Melanie Cole, MS (Host): Welcome to AHN Med Talks, 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 today we're highlighting the Atrial Fibrillation Program at AHN. Joining me is Dr. Joshua Silverstein. He's an Electrophysiologist with AHN Cardiovascular Institute. Dr. Silverstein, thank you so much for joining us today as we're talking about AFib. I'd like you to speak about the prevalence, the scope of the issue that we're talking about here today, and the main complications that we look to as providers to mitigate when we know a patient has AFib.

Joshua Silverstein, MD, FHRS: Great. Thank you, Melanie. Atrial fibrillation is the most common arrhythmia that we see in cardiovascular care. It affects millions of patients here in the United States, as most of the providers who are listening to this know. The main thing we worry about, first of all, is stroke prevention.

And so with that, we want to identify patients who may be at risk of having a stroke from their atrial fibrillation and make sure that they are receiving proper anticoagulation. And then secondly, we want to make sure that patients are not experiencing bad symptoms from the atrial fibrillation that may be impairing their quality of life.

Host: Well, then tell us a little bit about diagnosis. How important is that to improve the outcome prediction? Tell us about your rapid access for patients.

Joshua Silverstein, MD, FHRS: So, diagnosis of atrial fibrillation can occur in many different ways. And actually we've seen a big shift over the last several years of patients finding atrial fibrillation on their own with all the smart devices like smart watches that they may be wearing that's actually notifying patients earlier that they may be having atrial fibrillation when they may not be so aware of the arrhythmia.

But the devices help alert them earlier. And I think it's really important when dealing with atrial fibrillation, to understand the difference between being aware of the arrhythmia and being symptomatic, because although some patients may not know when they go in and out of it, they may have subtle symptoms such as fatigue or shortness of breath or more subtle symptoms.

That's why it's really important, to be able to identify the patients with atrial fibrillation early. And as I mentioned earlier, it's also important to identify those that would be at risk for having a stroke, such as those with coronary artery disease, high blood pressure, diabetes, or other risk factors that we look at.

When we do identify these patients, it's important that they are seen early to start their anticoagulation, and also to go through the possible treatment options that may go along with their diagnosis of atrial fibrillation. With our team, we take a very individualized approach with every patient to determine what their symptoms are, what their stroke risk is, and then go through the various options with every patient.

Host: Dr. Silverstein, as you discuss anticoagulation with patients, and then we look to procedures and some that maybe let the patient not be on those meds anymore. Can you tell us about some of the new procedures within your division, any current and emerging therapies, the exciting things going on in your field right now?

Joshua Silverstein, MD, FHRS: Yeah, this has been a very exciting last year, actually, for atrial fibrillation treatment, and there have been several advances in technology. One thing that we can offer patients is, atrial fibrillation ablation, which is a procedure where we, basically go into the heart and find the trigger or the as I say, sometimes a spark plug or match that starts the atrial fibrillation and make it so that can't occur any longer.

The most common cause of atrial fibrillation is actually extra beats coming from the pulmonary veins or the veins that bring blood back from the lungs. And the procedure has, really rapidly evolved over the last 10 years and fortunately has become a much safer and faster procedure, with better results and over the last year, some of you may be aware of a new technology called pulse field ablation, which uses a high frequency, high energy signal to make it so those veins that come back from the lungs can't fire anymore and therefore can't cause atrial fibrillation. You may say, well, why does that matter? Traditionally we used either heating or freezing to make it so those veins can't fire. And unfortunately, a lot of the complications that historically could occur during an atrial fibrillation ablation had to do with the burning or the freezing around those veins coming back from the lungs.

And so with this new technology, the incidence of complication or the complication rate tends to be much lower, closer to 1 percent compared to a 3 percent complication rate with the old technology. And thankfully here at Allegheny Health Network, we have access to these newest technologies, that we can use for individual patients. 

Additionally, I'd like to mention another procedure that can possibly help patients get off of oral anticoagulants. And that is a left atrial appendage occlusion, which some people may know as a Watchman Occlusion Device. There are other left atrial appendage occlusion devices as well.

But we also offer that at Allegheny Health Network, and recently, there's actually been a major change with reimbursement from Medicare, which has changed, how we're looking at left atrial appendage occlusion, where previously we could not get reimbursed for left atrial appendage occlusion at the time of atrial fibrillation ablation.

However, that was actually changed this past fall, where Medicare will now reimburse for left atrial appendage occlusion at the time of an atrial fibrillation ablation. So, this has changed how we're looking at left atrial appendage occlusion on two respects. One, if a patient needs a left atrial appendage occlusion device, it leads to the question of should they also have an atrial fibrillation ablation at the time of their occlusion? And then, same thing for those who are undergoing an atrial fibrillation ablation. There are some of those patients who are high risk for bleeding that we now have to consider doing a left atrial appendage occlusion at the same time as the atrial fibrillation ablation.

We're really glad that this decision has been made so that we can provide the best possible care for patients when doing these procedures that require access to the left side of the heart, it only makes, it makes so much sense to be able to do the left atrial appendage occlusion at the same time as an atrial fibrillation ablation.

Host: Well, while we're speaking about that, tell us about the quality and safety of the care you provide. And many of your initiatives have resulted in improved efficiencies, which allows decreased wait times for procedures, and you participate in the Real AFib registry, tracking your patients. Tell us a little bit about that.

Joshua Silverstein, MD, FHRS: Yeah, so many of our efforts at Allegheny Health Network and the Mario Lemieux Center for Heart Rhythm Care, our focus on improving patient care and doing the very best we can for every individual patient and treating them as we would our family members. A lot of those efforts have occurred on the inpatient setting and in our electrophysiology lab and making sure that we provide both safe and effective care.

We participate in multiple registries including the Real AF Registry, which has resulted in dozens of publications over the last five years. And most of these publications are focused on improving the care that we provide patients. We pay very close attention to how we treat every patient.

We track outcomes, success rates, complications, and we learn from every patient we can, to make the experience better going forward.

Host: And as you treat your patients like family and you're unified in your goal to provide the best patient care you possibly can, tell us a little bit about your team and the multidisciplinary approach, why it's so important for these patients.

Joshua Silverstein, MD, FHRS: As we like to say, we're only as good as the last person on the bench and with our team, we're blessed to have an amazing team of not only our physicians, but our physician assistants, our nurse practitioners, the nurses, the schedulers, the device clinic staff, it goes from the physicians all the way down to everyone else in the program.

And we're very fortunate to have a collaborative team. We work together. We pride ourselves on taking care of patients quickly, answering their questions and concerns, and providing the best possible care that we can.

Host: What about community physicians and referring physicians, Dr. Silverstein? What can they expect as far as communication with them after referral?

Joshua Silverstein, MD, FHRS: It's very important to have communication with the referring physicians. And another important thing is to make sure that patients return to you, and hopefully, in better shape than when you sent them to us. And of course, if we have any issues along the way, our goal is to provide the best possible communication about what those issues may have been, and to make sure that patients end up doing very well. And it has to be collaborative, not only with our team, but with the referring physicians.

And so I, think it's very important, that we work closely together with those that are referring the patients to us.

Host: Dr. Silverstein, as we wrap up, please let other providers know what you'd like the key takeaways to be from this episode we're recording here today. What's your vision for the program and how do you feel that all of these exciting advancements are going to improve the way patients receive their care? 

Joshua Silverstein, MD, FHRS: I think going forward, it's just such an exciting time for treating patients with atrial fibrillation, with better and more effective treatments than we've had historically. And we pride ourselves on providing access to care, that we get patients in in a timely manner. And then from the time we see them until getting the procedure, trying to make that as short as possible and doing it as safely as possible.

We also here at AHN, have all the cutting edge technologies to offer patients. And a team that can do it effectively and collaboratively. And one of the greatest strengths of our team is that we work together, and we will do everything we can to get the best possible result, in any individual case.

And I think that's something that really sets us apart from other groups. 

Host: Well, it certainly does. Thank you so much, Dr. Silverstein, for joining us today and to learn more or to refer a patient to Dr. Silverstein at AHN, please call 844-MD REFER or you can visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network. I'm Melanie Cole.