We're welcoming. Actually, there was a question in the audience. Do we look for atrial myopathy in the presence of atrial fibrillation? And every time we see atrial fibrillation in young patients, things come to mind. Is there a cardiomyopathy? It's not necessarily only the classic cardiomyopathies, but early hypertrophic cardiomyopathy, infiltrative cardiomyopathies, channelopathies that can cause like this. The suspicion should be high. I don't personally do an MRI in every single patient we see. What is common in patients, with young patients, with atrial fibrillation is that they usually start with an SVT, supraventricular tachycardia, and that has to be ruled out before we go for ablation of atrial fibrillation. So the answer is we always have a high suspicion for anything in addition to just atrial fibrillation on younger patients. But the truth of the matter in clinical practice is, in the majority of cases, it is isolated atrial fibrillation. Yes, please. A representative patient, yes. Those four months, that four-month window between getting the SVT and when he had his second stroke, did he get any antiretroviral at all? You talked about going first and fourth. Did he get any at all? He was. So he was on, he was still on Warfarin, but he was still intermittently therapeutic. And so when I saw him, I saw him after his stroke, but that was because of the long period of time between when he was referred and when he came to see me. Thanks. Should we go back to the questions and, you know, repeat the questions again with a different perspective this time, I think? Okay, while we're figuring it out. Okay, good. Okay, I think this time let's look at the answers. So this is the technology. We're talking about advanced ablation therapies, and the new technology is the BFA. So we've heard what it is, and the question is, what has changed? Okay, so let's get out the phones and let's talk about this. Okay, very good. I was, I just thought it would be cheating if we discuss about the correct answer, so maybe we won't be discussing the correct answer right here, so that you can guys get a credit. Okay, so just again, but maybe we can spend the next, like, maybe five minutes to discuss about in general. Maybe going back to those options, answers, and then just, I mean, we can just ask people just which one makes sense, you know. So the option A, efficiency has improved, and it has decreased the rate of, so far, the procedure-related complications. Yes, does someone have a question? No, okay. Yeah, if anyone has questions, and then. Okay, so if, actually I do have a question, because you presented the case where there's a lot of cardiomyopathies, and I just wonder, we've recently, not recently, but we've focused on the management of cardiomyopathy, on the comorbidities in management of atrial fibrillation, and I wonder what's your practice, and what's your practice? You see somebody who is overweight, sleep apnea, diabetes, uncontrolled hypertension, is it something that you would offer him ablative therapies? Would you offer, would you refer to electrophysiologist, or you would wait until they've addressed all the comorbidities before an electrophysiologist is consulted? Happy to hear your thoughts. Maybe someone in the audience can even answer. I don't know how many are EP. Yeah, I mean, you know, it's, it's, where do you start is the point. Sometimes I struggle with this. It's just such an important question, right? We tell patient, no, you got to exercise and lose weight before I do the ablation on you, but if the patient is like with the AFib, I don't feel good. I can't exercise. I can't lose weight because I feel poorly, so it's a vicious cycle. So somewhere we need to change that, and, you know, ablating, so tying that with the patient and saying, I'm going to go ahead and ablate so you have better quality of life. Hopefully you go back and exercise and do stuff, and, but if the patient has minimal symptoms, morbidly obese, then I tell them, you know what, yes, ablation is indicated, but why don't you start off with the lifestyle and risk factor modification, then we can treat it. And I also do a Holter monitor initially, like depending on symptoms. So if they're symptomatic, no matter, like I've ablated somebody who's 400 pounds before, mainly for that reason, because they were really symptomatic, and the question was, how do we get them to the next stage? But for patients who are asymptomatic, the first thing I typically will do is do a Holter monitor, and I'll tell them, you know what, go all out, do everything that you would do in a 24 to 48 hour period. And the idea behind me doing that is basically seeing exactly what their heart rate is, because if somebody, you know, intimately has a heart rate in the 170s, 180s, then I'm less likely to say, oh yeah, you know, go out and exercise, because you don't know what that can do in the future, even though the patient says that they're asymptomatic. Versus, you know, if they're normally in the 80s and 90s, and I say, okay, we can be, you know, a little bit less aggressive and see what we can do, particularly if they're morbidly obese and they have really bad sleep apnea. Yeah, as Kamala said, this is a vicious cycle, right? So they're overweight, they have a lot of comorbidities that would decrease the exercise tolerance, but you have to start from somewhere. So it used to be that, you know, ablation is the therapy for last resort. Now everything has to happen in parallel. We in EP recognize that the ablation wouldn't work as well if other things are not addressed, the comorbidities are not addressed. And it's not that we have to start from somewhere, we have to start with everything and address this in a multidisciplinary team. And the other thing that often I hear about the question of asymptomatic atrial fibrillation, which is we see more and more in cardiology, we talk about asymptomatic. I think other disciplines have actually progressed, you know, asymptomatic severe aortic stenosis, where we put those patients on a treadmill and see if they're really asymptomatic. Asymptomatic coronary disease, we do a functional test, where the functional test for asymptomatic atrial fibrillation, in most of our views, is let the patient re-experience normal rhythm and understand whether the atrial fibrillation is significant for the symptoms or not. Because often this is a slow, progressive process and, you know, patients get accustomed to a new level of activity and accepting that that's the norm. So vague symptoms is actually the most common manifestation of persistent atrial fibrillation and therefore restoring sinus rhythm and allow them to experience normal rhythm will solve the question of symptomatic or not. It's a great point that you bring up, right? I mean, we use the term very loosely, asymptomatic versus symptomatic, without knowing that it's a spectrum. And so are we talking about subclinical, you know, all the, it's a spectrum of a disease? Just going back about the first part of that question you were asking, you know, this is the time we have to start thinking of like AFib. It's a disease that needs a comprehensive and collaborative management. You know, sometimes they genuinely wonder, you know, a patient comes, they have anxiety, they're obese, they have no access to medications, anticoagulation. And, you know, if we had a nutritionist, we had exercise program and someone who can work with the EP physician in one center, just easier rather than give a referral, go 30 minutes out, you know, do this. It's just a lot. So I think AFib paradigm should shift to a more comprehensive care. I don't know what you think. I agree with you. I know at Northville we have AFib Center of Excellence and we try to bring all these people, you know, that are key players in managing risk factors prior to, you know, not withholding ablation so they don't come back in two years in persistent fib, but optimizing their outcomes so we're able to treat all the comorbidities. Yeah. It comes to the same thing that prevention, it's not only for atherosclerosis and coronary disease, it is true for arrhythmias. Okay. The time is 8.15. I think it's the best time to conclude our session. Thank you all so much for coming that late in the day. Hopefully it was a very constructive session. Thank you all.

atrial fibrillation

cardiomyopathies

comorbidities

multidisciplinary approach

personalized treatment