5.5.26 CVNOW: CV Webcast Live - Dr. Wolf

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[00:00:12]Good afternoon everybody. Cinco deio. Uh it's the first Tuesday of the month. Uh it's 5:00 central time. Uh you're here in Houston, Texas at the Texas Medical Center, Houston Methodist Hospital, the Bakey Heart and Vascular Center. We're going to discuss the treatment of AIB and the minimally invasive surgical treatment of AIB. My special guest today is Dr. Michael Osner. He is a cardiologist.

[00:00:44]He is a well-known author. He is a professor. He has a lot of knowledge.

[00:00:50]And I think he has wisdom when it comes to things affairs of the heart.

[00:00:56]His most he has published four books that I'm aware of. His most popular one is the Mediterranean diet. And when I checked online, it said it had sold over 600,000 copies. Uh he's a very modest man. He didn't mention that to me, but uh looks like that's been a very popular book. But he's really dedicated his professional year uh professional uh 40 years I think it's been to not just treating affairs of the heart but trying to change things make them better. Uh so he's an unusual uh physician from that standpoint. uh he's an innovator and he's looking not just to treat a disease but hopefully decrease the disease. Most of the diseases of the heart outside of the congenital diseases are really the results of different epidemics. We're in the middle now of the uh coronary uh atheroscerotic epidemic, but I do believe it's an epidemic and rheumatic fever was an epidemic and there were epidemics before and maybe epidemics after. Uh Dr. Osner is very significant in that he's not only treating cardiologists, but he's trying to find a better way. He has a personal uh history that's relevant to our discussion today.

[00:02:25]Uh and I want to thank uh Dr. Osner up front for coming on the program today.

[00:02:31]Uh we welcome him here. He is uh in Miami. He's live to you via Zoom. We're here in the studio at Methodist Hospital and uh the Bakey Heart and Vasach. So uh Dr. Osner, thanks for joining us and welcome to the program.

[00:02:51]>> Thank you very much. It's a pleasure to be here.

[00:02:55]I think maybe it's a good idea for you to start out so that the the people that watch this program who are mainly people that either have AIB that's being treated or AIB that's been treated uh but they still have AIB and they can probably relate to your personal story if you're willing to share it.

[00:03:20]>> Absolutely.

[00:03:21]So [clears throat] um I happen to have um a genetic history of atrial fibrillation. my father, my uncle, all had a fib um as they got into their 50s and 60s and and so [clears throat] it I guess it wasn't a about eight years ago when I felt a you know my heart beating a little faster than it should um and I basically um took a my uh um cardio mobile as well as an EKG G and it was clear that I was in atrial fibrillation.

[00:04:04]So I was put on blood thinners at that time as everybody is with Eloquis and um [clears throat] it um you know I I was told that um you know basically we're going to put you on medications and if the medications don't work uh then we're going to uh and you're an AIB we we can do a cardio version but ultimately you're going to need to have a catheter ablation.

[00:04:37]So, you know, basically, uh, I happen to be a preventive cardiologist, so I, you know, have, you know, is not a number of patients that had AIB.

[00:04:48]Um, and I ended up with a electrphysiologist.

[00:04:56]Uh and it was about that time uh before I spoke to him that I was reviewing everything about uh you know uh the how to basically treat atrial fibrillation.

[00:05:11]Um and if uh you know everything that I read say that medications can work for a while but ultimately they won't and ultimately you're going to need to have a cardiac ablation. And so I met with the electrphysiologist um and you know uh and I had already had read about the mini maze procedure um [clears throat] and basically the electrphysiologist said you don't want to get a uh you don't want to uh get a mini maze procedure because it's uh it's an it's a very very uh high risk intervention. ional procedure and I don't know that I bought that because you know from everything that I read I read um you know Dr. Wolf having developed this back in the what 20 uh >> 2003 is when I started. Yeah.

[00:06:12]>> Yeah. Yeah. So it just didn't add up to me. In any event, uh I figured, okay, well, let let me just let him do this uh uh the uh having catheter ablation, which I had.

[00:06:25]>> Well, these were these were probably your colleagues, weren't they?

[00:06:29]>> They were um you know, basically um you know, I I could tell you that uh the they been doing uh there's two electrphysiologists uh at the hospital.

[00:06:45]I was at uh as well as some others at the University of Miami School of Medicine. But in any event, I I had the uh I had a u >> you start with a cath isolation technique.

[00:07:00]>> Let me let me interrupt you there just for a second because >> uh we want to make sure that people can get on and ask you questions if they have some. So Mr. producers if you could go to that slide that shows how people can ask a question to Dr. Osner or or me. Uh the there are two ways. One is by your phone. Uh you go to 37607 and then you text to Beakey or if you're on your computer you go to pole plev.com and enter Debakei and then you can ask your question. So you can ask your question from your phone with 37607 and text to bakey or uh as I mentioned on the computer polev.com and I I would encourage uh that people are listening to this live to enter your questions early in the hour which would be now uh to help ensure that we can get to your question uh before we're finished with the hour because this is about 55 minute long webcast. So, sorry for interruption. Dr. Osner, please proceed.

[00:08:14]>> You can go.

[00:08:14]>> Yeah. So, you know, basically [clears throat] um the the procedure didn't work and I had a second procedure and and you know, worked for a while that didn't work >> and finally I [clears throat] you know I realized that atrial fibrillation uh is not what really a lot of the electrophysiologists claim that it is which is you know to go into uh the uh a endocardial uh which is the inside of the uh of the heart of the left atrium and uh and then proceed upward because basically uh you know what they are in my humble opinion what they're doing is they are going through the heart muscle uh and they are not looking to see what they are doing when they go to do an ablation.

[00:09:14]And uh I I very uh you know it seemed to me that atrial fibrillation is an autonomic nervous system disorder and the autonomic nervous system is uh very important. It leads to um the uh sympathetic and parasympathetic system which uh goes uh down the spine to the heart. um as well as many other places and it certainly is very important because uh what is very clear to me is that was very clear and still is that it seems more logical to go and to do uh uh get rid of the root cause and the root cause happens to be uh again the autonomic nervous system. It goes uh to both the sympathetic and parasympathetic nervous system and then uh to the ganglionic plexus which is a set of nerves uh in in in around near the left a left uh uh the pulmonary vein uh on and it seems to me that in order to com you know to do this correctly you would have to eliminate the problem and the problem is uh the u the nerves that are uh really u dysfunctional.

[00:10:49]>> Yeah. Well, so >> yeah, the nerves are generally 80% of the nerves are on the outside of the heart or in the subendocard subepicardial area. There's not much in the subendocardial area. So uh the approach to the outside the heart uh would make a lot more sense if and that's what the mini maze has been based on for 23 years now to get it straight I for our listeners how many ablations did you have and kind of what's the f the time frame it doesn't have to be exact but did you was your first ablation six or seven years ago?

[00:11:29]It was about eight uh years ago eight years ago.

[00:11:32]>> And then you had a second >> a second ablation about two years after that.

[00:11:37]>> And then [clears throat] I would say about oh a year and a half uh >> two years ago >> two years ago a third ablation. Now, after after your three ablations and you still had issues, other than coming to Houston, coming to see me, what was what was the plan that was submitted to you?

[00:12:03]Well, you know, the um the electrphysiologist that I I switched electrophysiologists and I went to the one uh at uh the hospital who I happened to know and uh he he very nice guy and he probably the most reasonable of all the electrophysiologists that I spoke to because I I I brought this up to him and he agreed that the you know it's the it is an autonomic nervous system disorder.

[00:12:34]And he told me that u you know if you're going to u he says there it's completely reasonable at this point to get uh a mini maze procedure. Uh but he said that you know at least if you get one you know make sure that you have uh you know atrial fibrillation that's really coming and going and I have paracismal atrial fibrillation all along it was uh so it would come and go uh and um in addition to that uh the one thing that I really uh liked is that they also um you the you with along with doing getting rid of the the nerves that are creating the problem but also getting rid of the left atrial appendage. Uh >> yeah.

[00:13:29]>> Yeah. Again, I taking Eloquis and to be very frank with you, I never had a problem with Eloquis, but I didn't like being on it. And I think the fact that you you could use the clip to get rid of the left atrial appendage. Uh and you know it I I I was asked so many times by electrphysiologists, you got to get the watchman technique. You got to get the watchman technique. And the watchman technique never really appealed to me. U because it's like putting a cork in a bottle. There's no way under the sun that you're gonna completely uh eliminate the left atrial appendage with a watchman technique >> is the fact that you not only by doing >> well in addition to >> doing a procedure >> but you also can get rid of a lot of arrhythmias in and around the left atrial appendage.

[00:14:38]That's true. And >> yeah, that's true because it electrically isolates the appendage.

[00:14:44]>> It and the watchman, as you're pointing out, doesn't electrically isolate the appendage, but the clip does.

[00:14:52]So, after the three ablations, um, did they want to do a fourth ablation?

[00:15:02]>> The electrophysiologist that I saw, uh, said, "Go ahead and go to >> [clears throat] >> to Houston. He's he's heard of you. I don't think he, >> you know, ever ever met you. Um and um I I would have no matter what he said, I was going to go. I mean, to me, I I I looked up all of the data. I could speak all day about it. You know, the the the the fast study, uh, many studies to show that not only is this is the mini maze procedure very effective, but it's more effective than regular catheter ablation in some of these studies like the fast study.

[00:15:40]>> And uh that that's not a surprise. is as far as the procedure uh which we have been told over and over again uh is a very very potentially dangerous procedure. I totally disagree with that.

[00:15:53]In fact, I will go so far as to say in many respects it's more it's it's a safer procedure than a catheter ablation, which uh they're going up into the muscular wall and using uh radiotherapy and uh you know uh uh >> transal heat or cold rather and it basically uh you can hit the esophagus, you can hit the frenic nerve there's all kind of problems that I have actually seen over the years. So if anything, the experience I have uh is that it certainly was not uh a a very invasive procedure. If anything u you know I was able to uh recover from that uh very quickly uh within a day or two and then I was you know uh really with the exception of some very mild discomfort uh I felt pretty good. I still feel good.

[00:16:53]Yeah. Well, um, Dr. Osner, your procedure was about what, three weeks ago now? Something like that.

[00:17:01]>> Correct.

[00:17:02]>> And, um, you were in the hospital, I think, two days. And I think your procedure was maybe on a Tuesday. And the following Monday, we went out to dinner.

[00:17:13]>> We did.

[00:17:14]>> And you look fine.

[00:17:15]>> Absolutely.

[00:17:17]>> So, >> you know, that was terrific. So I look at it that the catheter ablation is less invasive on the skin but it's a lot more invasive on the heart. The mini maze procedure doesn't burn up the muscle and I think that's a key factor. Now uh that's Mr. Producer just put up the way to join us again. You can join us by text if you have a question. Uh you just take your phone and you go to 37607 and you put in debake and then ask your question or if you're on your computer go to pole plev.com enterbakei and ask your question. Um I wanted to talk a little bit about uh what we presented a month ago uh with my fellow who's uh on a research year and we looked at 500 consecutive patients who had the wolf procedure or the mini maze and the reason I changed the name was because what I do is really not a maze. I don't even think a maze is a maze. Uh I think a maze is a pretty good partial cardiac denervation is which is what we do minimally invasively but I don't think it works because it directs the electricity in a in a particular path. I think that's uh pretty sophomoric to think that really works that way. Uh but uh the co the cox maze is an open procedure is a pretty good partial cardiac denervation and and so is the wolf procedure without having to do a sternottomy or having to go on the heart lung machine or even and without uh having to have anti-coagulants.

[00:19:06]Um but a month ago we looked at over 500 patients followed out three years and all almost all the patients had a implantable loop monitor. Um so we got an EKG on each patient every day for three years and we looked at the three different types of AIB. uh the paracismal which is what you described where the heart goes in and out of rhythm uh but doesn't stay out more than seven days or has not there's not been a cardio version and I think maybe you've had a cardio version so that may make you persistent by definition persistent is over seven days in a row in a fib or a cardio version longstanding persistent is over a year out of rhythm and we looked at those three groups and in patients who had paracismal AIB at 3 years with an implantable loop monitor, the chances of being in rhythm were 96%.

[00:20:05]And that's better than an open maze. And it's more than twice as good as anything else really. Uh and that's with a lower morbidity than a catheter uh based procedure.

[00:20:20]We for persistent people that had been in over a week or had a cardio version it was 92% at three years were still in rhythm. And we look at burden and the definition was uh anything less than 2% which means you're in rhythm all the time generally if it's less than 2%.

[00:20:41]And even with long-standing persistent people with big left atria, people that had been out of rhythm for over a year by definition, 85% of those patients were in rhythm at three years. We didn't uh a failure. Some of the failures were patients who underwent an AV node ablation and a pacemaker, which doesn't stop the AIB, uh but it makes the patients less aware and they stop calling the cardiologists all the time.

[00:21:10]And some of these patients were during the pandemic. The this uh data was collected starting in 21 or 22. So some of the patients didn't make it back here and they end up getting an AV node ablation which they would not have gotten if they would have come back here. But nevertheless, we counted those as a failure. So the numbers actually are better if you take those avion ablations out. But we count that as a failure. Those are patients that didn't come back here.

[00:21:39]What it showed are a couple important things. One is uh it it suggests that doing an epicardial procedure is much more efficacious.

[00:21:49]Um the stroke rate was extremely low. Um and it also showed that doing a longitudinal followup of these patients is key. I suspect in most EP practices after the ablation is over and they follow you for a little while they turn you loose most patients who've had a catheter ablation do not have a implantable monitor. In fact it would be very rare to have one.

[00:22:19]Uh but what we found if you follow these patients closely you can monitor this disease. If they need a cardio version you can do it. We do that a month after the procedure. uh some of the patients uh particularly if they have long-standing persistent AI fib may need a follow-up catheter ablation which is a hybrid procedure but we don't do that unless they need it. There are programs around the country that do a hybrid technique, but every patient has to get a catheter ablation along with the surgery and our um review suggests that in the case of paracismo, 96% of those patients didn't need the catheter ablation. So that's not so we believe it's better to follow the patients and intervene when necessary but don't do procedures that may not be necessary.

[00:23:13]So there's a lot of information in that.

[00:23:15]We also uh looked at patients uh with a transcranial Doppler device. So we looked at their corateed arteries uh because that had been reported with catheter ablation like you had had. And in catheter ablation patients, it was reported that there are 2,000 to 4,000 little pieces of stuff that go into your brain during a catheter ablation. Uh this could be thrombotic material, little p little clots. It could be gaseous material. It could be gas given off from heating up the tissue to high temperature inside the heart. Um, and it it happens with the newest way to do the catheter ablation as well, which is pulse field. They still found that. We did that with some of our patients and it was zero. It wasn't 2,000 to 4,000 little hits as they call them. It was zero. So, there's a big difference. You mentioned also closing the appendage from the outside which makes it electrically silent versus the watchman which usually leaks a little bit requires lifelong anti-coagulation in the form of aspirin whereas closing with the clip you don't need to I don't you weren't on you haven't been on any blood thinner since your surgery have you?

[00:24:35]>> That's right.

[00:24:36]>> Yeah. So there's some big differences there as well.

[00:24:40]>> So there's another study that we talked about that we did a long time ago was published in 2007 in the surgical literature, not the cardiology literature, I'm sorry to say. And I thought, well, if a partial cardiac denervation really works, what's the ultimate denervation? Well, it's a heart transplant.

[00:25:02]So, we looked at uh I think it was 397 consecutive heart transplants at Texas Heart retrospectively and we looked to see what the AIB rate was and normally it's accepted after a big heart operation the AIB rate is 35 to 40% and people that have never had AIB uh but the AIB rate after heart transplantation was 2 to 3% which goes along and and that's with a little bit of left atrium still left in there which probably accounts for the 2 to 3%. Uh so a cardiac denervation pretty much prevents AIB uh with a heart transplant.

[00:25:45]Of course that's a little radical thing to do for AIB. Uh but it proves the point. It shows that there's something important about the nerves on the outside of the heart. These are the nerves that are autonomic nerves as you mentioned. These are the nerves that make your hands sweat uh when you look over the edge of a tall building. Uh they're the nerves that make your heart rate go up when you're watching a scary movie. Why should your heart rate go up?

[00:26:11]You're sitting in a comfortable chair watching a movie. Um and it's what we believe is if you do a partial cardiac denervation, you blunt that response.

[00:26:22]And if you blunt that response, the heart settles down. the essay node isn't bombarded with as much nervous input and it dramatically decreases the chances of the heart going out of rhythm. Now, you told me as I recall, but I'd like to hear in your own words that even the day after surgery, you felt like finally something had been done.

[00:26:46]Could you amplify that?

[00:26:49]Well, I mean [clears throat] u I always carry my cardio mobile with me and um after the procedure uh and I was getting um the when using the cardiom even with paracismal aib it would always say atrial fibrillation.

[00:27:07]Um, [clears throat] every single time I used the cardiom post procedure, it said normal sinus rhythm. And boy, I tell you that was exciting to see that. And it's still that way. I was very happy about that.

[00:27:23]And one of the things I want to bring up is one of the things that you do which I think is very important and that is that after you do an ablation uh going from outside the heart uh to um the uh you you basically do testing.

[00:27:44]>> Yeah. to make sure that the uh area that uh you abladed uh is no longer active.

[00:27:53]>> That's right. That's right.

[00:27:55]>> I could tell you that I don't know of anybody else who's doing that.

[00:27:59]>> No, there isn't. And we started that a long time ago. Um I visited Sunny Jackman. This would have been about 20 years ago or more, 22 years ago. and went in his lab. And in his lab, they had animals that were in Aphib. And when they injected a little bit of alcohol into the fat pad, the AIB went away immediately. Just boom, stopped. So, a little bit of alcohol, which kills some of those ganglonic plexi, resulted in immediate sinus rhythm.

[00:28:34]Uh, and Ben Sherlock was the PhD, worked with Sunny Jackman at the time. And I said, ' Ben, what happens when you do that in humans? And Ben said, 'Well, I'm I'm in the animal lab. I'm PhD. I don't know. So, we bundled bundled him up and flew him to Cincinnati at the time. I was teaching at the University of Cincinnati and we did the first ever cases in the world. We didn't use alcohol, but we used I used bipolar radio frequency to burn these fat pad areas. I used a neurosurgical device from the neurosurgery area. It was a b a bayonet forceps. It was a a essentially a tweezer with electrodes on it so I could very discreetly burn areas in the fat pad. and Ben was there and he had his machine and we would take a EP catheter and put it on the outside of the heart and check the areas before and we could see that if we hit an area while we stimulated it just a little fat pad the heart would stop and then you stop stimulating the heart starts beating again and then we did our ablation with bipolar RF on the fat pad and we test again no response so that's how we could tell that we had done something. Uh, and that's still the way I do it today. We've changed the instruments around a little bit. Uh, I have a a bipolar uh device, call it a pen, that's a little bit easier to use.

[00:30:09]And through that pen, we can also do the stimulation. We don't need a a EP catheter to do the stimulation, but we still do the same thing. We test, deliver energy, the heart stops.

[00:30:23]We ablate that area of the fat pad on the surface of the heart, repeat the stimulation, and there's no response. So that's how we know that we got that area. And the most active gangalonic plexi is on the right behind the right inferior pulmonary vein. But in general, they're much more active on the right versus the left. So the right side is extremely important. And there are some people today that are doing what they call uh a robotic uh maze, but they do it through the left side and they don't do the right veins.

[00:31:02]Uh and they definitely don't do the right ganglonic plexi and unfortunately that's where the action is. So if you had to only do one side, you want to do the right side uh for the ganglonic plexi. Now for the left side uh the most important thing is the appendage I think but as far as the autonomic intervation of the human heart the actions on the right side and that's exactly what's left out of these this current uh totally thoroscopic or TT maze so I'm a little bit concerned about that now u we'll take a point that I want to bring up >> go ahead go ahead Yeah. Is more more convergent procedures. Not impressed with because a lot of the electrophysiologists are having cardiac surgeons come in and do a convergent procedure which is basically just burning the back of the heart uh and assuming that that is going to be effective. And quite honestly, I don't see how it could be uh as opposed to doing what you are doing, which is not only uh ablating the the ganglionic plexus and the areas around there, but then doing the testing to make sure that everything is successfully done.

[00:32:29]>> Well, that's a good point. Uh the only thing that might decrease the uh posttop AIB rate with a convergence is if they went over far enough on the right and maybe got a little bit of the fat pads.

[00:32:44]But I agree with you, just burning the back of the left atrium, the the back wall, uh is a waste of time. And that's mainly what the procedure is. And you end up with dead tissue, more dead left atrial tissue. And there have been many reports of people having multiple ablations and then having heart failure because their left atrium is pretty much just burned up and it doesn't contract at all and it interferes with the uh the overall function of the heart. Of course, there's no synchrony between right and left atria even if they're in rhythm with that much burned up because they've had Bachman's bundle burned.

[00:33:26]It's a more than what we need to talk about with our audience, but there is a a nerve that goes from the right atrium to the left atrium. So, the two atria are in synchrony and that's often uh uh damaged with ablations. We don't get near there. We don't do any roof lines or floor lines or get near the normal conduction system of the heart because our our our audience may not know but you know well they're really two systems. There's the autonomic system but there's also the conduction system of the heart and those are not nerves the SA node and the AV node. uh those are modified cardiomyia and we don't we don't we stay away from that. We're not interfering with the normal conduction of the heart. I think the AV node is happy to beat 60 beats a minute your whole life, but it's got all this information coming at it from your hypothalamus and your brain and your sympathetic areas of your spinal cord and your parasympathetic areas. It's bombarded with all this information and sometimes it gets out of whack and that ends up with AIB.

[00:34:42]Does that make sense to you? Kind of simplistic, but sure does. I mean you know it u I think that um it one one of the things that I can tell you that I'm also [clears throat] very impressed with and that is after a successful um mini maze procedure there's a lot of uh there's a lot of patients I know who are walking around with very low ejection fractions and you know it basically they're in so-called heart failure their low ejection fraction uh and post doing the mini maze and gain regaining normal sinus rhythm the that ejection fraction could start to rise to normal levels and I think that's amazing as well as diastolic dysfunction the same thing >> that patients post minimize diastolic dysfunction I'm not going to go into that but it's a very you know common problem that a lot of people have that you know lead to uh it could lead to heart failure but over uh time post mini maze procedure the diastolic dysfunction could go away. So there's a number of things that are very beneficial post mini maze procedure and being able to maintain normal sinus rhythm.

[00:36:08]>> Yes sir. Uh, Colonel Chuck Miller, who was on this program uh, several years ago, um, was a Air Force pilot and a colonel and retired as a colonel. And he was diagnosed with a with a AIB. He went into the hospital with Aphib and they did three vessel bypass on him. He said, "I went in with AIB. I came out with AIB." They didn't do anything about his AIB.

[00:36:37]And a couple years after his three vessel bypass, he came to me and said, "I think my problem is my AIB." And at that point, his EF was about 15%.

[00:36:50]And they told him he probably needed a heart transplant. He said, "Doc, I think it's the AIB." He very smart guy, obviously. So, I did a mini maze on him as a redo. He'd had previous heart surgery and that was about 23 years ago and ever since then he's been in rhythm and his EF went from 15% up to 57% and he's stayed uh there for the last 15 years and now he's about 86 years old.

[00:37:25]So uh that's not a study that's anecdotal report but it's pretty powerful to show that what could be uh tacoc cardia induced cardiammyopathy or fast heart rate induced heart failure can be completely reversed and it should not be treated with a heart transplant.

[00:37:50]Uh let's put in a couple get a couple questions here. uh do the cells in the heart that were triggering AIB die off or regenerate after the wolf procedure?

[00:38:03]Well, uh these cells are really extensions of nerves. Um and even if they regenerate, they won't be functional because they won't have a functional neuron. So even if the tube regenerates, uh they they they shouldn't be functional. And I have many patients that are 10, 12, 14, 17 out to 23 years out uh with no recurrence. Uh so the answer is uh they don't if they do re if if the tube regenerates the neuron doesn't so they're no longer active.

[00:38:43]Another question is, and by the way, if you have questions, now's a great time to get your question in either by text or web. Maybe we better throw that up there again. There you are. It's at the bottom of the screen. Follow those directions. 37607 on your phone. Uh, text and then put in debake or you can go to pleev.com and put in debake on your computer. Is the Da Vinci robot used for the mini maze? It's not used for the mini maze. It is being touted as a totally thoroscopic leftsided maze. Uh which includes closing the left atrial appendage, doing something on the veins on the left, and maybe doing something on the veins on the right, maybe not, but almost never treating what I think's the most important thing, which are the epicardial. These are the nerves on the outside of the heart on the right. It can't. If you come in from the left with the Da Vinci, you can't get to those nerves. You can't see them. And to me, that's a shame because that's where the money is.

[00:39:54]Um now um another thing I wanted to touch on was PFA because uh there was a lot of uh hyperbole about pulse field ablation and this was going to cure AIB and this was the end all and it's been proven so far in the last couple years that pulse field ablation instead of radio frequency is faster.

[00:40:23]may be safer.

[00:40:25]Although the initial study that came out recently showed a high I think it had eight strokes in it and then they changed their protocol and kept everybody on blood thinners before and after and did some other stuff. But nevertheless, the midterm results were no better than radio frequency from what I can gather. And I'm curious to see if you've seen any of these. If you haven't, that's okay. Or if you have any take on the pulse field ablation, which is the newest uh best thing for catheter ablation.

[00:41:03]>> Yes. I mean I basically [clears throat] one of the first problems I had with pulse field ablation was that um they [clears throat] basically stated that we are not going to go after the nerves uh and you know with uh so they're going [clears throat] they're they're using it uh but they're not using it uh properly in my humble opinion because I think that if you you if you don't go after the nerves namely the nerves like the ganglionic plexus, uh it's not going to be successful. And so again, they're going uh from inside the heart and they're going up and out.

[00:41:48]And you basically uh it's it's no wonder to me that there was no difference uh between standard catheter ablation and pulse field ablation uh because they neither one of those two uh in have gone after the the the root of the problem which again I mean you and I both mentioned this and that is uh the autonomic nervous system I mean you you know it's it's obviously the major player here and what happens when it becomes dysfunctional is you go into atrial fibrillation and so [clears throat] um uh just like you said I mean the uh it it might be faster uh there's you know it it may or may not be safer but unless you go after the root cause uh of atrial fibrillation you're going to have to undergo uh uh in the majority of patients, numerous follow-up catheter ablations or pulse field ablations.

[00:42:56]And as you mentioned before that the micro emblei of each one every time they go in is anywhere from 2 to 4 thousand.

[00:43:04]And there's a lot of people who feel that that might contribute to problems like uh you know >> problems with the brain the problems with TAS and strokes and you know it's it it that to me is dementia is another one and I I honestly believe that uh we uh you know that what you have done Dr. Wolf is you've hit the nail on the head because with everything we do in medicine, you have to understand the root cause and I don't think the the uh they they understand the root cause of the problem. The root cause is clearly uh the autonomic nervous system when it goes haywire >> and it it definitely at that point you need to go after what's causing this and you are and they're not.

[00:44:03]>> Well, well, thank you. We we did also look at these 500 patients to see what factors uh would possibly cause us to do additional interv uh uh interventions.

[00:44:19]Number one would be uh have to do a cardio version after the procedure which is not uh it's not a failure but why would some require a cardioversion and then why would some require a follow-up ablation and there were two factors that were were front and center. Uh one is the h a history of previous ablations.

[00:44:42]So the history of pre previous uh ablations was a strong predictor that you might need another one. So that suggests there are areas of the heart that were treated but not treated very well that are still a problem. The second was is as most of us know is the size of the left atrium. So once the left atrium gets quite large then it's much harder to keep that heart in rhythm. Uh those were the two factors that were important.

[00:45:14]We still have a I still wanted to we haven't touched yet on that book that's right behind your right shoulder uh the the uh Mediterranean diet. And if you would I would love it if you could go through us a little bit of why you how you came up this with this and why you wrote the book.

[00:45:37]Well, you know, it it basically um years ago u I started out as an I guess a interventional cardiologist and doing angoplasties but I I felt that there was a better approach uh a better approach to um be able to uh take you decrease the number of heart attacks that we that we have been seeing. It's gone up every single year. as well as strokes, atheroscllerotic strokes. And so one of the one of the things is um clearly uh lifestyle uh intervention and one of the lifestyle interventions that starts with diet diet and we have so much data to show that a Mediterranean diet uh is probably the healthiest diet out there and uh even they uh to this day they still feel that the Mediterranean diet is key and the reason for it is uh it basically is a healthy diet because it's it's not u it doesn't have a lot of additives and food and you know it it clearly has food directly from the earth and the sea uh you know a lot of fish and you know it in in a way uh a lot of people today uh don't eat properly. there's a ob major obesity epidemic. Um [clears throat] but you know and then of course the other things that play a role when as a preventive cardiologist is making sure that people uh get the right amount of exercise that they you know that they can lower stress and I could go on and on about that but that's very important but none of these things the root cause of and that is uh the sclerotic plaque that were young in their early 20s and it can go several decades before it gets inflamed and can rupture.

[00:47:53]So you know I basically feel that we can now through genetic engineering and other things eliminate uh the root cause which is uh eliminating the atheroscllerotic plaque and especially what we call soft that was one of my more recent books heart attacks are not worth dying for but I honestly believe believe that we should be doing this and we should be uh able to uh have a significant decline in the number of heart attacks and strokes by getting not only LDL down but what we call the apol lipoprotein B which is all of the atheroscerotic plaques and doing it early enough uh so that uh you know we can stop this before these plaques get inflamed and and can rupture.

[00:48:46]>> Uh somebody wants to know if your books are still available. You have four books that I know of available on Amazon.

[00:48:56]>> Yes, they are. They are. They um you know the probably the the the top three I would say was is heart attacks are not worth dying for. the Mediterranean diet and the great American heart hoax which is a book I wrote a number of years ago but um it really boils down to a lot of what we've been talking about today and that is that [clears throat] you know you have to use common sense uh you don't want to take people that are completely asymptomatic uh and uh not not having any symptoms and say my gosh we found a 60% plaque, we need to do bypass surgery on you.

[00:49:41]That wouldn't be right. Um, you know, and I'm I have the highest respect for, you know, cardiac surgeons and the ones that, you know, they they do things uh they they do um uh procedures that save lives. And it it's true. And I think at the end of the day [clears throat] uh what is so important is that uh we have a good discussion with patients that we see. Uh and uh it could apply to everything that we need to go through all of the options.

[00:50:15]U you know the hypocratic oath says do no harm >> and you know make sure that you do the right thing. And if you look at it, it basically u as it relates to for instance uh doing catheter ablation. Um I think that there's you know if doctors would sit down and say okay here are the options that you have. You can start with the proper diet and lifestyle changes. Uh we could put you on medications. We could do a catheter ablation. But they haven't hit the number fourth thing that they should bring up and that is or you can look into a mini maze procedure.

[00:50:58]Um and you know it basically the let the patients understand what are the options and then you go from there.

[00:51:07]>> Well that's a good point. That's probably one of the most common comments I see of patients that come here is, "Why didn't my EP tell me sooner that this was an option?" And generally, I say they they usually only tell you about what they do. Um, they don't tell you what else is out there. Now, this I ask you a a question that you don't have to answer if you don't feel comfortable answering it. But if you had to do it all over again, would you do anything differently? He had three ablations over what uh [snorts] seven years or something and and then uh came to Houston. Would would you do it differently?

[00:51:48]>> 100% I would I would get a mini maze from the beginning. Um and [clears throat] um you know the advantage with doing that is that you don't [clears throat] get the scarring uh in your in your uh atrium that you would get by having multiple uh procedures. Um, and I think that in addition to that, you know, I guess I'm fortunate because um, I didn't end up with heart failure, but I could tell you that a lot of people who have who are walking around with paroxismal atrial fibrillation uh, and think everything is going to be okay. Unfortunately, it's a major cause of of heart failure. And you know when you go back into sinus rhythm it mitigates that. So I think it's um you know for for those individuals that had one or two ablations or had no ablations but feel that they feel okay to walk around with atrial fibrillation.

[00:52:56]it is a significant cause of um of heart failure and it's also a cause of cardiovascular disease uh as well as others. So I think it's you know I I I think what we know now uh in in my humble opinion would be for a patient who comes in to see me that uh uh I put um obviously you want every patient's different by the way no two people are alike. Somebody could be extremely obese. They may might not be a candidate for many maze until they lose weight or there could be a lot of other factors going on. But assuming that they are u a a candidate and they have been out of rhythm uh for you know the certain amount of time uh to me the number one procedure would be a mini maze procedure. not to have multiple catheter ablations uh and not uh to do nothing uh I think that uh is really uh it it in my opinion it's truly a gamecher.

[00:54:07]>> Okay. Thank you. Well to your point two things that we do in the clinic if the patient's uh morbidly obese we ask them to lose weight down to a BMI of 31 at the highest. And we've had many patients that have lost 70 80 pounds and of course they feel a lot better and then if they still have AIB we still take care of them. Um so that's that's been um helpful. And the other thing is if we're not sure what their AIB burden is I don't hesitate to put in a monitor a subcutaneous monitor before we make a decision and say I tell them let's be objective. Let's put in a monitor, see what your burden is, your AIB burden, because all the modern devices calculate burden per month, 0%, 2%, 100%. And I think that's very helpful because it's objective and then you can go back to the patient and say this is your AIB burden. What do you want to do? I mean, if it's 1%, maybe you don't do anything.

[00:55:16]>> Totally agree. And I think [clears throat] one of the problems that I see are a lot of people uh get a watch uh that tells you what your um heart rhythm is doing uh or the cardio mobile for that matter uh which I like but it's still they're not accurate enough uh to be able to say this is your burden that they don't do um you know you basically if you look at the link monitor you know that is much more accurate.

[00:55:49]>> Yeah.

[00:55:49]>> Uh and you know the fact that you're able to put that in u during you at the end of the procedure is wonderful and I think that a lot of people would really uh be would would be very happy to have a link monitor put in and especially given the fact that it's titanium. So it doesn't mean that you can't have an MRI done or uh any other procedures done. So it's very safe. It's very good and it's very effective.

[00:56:20]>> Yep. Well, I want to thank you Dr. Osner for joining us. Uh it's been fun to talk to you. Maybe you need to write another book. Maybe I need maybe I should help you. [laughter] I I think I think I know what the title might be.

[00:56:40]>> [laughter] >> Let's do it.

[00:56:42]>> Well, thank you very much uh Dr. Wolf. I appreciate it greatly for uh everything that I had at Houston from the surgery to the you know after surgery was was excellent. Uh my wife came with me. We had a actually it was almost like a vacation after we got out of you know the operating room and out of you know and it was a wonderful experience. So, uh, kudos to you and you did a wonderful job.

[00:57:12]>> All right. Well, we'll continue to follow you and thanks for presenting on our program. Have a good rest of the week. Take care.

[00:57:22]>> Thank you.