Joey Wahler (Host): This podcast is for informational purposes only, and not intended to be used as personalized medical advice. 

It treats abnormal heart rhythms, so we're discussing Cardiac Electrophysiology. Our guest, Dr. Fima Macharet. He's a Cardiac Electrophysiologist with Skagit Regional Health. This is Be Well with Skagit Regional Health. Thanks for joining us. I'm Joey Wahler. 

Hi there, Dr. Macharet. Welcome.

Fima Macheret, MD: Good morning, Joey. Thank you for having me.

Host: Oh, great to have you aboard. We appreciate it. So first, what in a nutshell does a cardiac electrophysiologist, also sometimes called an EP, do? And what made you choose to be one in the first place?

Fima Macheret, MD: Yeah, a cardiac electrophysiologist deals with the heart rhythm or the heartbeat that we all have. We specifically deal with heartbeats that are too slow, too fast or abnormal. I chose to be an electrophysiologist because I learned about the procedures that we do that can restore quality and quantity of life to people's lives.

Host: That's awesome. And so what's the training path to become a cardiac EP?

Fima Macheret, MD: We train first in undergraduate, then medical school and then internal medicine residency, followed by cardiology fellowship, followed by a two-year electrophysiology fellowship just devoted to electrophysiology procedures. I actually spent an extra five years doing internal medicine and clinical informatics in between my internal medicine and cardiology fellowship.

Host: And I guess it's safe to say, isn't it, Doc, that a healthy heartbeat, a regular one, if you will, is something most of us take for granted until it's irregular, right?

Fima Macheret, MD: I think that's exactly right. We have a heartbeat about once every second, thousands of them throughout our life. And most of the time, ideally, we don't notice them. It's when we start to notice them that could be a signal that there's actually something wrong.

Host: Right. So, speaking of which, can you describe for us the heart's electrical system and what happens when it malfunctions?  

Fima Macheret, MD: Absolutely. This is one of my favorite conversations to have with patients. Every heartbeat, the one we have every second, starts in a cluster of cells in the upper right chamber of the heart, called the sinoatrial node. It's also known as our own pacemaker cells. Under the influence of the nervous system that can speed up or slow down the heart rate; that cluster of cells releases a signal or an electrical wave front that travels through the upper chambers to the middle of the heart where it quickly travels down the bottom pumping chambers of the heart, the ventricles, and causing them to squeeze at exactly the same time.

Host: And so what happens when that malfunctions?  

Fima Macheret, MD: The signals can be blocked or not travel to their downstream destinations. That can lead to everything from a single skipped heartbeat to asystole, not having a heartbeat at all. Some of those signals can get stuck in certain short circuits and can then cause really fast abnormal heart rhythms to occur.

So rather than a nice, normal, linear progression through the heart, those signals can not make it through or get stuck in other places.  

Host: So you just touched on it there. Tell us, if you would, a little bit more about some of the more common conditions you treat.  

Fima Macheret, MD: One category of them are the bradycardias or the slow heart rates. So that's where those pacemaker cells, or the cells down below them that send signals to the lower chambers, don't function. So the heart rate is too slow or beats are skipped. The other side of it are fast and abnormal heart rhythms, that includes tachycardia’s, whether that's in the upper chambers called supraventricular tachycardia, or in the lower chambers called ventricular tachycardia. Those are the common slow and fast heart rhythms that we treat.

Host: Which makes me wonder, what would typically cause a slower than normal heart rate as opposed to a faster one?  

Fima Macheret, MD: The slow heart rhythms, when they're due to dysfunction in those pacemaker cells or what's called the atrioventricular node down lower in the heart, those can be due to aging, genetics, cardiovascular risk factors, coronary disease, all the usual suspects that we see for other problems in the heart can also lead to those.

Fast heart rhythms or tachycardia’s have a wide variety of causes. Everything, from aging and genetics to our own predispositions, to arrhythmias, to coronary disease and scar tissue in the heart from viral infections or prior heart attacks. Or ongoing inflammatory diseases can also drive the heart rate up.

Sometimes the heart rate is elevated in a normal response that's called sinus tachycardia. If I'm going to run up the stairs, I'm going to need a fast heart rate. But all the rhythms that I deal with are more abnormal responses and not the normal ones.

Host: And so, what are the typical symptoms of an irregular heartbeat and what should someone do if they experience it?

Fima Macheret, MD: The most common symptoms that we see are fatigue, dizziness, shortness of breath, chest pain, palpitations, loss of consciousness or syncope, fainting. All of those can happen with both slow and or fast heart rhythms.

Host: And so, if experiencing that, people should do what?  

Fima Macheret, MD: It usually depends on how quickly these come on and how people feel. It's never wrong to be immediately evaluated for any sort of heart concern. But commonly, patients will see a primary care physician, urgent care, emergency room or any other type of primary doctor first. Once a diagnosis is made that it's an electrophysiological one, as opposed to any other cause for those symptoms, then patients will be sent to see me.

Host: And when they do, what are some of the diagnostic tools that identify these electrical issues in the heart and how do those work?

Fima Macheret, MD: We typically will get an echocardiogram. That's an ultrasound of the heart. That's where we take pictures of the heart and make sure that it's structurally normal and that it's pumping well, because sometimes electrical problems are actually due to a heart problem rather than the other way around.

We will get an EKG. That's where we put stickers on the chest and we record the heart rhythm for several seconds and see if we can catch exactly what the rhythm disturbance is. We can also put people on a treadmill. Some arrhythmias are worse with exercise and so capturing those on a treadmill can be very effective.

Escalating from there, we can monitor people for periods of time. Most commonly, I order, a 7-day monitor. It's about the size of a silver dollar. It's a sticker that you wear on your chest, and it records continuously for 7 days. If that is unable to catch a really rare heart rhythm that someone's having, we sometimes implant a loop recorder.

It's about the size of a pen cap, and we implant it, in a few minutes just under the skin, and that can record your heart rhythm continuously for several years. We also do advanced imaging, like CAT scans and MRIs. MRIs are really good tests to actually show us whether there's any scar tissue in the heart.

And then, finally, the most invasive is the electrophysiologic study where we actually bring people into our lab. We give catheters through the large veins in the groin that go up to the heart with little electrodes or metal tips at the end that can record the heart signals and point us exactly to where arrhythmias are happening.

There are even more advanced tools, including biopsies, but usually that's not the electrophysiologist at that point.

Host: Gotcha. And to expand on that just a little bit, Doctor, how would you say technology, like wearable devices, plays a role in monitoring and treating these heart rhythm issues?  

Fima Macheret, MD: We've seen an increasing number of patients whose arrhythmias are brought to their attention by wearables. Without naming the brands, there are certain watches and wristbands, even rings that can continuously record so long as the user is actually wearing it.

That's where our implantable loop recorders can catch arrhythmias that might occur when somebody takes their watch off. But otherwise, these devices are often now FDA approved to actually catch abnormal heart rhythms. And so we take the data from them pretty seriously and can often make a diagnosis with them.

Host: And then switching gears just a little bit, there's also a procedure that's used for various things in the medical world, including in yours, in your part of it, an ablation. How does that work?

Fima Macheret, MD: I think more and more people are going to be hearing about ablation because our aging population is increasingly at risk for or being diagnosed with atrial fibrillation, which is the most common arrhythmia worldwide, and is now the leading cause of hospitalizations for heart reasons. It's even surpassing heart failure, which is really amazing, and that wasn't the case 20 years ago.

Ablation is a procedure to eliminate certain heart cells that are responsible for arrhythmias. Historically, this was done with radiofrequency energy, or what we think of as electrocautery. Over time, tools were developed to freeze tissue. And most recently, we're all very excited about a technique called pulse field ablation, where a very short, very high frequency energy burst is delivered from one of these catheters in the heart.

And it actually selectively kills heart cells without injuring any of the nearby tissue. When you use radiofrequency energy, you can be very precise, but other structures can be injured, whereas this pulse field ablation, tends to be very localized to the heart tissue. So, as I mentioned earlier, we put our catheters up into the heart, we identify exactly where they need to go, most often using ultrasound actually in somebody's heart.

And we target our catheters directly to those areas where we ablate or destroy those cells and then we can check our work and take our catheters out and people go home ideally without those arrhythmias. Ablation for atrial fibrillation can be anywhere from 60 to 80 percent or more effective. Ablation for other types of arrhythmias, like supraventricular tachycardia, is on the order of about 95%. So that happens to be a very effective procedure.  

Host: And having said that, what do you think people should know about the capabilities of the cath labs at Skagit? 

Fima Macheret, MD: We are very lucky to have a very advanced electrophysiology lab here. Both my partner and I trained at University of Washington, and have brought all of the latest technology, including pulse field ablation, to the lab here. We do several cases a day. We have a highly trained team, and we're always looking to use the best technology that we can. 

Host: A couple of other things. First, pacemakers. We've all heard of them. Not everybody knows exactly what they are, so what are they and what kinds do you implant?  

Fima Macheret, MD: I'm so glad you asked that question. And in fact, just like my previous answer, for atrial fibrillation, because that is very commonly associated not just with fast heart rhythms, but actually slow heart rhythms because of dysfunction in other parts of the heart. So we're actually seeing a lot more patients with pacemakers than we ever did.

There are two main categories of pacemakers. One is a transvenous pacemaker, which means it goes in the veins. There is a vein that we all have in the chest that runs directly to the heart. And we implant a couple of wires about the size of the inside of a ballpoint pen with electrodes at the end, directly into the heart.

And then we plug those into a battery and we put it under the skin in the chest and we sew it up shut from the inside. There's also another type called a leadless pacemaker. It's about the size of a AAA battery, even a little bit smaller. We can implant that directly in the heart through a catheter through the groin and then take our equipment out and the only thing that remains is that small device in somebody's heart that actually contains both the pacing lead, the battery and the computer circuitry in it. And these batteries often last, 10 or more years, at which point patients come in for a battery replacement. 

Host: I wish they could get a phone battery to last that long, right?

Fima Macheret, MD: I think they want to make sure we keep buying their batteries periodically.

Host: I presume you are correct, Doctor. Finally, in summary here, generally speaking, what would you say the chances are of effectively treating patients with an irregular heartbeat?

Fima Macheret, MD: It entirely depends on number one, what somebody's heart function is. Are we dealing with arrhythmias due to other heart problems that need to be treated, versus primary electrical problems. Atrial fibrillation is a challenging problem to treat. Sometimes we're able to get a really good durable result that lasts for years.

And sometimes people need multiple ablations and ultimately need more advanced therapies to keep the effects of the atrial fibrillation away. Atrial fibrillation is a disease best treated early. When it's caught in its early stages, the results of ablation are often more than 80 percent successful.

Once it's been around for a long time, those results drop to more like 60%. Although atrial fibrillation is the most common arrhythmia that we treat, as I mentioned, we treat supraventricular tachycardias, including atrial flutter what's called AVNRT, AVRT and atrial tachycardia. Our ability to ablate those is on the order of 95 percent or greater, because the mechanism is much more discreet and our ablation much more focal. And the problem is not as widespread as it is in atrial fibrillation, which is due to a scarring or fibrosis in the left atrium that becomes more difficult to treat over time. We haven't really talked about ventricular tachycardia.

Some of those can be eliminated for one's life whereas some of those are due to really abnormal hearts. And it becomes a bigger challenge to treat. In general, though, we're happy to evaluate every case individually.

I think every case should be. We should always consider all of the aspects of somebody's heart function. And electrophysiologists can do that and help design the best treatment for each patient.

Host: And so it sounds like for one, you're saying if someone suspects something may be wrong with their heartbeat, get it checked out sooner rather than later, right?

Fima Macheret, MD: Absolutely. Many patients will get monitoring of some kind and that will ultimately lead to a diagnosis that leads them to us. At the same time, there can be other causes for these symptoms and physicians who sent people to us also evaluate for those and if they don't need to see us, then they don't. But if a heart rhythm issue is discovered, then they are sent to us.

Host: So indeed, better safe than sorry. Folks, we trust you're now more familiar with cardiac electrophysiology. Dr. Fima Macheret, valuable information indeed. You sound very passionate about what you do. Thanks so much again.

Fima Macheret, MD: Thank you so much for having me. I love talking about this stuff with my patients or with anybody.

Host: It certainly comes through. And for more information, please visit SkagitRegionalHealth.org. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for being part of Be Well with Skagit Regional Health.