Amanda Wilde (Host): AFib or atrial fibrillation is a long-term condition, but the good news is that you can continue to lead a long and active life. We'll dive into AFib basics, symptoms, and the exciting treatment options available with attending physician in Cardiology and a cardiac electrophysiologist, Dr. Gregory Cunn. This is Maimo MedTalk. I'm your host, Amanda Wilde. Dr. Cunn, thank you for being here.

Dr. Gregory Cunn: All right. Thanks so much for having me, Amanda.

Host: It's great to have you here to talk about this. Can you start by explaining what atrial fibrillation or AFib is for those who might be unfamiliar with the condition?

Dr. Gregory Cunn: Atrial fibrillation, or we shorten it for AFib, is by far and away the most common arrhythmia that we see, particularly as patients get older. And basically, what it is, is an abnormal heart rhythm that originates from the top chambers of the heart. Now, normally, the top two chambers squeeze and the bottom chambers squeeze, the top two chambers squeeze, the bottom chambers squeeze. That's how the heart functions in normal rhythm.

When people are in atrial fibrillation, the top chambers beat very, very fast and erratically due to abnormal electrical signals, and that causes the rest of the heart to beat abnormally and erratically. And this causes the heart to beat quite inefficiently. That's basically the basics of AFib, and that's what we see when patients come into the office, is that their heart is beating very erratically and irregularly.

Host: I was going to ask, what are some of the common of AFib that patients should look out for? Obviously, if your heart is beating in a thready way like that, and you can tell it's speeding up, that's one symptom. Does that also cause fatigue or are there other symptoms we should watch out for?

Dr. Gregory Cunn: The symptoms can be as overt as very severe palpitations. They feel their heart racing very fast. But a lot of times what we see is symptoms are a little bit more insidious and not as obvious, things like fatigue or exercise intolerance. So, a lot of times patients who were able to walk five, six, or even 10 blocks, now all of a sudden, over the last few months, they can only walk one or two blocks before they have to stop and take a breath.

Now, they can only walk up one flight of stairs. Before they used to walk up two flights of stairs. So, a lot of times, that's usually more than presenting symptoms, fatigue, exercise intolerance, but other times patients have severe palpitations where they feel like their heart is racing as well.

Host: Who is most at risk for developing AFib?

Dr. Gregory Cunn: It's by far and away more commonly seen in older patients. So, as people get older, the risk of developing AFib goes up, and somewhere on the order of about 15-20% of people over the age of 75 will have atrial fibrillation. So, it's very common. However, we also see it in younger patients as well. We call this lone AFib. Patients in their 30s and 40s who have severe palpitations, they come in, a lot of them have atrial fibrillation as well. Patients who have high blood pressure, patients who are obese, diabetes, sleep apnea, all of these comorbidities put you at risk for atrial fibrillation.

Host: So, there are some lifestyle elements here that you can control.

Dr. Gregory Cunn: Yes. There are some risk factors you can control. There is a genetic component to it as well that we can't control. Females are a bit of a higher risk as well. So obviously, you can't control that. So, gender plays a bit of a role. And age, obviously, we can't control that. But other things like high blood pressure, obesity, sleep apnea, these are modifiable risk factors is what we call them, that we can control to potentially prevent the development of AFib.

Host: You mentioned that the symptoms of AFib are often subtle. So, how does someone know when to go to the doctor?

Dr. Gregory Cunn: Sometimes they don't. And a lot of times this is picked up routinely on an EKG done in your primary doctor's office or in the general cardiologist's office if you're seeing them for something else. A lot of times patients will catch it on a home monitor. So when they take their blood pressure, some of these home monitors will tell you if you have an irregular rhythm, or a lot of people have Apple watches now or any sort of smartwatch. And a lot of times that will also pick it up as well. So, there are methods to sort of picking this up if you're not completely symptomatic.

But that is one of the issues that we're seeing is that we see people coming in and they've had AFib for we don't know how long and they just didn't know it. So, this is why we're trying to do things like this to get out the word and educate people, to keep an eye out for subtle symptoms like fatigue and exercise intolerance that may be a sign of underlying AFib.

Host: And how does your field of electrophysiology play a role in treating AFib?

Dr. Gregory Cunn: This is of main things that we treat as electrophysiologists. We're basically the electricians of the heart and we deal with abnormal heart rhythms, AFib being the most common one. Now, the treatment approach is sort of a two-pronged approach, and I'll sort of go through how we approach treating AFib.

 First, we deal with the arrhythmia itself, so the actual atrial fibrillation. The treatment for this has sort of shifted over the last few years. The paradigm has sort of shifted. Ten years ago, we would get patients who were in atrial fibrillation and would just say, "Okay, not a big deal." As long as your heart rate isn't going too fast, we didn't really care too much about getting you back into a normal rhythm. That has shifted, however. Nowadays, we realize, with good data, that getting you back into a normal rhythm and out of atrial fibrillation is much better in the long-term. It keeps people out of the hospital. It helps with their heart function. And potentially, it may make them live longer.

So, the way we do that, the way we get them out of atrial fibrillation, is with something called an ablation. And what an ablation , is it's a procedure where we put catheters into the groin, we go up into the heart, we find where these abnormal electrical signals are coming from, and we get rid of them.

Host: Well, how do you get rid of them? What is the ablation?

Dr. Gregory Cunn: There's a few different modalities. One where we use heat energy. So, we go up with a catheter and we go inside the heart in the top left chamber of the heart. That's where atrial fibrillation comes from. The abnormal electrical signals that cause atrial fibrillation come from this top left chamber of the heart. We put our catheter up in the top left chamber, and we deliver heat energy to the tissue to basically burn or cauterize the tissue to get rid of those abnormal signals. That's one way to do it.

Another way to do it is with freezing. So, we're using cold mechanism. We actually freeze the tissue to destroy the abnormal electrical signals. And the newer technology, which is what we use now, is something called, big name called electroporation. Basically, that's a fancy way of saying we put electrical field or electrical energy into the tissue to destroy the tissue, and that has become much safer. The procedure takes only about an hour, an hour and a half to do. It's quite safe. Patients come in and they leave the same day. It's an outpatient procedure, and the risks are quite low with the procedure, and it's quite effective. About 80-85% of people who get this procedure do not have any more atrial fibrillation at about one year. So, it's a very effective procedure. It's very safe. And we know that getting people back into a normal rhythm is much better for them long-term.

Host: Because they won't go further into atrial fibrillation. If you catch it early, you're saying it may go away entirely.

Dr. Gregory Cunn: That's right. So early treatment important. And again, sometimes, Patients come in and they've been in AFib and they didn't know it, so they've been in AFib for some time. And that makes our job a little bit harder, because the longer you are in AFib, the harder it is to get you out of AFib, and the less successful these procedures become.

Host: So, this newest procedure for ablation, is that a treatment option that's available to patients right now?

Dr. Gregory Cunn: Yes. This is what we do in our hospital here. That's what I do. It's called PFA or pulse field ablation. And again, it delivers electrical fields to the tissue from the inside to destroy that abnormal tissue without affecting the structures surrounding the heart. The issue with some of the older modalities, older technologies, is that you can imagine if I'm delivering heat or freezing energy inside the tissue, the tissue is quite thin, so that can affect the surrounding structures like the esophagus, the food pipe, the lungs, the nerves that surround the heart. However, this new technology is very specific for the heart muscle itself and the heart tissue, so it only destroys or damages the abnormal signals in the heart muscle without affecting the surrounding structures, making it much safer for patients.

Host: So, you said there's been a paradigm shift and this is part of it, catching things early and then this new effective technique has been developed. Is there any downside to that?

Dr. Gregory Cunn: To the procedure itself?

Host: Yes

Dr. Gregory Cunn: Yeah. I mean, there's risks to any procedure we do. The risks with this procedure are quite low. All in all, to give a number on it, the risks of the procedure are probably about 1%. And that includes damaging the blood vessels in the groin where we put catheters in. Obviously, we're moving catheters inside the heart. So, there's also a risk of damaging the heart muscle itself. But again, this is all done with all new technology. We're visualizing ourselves live within the heart using an ultrasound. We have 3D mapping systems that allow us to see exactly where our catheter is within the heart. So, we have all this new technology to make things safer and more effective. And the procedure has become markedly, markedly safer and much more effective for patients.

Host: So, newer technology means more information for you and fewer side effects for patients. Since this seems to be an evolving field, looking into the future, what advancements do you see on the horizon in cardiac electrophysiology?

Dr. Gregory Cunn: That's one of the nice things about this field is that it's constantly changing and there's constantly innovation. PFA is relatively new. This pulse field ablation, this newer ablation technology is relatively new, so we're sort of excited to see where that goes in treating other arrhythmias other than just atrial fibrillation. But the good thing about this technology is that, as it is now, patients are intubated and it's done under general anesthesia.

 Probably within the next few months to six months, we will actually start doing this under just sedation, where patients don't even need to go under general anesthesia anymore. So now, not only are you making it safer in terms of the procedure that I do, but not having to go under anesthesia, you take away all the risks of general anesthesia as well. so this procedure is becoming much safer, much quicker, so now patients don't have to be under sedation for a long time or be under anesthesia for a long time, taking away those risks, and not have to be in the hospital for as long.

So, all these things are sort of moving towards a faster, safer treatment option for AFib. Ten years ago, this procedure took probably about three, three and a half hours to do, and patients would stay overnight, one or two nights. Now, this is done probably about an hour, an hour and ten minutes, and patients go home the same day. They're out of the hospital within a few hours after the procedure. So, it's been a real shift in terms of the efficiency, and the safety of the procedures that we do.

Host: Dr. Cunn, thank you for enlightening us today on the management of atrial fibrillation and bringing us up to date on these new developments.

Dr. Gregory Cunn: Of course. Happy to do it. Thanks for having me.

Host: That was attending physician in Cardiology and a cardiac electrophysiologist, Dr. Gregory Cunn. Thank you so much for joining me today on Maimo MedTalk. I'm your host, Amanda Wilde. For an appointment with our cardiac team, call 718-283-7693. For more information, follow us on social @MaimoHealth or visit maimo.org. If you found this Maimo MedTalk podcast helpful, please share it on your social media channels and to hear additional episodes of Maimo MedTalk, please visit maimo.org.