's higher mortality associated with atrial fibrillation. Not necessarily just, oh, you're going to die from AFib.

Not necessarily. It's everything else that's associated with it. Once you have AFib, I like to say, AFib begets AFib. The more AFib you have, the more AFib you will have in the future. It's self promoting. Why? Because it scars the heart. The more you're in atrial fibrillation, the more the heart gets scarred, cardiac tissue, and that begets even more AFib, and then your left atrium can dilate.

It can cause filling issues the heart. it could cause valvular issues, where blood's flowing backwards and just all these symptoms. It's just on and on. It's like a snowball effect. So I'm definitely a big proponent of not only aggressive approach towards AFib, the management and treatment of AFib, but also diagnosing it and picking up on it.

Host: And, just in a nutshell, that is my next question. How do you diagnose AFib?

Ayhan Yoruk, MD: In a nutshell, just feel your own pulse. Are you, are you having irregular heartbeat? That's first and foremost. There's all this new technology out there. Even the Apple Watch can pick up on things. It's not always accurate, so mind you that. But that's why I want you to talk to a professional such as myself or even your primary care physician can help diagnose atrial fibrillation.

There's heart monitors out there on the market, Kardia is one of them, where you place your fingers on this little tablet and you can spot check yourself. Or there's long term monitors, two weeks at a time. Sometimes they can check for AFib.

There's even loop recorders, which are devices that last three to five years that we can implant. It's like a dog chip, if you want to think about it that way, that evaluates for atrial fibrillation. But this is all handled through the guidance of your primary care physician or your cardiologist. I wouldn't indicate everyone to get a monitor like that.

I think if you're suspicious for symptoms, if you have risk factors, I think the first and foremost thing you should do is talk to your physician.

Host: What about genetics?

Ayhan Yoruk, MD: Genetics. Interesting that you say that. There's more and more we're learning about genetics. There's definitely a genetic component. I've had many, many patients who have AFib.

Then their brother and sister and father and mother have AFib. There's definitely a strong genetic component to atrial fibrillation. Not for everyone, certain families for sure. There's definitely some genes being identified and more work is being done on this. But, do I routinely do genetic testing? The answer is no, but that's going to be a definitely a changing, factor in the coming years.

Host: Dr. Yoruk, what are the non procedural or pharmaceutical options for treating AFib?

Ayhan Yoruk, MD: There's a few options that I like to discuss with my patients. So, when a patient comes in with atrial fibrillation, first of all, I like to assess how is it impacting their life. How frequently are they having it? So I ask all of those questions. But when it comes to therapy, regardless of therapy, I always talk about defensive measures too.

Just because you have AFib, you're going to have it again. We want to prevent ways of it coming back. So preventive measures I emphasize. Sleep apnea evaluation and management is one of them. Weight loss can be another one. Healthy eating. Moderation of your alcohol intake. There's recently studies showing that a lot of people are afraid caffeine or coffee can cause AFib.

The answer is not really. There's a study recently done at UCSF that suggests that that's not necessarily the case. So prevention I would emphasize. When it comes to treatment, yes, I'm a big proponent of rhythm control strategy. What does that mean? That means we want to emphasize keeping you in normal rhythm.

Right? So, how do we do that? There's two main options. One's medical therapy, medication, and the other one's catheter ablation, which is what I specialize in. I mean, I specialize in management of AFib, but I also perform the procedure catheter ablation. When it comes to medication, there's many different types.

If you have no structural heart disease or any cardiac, significant cardiac disease, a lot of times, class 1c agents such as flecainide and propafenone are drugs that are relatively benign that we can use. after that, if you have any valve disease or structural heart disease, our options become limited.

And of course, this all, we look at the big picture. We want to make sure you have normal renal function, normal liver function. And if everything checks out. There's other options called sotalol and Tikosyn, but those medicines require you to come to the hospital to be safe for us to monitor you as we load the drug into your system.

As you take the drug, they're usually twice a day drugs. We like to monitor you on a heart rhythm monitor in the hospital, make sure things are going safe. There's no changes in arrhythmia, or changes on your EKG. Once we reach a safe level, then we discharge you. And those are great drugs. There's great evidence behind it, but they're a little more involved.

 Lastly, there's a classic drug called amiodarone. But unfortunately, amiodarone can have a lot of side effects, lots of toxic side effects when you use it long term, so I'm not a big proponent and I don't like using that drug.

Host: How long can a patient generally live with AFib before they need or want a procedural treatment?

Ayhan Yoruk, MD: Everyone's different. I like to individualize everyone's therapy based on their preferences and their way of life. So some people tolerate it. Some people don't even know they're in AFib. Some people may have low burden called proxysmal atrial fibrillation.

Proxysmal meaning it comes and goes. Less than seven days of AFib, gone. And if it comes back, it's proxysmal by definition. Those patients I still give them all the options. Why? Because eventually they're going to progress to more and more. Then there's some patients called persistent, meaning you're always in AFib, more than seven days, persistent atrial fibrillation.

Those, I definitely would want to be more aggressive with, but also their chances of successful treatment are not as high as those with paroxysmal. Everyone's individual, it all depends, and do they have other comorbidities, such as heart failure? It's now class one, we're more so advocating atrial fibrillation ablation for patients with heart failure, who also have concomitant AFib, and we're definitely recommending ablation therapy for those patients.

Host: Okay. And you mentioned some of these already, I believe, but, what are the minimally invasive options for treatment of AFib like ablation, Watchman?

Ayhan Yoruk, MD: So, there's no invasive with medication, right? Medication is the most minimally invasive because there's no procedure involved. When it comes to catheter ablation, it's not open heart surgery. It's minimally invasive, in regards to you come in one day. We find the time that works best for you.

 Community Memorial Hospital is a great facility. We bring patients in, we check them in, we prep them. My anesthesia colleagues, I only do this procedure with an anesthesiologist. Safety is our biggest priority. So we have, it's me and an anesthesia doctor, five or six nurses and techs.

We're watching the patient very closely, and safety is our priority. We put them to sleep under general anesthesia. Because we don't want them to move. By minimizing movement, we create a safer environment for the ablation. Then we go up with catheters through the femoral veins that lead up into the inferior vena cava, which is the main vein that goes up into the heart.

That's the access point with catheters into the heart. We then use a camera inside the heart and a small wire. We cross over through a transeptal puncture. We go through the atrial septum into the left atrium. In the left atrium. That's where most commonly, we have four pulmonary veins. Studies have shown the most common trigger of atrial fibrillation are these ectopic beats that come from these veins, which short circuit the heart and put you into atrial fibrillation.

That's where these most common triggers of AFib come from, are from these pulmonary veins. And our goal is to burn around these pulmonary veins through electrical energy, radiofrequency ablation. That's my preference. So this catheter has electrical energy that slowly, basically burns the cardiac tissue, the heart tissue, around those veins.

So we draw basically a circular lesion around those pulmonary veins, one on the right side, one on the left side. And that allows us to electrically silence those veins. We don't want signals going in, we don't want signals going out. So there's entrance and exit block is what we call it. I like to think of it as having a moat around the castle. Think of a castle. A moat around it, therefore, if you have this moat, if no signals come in or out, these signals are not going to trigger AFib, right? So that's the goal. It's called pulmonary vein isolation, PVI ablation.

Host: I'm surprised this is called minimally invasive because it sounds pretty invasive when you need to use an anesthesiologist.

Ayhan Yoruk, MD: It sounds pretty invasive, and maybe I'm jaded because I do it so much, but, yes are there risks involved? There are risks, but those risks are quite low. Less than 1%.

Host: What is the benefit to having these procedures done close to home?

Ayhan Yoruk, MD: Being at Community Memorial Hospital in Ventura, California, all our patients are within the community. Some may even come outside of the community. It's a great facility. What's the benefits of doing it in your own community is the fact that you can have family nearby. You go home the same day. It takes about an hour and a half I would say. The procedure, you lay flat for a couple hours after, we want, we make sure the groins heal nicely, the veins are closed, and you walk around, we make sure you tolerate things. If you're comfortable going home, we discharge you the same day.

It's nice to just go home, nearby, say your neighborhood's right around the corner. How nice is that? You go straight home and it seems seamless. So there's a benefit to that. There's also a benefit to just the comfort of your own community. There's so many people that come by, having families nearby that social support.

The mental support. In the end, it's a big procedure. If you think about it, it's nice to have family around and support around. And Hey, I tell all my patients, after I perform an ablation, we're lifelong friends. We're going to manage this disease together.

It's a chronic disease. Even if you do an ablation procedure. Atrial fibrillation, unfortunately, can always come back. Those veins can heal. The heart's a beautiful thing. The heart can heal, reconnect, or there may be other triggers in the future. So, I always follow my patients regularly, and we always assess how they feel, how they do, and it's just nice being in the same community. You become part of a larger family unit there.

Host: And how effective are these procedures for long term treatment?

Ayhan Yoruk, MD: Quite, effective. People with proxismal atrial fibrillation, those that come and go, you would think that they have less scarred hearts. The earlier you treat it, think the better outcome you have. And also, what I like to say, five years down the road, 80 percent chance, I'd like to say, that you will still be in normal rhythm, which I think is pretty good.

The technology is always changing. Our abilities are, we're learning more and more about this disease. We're getting better at it. So those results are way better than they were 10 years ago, or even five years ago, or even last year. Technology we use is constantly changing.

We're mapping better. We're learning more about the pathophysiology. We're addressing certain triggers that we weren't, or even mechanisms we weren't aware from before. So it's constantly changing, constantly getting better. And that's what's so exciting about this field.

Host: That's very encouraging. What should someone do if they are living with AFib and they want to know their options?

Ayhan Yoruk, MD: I'm always available. Dr. Ayhan Yoruk. I'm here in the community. Talk to a cardiac electrophysiologist. But even before then, your local cardiologist can help or even your primary care physician. Like I said, we're learning more and more about this. I, myself, do give talks in the community. I'll do outreach programs.

I'm always available if people have questions. I have an email address I can give out. There's certain websites that are more helpful than others, but I think just speaking to your local physician is the best thing you can do because they can help refer you and guide you, where to get further treatment.

Host: Right. And so that kind of answers this next question. How does a patient's journey look when they're referred for electrophysiological evaluation and treatment at Community Memorial Healthcare? I mean, let's say you're referred to go there and then just what are the three steps? What do you start with, in the middle and the end?

Ayhan Yoruk, MD: So, just diagnosing is the first step, right? Once you find out you have AFib, talk to your primary care physician. Or if you have a cardiologist, talk to your cardiologist. They will know, when it's appropriate to refer, and referring to an electrophysiologist is usually if you're going to start antiarrhythmic therapy, or at least, the more involved antiarrhythmic therapies, and or catheter ablation. My personal viewpoint is they should be referred regardless so we can at least explain the procedure since we perform the procedure. I'll always review a comprehensive approach. I give every single one of my patients an option. They have all the options and my job is to explain those options to them.

 Maybe medical therapy, maybe catheter ablation, And I explain it to them and I coach them through and I allow them to make the choice. But of course we're there for guidance and we show the pros and cons of each one and what we would do, but ultimately, the patient is the boss. I'm just the coach.

Host: I like that. In closing, could you share a memorable case or a story that illustrates the impact of electrophysiology treatment on a patient's life?

Ayhan Yoruk, MD: Absolutely. I just received a letter from a patient of mine. His name's Steven. He doesn't mind me sharing his name. I saw him yesterday, and he sent me a letter on January 19th, actually. I have it in front of me, I'm happy to read it to you, but I'll summarize it.

 He says, your knowledge, technology, and technique is a miracle from my perspective, and I can't thank you enough. For well over a decade, I believed there was nothing that could be done for AFib. Dr. Yoruk, you gave me a steadfast hope and confidence, that you could help me out, and you did.

I'm in normal rhythm. I'm no longer shorter breath. I can do simple things again in normal ways, like walking, going upstairs, without feeling exhausted. Doesn't sound like much, but this is a big deal to me. And he says, my personal objective was not to live longer, but a fuller one. I feel that I've been kick started again, and it's wonderful.

 It will help me raise my grandson, which I am most thankful for. I fully appreciate what you've done for me, and wanted to express my gratitude and personal feeling for changing my life. Thank you. That's the kind of feedback when we get that makes, you know, that's exactly what we do. So, I'm very happy to hear back from patients like that and honestly we can impact many people's lives. So, I hope we all work together as a community to learn more about this disease and address it appropriately.

Host: That's amazing. That's got to make your day. I think every patient should write a thank you note, but I know it doesn't happen, but when they do, I'm sure it's very special. Thank you so much, Dr. Yoruk for filling us in. So informative and fascinating.

Ayhan Yoruk, MD: Thank you, Maggie. I appreciate it

Host: Again, that's Dr. Ayhan Yoruk, and if you'd like to learn more, please visit mycmh.org. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay, thanks for listening. This is Wise and Well presented by Community Memorial Healthcare.