Melanie Cole, MS: Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole and joining me today is Dr. Amit Thosani. He's the Director of Cardiac Electrophysiology for AHN, and he's here to highlight the field of cardiac electrophysiology.

Dr. Thosani, it's a pleasure to have you join us today. I'd like you to start by telling us a little bit about this field of cardiac electrophysiology. What does AHN Cardiac Electrophysiology focus on? Tell us about this burgeoning field.

Amit Thosani, MD: Thanks, Melanie. Nice to be with you. Excited to talk with you about Cardiac Electrophysiology, obviously my area of focus and passion. We treat all aspects of heart rhythm disorders, ranging from very common rhythm problems like atrial fibrillation, to life threatening arrhythmias arising from the main pumping chambers of the heart, the ventricles, to slow heart rhythms that require pacing, to lead management and device extraction for malfunction or infection reasons, and more recently, structural heart interventions, specifically something called left atrial appendage occlusion, which is designed for stroke prevention in patients who can't take traditional medications to reduce their risk of stroke.

Melanie Cole, MS: So I'd like you to speak about what you're seeing in the trends as far as abnormal heart rhythms. The most common that you see, and are these on the rise?

Amit Thosani, MD: Yeah, great question. You know, by far and away, the most common, and most rapidly increasing rhythm is atrial fibrillation. So, millions and millions of Americans now, are being diagnosed with atrial fibrillation. I think that the public awareness of atrial fibrillation has significantly increased.

And unfortunately, some of the risk factors which drive the presence of atrial fibrillation, obesity, high blood pressure, diabetes, et cetera; those major cardiovascular risk factors are all drivers that promote atrial fibrillation. As a result, on top of, not to mention, probably most importantly, the fact that our population is aging; all of these things are contributing to the significant rise in atrial fibrillation that we're seeing in our practice.

Melanie Cole, MS: I'd like you to speak about symptoms because not all atrial fibrillation can be felt. And it's so common as you say, are there specific signs that a family physician, for example, should look for? And when do you feel if they are noticing these things is the best time for referral?

Amit Thosani, MD: There are two sort of categories as far as what patients may feel with atrial fibrillation. And broadly speaking, there are patients who feel this rhythm and there are patients who don't. And both need to be identified for various reasons, but the patients that feel their atrial fibrillation will probably come to you complaining about fatigue, malaise, just not feeling themselves, not being able to exercise. Some may experience heart racing, heart pounding, palpitations, and if that's the case, obviously an office visit, a good physical examination and an electrocardiogram is enough to make the diagnosis. Very frequently, these rhythms are not the cause of symptoms. And that becomes a challenge because even in the absence of symptoms, whether or not you feel this rhythm, of course, there is the risk of stroke associated with atrial fibrillation.

And so, routine surveillance and general medical checkups are important, and often the times at which atrial fibrillation is initially diagnosed.

Melanie Cole, MS: Dr. Thosani, the increased risk of stroke is one that we take very seriously. When do interventional procedures become that discussion or really the only option? What are some of the interventional procedures that you perform that can help with these heart rhythm disorders?

Amit Thosani, MD: There are two categories of procedures. One category is designed to improve symptoms. Most of the procedures that I think other physicians are aware of, specifically atrial fibrillation ablation, which is a minimally invasive procedure that's designed to quiet the triggers that start atrial fibrillation. The purpose of that procedure is to reduce the burden of symptoms related to the rhythm, not necessarily to reduce the risk of stroke. Most of our treatments are geared toward improving quality of life and preventing the consequences that keep patients from living their fullest lives because of the symptoms associated with this arrhythmia.

We do, however, offer procedures that are designed not towards symptom control, but reducing the risk of stroke, and that procedure is called left atrial appendage occlusion. It is geared toward patients who are not able to take anticoagulation safely because of bleeding concerns or other contraindications to being on blood thinners.

And that procedure involves implantation of a device in the specific area, in the left atrium, the appendage, where most clotting occurs as a result of atrial fibrillation and then places that patient at risk of having a stroke. That device implantation allows us to step down the blood thinners over a period of time after it's implanted, still protecting the patient from the risk of stroke, specifically related to atrial fibrillation, not from all stroke, and is a good option for those patients who have difficulty with traditional anticoagulation.

Melanie Cole, MS: I'd like to get into your program's care philosophy. But before we do that, I'd like you to expand a little bit on the Watchman procedure. What most excites you about this procedure? What have you seen as far as patient satisfaction outcomes, when you've done however many of these and they're becoming quite a popular procedure? And for good reason. Tell us a little bit about what you've seen as far as patient satisfaction.

Amit Thosani, MD: Yeah, I think that those patients who've had life threatening bleeding, hospitalizations, blood transfusions, because of or worsened by being on blood thinners, which they need for stroke protection, obviously have a huge improvement in their quality of life, once they're able to more safely discontinue anticoagulation over time after left atrial appendage occlusion.

I would say, related to this topic, but not quite the same, is that one of the upcoming initiatives that we're involved with now on the research side looks at or addresses this question of anticoagulation. So traditionally, once you have a diagnosis of atrial fibrillation, whether or not you're in that rhythm at a given time, the decision to anticoagulate the patient is based on risk factors that don't include the burden of atrial fibrillation. In other words, whether or not you're in atrial fibrillation today, if you have risk for stroke based on your general clinical profile, we recommend anticoagulation. That, is a significant burden on a lot of patients, not only from adding a daily medication, but being on a blood thinner, costs and bleeding issues, et cetera.

So we are in the era now where we're able to monitor the heart rhythm using wearable technologies. And in fact, as of the time of this recording, we're part of a clinical trial called REACT atrial fibrillation, which is randomizing patients to our traditional uninterrupted anticoagulation versus using an Apple watch to help guide the use of anticoagulants only when patients are in atrial fibrillation and then stopping those anticoagulants when they're in normal rhythm. So, I think that we're seeing the evolution in the last few years of not only stroke prevention for patients who can't be safely anticoagulated, but also potentially for the future, minimization of anticoagulation and sort of a more personalized, tailored approach to being on blood thinners, while hopefully protecting risk of stroke and minimizing the risk of bleeding.

Melanie Cole, MS: That's fascinating. And it really is where we're going with so much of those and the wearable technology is just absolutely amazing. It's an exciting time in your field, Dr. Thosani. So expand a little bit. You can talk about health REACT, atrial fibrillation, or any other research that you're working on that you'd like other providers to know about.

Amit Thosani, MD: So we've been very fortunate. I think, we're fortunate one to be part of a health system and a cardiovascular institute that's been sort of pushing the, the cutting edge of care, for cardiac and cardiac surgical patients for decades. And I think that history of innovation is one that we're proud of and we take seriously in the Cardiovascular Institute at AHM.

And to that end, we've been fortunate that in the city of Pittsburgh, with our rich sports tradition, that we have a partner with the Mary Ellen Mewes Foundation and Highmark Health, both of whom have made significant investments

in contributing to the establishment of the Maryl Ellen Mewes Innovation Center for Heart Rhythm Care, and we've been able to leverage this partnership to really offer some pretty amazing research progress, clinical trial work and care advancement, that I think has a very local flavor and one that we're quite proud of.

So, to expand on that, to get sort of granular with those details. One of the projects that we're working on is applying, machine learning artificial intelligence technologies to better understand the development of electrical disorders of the heart, number one, and to better understand the likelihood that patients will respond to treatments for various heart rhythm disorders, and we're fortunate that in our city to have Carnegie Mellon University in our backyard, you know, the world's experts in deep learning and artificial intelligence are right here.

 And we're fortunate that as part of the Lemieux Foundation gifts, we have embedded on our team, a machine learning data scientist who we've been working with closely, uh, to start elucidating some of these relationships, which are not easily understood outside the world of really sophisticated computing and deep learning.

And we've presented some of our initial work at our Heart Rhythm Society international meeting this year in 2023, and a lot more to come in, in the future. As part of the Lemieux Foundation's support, we've also been able to advance the improvement of safety, efficacy, and really push a lot of the envelope for treatment, not only of atrial fibrillation, but also of life threatening rhythms that we've been able to work with partners in radiation oncology and other fields to deliver non-invasive therapies for certain patients who are, you know, out of traditional options to treat otherwise dangerous heart rhythms. So we're very excited about this initial relationship that began in 2019 and hopeful that it'll continue into the future.

Melanie Cole, MS: So many more tools in the toolbox. Dr. Thosani, before we wrap up, I'd like you to speak about your program's philosophy of care. What makes it so successful? And tell us a little bit, you mentioned, about multidisciplinary team. Tell us about your team and why this approach is so important for patients because there are many providers across the spectrum that are working with these patients.

Amit Thosani, MD: Yeah. I think, Melanie, if you were to ask me what I'm most proud of in my career, it's not everything that I just mentioned. What it is, in addition to the things that I just mentioned, is our team. And I think that is really the strength of AHN's Cardiac Electrophysiology program. We are incredibly fortunate to have unbelievably talented electrophysiology physicians here at AHN. I've been fortunate to recruit a number of colleagues from previous institutions and friends, and really just amazing human beings and tremendous, tremendous physicians, all of whom have trained with the top physicians and founders of our field. And, you know, we've been fortunate to train with the best people and many of us are in the primes of our careers now.

And, you know, everything we mentioned from both clinical care to research, and sort of the upward trend that this program has had, is in no small part because of the talented people that we have. And I would say beyond even the physicians, we've been really, really fortunate to have really the best nurses, nurse practitioners, physician assistants, technicians, laboratory nurses and staff, just the whole care spectrum all the way from, you know, everyone that interacts with our patients from the time they call for an initial referral, to the time that they're seen in the office, to scheduled for surgery, to going through surgery, to their post operative care.

Everyone that we've been fortunate to grow as part of our team is really top rate and world class. And I think that, we pride ourselves on working selflessly. The patient is always the focus of everything we do. We think very thoughtfully and deliberately about optimizing our processes, our procedures, our safety, our efficacy.

And what we're really after, is providing the type of care that all of us want for ourselves and our families. We say that we're concierge care for the entire region. And while that seems like a bit of a platitude, it really is what we're after. We want every patient to get a level of care that we think is world class and that we think all of our patients deserve.

Melanie Cole, MS: Thank you so much, Dr. Thosani. That was an absolutely fascinating episode and thank you so much for sharing your expertise with us today. Thank you for listening to this edition of AHN MedTalks. To learn more or to refer a patient, please call 844-MD REFER or you can visit ahn. org. I'm Melanie Cole.

 Thanks so much for joining us today.