Andrew Rubin, MD holds Board Certifications in Cardiac Electrophysiology, Cardiovascular Disease and Internal Medicine. After completing his internship and residency at The Grad Hospital/University of Pennsylvania, Dr. Rubin earned a Cardiology fellowship at Temple University Hospital and an Electrophysiology fellowship at Lankenau Hospital. At Eisenhower Medical Center, Dr. Rubin serves as co-director of Electrophysiology where he oversees Cardiac Research and the Pacemaker Defibrillator Clinic at Eisenhower Desert Cardiology Center, and previously served as Section Chief of Cardiology. He is also director of Cardiology teaching for the Internal Medicine and Family Medicine Residency Programs at Eisenhower Medical Center. He has been honored as the Eisenhower Medical Center Auxiliary Physician of the Year in 2009 and Eisenhower Medical Center Physician of the Month in January 2010. Furthermore, Dr. Rubin is President and CEO of Genetic Research Institute of the Desert and served as a member of the Steering Committee of the National Institutes of Health Atrial Fibrillation Trial. Working as principal or co-investigator for more than 63 clinical investigations related to cardiac arrhythmias, Dr. Rubin has peer reviewed more than 18 publications, two book chapters and numerous abstract presentations and clinical presentations. Dr. Rubin was born, raised and trained in Philadelphia. He came to the desert in 1994 after practicing in an academic electrophysiology practice in the Philadelphia region following his training. He remains active in the field of clinical research with special interest in atrial fibrillation and anticoagulation.
Leon Feldman, MD, FACC, has received Board Certification in internal medicine, cardiovascular disease and clinical cardiac electrophysiology. In addition, he also received a Bachelor of Arts degree with distinction in psychology from Cornell University College of Arts and Sciences in Ithaca, New York before attending Tufts University School of Medicine in Boston, Massachusetts. He completed his internship and residency at the UCLA Center for Health Sciences, prior to completing two fellowships in cardiology and cardiac electrophysiology at Oregon Health and Science University in Portland.
Dr. Feldman treats people with all aspects of cardiovascular disease but has special training and interest in cardiac arrhythmias. "The first time I put on a gown and mask to perform a procedure I was hooked," says Dr. Feldman. "One aspect of my work is to implant pacemakers and defibrillators for patients with serious heart rhythm issues. These devices are small sophisticated electronic marvels and save patient's lives." As Co-Director of the Electrophysiology (EP) Laboratory/Arrhythmia Center at Eisenhower Medical Center, Dr. Feldman's expertise includes implanting pacemakers, defibrillators, heart failure devices and performing cardiac ablations. He remains actively involved in bringing the latest technologies and techniques to the EP lab for patients in the Coachella Valley. Dr. Feldman remains active in clinical research, being involved in numerous trials since joining the staff at Eisenhower Medical Center, often serving as primary site investigator. Dr. Feldman also teaches cardiology and electrophysiology to the interns and residents at Eisenhower.
Bill Klaproth:(Host) So what is atrial fibrillation or AFib? Are there any signs or symptoms and what are the treatments? Let's find out what Dr. Leon Feldman board certified in internal medicine and cardiovascular disease, also board certified in clinical cardiac electrophysiology. And Dr. Andrew Rubin, also a board-certified electrophysiologist, both from Eisenhower Medical Center. Dr. Feldman and Dr. Rubin, thank you so much for your time, Dr. Feldman, first off, what is an electrophysiologist?
Dr. Leon Feldman:(Guest) That's a bit of a long and complicated name to mean a heart rhythm, arrhythmia specialist. So it is a subspecialty of cardiology. It requires some extra fellowship training and testing, and then you get to focus on the electrical side of the heart. Mostly that means heart rhythms and the related disorders from the heart rhythms.
Host: And then that leads us to atrial fibrillation and Dr. Rubin, can you explain to us what is atrial fibrillation or AFib as it's known?
Dr. Andrew Rubin:(Guest) Atrial fibrillation is one of many types of abnormal electrical heart rhythms. It's actually the most common type of abnormal electrical heart rhythm and has been increasing in diagnosis around the world significantly over the past several decades, and it's expected to continue to increase. It typically is associated with a variety of symptoms and a variety of poor outcomes that I'm sure we'll discuss later.
Host: And Dr. Rubin, is it true that 30% of people have AFib and it's undiagnosed?
Dr. Rubin: In a minority of patients is associated with minimal to no symptoms. And unfortunately in those people, the first presentation of atrial fibrillation may be a stroke. So there is community awareness of better ways to try to detect this silent AFib subgroup.
Host: So then Dr. Feldman, these people are at greater risk for stroke, is that right?
Dr. Feldman: The number one job I was positioned was treating a patient with atrial fibrillation is to prevent the disastrous outcome of a stroke. Patients who have atrial fibrillation can have up to a five times greater risk for stroke than a similar age cohort. And so it makes up a significant amount of strokes, especially as you get into the older population. And the stroke is caused by a small blood clot that we think form in a portion of a left atrium that can break off and go to the brain. It can also go to other parts of the body and cause similar, but not quite as disastrous complications.
Host: So as we've talked about, a lot of times AFib goes undiagnosed. So Dr. Feldman, are there any signs and symptoms of AFib? Is high blood pressure a sign, or if someone is getting that flip-flop feeling in their chest, is that a sign?
Dr. Feldman: For sure. The flip flop feeling is a sign of atrial fibrillation. People also report things like this that are called palpitations, and it can come in a number of forms. They can feel like a fluttering sensation in the chest or a vibration in the chest. Other people feel shortness of breath or fatigue, exercise intolerance, general weakness, and malaise. All of those things can be symptoms of atrial fibrillation. Sometimes he even presents with chest pain, or signs of heart failure, such as lower extremity or leg swelling and that kind of presentation. While hypertension or high blood pressure itself is not a sign of atrial fibrillation. People with high blood pressure often are at higher risk for having atrial fibrillation and that's why those two disorders are closely related.
Host: Dr. Rubin, if someone feels, these things like Dr. Feldman was just explaining to us, what should someone do who has these signs or symptoms? Is it a visit or a call to the primary care physician first or should they go right to a cardiologist?
Dr. Rubin: The answer is quite variable. It depends if this is the first time there are feeling the symptoms and how severe the symptoms seem to be. So if someone has a known history of atrial fibrillation and they have what feels to be a recurrence, then they've been to this rodeo before and they will conduct, however, they've been instructed to conduct previously. If this is a first time and the symptoms are quite bothersome than likely in a visit to the emergency room is probably the best way to go for the first time visit to clarify whether this is atrial fibrillation or not. And if it is to give the appropriate therapy.
Host: And then Dr. Feldman, what are the common treatments for AFib? Are there medicine treatments that can treat this?
Dr. Feldman: Like we talked about the most worrisome complication, especially as you get older and accumulate signs is to minimize the risk of a stroke. So the medicinal treatment for atrial fibrillation in many people, but first one is anti coagulation, which can be warfarin or Coumadin, or one of the novel agents, the newer agents called or eloquence or similar. That is the first order of business with treating atrial fibrillation. Afterward, the decision needs to be made as to whether people can stay in atrial fibrillation and feel okay with it. Just keep the heart rate well-controlled or whether they go in and try to correct the atrial fibrillation. You can simply correct it with a shock treatment, which means a thing called a cardioversion, which is a very simple cardiology procedure to reset the heart rhythm. There are anti rhythm drugs that can be used to stabilize the heart rhythm as well. And in the more invasive sense and things that are becoming more and more commonly done or ablations to actually treat or try to cure the atrial fibrillation in order to minimize long term medicine exposure and potentially do better long term.
Host: Okay, and then Dr. Rubin, what if the typical prescriptions don't work, are there other treatment options or new advancements or is there a risk to being on blood thinners for too long, do they stop working in some people?
Dr. Rubin: There's a multifaceted approach to the treatment of atrial fibrillation as Dr. Feldman was discussing. One is, providing proper speed control to the atrial fibrillation, which can usually be handled with relatively benign drugs. Number two is whether you need to regain a normal rhythm as opposed to living in atrial fibrillation. And those may involve a number of different anti arrhythmic drugs as mentioned or proceed with ablation, which is a curative type procedure, which is done increasingly frequent around the world over the past 15 years. In terms of the third aspect of treatment that would involve anti coagulation as mentioned by Dr. Feldman. The blood thinners are very effective, but blood thinners are by definition blood centers carry the risk of bleeding. And there is a significant percentage of patients who cannot take blood thinners. It's not that the blood thinners don't work. They just may be difficult to take because of compliance reasons and remembering to take the drug or bleeding complications.
Host: And then Dr. Rubin, are there any other treatments that exist beyond prescriptions or what we've talked about?
Dr. Rubin: In terms of the curative ablation, there are many facets of ablation that could be discussed with evolving techniques, which seem to have better success and less risk to the patient. And in terms of anti coagulation, as we'll be discussing, I suspect shortly the Watchman procedure, which has now been done about 120,000 times around the world.
Dr. Feldman:in addition, when we're talking about what are the treatments that exist beyond prescriptions? Dr. Rubin nicely pointed out that curative ablation is available, and I'd like to point out to our listeners that we've been doing curative atrial fibrillation, ablations at Eisenhower for about 15 years now., and in, so doing, we're doing atrial fibrillation, ablations routinely every week. And so we have a robust program here for atrial fibrillation. And more than that, we have some of the most modern mapping and treatment equipment available here. And we were one of the first centers in the United States to use some of this new equipment and so we've been able to build a special program at Eisenhower, and that is able to take on most atrial fibrillation patients as they would almost anywhere else at the major centers.
Host: Thank you for adding that in Dr. Feldman. And then let me ask you this. Since Dr. Rubin brought up the Watchman procedure, what is the Watchman procedure and how is it done?
Dr. Feldman: Watchman procedure are relatively new technology that addresses patients who need a blood thinner to prevent a stroke, but maybe having difficulties with blood thinner either because it's hard to take the medicine on a regular basis because of remembering to do so or have competing medicines and that makes it contraindicated. Or perhaps there were bleeding complications. One of the most difficult patient populations to use anti coagulation to those who are frail and unsteady on their feet, and then a risk for fall and traumatic hemorrhage. So those patients we'd like to offer an alternative. Watchman came out a number of years ago. It's been used in the United States for about five years. Eisenhower has had it for a bit over two years. It is a small device that is basically like a small umbrella that gets implanted by going up through the vein in the leg and into the heart and this little umbrella-type device is deployed. And that's the only thing that's left in the heart that covers the region of the heart, where most blood clots form and over the course of several months, this device will heal in place and it's successful. And we follow it up with ultrasound. No blood thinners are subsequently needed. It takes the place of using blood thinners.
Host: This is amazing. It sounds like everyone would want the Watchmen. So Dr. Rubin who qualifies for this procedure?
Dr. Rubin: Presently, the people who qualify for the procedure are patients with atrial fibrillation who carry a heightened risk for stroke associated with the atrial fibrillation. But for one reason or another are not felt to be good candidates for a long-term anti coagulation, because as Dr. Feldman said, frail, frequent falls, bleeding problems, either from the bladder or from the gastrointestinal tract or for any significant bleeding reasons would be the best patients. So those who have a higher risk for stroke with atrial fibrillation, but for whatever reason, it's not felt that they are good candidates for long term blood thinners.
Host: And then what outcomes can be expected, Dr. Rubin?
Dr. Rubin: Thank goodness the outcomes quite good. The procedure typically there's variability, of course, but we'll take anywhere from 25 minutes to an hour and 25 minutes. The likelihood of a successful implant approaches 90% with the present Watchman device, but with the future Watchmen advice, which we may discuss shortly success rates for the implant, maybe approaching 95%. And this all comes with a risk with experienced operators of less than 1% of any type of interoperative of postoperative complication.
Host: This really sounds fantastic. So, Dr. Feldman, it sounds like this could offer freedom for those with AFib, from blood thinners and worry of stroke risk, is that right?
Dr. Feldman: I don't want to oversell, even on blood thinners, there's a small risk of stroke that remains the same can be, you said for the implanted device, the left atrial occlusion device, which right now is the Watchman. So it brings the risk of stroke down to a marginal and acceptable level, very similar to people who do not have atrial fibrillation. So there's always a small risk, but it is certainly much safer feeling for patient and doctor when you have a Watchman device in place. This idea about being on anti coagulation or having a Watchman placed is actually being addressed in a trial that we will be running at Eisenhower's one of the centers where you could be randomized to be on a blood thinner, or have a Watchman place in a 50, 50, or one to one randomized fashion. In the past Watchman's were only given available for people who couldn't tolerate the blood thinner for some reason or other. But we may be moving to a day where the watchman could be the first line against strokes for those with atrial fibrillation. And we wait to see what the results are.
Host: We certainly will be watching that study. And Dr. Rubin then does it require a special treatment room or equipment and what kind of downtime will the patient expect after the procedure?
Dr. Rubin: The procedure is done in a hospital setting and it may be done in an electrophysiology laboratory suite where we specialize in heart rhythm abnormalities or could be done in a cardiac catheterization laboratory. There will be several nurses present. There will frequently be an anesthesiologist present. At Eisenhower, we do use general anesthesia for the procedure, and there are representatives from the company who are supplying the device to be implanted. Downtime. The patients typically stay overnight. That is not in all cases. Sometimes patients do go home the same day and in terms of downtime simply taking it easy for a day to let the puncture site in the groin heal. So the procedure is performed typically from the right groin in a vein and that's where the Watchman begins its insertion process. So we let, that area heal for a day. So just taking it easy, but there's no expected significant downtime.
Host: Got it. Dr. Rubin, thank you for that. And then Dr. Feldman, can you tell us about the experience you've had with the Watchman at this point at Eisenhower?
Dr. Feldman: We began the program at the very end of July 2018. That was our first implant. Over the course of these two years, we've now planted just about 205 devices. So right around 100 devices per year. We've had a very good acceptance. And we have a lot of need and we have this relatively high volume of implants even before we've made big outreach into the community. There's such a demand for patients who've had difficulty with anti-coagulants. It puts us actually in a good spot and given our volume, it makes us the third-largest implanting center in Southern California, which even includes all the major med schools. And so we're really proud of what we've been able to do in this short period of time.
Host: Well, that experience certainly matters Dr. Feldman. And then Dr. Rubin, if you could wrap this up for us, are there any other benefits patients should know about any other considerations?
Dr. Rubin: All of the implanters have been gaining experience and nothing substitutes for experience in terms of developing a safer approach to the patient. In addition to the operator's experience, the technology has advanced and within weeks, Eisenhower will be one of the few centers in Southern California with the newest version of the Watchmen, which should provide significantly greater safety margin and success and implantation. So we are all very excited for our patients that have this improved device, for them
Host: Absolutely really great information about AFib and the new Watchman technology. Dr. Feldman and Dr. Ruben, this has really been informative. Thank you both for your time today we appreciate it.
Dr. Feldman: Thank you very much.
Dr. Rubin: Thank you very much.
Host: That's Dr. Leon Feldman and Dr. Andrew Rubin. And to learn more, please visit Eisenhowerhealth.org. And if you found this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you. This is Living Well with Eisenhower Health. I'm Bill Klaproth. Thanks for listening, Eisenhower Health, Healthcare as it should be.