Dr. Mike Smith (Host): This is Memorial Health Radio with Memorial Health System - Ohio. I'm your host, Dr. Mike. Dr. Maninder Bedi, an electrophysiologist joins me as we discuss the future of atrial fibrillation treatment using FARAPULSE pulsed field ablation. Dr. Bedi, welcome to the show.

Dr. Maninder Bedi: Thank you, Mike. Thanks for having me.

Host: So, what is a pulsed field ablation? Why are we so excited about this?

Dr. Maninder Bedi: It's a good question. Atrial fibrillation is something of a pandemic right now. A lot of people we are seeing with atrial fibrillation until 10 years ago, we did not have any way to fix atrial fibrillation or to do a procedure called an ablation.

So a few years ago, maybe 15 years ago, we started doing AFib ablations to cure people from atrial fibrillation. And the success rate of that is around 90%. And we were using technology called radiofrequency ablation, which we went into the heart and we burnt heart tissue at a certain temperature. And over 10 years ago, we started using something called cryoablation, where we used the freeze technique and we were freezing the tissue in the heart to cure them from atrial fibrillation.

A year ago, pulsed field ablation came out and the pulsed field ablation system has been groundbreaking. And most of my colleagues in the country have switched to it, almost 80% of them switch to pulsed field. The advantage of pulsed field is that it gives targeted electrical jolt to the cells in the left atrium where the atrial fibrillation comes from. And the technology over the last year has been very safe. Before, the procedure time used to take maybe 90 minutes to 120 to do. With pulsed field, we are actually at half that time. But the most important thing for patients is that the complication rate went down from almost 2.5% to 0.7%. So, the complication rate going down and the success of the procedure from what we see is exactly the same. But once the procedure is done, it takes an hour for the whole process to happen, patients don't have many symptoms of pain or they don't complain of any symptoms. Postoperatively, they go home the same day. So because of this new technology that we are able to treat patients more effectively and actually more safely. And because of that, the treatment of atrial fibrillation has become much more advanced in the last 12 months than we've had before.

Host: So, it's just as effective, safer, shorter time, less complication. Is that a good summary?

Dr. Maninder Bedi: I think that's actually correct. But I think over the next year, we will notice that it's going to be even more effective, but we don't have the data to suggest that yet. But it is equally effective and safer, quicker, and better for the the patients. That's correct.

Host: When it comes to ablation or pulsed ablation system we're talking about, there must be some training on this. So, is there extra training that physicians like you would go through?

Dr. Maninder Bedi: So, I am a cardiac electrophysiologist. So, I treat and deal with electrical system of the heart. I call myself the electrician of the heart. So, what happens is we are already trained to do it, and most people who do pulsed field ablations have to be an electrophysiologist, which I am. And also, we have to have been doing atrial fibrillation ablations in the the past.

And once we are trained for that, since we've been doing many AFib ablations, basically the procedure the same, the technology is different, so we have to to a few training classes for a couple of days and then start doing it. But it's pretty intuitive. This procedure is pretty intuitive. It does not require much training. I mean, we're already trained in electrophysiology. So for us, it's intuitive. But I think we were very surprised at how quick the adoption was to this technology. Especially in the last twelve months, it has really taken off.

Host: You mentioned about 80%, I think, is what you said your colleagues are using this.

Dr. Maninder Bedi: Yeah, I think 80%, even more. I think, now, from when we we went to a recent Heart Rhythm Society meeting, I think within by the end of the next few months, it's going to be a 100%. Most of the physicians want to use pulsed field. I think 80% have acquired it in the hospital. And little by little, our colleagues are all getting it all over the country.

Host: There are different types of AFib. Is this type of ablation specific to a type of AFib or is it good for all the different ways we categorize AFib?

Dr. Maninder Bedi: So, atrial fibrillation is very interesting. We categorize it in different forms. The forms we categorize them depends on how long you've had AFib. So, we categorize them as paroxysmal, persistent, or chronic. One thing we've realized over the last 15 to 20 years, the longer you're in atrial fibrillation, the success rate of atrial fibrillation ablation is much lesser.

So, we try to capture the patients when they're early in their atrial fibrillation so we can ablate them because the earlier we see atrial fibrillation, there are less changes at the cellular level. So when we ablate, we don't have to ablate a larger area in the left atrium where the atrial fibrillation comes from, and our success rate is much higher.

But is anybody a candidate for an ablation? The answer is yes. It doesn't matter what kind of atrial fibrillation you have, we can ablate either paroxysmal, persistent or chronic atrial fibrillation depending on the duration. We can ablate any atrial fibrillation. The success rate depends on how long have you had atrial fibrillation. So, the earlier we catch the atrial fibrillation, the earlier we ablate it, the success rate is over 90-95%.

Host: Wow, that's pretty impressive. I know you have mentioned that with this type of ablation that the complications have gone down, which is great, but what are still some of the risks or side effects that you do see with this procedure?

Dr. Maninder Bedi: So, you know, anytime you go into the heart, there's going to be a complication. The biggest complication we worry about when we go into the heart is bleeding. We worry about strokes. But when we use the other technology, we are worried about injuring the nerves, which go to your diaphragm. We are worried about the esophagus heating up or cooling too much.

So with this new technology, we don't see any damage to the ancillary structures. There's no damage to the esophagus. There's no damage to the phrenic nerve, which is the nerve which supplies your diaphragm and helps you breathe. The complication rate really went down from 2.5% to-- I think the data suggests 0.7%.

The last year, from our experience, we really have not seen any major complications, which we categorize as stroke or having a heart attack or having a bleed in the heart. We have not seen any of those complications. Can they happen? Absolutely. But the data has been suggesting that it's been very minimal. And a lot of times when we do an ablation and when we ablate before, people would complain of a symptom called pericarditis, which is an inflammation around the heart side because when we apply it, we create some inflammation. We haven't even seen that happen in patients. So, the patient satisfaction after the procedure and quality of life has significantly improved since this procedure.

Host: I would assume the pericarditis or the inflammation, that probably clears on its own pretty quickly or with some minor treatment, right?

Dr. Maninder Bedi: That's correct. Even if you do have pericarditis, you just give them some anti-inflammatories. Usually within one week, it goes away. So, that's correct.

Host: Can you review the recovery time again with this?

Dr. Maninder Bedi: So when we do a pulsed field ablation, you know, we bring the patient to the hospital, we put them to sleep. We prefer to use general anesthesia, then we go through the leg into the heart and make a tiny hole go to the back and we do the ablation. The whole process may take around 40 to 45 minutes. Within an hour, the patient is extubated. They're out in their room. And depending on physicians, within four hours, we send them home.

Host: Okay. Very nice. So now that you've been doing this for a while now and we have more electrophysiologist doing this procedure, are we able to start gathering some of the long-term benefits now?

Dr. Maninder Bedi: Yeah. So, they've already had data long-term saying it's very safe, the technology is very safe. Now, I think, since we've been doing it since April of last year. In the recent one year data, they said that the effectivity, or if you do an ablation, the success rate is almost over 90% and the complication rate over one year-- in real-world data, right? We have to see it in real patients, even though they come out in studies saying they're safe. In real-world data, we are noticing that it actually matches the research data and our complication rates are very low. Success rate right now from six-month data said that it is almost 90 to 94% of the ablation being durable. So now, we should have a couple of years data over the next few years. But real-world data is matching the research data that they've done studies for the last 10 years.

Host: Very good. You've already kind of touched on this a little bit, but I kind of want to go back to it. We mentioned that there's different types of AFib based on how the length of time of the disease. How does a patient know? Like, how does a patient know that-- if they're listening to this, this sounds good, I'm interested, how do they know if they're a good candidate?

Dr. Maninder Bedi: So, most of the people who come to us who have atrial fibrillation are symptomatic, right? When I define symptoms, they can be short of breath, they can be tired. They probably have seen their cardiologist and they've had atrial fibrillation. Some of them have been shocked back at rhythm, and some of them have gone back to rhythm on their own, or they've been put on antiarrhythmics. So most of the time, the cardiologists decide to send the patients to the electrophysiologist to look at advanced therapies for atrial fibrillation.

I think, the key word here is symptoms. Most patients are symptomatic with their atrial fibrillation. And if you let atrial fibrillation continue for a long time, they can develop congestive heart failure. And the one main worry is they can have a stroke. They can also have something called cardiomyopathy, which is a weakening heart. So, all these symptoms come into play depending on how long they have atrial fibrillation. So, the cardiologists send them to us. And then, we kind of talk to the patients and design a plan for them regarding an ablation or they want to take medications.

But right now, atrial fibrillation ablations, because of how effective ablations are, has almost become first line therapy for atrial fibrillation. Five to six years ago, they used to tell us that the guidelines would state that you have to fail an anti-arrhythmic before we do an ablation. Now, most people are reaching to an ablation. And I mean case in point, if you tell a young patient who's in their 50s that you have to take a blood thinner for the rest of their life, they would rather do an ablation than take medication. So, I think because of that, a lot of patients, at least the patients we see, prefer to get an ablation so they can get off medications also.

Host: Yeah. Makes sense. This was fantastic, Dr. Bedi. Thank you so much for coming on the show today.

Dr. Maninder Bedi: Thank you, Mike.

Host: For more information, you can visit mhsystem.org and connect with the provider who can help. If you enjoyed this episode, please share it and explore many other Memorial Health Radio podcasts. You've been listening to Memorial Health Radio, and I'm Dr. Mike. Thanks for listening.