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 going beyond arrhythmia management, what referring physicians should know about AHN Electrophysiology.

Joining me is Dr. Mati Friehling. He's the Director of Electrophysiology at Forbes Hospital at AHN. Dr. Friehling, thank you so much for joining us today. As we think about the state of electrophysiology today, it's evolved rapidly over the last several years. What are some of the most exciting and significant advances that you're seeing in heart rhythm management, and how is AHN bringing those innovations to patients?

Dr. Mati Friehling: Oh, well, thanks, Melanie, for having me. And you are right. EP, electrophysiology is a really a rapidly evolving field. We are technologically heavy. So as things advance with computers and different technology, EP is oftentimes at the forefront of that.

So, in general, we have two different broad categories of procedures that we perform. First is a procedure called an ablation. We do ablations for all different types of rhythm issues, usually for fast heart rhythms, atrial fibrillation, SVT, ventricular tachycardia. And then, we have our other broad category of procedures involving device implants, pacemakers, defibrillators, other types of cardiac rhythm therapies.

And there are a ton of changes. A lot of things have changed over the years since I've been in practice. And we can certainly talk about some specifics as we move along here.

Melanie Cole, MS: Well, I definitely would like to do that, and thank you for that. When we think about those new procedures and technology at AHN, you were an early adopter of several advanced electrophysiology technologies. So, speak a little bit, expand for us on the pulsed field ablation and fluoroscopy-free electrophysiology, what those advancements mean for patients and for referring providers. Tell us a little about the benefits for both the physician doing these and for the patients.

Dr. Mati Friehling: That's great. I think that it is very exciting for both physicians and patients to be involved with these new technologies. Specifically, pulsed field ablation is a relatively new type of ablation technique that's used for the procedures that we do every day. We've been doing ablation procedures for a long time. Historically, the energy that we used to perform the ablation was either using thermal or heat energy. Sometimes we would use cryo or cold energy. And in the end, we're trying to target and destroy abnormal electrical signals in the heart. This new technology, pulsed field ablation, is a way for us to still accomplish the same thing in a way. We are still trying to destroy abnormal cells in the heart. The difference is that this is not a technology that uses heat or cold. So, it's a really a non-thermal-based ablation. And what that means for patients is that we are delivering high-voltage energy, electrical energy to specific areas of the heart to target those areas and destroy those abnormal electrical signals.

And the idea is that because it's not heating or cooling, it's going to be safer. We are not going to have damage to structures around the heart. So, we have essentially eliminated some of the risks of AFib ablation, which in the past have included damage to nerves around the heart. The phrenic nerve was something that we were always concerned about, the nerve that goes to the diaphragm. And the esophagus actually sits right behind the left atrium, and the left atrium is the location where atrial fibrillation often is triggered.

What we can do now when we offer patients ablations, and we are doing ablations for something like atrial fibrillation, we are now delivering that electrical energy that is high voltage enough to destroy specific cells in the heart, but it's not affecting structures around the heart. So, it's not affecting the esophagus, not affecting the phrenic nerve. So, it's safer.

And the second huge advantage of these technologies is that it's faster as well. So when we deliver a lesion with one of these catheters, we are really creating a pretty significantly larger lesion size. And so, we can do less ablation lesions to accomplish the same thing.

I mean, going back, when I was a fellow in 2011, 2012, it would take us four hours or longer sometimes to do an ablation for atrial fibrillation. I mean, if we have a very straightforward AFib ablation now, we can do it in under an hour, sometimes as fast as 40, 45 minutes.

And so, that means, number one, we can improve patient access to these procedures, because we can accomplish more in a day, so patients don't have to wait as long for a procedure. And again, it's safer for the patients. And because they're faster, they're under anesthesia for a lot less time. And when they wake up, they feel better. They're not having the same side effects of being under prolonged anesthesia. Obviously, we're using pulsed field ablation for more than just atrial fibrillation ablation. We're using it for ventricular tachycardia procedures. It's really a huge game-changer for electrophysiology.

And I'm actually excited that I have the opportunity to use it. And at AHN, we were very early adopters of this. We have a lot of experience using this technology. We also have multiple different vendors for this technology. So, there are multiple companies that make the catheters that are used for pulsed field ablation. And we are very lucky at AHN to be able to use the catheters from different companies and use the one that we think is most appropriate for the patient.

And I can tell you that other systems, even in this area, don't necessarily have access to more than one of the different types of catheters. So, we are lucky at AHN to have that opportunity.

Melanie Cole, MS: Isn't that amazing? This is really an interesting discussion, and what an exciting time in your field. So, I'd like you to expand on what you were just saying as you were early adopters of all of this really advanced technology. What makes AHN Electrophysiology Program different? For a referring physician, Dr. Friehling, evaluating their options for their patients, what distinguishes the AHN Electrophysiology Program from other programs in the region.

Dr. Mati Friehling: I think that we have a lot of things that differentiate our group. We currently have eight electrophysiologists as part of our group. I can tell you that we all work very closely together. We have a very good relationship amongst all of us. I think that our program is probably one of the most cohesive programs even throughout the country, I would say.

We are always able to bounce ideas off of each other. If we have a challenging case or we see somebody in the clinic that may pose a challenge, we are always able share that with the rest of the group, get different opinions and come up with a good solution for each patient individually.

So, I think that that's one thing that really does differentiate us. We work very well together. We as a group have a ton of experience with all of these procedures. I don't know the exact numbers. I know that we are performing amongst the group over three thousand procedures a year. We have a lot of experience with all of the different types of ablations and device implants.

And because we have a high volume of procedures, that is actually what allows us to gain access to some of this technology earlier than other places, because the companies that create these technologies want to be able to bring it to a group that is going to use the technology and see the benefits. So, the fact that we do have a high volume really gives us access to some of these technologies that other places don't have.

I think another big differentiator for us is our research program at AHN. We have a pretty significant group of dedicated research staff that helps us start research projects be part of bigger research projects get our research published. We have a lot of homegrown research where we have investigator-initiated research studies, and we also are part of multi-center clinical trials. So, the research arm of our group is pretty robust and, you know, we've been lucky to receive funding from the Mario Lemieux Foundation. And this has allowed us to accomplish even more. And it's been really great to be a part of that.

Melanie Cole, MS: Dr. Friehling, I'd like you to tell us about the importance of multidisciplinary cardiovascular care as far as the importance, and you've told us all about the technology and the high procedural volume and the unique qualities at AHN. Tell us a little bit about the importance of access to complex ablation and device therapies, clinical trials, innovative treatment options, and the collaboration that's so important with these referring physicians throughout the patient journey.

Dr. Mati Friehling: I would say that because we work really well as a group, that actually significantly improves patient access to care. If we were all competing against each other, which we are not, that creates an environment where certain providers may have a backlog of referrals to those specific providers, and other providers may not have as much of a referral base.

And because we all work really well together, if there's a patient that needs to be seen, we get them in immediately. I can tell you that I personally will see a patient within a day or two, especially if there's a primary care provider or a cardiologist that tells me, "Oh, I have a patient that more urgently needs to see an electrophysiologist." We have the ability to get those patients appointments very quickly. It may not always be an in-person appointment. We are doing a good amount of telemedicine visits, which really does improve access to care.

And by doing these telemedicine clinics, we're able to see patients very quickly. And because, again, the technology has allowed us to improve the efficiency of what we do, we're able to get these patients in for their procedures very quickly as well. It's pretty routine that we can see somebody and schedule them for a procedure within a few weeks. Especially if it's more urgent, we can even do it faster.

This is something I don't think other providers in the area are able to offer as well. Just the patient access to the care at AHN is great. I mean, I think our team has done a really good job with that. There's always room for improvement and things, but I think that we have a very good system set up currently.

Melanie Cole, MS: Yeah, that's so important. And Dr. Friehling, one thing we haven't covered. And one of the questions that we hear frequently from community providers is when they should refer symptoms, diagnoses, patient scenarios, because oftentimes they are the first line that the patient will see. Tell us a scenario that should prompt that earlier referral to electrophysiology.

Dr. Mati Friehling: Yeah, I think that some of these things are a little bit different between primary care providers versus cardiologists. Obviously, I think most of our referrals come from cardiologists, but we still obviously get primary care physicians sending us patients. It's something that doesn't necessarily need to see a cardiologist first.

So, I would say that a huge part of our practice, just because of the volume of patients with this arrhythmia, essentially, is atrial fibrillation. And atrial fibrillation, given that it's the most common rhythm issue that people are having, this is definitely the biggest type of referral that we're seeing.

And I think that it is very appropriate to send a patient to an electrophysiologist, even with a new diagnosis of atrial fibrillation, if they are younger, if they're having recurrent episodes of atrial fibrillation, if they're symptomatic. These are patients that we do want to see because the earlier you treat atrial fibrillation, oftentimes the more success you have with procedures like the ablation.

Any time a patient has a documented, you know, arrhythmia like AFib or super ventricular tachycardia or SVT, we have ways of treating them from an electrophysiology standpoint with ablations and other types of advanced anti-arrhythmic therapies that we do want to see those patients.

I mean, really, any symptomatic a documented arrhythmia, I think is appropriate for us. We do like people to get some testing, you know, and even if the referring provider wants to get some of these tests first, it would be very helpful. Like, an echocardiogram is something that we almost always get or, you know, a Holter monitor. You know, having some information gathering, and then sending the patient to us works very well.

And then, on the flip side of that, obviously, we have the referrals for patients who need specific devices like a pacemaker or a defibrillator. I would say if somebody has symptomatic bradycardia, their heart rates are really slow and they're feeling terrible, we want to see those patients. We can help them with devices. So, I would say that gives a good idea of which patients we think are appropriate. You know, essentially, symptomatic patients who have an arrhythmia can be a great referral to electrophysiology for us to help them.

Melanie Cole, MS: Dr. Friehling, we've discussed so much. And if you were to look ahead in the future of heart rhythm care, which developments in electrophysiology are you most excited about? How do you see patient care continuing to evolve? And I'd like you to offer your best advice here. What's one thing that you would like every PCP or cardiologist to know when they're referring patients for electrophysiology care?

Dr. Mati Friehling: The first part of that question, I can say that the future right now in the immediate term, you know, who knows what happens down the road in 10, 15 years. But I think the biggest innovation coming now is probably in the form of a leadless pacemaker therapy.

So right now, we do have leadless pacemakers, little devices that we can implant in the heart that don't require a pacemaker box, that don't require making an incision. I mean, it's all done through the groin into the vein. But those devices still have a ways to go. They're not exactly where I think we want them to be yet. So, I think that's where the future is right now, at least in the pacing side of things. It's going to be improving the leadless pacing technology and delivery systems.

The other huge area really to expand is still with pulsed field ablation and just improving the tools, changing the tools, having pulsed field ablation catheters that not only deliver the electrical energy but can do both. They can deliver electrical energy, and they can deliver heat energy. So, those dual energy catheters are going to be pretty exciting.

And I think something for the primary care physicians to know about referring to AHN is that we have access to really all of the technology. I mean, there isn't something that we don't have. We are able to take care of everything. And I think that remembering that we do have very good access to care and we are able to get patients in very quickly is sort of a, you know, another take-home point for the referring physicians.

Melanie Cole, MS: Thank you so much, Dr. Friehling, for joining us today and really sharing your incredible expertise and the exciting time in electrophysiology at AHN. Thank you so much. And to learn more or to refer your patient, please call 844-MD-REFER or visit findcare.ahn.org. Thank you so much for joining us on this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.