Hello, my name is Doctor Sarah Walker, and I'm honored to serve as the 2025 president of the El Paso County Medical Society.

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Presented by the El Paso County Medical Society and hosted by Kathrin Berg.

When your heart is beating normally, you hardly ever notice it.

An arrhythmia, however, is an abnormal heart rhythm where the heart beats either too fast, too slow, or with an irregular pattern.

It occurs when the electrical impulses that coordinate heartbeats malfunctions.

This evening's program is underwritten by Tenet: the Hospitals of Providence.

And thank you to the El Paso County Medical Society for bringing this program to you since 1997.

I'm Kathrin Berg, and this is the El Paso Physician.

Neither the El Paso County Medical Society, its members, nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

And.

Thanks for joining us.

Sometimes our heart beats a little irregularly.

Too fast, too slow.

We're not quite sure if it's dangerous.

What's the deal?

I know that is a problem that I have.

I know quite a few people do have that problem.

So we're going to kind of spill the beans on what the situation is on that this evening.

We have Doctor Clifton Espinoza here with me, who has been here either 3 or 4 times.

We're going to duke it out later and figure out which one it is.

But it's always a joy to have you on.

You are a noninvasive guy, as you say.

So you're a noninvasive cardiologist.

And then we have Doctor Maria Elena De Benedetti, and she's also a cardiologist.

She's also noninvasive, but she kind of specializes in the electrophysiology.

And Doctor Espinoza says you can call her the part time electrician.

So I kind of love that about you guys.

Doctor Espinoza, since you are our veteran, I'm going to ask you to kind of start first.

And even though you are a noninvasive cardiologist, what exactly does that mean to our audience?

And on a normal day, what is it that you do your day to day functions and day to day duties?

So as a noninvasive cardiologist, I would be considered what most people would think of a traditional cardiologist.

I see mainly patients in the office.

You know, I read their cardiac studies or EKGs, echo stress test.

I do see patients in the hospital.

My primary focus is in diagnosing and treating cardiac conditions without getting too invasive, meaning I don't have to do invasive procedures.

Most of the time, I'm more of a thinker.

You're more of a thinker.

Yeah, I've heard people that call themselves a thinker, but you really are.

I do get that, doctor De Benedetti.

I'm going to do that a couple of times.

So as a noninvasive electrophysiologist electro cardiology.

Oh my goodness.

Electro.

So you do a lot with electrophysiology in cardiology?

Yes.

Easy for me to say.

Explain to the audience what that means.

So, we mainly deal with the rhythm disturbances with, all the problems of the rhythm of the heart.

My main focus is on the device implantation for patients.

So when all that it has to do with the slow rhythms, which would have to do with pacemakers or fast rhythms, we do have to do mainly with defibrillators.

And now the advancements in device implantations and technologies are huge.

So we're doing leadless pacemakers, subcutaneous for younger patients, complex devices by ventricular pacemakers.

So that's mainly my the focus of my practice.

So but I do have a very large, general cardiology practice, just like Doctor Espinoza does, which I quite enjoy because I think, you know, the arrhythmias is like a very specialized portion of cardiology, but I do like to be able to treat the patient as a whole and know all the other areas as well.

So most of our procedures are invasive.

That means that we do them in the cath lab and in, in the EPI lab, where we basically do the implantation of all these devices and where they also do ablations and our more complex procedures.

Watchmen's, which Doctor Espinoza assists with the imaging part.

So I think we'll work as a team.

I mainly, have a very large device based practice, so I follow, I spend a lot of my time, following these patients because not only the implantation of the device, but the follow up, we do monitor them periodically for the development of arrhythmias that can be picked up through the remote monitoring of these devices.

So we have a very large practice.

So I do review their remote transmissions.

Some devices are transmitting every month.

Other devices transmit every three months.

We bring them in-office for checks.

We find, you know, we have other partners are older than us that have been implanted.

What, older than you?

Well, a lot older.

Well, we're kind of on the young side Like, they've been putting devices for a long time.

So then we have, problems with the leads, fractures, and sometimes the patients need upgrades.

So we do follow them in our device clinic.

And we do read carefully their interrogations and decide what's best.

It might not be my patient might be somebody else's patient.

And we do communicate with them and we work as a team very well.

This is great.

I'm kind of taking some notes as you're talking to because we talk about older but pacemakers, I don't know when they came around.

Is there like an approximate decade that they came around because they are so different now than they were, what, 30 some odd years ago?

Controlling with the phone now, you were talking about how remote you can actually control the pacemaker remotely.

But I love that we're going to get into a lot of that in a little while.

Actually, the first pacemaker was external.

Remember the patients used to walk and push the pacemaker?

No kidding.

That was the first pacemaker ever implanted.

I actually have a slide.

I gave a talk not too long ago, and in one of the journals they had like the history of pacemaker.

So the first pacemaker, the patient is walking and you see him pushing this whole thing.

There was a pacemaker.

I'm going to see if perhaps we can get that from you.

Yes.

So that we can show this on this program.

I'm looking at all the interns and everybody who's doing the show right now.

We can see if maybe we can put that on the air that I'm in.

And now we have leadless pacemakers that are the size of like a triple A battery, you know, so this has evolved that technology that we have these days is amazing, I love it, I love everything about it because I'm not there yet, but I know I will be.

So I'm thinking every every couple of months is going to be better for me going forward.

So here's a question what qualifies as an abnormal heartbeat?

Doctor Espinoza, I'm going to start this with you.

So what qualifies is that?

Because, I was you know, they used to call it a heart murmur.

And then when I was in high school, it's like, oh, you have a mis beat here and there.

And then I had mitral valve prolapse, and there is regurgitation, but then you're all over the place.

So I feel like so many of us have some kind of a weird, irregular heartbeat somewhere along the way.

But when is it something to be concerned about or just take note of?

Maybe not even be concerned about?

When is it time to take note of what qualifies as abnormal?

So I think in order to understand what's abnormal, we need to understand what is normal rhythm.

Right.

So everyone's heart has a natural pacemaker in their electrical system.

So the heart has an electrical system.

The SA node or the sign or atrial node is what's responsible for setting your heart rate.

It basically shoots the impulses on the electrical system.

So basically, you know, if your heart has four chambers.

And for normal sinus rhythm, you know, there is a synchrony to where the chambers kind of contract, right?

It has to make sense.

The top chambers contract first and then the bottom chambers contract next on the EKG, we look at certain, you know, waves to determine whether someone's in regular rhythm.

But that's kind of the gist of it.

There has to be this synchronous contraction of the chambers.

And abnormal rhythm is anything that strays away from that.

Right.

So if you have extra beats, which we call premature contractions, either from the top chambers, bottom chambers, that's an irregular rhythm It causes abnormalities in the beat to beat a atrial fibrillation.

You know, atrial tachycardia, ventricular tachycardia those are all rhythm abnormalities I can come about.

But in that sense it's anything that strays from what the normal beating of the heart is.

That's what we consider an arythmia So here's the follow up question to that with the abnormal beating.

And I'm just going back to what my experiences.

And from my perspective, it's like, yeah, you're a regular, but it's it's it's regular for you.

Meaning it's never been an issue for you.

It's not a problem.

I had a heart monitor once for a month and like, yeah, you're all over the place, but it doesn't mess with you, so you're fine.

So.

So that's the follow up.

When is it something to be concerned about.

So there are benign arrhythmias.

And then there's the problematic arrhythmias So a lot of times patients will feel palpitations.

You know what they come to see us for.

You know you put a monitor on and you find that they have premature contractions back.

PVCs, those are considered benign.

If we were to put a monitor on every one, a large portion of the population, would have this.

But it becomes problematic when the patient develops symptoms.

As a consequence, they're short of breath or lightheaded or they just can't take the palpitations.

That's when it becomes pathologic.

We have patients that come in with rhythm abnormalities all the time, and they don't feel a thing.

Patients in a-fib, their heart rate's 120 and they tell you that they don't feel a thing.

But I mean, it becomes more of a problem once the patient starts feeling, you know, unwell.

Yeah.

So when a patient comes to you and doctor, De Benedetti, I'm going to ask you actually what diseases can cause some irregular heartbeats going forward.

And then I'll follow back up with some of the stuff that we were talking about.

But in general, what some diseases can cause that.

And there are these things that happen congenitally.

Or are they something that happens as a child comes on as an adult?

Feel free to take over that whole gamut.

So I think along the things that happen more on the congenital side, as you know, congenital heart disease is is a serious thing when kids get these, big surgeries, when they're born with tetralogy of follow and they undergo all these surgeries to, to fix the heart, obviously the surgery leaves a scar in the heart.

And every time you leave a scar in the heart for any surgery scar is is a substrate for arrhythmia because it can create a reentry circuit.

And around that scar the electricity starts to travel.

So rather than to follow the native electrical conduction system like Doctor Espinoza, just explained very well, it finds this kind of place where it's easier to go around that.

So then, rather than taking certain number of milliseconds to conduct from the native conduction system, like he was explaining from the sinus node to the AV node to the bundles to depolarize the ventricles, it finds this area.

And he just likes it because it's easier and it starts to run around it.

But rather than it being 60, this small circuit can be 300.

So then your heart is beating at 300 beats per minute.

So congenital heart disease with extensive repair is, it's, it's, a condition that can lead to arrhythmia developing later in life.

And it's actually arrhythmias that are very, very difficult to treat.

You can also have other things like what you were saying.

You can have mitral valve prolapse.

So just your leaflets are prolapse.

And then you have backflow of blood.

So that backflow of blood stretches the upper chamber.

tha Dr.

Espinoza was explaining we have four chambers starts to stretch the left atrium because the mitral valve is on the left side and then it by stretch and it makes it more prone.

There's certain slips of muscle that revolve around the pulmonary veins that drain into the left atrium and makes those easier to fire.

And then you have a circuit again, it's electricity.

It's all about circuits, and it starts to conduct there rather than again, it's easier to do this than to take all that electro mechanical contraction from the sinus node to the a.v node.

So then atrial fibrillation is a common arrhythmia that occur in patients that have a mitral valve disease.

And the problem with AFib, like Doctor Espinoza was explaining a second ago, it's that it gives a lot of symptoms, but there is a large population of patients that, for reasons that we quite don't understand, don't have symptoms, and they may just present with a stroke as their first.

That would be the question.

So if they don't know, they don't have any symptoms, they don't know, when they first present to you.

So let's say they do have a stroke.

That was a perfect Segway there.

So let's say they do have a stroke.

And now that you're you're in you're doing whatever, whatever you do to try to get that situation in line there.

Now you're finding, oh my goodness, this person maybe does have scarring on the heart.

Maybe this person does have issues where do you take it from there?

If it's someone who's never had any kind of a symptom, and now they're 59 years old and they're in a situation like, oh, well, now we have to address this with maybe a pacemaker or with maybe whatever it is coming forward and feel free to think of.

So I talk about this a lot.

Whatever case study you've had in the past, that's kind of weird or stuck out to you.

We love hearing about them because I think sometimes you find a story about a certain patient, no names or anything, and you think, okay, well, this person had this and kind of explain how you treated that situation.

Is there any one that sticks out in your mind?

Well, I just think for the AFib specifically is probably the most common arrhythmia that we see.

You know, I think, as population age with hypertension and all the risk factors, sleep apnea is a huge and undiagnosed sleep apnea is a very big risk factor for atrial fibrillation development.

So when I have patients that, you know, you're not sure why this is happening, you send them to have a sleep study because these patients, you know, sometimes said, no, I never snore.

My partners say then snore.

Really?

Then they have a sleep study and they have a lot of episodes where they're actually.

And that when you have that episode where you close your airway decreases the tension of oxygen in the left atrium and makes you more prone to having atrial fibrillation.

So we hear about sleep apnea all the time because we're in this field.

So, Doctor Espinoza, if you can explain to the audience because they probably hear it too, but don't know what that means.

So when somebody has sleep apnea, what does that mean?

Well, there's two types.

So there's central and then there's obstructive.

So central.

You see more in patients that I've had you know strokes you know neurological disorders even sometimes very severe heart failure.

Where the breathing center in the brain isn't working very well.

And, you know, patients just stop breathing when they're sleeping.

And it's not until they've lowered their oxygen levels to a certain point that certain reflexes kick in and then meets some, you know, start breathing again.

So at central and if you're with a partner, it's almost as if that I've just programs.

You've had me before.

It's almost that partner just all of a sudden gasped for air.

So when you're with someone okay, if that's happening, we need to get you checked.

So either they tell you he gasped for air, or he sounds like he's suffocating, or all of a sudden he just stops breathing for five seconds and then starts reading.

Then there's probably sleep apnea.

The other type, which is actually more common, is the obstructive sleep apnea, where there is an obstructive process in the back to the throat, larynx, pharynx, and a lot of times it's associated with obesity.

So the, you know, obese patients tend to have a higher incidence of obstructive sleep apnea.

And again, it's an obstructive process where either the tongue, you know, falls back there or the they just have a narrow airway.

And again it drops their oxygen saturations.

They stopped breathing.

And then you know, they're prone to the rhythm abnormalities.

The good thing about obstructive sleep apnea is that there's treatments for it.

This is the famous CPAp, right.

That the patient is just absolutely hey you know anytime you have a patient and you ask them, hey, how's your you know, you do your sleep, I was like, no, nothing suffocates me.

I feel worse.

So and that was a challenge too.

We did a program to ways that there's, inspire.

Inspire implant.

Exactly, exactly.

So on your point, somebody is listening to this and it's like, you know, I'm going to say my husband, but no, my wife, my wife, man, she just she snores.

I go, I don't know what.

And then all of a sudden she starts gasping, what do what do we ask those people to do?

Do we ask them to go see their internist and get a sleep study done?

Like what would the suggestion be from here?

Well, the 100% need a sleep study because until proven otherwise, they have sleep apnea.

So they need to have a sleep study to determine, you know, is it central obstructive and severity.

Because depending on the severity, you know the therapies might change.

There's different types of CPAp.

There's BiPAP by level.

So it really depends on what the process is that's causing the problem and how severe it is.

Okay.

So let's go to Doctor De Benedetti I'd like to ask you about diagnosis.

So we were talking a little bit about sleep apnea.

That's one of them.

If a patient suspects that they have arrhythmia what kind of tests are available.

So let's take sleep out of the way because now we've kind of talked about that.

What else can, how else can you find out which most of us will start by doing an ambulatory monitor.

Because patients describe what that is.

Yeah, I'll explain it sometimes.

You know, I think palpitations is a very like, broad symptom.

Patients vague.

Right.

Patients say I have palpitations and you're like, what do you mean?

Like, sometimes I get a get mad at my husband and then my heart races.

Is that an arrhythmia?

You know, you it's it's heart.

So I think the monitors play a very important role because they allow us to correlate what the patient is saying with what the heart is doing these days.

Sometimes patients are like, no, I don't want to wear that.

That is so cumbersome.

These days we have these little things are like literally a patch.

It's a sticker.

It goes in the chest.

You know, I, I have patients, there are doctors that are wearing it and nobody knows that they have that on.

And this is the heart monitor.

Yes, I had that big honkin thing.

Good thing I had the sling.

Yes.

Not anymore.

Like we have like little sticker.

It goes on the chest.

It's a little recording thing there.

Like a little chip.

They need to like disconnect the part.

Obviously if they're going to go like take a shower with the water.

But other than that they can live a normal life, do all their activities if they have symptoms.

It comes with like a kind of a cell phone, and they can press if they're having symptoms.

So if you tell me I have palpitations and you press and then I see a recording that is completely normal, then they know that this is something.

It's not that you're having an arrhythmia, but so this could be a psychosomatic thing too.

Sometimes.

These patients are going through a stressful situation, death of somebody divorce like patients sometimes don't know what's going on.

And if they're in an age where it's concerning they get worried.

You know they're like so and especially I think the value of the monitor, it also gives peace of mind to a patient.

Right.

Because you can show them, say I do that all the time.

Listen you press here.

Do you remember this day.

And the patient goes like, oh yes, I felt it, I know.

So then I show them, here you press, this is the time.

This is the strip.

And I show them a normal rhythm.

And then they can show them something they have stored in my computer of an abnormal rhythm.

So, like, to the naked eye there is a big difference.

So then they like kind of calm down and they say, oh okay.

So then maybe it's not what I was thinking.

It is.

And I think that's pretty much where we all start.

Sometimes we find serious thing.

And the and the beauty of these things is it's like live telemetry.

They're wearing it and people are monitoring it.

So the patient has like even if they don't feel it, if the patient has a bad arrhythmia Yeah, we're going to get called from the the company that produces it.

There's someone always on call.

That's a good thing of being in a group.

There's always someone covering.

So say he's covering the weekend.

And I put a monitor in my patient on Thursday.

And then on Saturday he passes out and he has a long pass like he's heart just stopped.

They're going to call him and he's going to call the patient and tell him go to the hospital, Dr.

Benedetti will see you Monday.

If it's an emergency, Sometimes, you know, there's our people and if it's something needs to be done right away and I am not there, one of my partners will do it.

You know, that's one of the beauty of being in a group where the patients are covered all the time.

But I think these monitors are really important to diagnose what's going on.

And then, of course, we also need to think about everything else, right?

Like you need to check.

Sometimes you get referred and nobody has done anything.

Like I check their thyroid function.

What about their hypothyroid?

Their thyroid is through the roof, of course.

They're having like fast heartbeats with I mean, do that, get an ultrasound of the heart is something really important to look at the structure.

Like we said, there's a relationship between the valves and like, you know, the this backflow of blood or stenosis that leads to increased pressures.

So we get an echo.

And then I think that's where we mostly start.

Right.

And then based on what you see then you can decide what next.

Okay.

So let's go back to the individual who on Saturday, you're getting a phone call because something's going on on this monitor.

He has no idea.

So we were talking earlier about people that don't have symptoms.

So again case study.

So let's talk about what you would do there.

So he gets a phone call say he's passed out though.

So who gets the phone call then.

Is it somebody who's around.

Seriously.

I mean I'm being dead serious.

I mean, it is a special situation, but, I mean, ideally, yeah, we would try to get ahold of the contact or the patient's emergency contact if we can't get ahold of them.

And then from there, where does it go?

So if he is conscious and he's able to get to the hospital, you say, okay, go to the hospital.

Now, if he's not in that situation, would you call 911?

I would tell, I think most of us would tell them, call 911, right.

Because you truly don't know, like what's going to happen next when patients start having pulses.

Sometimes the next one is so long.

And then there is just the fine line between a long pass and a cardiac arrest, like the heart.

Like sometimes patients tell me, well, but I'm not having a heart attack.

I'm like, sir, this is way worse if you have.

And if you don't have an electrical, if you don't have a heartbeat, you're not in this world.

You know, if you're having like, this long past, you are gone.

So you need to understand that part.

Going to what you were saying about things that we have seen.

You know, I, I've been in El Paso for almost eight years.

So but before this I used to work in a very rural area in Nebraska.

And, I thank you for coming in El Paso, Nebraska you know, it's a lot nicer here.

I liked it though , it was nice, patients were super nice, but yeah.

Anyhow, like, I have this patient that he was wearing the monitor, right?

And this guy kept calling him because of his pauses and pauses and pauses Right.

And he lived in, a mobile home in, like, a very rural area, you know, like, and they said, I'm going to send you like, the hospital had a helicopter, you know, to go to these very rural areas.

I said, we're going to go get you.

You're having like five second, six second pauses like one after the other.

And then he goes like, let me think about it.

And I hear, like I said, sir, are you smoking?

And I said, like, I know this patient for a long time, sir, you're in an oxygen tank.

You are wearing oxygen in your nose.

And he's like, I know that sweety And I'm like, I was like.

And he's like, you know what?

I don't feel like I'm coming to the hospital today.

Maybe tomorrow.

I was like, oh Lord, I said like, sir, you have to don't smoke when you have the oxygen tank and don't do that, you're going to explode and then you're having these pauses.

You need to come to the hospital.

Finally, we got him.

He came to the hospital on his own terms.

Like three days later with a heartbeat of like 30.

Like three.

Like from, like nowhere in Nebraska to, like, a hospital, you know, like, he was in a very rural area.

And we finally put the pacemaker and he did good.

But sometimes patients are stubborn, you know, you keep telling them like you need to do this.

And they're like, because going back to what we were saying, if they don't feel like they're dying, sometimes they don't feel like you need to put metal.

So you've got the two extremes, right?

You got one that's kind of a hypochondriac and oh my gosh, I'm dying.

I'm, you know, it's like, whatever.

So you came to my next question too.

So talk about now treatment options.

So, you said you put a pacemaker in this individual.

Correct.

So, you know, took him a couple of days to get there.

But after that, and I don't know how long ago that was.

So I guess let's put that in perspective.

Two is a what kind of a pacemaker was and how he is, does he control them.

Again he didn't feel the symptoms though.

Right.

So it would be like you all would be able to control well, the pacemaker once we put it in, we set it up like, you know, there's different companies that produce them.

And the reps of the companies are with us in the cases they're responsible for the programing, but they do that under the guidance of the doctor.

So I tell them I want these programed like a such these, these intervals, this lower rate, whatever I want.

I tell them and then they'll program the device that way.

Then imagine it's Doctor Espinoza patients.

He doesn't do pacemakers but he might not like what I did Or he might think no, but he might think that the patient maybe needs a higher, like a lower different rate.

Or maybe turn on the rate response.

There's many other changes that can be made when they go to the office, and that can be tailored to the patients feeling better.

You know, not everybody needs rate responsive.

You're in a wheelchair.

You don't need that.

But someone that is active probably needs that.

So.

And you can tailor that.

We can walk the patients in the clinic, see how they're doing.

If they're chronotropic incompetent.

And a lot of that is done by their own cardiologist.

They don't need me to tell them that.

We learn that in my in cardiology fellowship.

So you can tailor a lot of these things to make the patients feel better.

But like the general program is at the time of implantation.

But anytime they come to the office, you can put a little wand on top of the pacemaker and connect to a little computer, and you can make any change to that you want to that initial program.

And that is so amazing.

Now, I mean, I'm trying to think of doing this show now almost 29 years.

And I just think to myself when we were talking about pacemakers 29 years ago, completely different ballgame.

On the note of noninvasiveness now.

So Doctor Espinoza, let's talk about that.

So and we're not done with devices because we're still going to do a lot of devices, because I want to talk about the all kinds of stuff.

So if you're looking at a noninvasive treatment of AFib, in general, where do you start non-invasively?

And does it always graduate to devices?

Does it maybe to hang out with noninvasiveness for a while?

AFib is a very particular beast.

You know, because if you're needing device therapy for atrial fibrillation, then that means that the atrial fibrillation or the AFib just refractory to everything you've thrown at them.

So basically, when you have a patient with AFib, you got to first gauge, you know, how symptomatic are they.

The more important aspect is to determine the patient's stroke risk, because that's the most dangerous portion of the AFib.

Not so much the symptoms, but the fact that it can cause strokes.

And mainly because that top chamber is doing this quivering motion, blood stays in a particular area longer than it should call the left appendage forms a clot, and that can go out and form a stroke.

So we have a scoring calculator that we use to determine who needs anticoagulation and who doesn't.

So that's usually my first step is okay, this person has AFib.

How symptomatic are they.

And then after that what is their stroke risk.

You know, because then you have to have a conversation with the patient and tell them, hey, you need blood thinners to reduce your chance of stroke, which is a very tough pill to swallow for some patients.

You know, some patients don't want to be on anticoagulation either, because of what they do for recreational purposes or employment, or some just don't want it.

We'll talk about, if you don't mind, since we're on that subject, what are the symptoms and why?

Why are you hearing patients do not want to be on a coagulation.

Well, you know, first of it's all the things that we hear from other people a lot of times.

And that's the point I'm trying to get to.

So let's do some myth busting right now.

Yeah.

So, you know, you have patients telling them that the blood thinner is going to cause all sorts of issues.

You're going to be bleeding all over the place.

They're not going to have a normal life, which is not really the case with the newer drugs nowadays.

You know, the chance of major bleeding has been reduced substantially.

But these are myths that patients come into the office feeling like, oh, or they had an aunt or neighbor, that they were on blood thinners and they had a catastrophic complication.

And they just don't want to deal with that.

So that's that's kind of, you know, where we have to sit down until the patient.

And this is what's reality and this is what is hearsay.

Now in that aspect of thought process.

Right.

Would they rather have medication or would they rather have a device.

I mean, is that something that is at that point discussed?

Well, there is an alternative to blood thinners called the watchman.

So it's an implant.

Oh, you talked about that.

Yes.

Okay.

So it's a special you know, it's a plug for, you know, lack of better wording.

It's basically a small mesh plug that they place in that particular area of the heart with the clots form with the atrial fibrillation.

Over time that gets covered in normal healthy tissue and it frees a person after a certain period of time from having to take the blood thinners.

And the stroke risk is comparable to the blood thinners.

So I'm going to have you back up so that people can visualize what you're talking about.

So the clot that's that's creating the AFib.

Right.

The AFib forms a clot.

The AFib forms the clot.

So when you're talking about this device, it goes to the clot and dissolves.

No.

So it goes.

So the area where the clots form is is little area.

You know most there's different morphologies, but it looks kind of like a windsock okay.

It's called the left appendage.

So basically this little mesh goes at the entrance of that windsock and closes off that area.

So blood no longer enters in there and forms clots okay.

And so this is in your heart for the end of time.

It stays in there forever.

Yep.

Okay.

So their body then naturally is doing what with this.

So the plug covers that area.

And then your body over time covers it with healthy tissue okay.

So you basically close off that area completely.

See in my head I'm going back to Doctor Benedetti when you were talking about any time you touch the heart there becomes a scar and there becomes, you know, like you said, that natural conductor to do things.

Is that an issue with this at all going forward?

Not necessarily because the it's it has small little hooks so that it can be held and anchored in place.

But, you know, it's not like, when she meant scars and more like a heart attack where healthy tissue, basically, you know, fibrosis and scars off.

This doesn't necessarily cause a scar to the muscle tissue.

It just closes off that area.

Okay.

Very nice.

I think, that also a concern that patients have with them.

The correlation is, not only they have heard and seen, you know, from somebody else have a problem.

Some of them also are very active.

I have patients that are doctors or physicians that they like to hike, and they have AFib like, you know, like a big motorcycle.

They like they go hiking on the weekends.

And I'm sitting there thinking like, you know, he's hiking.

If he falls on the blood thinner, he can hit his head.

But I cannot tell him, sit down at your house and don't go hiking.

That would be ridiculous.

So but I think also when we see the sicker patient population like they have AFib.

AFib is generally like accompanies many other cardiac conditions.

So they have heart attack.

They have stents in the heart.

So they need to take other medications that thin the blood as well.

In addition to the blood thinners.

They need to take antiplatelet blood thinners.

So then you have the perfect milieu for a GI bleed or a brain bleed, because they're in all these medications and they're 90, you know, they're elderly, they're frail, they're a woman that is like 50 kilos, like 100 pounds taking all these medications.

And you know that her chance of bleeding is super high.

So I would very much rather her get intubated and get for that because for the watchman, this what he was describing.

You need to get intubated.

So I very much rather her get intubated and get a puncture like that is risky of course, but in the hands of people that have done a lot, it's done very safely, you know, and get that close so she can come off at least the Eliquis and she can continue taking her medications for the stent, but then her bleeding risk decreases significantly.

So I love that you talked about age.

So somebody in their 90s and I think, I think throughout time you always think, okay, well when do you when do you qualify a risk like after the age of 70, ah no, after the age of 80, no, because now people are living a lot longer.

And I'm not saying living longer.

They're healthy a lot longer as well.

So I'm finding like in the last decade, that surgeries or procedures that would have not been done, you know, a decade, 15 years ago are now being done on 80 year olds, 90 year olds.

And I think two parts of that.

Number one, we are living longer and healthy, longer.

But you were talking about, now things are just the size of a patch or this and the other.

On that note, I'm going to try to transition into the different types of devices.

So when we first opened up the show, we were talking about, pacemakers, but you're talking about all kinds of different devices.

So from there, I want you to just kind of give us the shopping list of devices that that you work with.

So I think and maybe most the most common because there's going to be like 80, right?

So maybe the top five most common.

And what those are particularly doing.

Okay.

So I think the most simple one is the loop recorder, which we think, all use.

Say that slowly.

It's called the implantable loop recorder.

The loop recorder.

All right.

So we talked a minute ago about the ambulatory monitors.

The they got a sticker in their chest.

We normally use those for up to 30 days.

But for example if you have atrial fibrillation this is a problem that is going to be with you.

We can't cure it.

It's likely to come back.

You need more procedures.

So the loop recorders were developed to monitor arrhythmias for a longer period of time.

So it's like having that monitor sticker on your chest.

But it has battery for up to four years.

Oh nice.

So then okay.

So then we use it for example when we have patients that are passing out for example, they come to us they say doctor and passing out.

So we put we do all the work.

We put the monitor, you know, and, and going back to like telling little stories.

When I was in Nebraska, I have a lot of stories from Nebraska.

I like stories of how people remember things.

Well, I had this patient, she was 30 something, you know, little kids who would come to the office all the time.

She worked on the fields, on the corn fields.

And she kept telling me I pass out like I passed out picking up the corn multiple times.

And I go like, well, maybe it's the sun, you know, Nebraska.

So sunny.

Maybe it's just like a vasovagal We did all the work, so I said, why don't we get a loop recorder?

You know, I think if you if she keeps telling me, like, genuinely, that this is happening, all the work was normal.

She even had a cardiac MRI.

I didn't know what else to do for her.

She kept passing out.

So I put the monitor.

She had it for two years and she during that time she never passed out.

I was about to leave Nebraska like probably three months before I left.

She was driving, going to Denver with her kids in the car, and she passes out with the loop recorder.

As she's driving.

And she had a long pause, you know, so probably whatever had happened, like she almost like her kids were in the accident.

They got injured and then, you know, there was one of the most like it all stuck with me because she got the a leadless pacemaker and she did great.

Never had that problem again.

And I mean, if I wouldn't have put the loop recorder, maybe the next accident, maybe she would have died with her, you know.

So those are those things that, you know, sometimes you got to be persistent when you're looking for these diagnoses because they might not be right in your face.

So I'm going to back up on that too.

So she had this loop recorder.

She had it for two years.

This incident happened.

The message went back to you that said, there's this long pause, something's wrong, you telephone, you located her, etc., etc.

she was closer to Denver than to, Well, I used to live in North Platte, that is, western Nebraska is closer to Colorado than to in any other town.

So she was closer to her.

So they took her.

They took her to UCH.

It was a small hospital.

So a lot of my procedures, we were done at the university, you know, so I had a very good relationship with them.

So they called me from there.

Your patient is here.

She passed out driving, her kids are okay.

They're injured, but they're okay.

Nothing bad happened.

We interrogated the loop recorder.

She had, like, a super long pulse that led to, like, she literally went on the other side of the freeway.

I mean, thank God there was not a car coming.

I mean, she could have died.

And then they told that, so I then I went and we put a leadless pacemaker.

So so needless.

Is that what you said?

So describe what a leadless pacemaker is.

The leadless pacemaker.

Yes.

The leadless pacemaker is the one I was telling you the beginning It literally looks like a battery.

Okay, so it's a tiny, tiny one, has no wires.

Okay.

And it's placed from the groin into the heart, okay.

With a catheter.

And then we take the catheter out and the thing stays in.

Okay?

You know, that lasts how long?

Like, how long is the battery?

About 12 years.

Because we're in the second generation, they started doing them when I was in fellowship.

I did my first ones in fellowship.

So they've been going on for like 12 years now, more or less.

So we're the second generation.

So is that the most common type of pacemaker now?

I think it depends on the indication.

So standard transvenous pacemakers, the one that you get the little incision in the wires in the heart have their role too.

But you would agree that Micra has helped us tremendously.

Like for a lot of the procedures that Doctor Espinoza helps with the TAVRs and all the structural thing.

Imagine you have open heart.

And then we were just talking about this a second ago.

Like imagine that you have open heart.

Now you have this sternum.

They that surgeons come in.

They need to take the wires, the AP cardio wire.

So they put in the patient goes into complete hard block.

So what are you going to do, cut them again up here.

Now you have this huge incision.

So you're going to do another cut here.

Put leads into the heart.

That patient needs to do rehab.

They can't even walk.

Sometimes those leads are likely to dislodge to move.

So you put this new thing there is like a pellet that goes literally in the septum of the heart.

And the patient is feeling like a million bucks, you know, like walking around normal heartbeat.

And then later they can go back to their cardiologist and you can tell me, you know what?

I think this patient needs some more complex events.

They might need another, more complex.

But that pacemaker helps the breach and helps them have quality of life and get better faster.

So they I feel like also like I have to deal a lot with old devices because we inherited a practice from doctors that have retired already.

So they were doing pacemakers here in El Paso 25 years ago.

So I have leads that are fractured.

I have patients that have infections and problems like that.

So this leadless technology is great because you can use it as a breach while you extract all the other stuff.

You put the leadless one while you figure out what's next.

So I think it gives, peace of mind to a clinicians to a noninvasive cardiologists are treating these patients.

So that's a good transition news.

I feel like, you know, please.

And I hope this comes out right.

I know the devices are very sexy, right.

Because it's like, oh, it's this it's at the other.

But the noninvasive portion of it too, I'm thinking to as a cardiologist, noninvasive cardiologist in general, you are dealing with people who also have had a pacemaker put in 20 years ago, 30 years ago, and now they're coming to see you because they know you.

Hey, I'm going to go see Doctor Espinoza.

So give to me some of the the questions that you receive and some of the issues that you receive from people who have already had devices put in them.

They've been on a watching list, but everything's fine.

I think, you know, years ago, I remember, I remember, I think maybe a battery lasted 3 or 4 years, years ago.

Describe some of that before it gets into.

Okay.

Well, now we have to replace things.

I do want to talk about you having to go in and replace older devices and what the success rate on that is and then what the lasting rate is going forward to.

So I hope that question.

Yeah.

Out.

Right.

So I mean all the devices can have some unforeseen problems.

I mean, I think one of the big problems that we encounter with older devices is now the patient needs an MRI for some reason.

They've had a stroke, right.

But the device was placed 20 years ago.

And the MRI, the can or the wires are not MRI compatible.

So what do you do in that situation.

So now you have to kind of figure out, you know, what do you do in that situation.

So you know, in cases where it's not time to remove the pacemaker or even if you replace the pacemaker can or the generator, the wires might not be compatible.

So that patient is just not going to be able to get an MRI.

So then you kind of have to talk to you.

The neurologist or the care team to see if there's an alternative imaging modality that you can use to still get the same answers that you're looking for.

Sometimes it's not possible.

Sometimes an MRI is the best situation that you can hope for to get the answer.

But you know, we run into those problems all the time.

So that's one issue with the older devices like doctor, the Benedetti says.

Sometimes too, the longer the wires have been in there, scar tissue forms around there, and then the wire may not function appropriately, and they need to get a laser lead extraction in order to put a new lead in.

Sometimes the pacemaker malfunctions, like the generator here, doesn't work like it should, and sometimes you have to go and replace that.

So there's lots of challenges that we that I see in my clinic too, with, with devices, other things, you know, some heart failure patients need defibrillators because we haven't talked about defibrillators yet.

Let's.

That's a great.

Okay.

Okay.

So a defibrillator is basically it looks similar to a pacemaker, but it's an entirely different function altogether.

So a pacemaker basically will stimulate your heart to beat, you know, in short term a defibrillator is a shock box.

So basically it's like what it's like what you see in TV when someone's having a cardiac arrest and TV and they come in with the paddles and they shock the patient and revive him.

Exactly.

So that's essentially what a defibrillator does.

But, you know, in TV it's not real life.

So a defibrillator, what it does is that it will detect certain malignant arrhythmias, usually coming from the bottom chambers that we call ventricular tachycardia or ventricular fibrillation, that if they're prolonged enough they can be fatal.

So what the defibrillator does is that it detects this rhythm abnormality and it has certain protocols that it does.

It tries for pace, the patient out of the rhythm abnormality.

It does that after a after a certain number of tries, 2 or 3 depending on the programing of the protocol.

If it's unsuccessful, you're getting the patient out of that rhythm abnormality It will shock them and basically reboot the electrical system so that they're out of the rhythm abnormality.

So that's what a defibrillator does.

What I tell patients with heart failure, that need a defibrillator is that it's their guardian angel.

It doesn't really do anything for their heart failure.

It just sits there and jumps into action when it needs to.

But that's really just what a defibrillator is.

There's external defibrillators and then there's the internal ones.

Right.

So on that end.

But a little bit opposite, let's talk about ablation when there's like a little bit too much going on in there.

And describe what an ablation is and what are you trying to accomplish with an ablation.

So an ablation is a catheter based procedure.

For some rhythm abnormalities.

You know, you can do an ablation for atrial fibrillation, atrial flutter SVT or supraventricular tachycardia.

You can also obligate ventricular tachycardia or these PVCs as we call them.

These extra beats from bottom chambers.

So basically what Electrophysiologist does is that they enter in through the groin with special catheters, and they go inside the heart.

That special catheter has a mapping system that you know, the it's programing.

And it basically has four and 4 or 5 little fingers on it.

And it basically maps out the electrical system.

And once they've mapped all the electrical system, they find out where the problem is in the electrical system, and then they cause a small little burn or scar, and then that rhythm abnormality is gone.

Some rhythm abnormalities require a little bit more work in terms of the ablation.

Others can be very simple.

But that's essentially what an ablation does.

I remember talking about ablation for the first time years and years ago, and I was absolutely fascinated that that even is something that you can do it just like make that one little electrical pulse go away like you ablated.

See you later, alligator.

And you can go to.

The success rate of ablation is different depending on the arrhythmia.

So there are some of them like Doctor Espinoza was mentioning like flutter.

I mean, you if you burn that rhythm, it probably it's very unlikely to come back like a typical flutter because it's a circuit that defines circuit.

But for example, others arrhythmia, other arrhythmias are much more cumbersome.

And sometimes they're coming from areas where we can't reach with a catheter or if we try to reach too much, we might cause damage.

Because remember that ablation is radiofrequency.

Electricity that transmits creates like a burn.

And then there is edema around it.

So if you're too close to, say, an artery when you come, it's coming from very close to this area.

And you put too much energy, too much burn.

Yeah, you're done with the burn.

You burn the arrhythmia.

But a few hours later, that edema starts to expand and it can press on the vessel.

And it's like if you're having a heart attack because there is no circulation, because the edema continues to expand.

So there's some review.

They're very hard to treat, especially like when he was referring to ventricular tachycardia rhythm from the bottom of the heart, especially in patients that have cardiomyopathy.

If they have had multiple heart attacks, they maybe have multiple scars.

Or they're not only scheming, meaning that their heart is weak, but there is no blockages.

You know, it's all the muscle itself is sick.

So it's like when you do that map, it's like little dots everywhere.

Like you can are going to burn all of the heart.

So then these patients have these defibrillators that he was mentioning and they bring them back to life so many times, you know, because these rhythms can sustain and they have patients that have had ablations.

I have patients that I have sent to Mayo Clinic to have ablation done with people that I know that trained me, that are like the gurus, that all they do is VT ablation.

That's all they do.

And they have like special catheters.

They don't do any type of ablation, they just do VT ablation.

It's out of all the ablations.

They just do this one.

That's all they do all day.

Because in these like very advanced centers, they're very specialized.

There's people that just do devices, people that just do VT.

People just do AFib like they here.

We are not like that because we need to to cover multiple things.

But over there, there like that.

And I have some patients like to have this ablation.

They come back and two months later they have the VT again.

So it is just like some rhythms are very hard to treat, even in the most expert of hands and with the most even in Harvard there is a doctor, Bill Stevens, and he developed a special needle for it that he uses in the tip of a catheter.

Like for these very complex beats.

And the patients still have VT.

So VT is a very difficult.

They're an antiarrhythmic.

Sometimes they're young patients.

So not all the arrhythmias are like oh this is very easy.

I'm going to go for it.

Some arrhythmias are very more complicated.

I think AFib has become kind of like a bread and butter ablation.

And you hear about it all the time.

You know, the media just throws AFib out like right and left.

Those ones are like more standard.

The other ones, all the ventricular rhythms are way more complex.

So that's when defibrillators play a huge role because what do you do with a patient that you put on antiarrhythmic that are medications to control these rhythms that are sometimes very strong and very toxic, have a lot of side effects.

And then they have these procedures, then multiple times and they're still having these rhythms that can literally kill them.

So when you put a defibrillator, you know, and this if this rhythm sustains to the point that they would be dying, otherwise the defibrillator will shock them like you very well explain and bring them back to life.

My favorite part is and bring them back to life.

Oh, I just I'm totally with you.

Yeah, literally one of my patients, one of my patients.

That's again, going back to the concept of the group.

He went to these campus because he was having chest pain.

So one of our partners treated him over there.

I don't go to these campus.

So he called me and I said, go ahead.

They put all the stents.

Everything went well.

And the it was still low, so his heart was still weak despite they put multiple stents.

So like a few days, like months later, we checked the echo that we were saying, put the gel.

DF is still low.

So this patient lives in Chihuahua He comes to El Paso all the time So I put in the defibrillator.

He was crossing the bridge like leaving the hospital like he had stayed in El Paso a little bit later, crossed the bridge and in the bridge gets shocked.

It has a bad rhythm and he gets shocked.

So because he lives in Chihuahua, he he didn't want to take the life vest because like there is the external defibrillator.

He was saying that goes on top of the body that is just to protect him as a bridge until we get a permanent one.

He said that I don't want that, I'm going to have problems in the bridge, you know.

Let me cross.

He was very scared, so I begged him to wear it.

He didn't.

But God was good to him because during that time nothing happened.

He got the defibrillator.

Stayed in El Paso for like ten days.

Was leaving, crossing the bridge.

Gets shocked right back to the hospital.

But then, I mean, like, we took care of him.

Nothing happened.

But he was like crying.

Like saying this could have happened to me when I was not wearing the life vest and it wouldn't be in this table, you know?

And I said, yeah, but thank God it didn't happen.

And then the defibrillator brought you back to life.

So that's all good.

It is all good.

And we are we are at a point now we've got a little bit less than eight minutes to go.

So I'd like to kind of stop for a second and everything.

I still have questions.

There's all kinds of stuff to talk about, but is there anything that we have not talked about yet tonight that you really want to get across to the audience?

Anything you want to say, Doctor Espinoza?

Well, I think that, you know, if there's any concerns whatsoever that you might be having a rhythm abnormality, you know, don't don't take it for granted because that's another mistake that a lot of patients do.

They're like, oh, well, maybe I just drank too much caffeine day or maybe overdid it with alcohol.

If I calmed down, then this is going to settle down.

And sometimes it might be the case, but a lot of times it might not be.

There may be an actual problem that's going on that could, you know, lead to some negative consequences.

So I always tell patients, don't assume things, you know, if you're not feeling well, it's best just to check it out.

Best to be safe than sorry.

So don't don't take things for granted 100%.

And I'm going to ask you to talk about that too.

We were talking about being able to call that patient, for example, with a lot of the remote things we have going on, of maybe educating the people who you are with most often, whether you're you have a partner, your children or whomever.

Maybe talk a little bit about that.

So when you consult your patients, you're also consulting people who are with them most of the time.

Correct.

Right.

So you usually, you know, let's say you have a grandmother that just had a pacemaker defibrillator implanted.

You know, there's certain teaching that we do in the hospital for them and the family members for troubleshooting, you know, you know, should the pacemaker do this or, you know, your monitor is not working.

Things to follow or grandma passed out again, you know, what do we do?

So there's a lot of teaching that we do with the patient, the patient's family members, so that they become, educated as to what they have, what it actually does, what it doesn't do.

And we set the expectations straight because sometimes patients feel like, okay, now I'm I'm basically invincible.

I have this pacemaker, and I can do whatever I want.

Right.

And that's not the case, you know?

So you kind of have to set the record straight with your patients and set the expectations so that, you know, if you know, missed messages, go, you know, with the patient.

Exactly.

Doctor De Benedetti, is there anything like on the horizon that you're excited about again is devices?

I always feel like there's new toys coming about a studies that you've been part of or interested in the I think we covered most of like the advancement in terms of pacemaker technology.

I think the Leadless pacemaker just is amazing.

It's amazing technology that we have in terms of defibrillators.

The big advancement is the external defibrillators.

I mean, not like external out of the body, but not transvenous necessarily going through the vein into the heart.

They're called subcutaneous.

And now we're coming with an extra vascular one that is going to be right on top of the sternum.

So these are all technologies that help because sometimes we have very young patients.

You know, we're seeing cardiomyopathy like, you know, we talk about things we haven't talked about the young patients.

I know we don't have a lot of time.

But I feel like nobody thinks about heart issues with young.

Oh, we see it so often, like very young patients like I. I'm going again to examples at Memorial.

The other day I was doing a case and they called me the lady that does picks up the trash.

She passed out.

She's like 20 something.

She passed out.

They took her to the ER, and then she kind of regained consciousness in the way, in the year she went again into a ventricular rhythm.

They shocked her again, so they put her in the ICU.

She said 20 something.

She's my patient now.

But in the ICU we did the catheterization and all the work up there.

We always do everything clean.

So she just has a weak heart.

You know, her ejection fraction is low and she's having never had any issues before that.

Nothing.

Nothing.

You know, just her it her heart is very weak.

She's one that we already we don't do a heart transplant.

But she's a young she's 29.

So I have already hooked up with Dallas for heart transplantation and all these things because she said they're going to work up because she this is not getting better.

She is getting worse.

So her diagnosis is if I'm correct on this week heart.

Yeah.

And I know you hear that often too.

And again I know we're short on time, but I'm curious what does a weak heart mean because I know that can mean.

So just with my hands to show it.

The normal heart will do this.

A weak heart just does this.

So it can't push the blood outside of the heart.

So it stays in the heart.

And when it stays, it backs up to the lungs.

You get winded, you don't get enough blood to the brain, to the liver, to the kidneys.

You start getting kidney failure is just because the heart cannot push the blood.

And and the.

And she's been to the hospital already six times.

I put in the defibrillator.

Just to round up, there's one type of defibrillator that does help it.

It is a prevents cardiac death by shocking, but it also helps the strength of the heart muscle is one that helps squeeze the blood.

But you need to have a special characteristic on the EKG for that type of device to be implanted in to help you.

Vast majority of patients don't have that.

They end up getting the defibrillator like he very well said.

A shock box.

It's not helping their heart get better, but there is new a little bit new advancement in in that field.

Some devices called CCM, it's called cardiac contractility modulation.

And it's a device that basically I've been doing in El Paso.

I've done like 30 patients already.

It delivers electricity impulses in the septum of the heart and activates the electrical conduction system.

So it's not a pacemaker, it just delivers electricity to help kind of wake up the electrical system and help the heart contract.

It stays there.

It looks like a pacemaker.

But it but the leads are two leads placed in a very specific.

We spend a lot of time finding the EKG.

Perfect position where it just is two leads.

And between those two leads the electricity is delivered.

Now this company, this device is already to market and I've been doing quite a bit, but I'm involved with them in trials and other stuff.

This device, they're coming up with a defibrillator built into that device.

So they'll get the CCM and the defibrillator in just one thing.

So there's there's a lot of advancement.

There's a lot.

And I hate to say we have to cut things off now.

But there is a lot.

So I appreciate both of you for being here.

And I would love to do this program again.

Because I think it would be exactly, completely different than what we said today.

So, think about that for a minute.

And for those of you that are watching right now, if for some reason you didn't catch the entire program, there's a couple of places that you can access that access this again and same thing for you all.

You can go to pbselpaso.org.

And on there you will find a link to this program also to the El Paso County Medical Society website.

That website is EPCMS.com.

And you can always go to YouTube.

And I see that often YouTube.

I just feel like that's what everybody's watching now.

You can talk specifically about this show.

This is understanding arrhythmias when the heart falls out of rhythm.

But there's also all the other shows that we have done here on KCOS.

You can also find that on YouTube as well.

So youtube.com and just look up the El Paso Physician and then the later shows will automatically show up.

And from there you just put in your ailment of the day.

I thank you so much for being here with us.

Doctor Espinoza, thank you so much.

This is officially your fourth time.

Maybe your fifth.

We'll find out.

And Doctor De Benedetti, I hope that you come back again.

You guys have been fascinating.

This is the El Paso Physician.

I'm Kathrin Berg.

Good night.

The El Paso County Medical Society is a nonprofit organization established in 1898 that unites physicians to elevate the health of the El Paso community.

We have been bringing the El Paso Physician Television program to your home for the last 27 years on PBS El Paso.

If you should have any medical questions relating to this program, you may email us at epmedsoc@aol.com And we will try to have our experts answer your questions.