>> The heart is a pump.

And like most pumps, it requires electricity to work.

So what happens when the circuit is disrupted?

Stay with us as we talk with cardiac Electrophysiologist doctor Kevin Parrott about arrhythmias and other cardiac conductive disorders.

Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> I think that we can all agree with astronaut Neil Armstrong, who said, I believe every human has a finite number of heartbeats, and I don't intend to waste any of mine.

If you are like me, you take the beating of the heart for granted and may only notice it during moments of quiet solitude.

The regular filling and expulsion of blood by our hearts is under the control of an intricate network of nerves, which comprise the electrical conductive system.

These nerves are located within the walls of the heart, and when functioning normally, we know the heart is working by feeling our pulse or listening to it with a stethoscope.

However, when there is a disruption in the cardiac neural network, we may experience palpitations, fluttering and sometimes no contractions at all.

Things that may cause this include cardiac enlargement, changes in cardiac perfusion, smoking, electrolyte imbalances, stress, metabolic disorders, medications, and sleep disorders.

Today we'll be talking about disorders of the electrical system of the heart.

We will touch upon how frequent these problems occur.

Who is most likely to be affected?

How the problems present, the methods used to diagnose this condition and how they are treated.

Our guest today is cardiologist Doctor Kevin Parrott.

Doctor Parrott is a graduate of the University of Kentucky College of Medicine.

He completed a residency in internal medicine at Duke University Hospital, followed by fellowships in cardiology and clinical cardiac electrophysiology at the University of Kentucky.

He is now in practice with the Baptist Health Medical Group.

Cardiology doctor Parrott.

Thanks very much for being with us.

>> Thanks for having me.

>> So tell me, Kevin, somewhere out there does a kid who is looking at an electrical circuit and he thinks, man, I want to work on hearts with electrical circuits.

How did they get to do what you did?

>> How do you get to do what I do?

Well, you have to be stubborn because you have to go to school for a long time.

But as you outlined there, you go to medical school and then we are a subspecialty of internal medicine.

So we do an internal medicine residency.

And then you're a licensed physician after that, but you continue in training.

You do a cardiology fellowship, and then epi or electrophysiology fellowship, which is another two years.

>> Beyond.

>> Cardiology fellowship.

So total post med school that ends up being a seven years of training.

For most people.

>> What was the.

>> Moment, though, that said, I want to be a doctor?

What was.

It for you?

>> Well, I grew up.

I had a health care providers in my family.

My great grandfather was a family practice physician in Eastern Kentucky, and my father's dentist, my mother is a lab technician.

So it was kind of always around it.

And I always really enjoyed science.

And I just kind of gravitated there.

I think even when I was starting college, I pretty much knew I was going to go on to medical school.

>> Sounds good.

So tell me, what are the normal phases of cardiac rhythm?

You know, what are we talking about?

What's happening here?

>> Yeah.

So when you when you think of a normal heartbeat, it it's typically going to start in a structure in the heart called the sinoatrial node or SA node, which is in the top right chamber of the heart.

And it it spreads over those top chambers, the atria, and it goes into a structure in the center of the heart called the AV node.

And then into the ventricle through these specialized fibers called bundle branches.

And that it kind of from top to bottom is how it how it should go.

>> So we oftentimes we all see an electrocardiogram and it's a whole string, but we know there's some thing that spikes up, spikes down and comes back.

And then there's another little hump.

>> So you normally have.

So the, the p wave is, is first.

That's kind of the contraction of the atria.

And then you have between the P wave and the next hump.

That's called the p-r interval.

That's the period that the contractions kind of spending in the AV node.

And then the, the usually largest spike there is called the QRS.

That's the ventricular contraction.

>> Okay.

>> And then you have usually after that a more rounded hump called the T wave, which is the kind of recovery of the electrical signal in the ventricle.

>> And all this is happening at the same time.

Or was this being propagated through different layers or.

>> Well, it should be sequential where you have the p wave to the QRS, to the t wave, and yeah, so it's kind of spreading from top to bottom.

>> Is the whole heart contracting at the same time, or does the atrium contract and the ventricle?

How does.

>> That work?

So yeah, in a typical heartbeat, the atria are going to contract first and they kind of push blood into the ventricles to prime them for the strong heartbeat.

That's the heartbeat you feel is the QRS, the ventricular contraction.

So you know it's going again top to bottom atria contract and push blood into the ventricle.

The ventricle contracts pushing blood out into the body.

The pulse we feel.

And then also circulating through the lungs to pick up oxygen.

>> What tells that you said the SA node to contract it tells it hey.

Okay.

All right everybody do this.

>> Do this.

Yeah.

It's a magic property called automaticity.

Automaticity automaticity.

So the, the they basically the cells in that area have specialized channels and they kind of have a timer, a countdown.

So they're, they're kind of going toward contraction the whole time.

And then it reaches a threshold and jumps.

And that's what starts the heartbeat.

>> Interesting.

Are there any extrinsic factors that can act on the SA node or on these little, these little cells that tell it what to do or that can cause it to fire too early.

>> Or too late?

Well, many things affect it.

So just, you know, simple would be activity.

So when you get up and walk or do more, you know, the heart rate is going to increase when you exercise.

And so it can be acted on by the sympathetic system of the body to increase the heart rate.

Medications can affect it.

You know, caffeine can affect it and push the heart rate higher.

Smoking can push it higher.

Medications that we use and medicine can affect it.

Beta blockers, metoprolol, they tend to lower the heart rate by acting on the SA node.

That would be the common, you know, common things.

It varies throughout the day.

You know, there's a circadian pattern to the heart rate.

It tends to go up during the day and decrease at night.

Really?

Yeah.

>> So when we're sleeping, you mean that nighttime like sleeping or just nighttime in the evening and we're.

>> Nighttime like sleep?

But yeah, also just in the evening, you know, if we look at these monitors that we'll talk about, you do see a variation in the heart rate throughout the day.

>> Wow, that's pretty good.

I always thought it was just.

>> No, it's not, it's not fixed.

It can vary widely throughout the course of.

>> A day.

So there's stuff that's going on.

So normal rhythm.

You describe that.

So what do you mean when you say a arrhythmia.

What is that.

>> Yeah.

Well there's literally can be dozens of things.

But arrhythmia just means some abnormality of that of that sequence.

You know, probably the most common things that people have heard of would be atrial fibrillation is an arrhythmia.

Supraventricular tachycardia really tachycardia because there's multiple.

And just something about that, that normal cycle kind of becomes perturbed in different ways that can be in what we call a reentry, an endless loop where it goes from the top to the bottom and then comes back to the top.

It could be that part of the circuit, like the atria has become completely disorganized, like it does in atrial fibrillation.

Just a wide variety of things.

>> I'm sure you're going to be inundated with people concerned about their hearts, since the singer Lionel Richie was just had to come off a tour because he had an arrhythmia.

So how, you know, how common are arrhythmias?

>> They're very common, you know, I think specifically he had atrial fibrillation, which is probably the most common abnormal heart rhythm I deal with in my practice.

And it's incredibly common.

I'm sure most of our viewers probably know someone that's had it.

It tends to increase and become more common as people, people age, you know, there's estimates that by the time people live to their 80s and 90s, you know, up to maybe 20% of people have some, some atrial fibrillation.

>> People who are cigarette smokers, they tend to have more of a problem or any other chronic illnesses that.

>> May cause it.

So when we think of AFib and kind of risk factors, it would be there are things that we can't change, right?

So as people get older, it gets more common.

It's also interesting.

Taller people tend to have more AFib.

Really?

Yeah.

Yeah.

And then and then there would be things that maybe.

And then there is a role for heredity.

There are family clusters of AFib.

When you think about modifiable risk factors, smoking.

Yeah, it does tend to associate with a higher incidence.

Other you know metabolic disorders, diabetes, obesity, those tend to have a higher prevalence of of AFib as well.

>> Now tell us the difference between atrial fibrillation and atrial flutter.

Really what does flutter really mean.

>> Yeah.

They're they're cousins.

They are related.

So atrial fibrillation is a totally chaotic rhythm.

There's no pattern or organization to it.

Atrial flutter, I like to think of it as kind of a subset of atrial fibrillation, because they probably start in a similar way, but in atrial flutter due to properties in that person's heart, it's able to kind of organize and it starts going in a consistent path.

Okay.

So if when we go in and say, do an ablation for atrial fibrillation, you know, we see no pattern to the electrical activity generally.

But when we do for atrial flutter, there is a pattern or a pathway that that circuit is going to.

And it's a, it's an endless loop.

It starts here and it goes all the way around and comes right back to the beginning.

And it's doing that several hundred times a minute.

>> Now, is there a difference between what's going on in atrium, which I guess is the portion where the blood is coming back to the heart from the body or the lungs and, and what's going on in the ventricles which are pumping the blood?

Actually.

>> Yeah, yeah.

So, you know something I like to talk about.

So the, when you're in atrial fibrillation or atrial flutter, those top chambers are beating hundreds of times a minute.

Wow.

Yeah.

And fortunately, we have this structure in our heart that we mentioned a minute ago called the AV node.

And that's really there to honestly, one of the big things it does is protect us from these rhythms because it acts as a governor and doesn't let all those signals go down to the pumping chamber.

So our heartbeat.

So even though that top chamber may be going 400 times a minute, you know, the bottom chamber, it usually will increase.

It may go into the, you know, 140, 150 beats a minute.

But people can tolerate that.

If the bottom chamber were to accelerate and go 400 times a minute, that kind of becomes a different problem of ventricular tachycardia, which is a condition that's more life threatening.

Well.

>> What is the potential problem when the ventricles aren't contracting properly or blood's going out?

I mean, I.

>> Well, when they're beating that fast, they can't really fill adequately with blood.

So that can cause, you know, cardiac arrest.

That's one of the rhythms that people get defibrillated for shock to restore a normal heart rhythm.

>> So that's what's going on in every TV show, no matter what happens to you when you show up in the emergency room.

>> You're getting the paddles.

>> So do people pass out when they have these abnormal rhythms like this?

>> Oh, it varies.

So.

So with something like a-fib or supraventricular tachycardia, I would say it would be unusual to have a complete syncope.

Yeah.

There are ways that that can happen, but it's, it's pretty unusual with ventricular rhythms like ventricular tachycardia.

It's it's common.

>> How would I know?

I'm having a problem?

Is there anything that you would sense?

>> So in something like A-fib, you know, it's fascinating as someone who spends all the time talking to A-fib, the symptoms can vary from none.

I mean, some people, many people I would say, have no awareness that they're in A-fib.

Yeah.

I mean, people do experience symptoms, you know, they typically experience tachycardia.

They feel the heart racing, particularly when it, you know, it shouldn't be racing when they're at calm sitting or quiet at night.

They, they may have a, I would call it a sensation of irregularity or skipping.

Sometimes those would be what I kind of call the direct symptoms.

Sometimes it's can be more subtle.

People just.

They get a lot more dyspnea with exertion.

They find they can't exercise or do activities like they used to.

But that would be kind of the basics.

>> So take me through the algorithm.

How do you treat someone who has one of these arrhythmias?

What are the things?

>> Well, again, it's going to vary.

So, so much by what what it may be specifically, if we're talking about atrial fibrillation, you know, the first thing, of course, if you meet with me, we're going to do is we're going to talk about a History things I'm trying to establish are when, when do we think the A-fib started?

Because again, it can be clear.

It can be like it started on Tuesday afternoon at 230.

I felt my heart racing.

Or it may be I you know, they go to their primary care doctor or they get an EKG for another surgery or something, and they're in A-fib.

And we we may have to go back and try to find other EKGs they've had.

And see, is this something that's been going on for years or months?

Sure.

And then the next thing we're going to talk about is probably your risk factors for stroke and atrial fibrillation.

So we ask, like, if you have diabetes, if you've had a previous stroke, do you have high blood pressure?

And we kind of stratify people's stroke risk.

And, and we have to talk about anticoagulation in AFib because when that top chamber is quivering, because it's not really beating in an organized fashion, it can promote the organization of blood clots and cause an ischemic stroke, which is something we worry about with atrial fibrillation, particularly as opposed to something else, like a supraventricular tachycardia.

>> Gotcha.

So are there specific medications that you may want to start off, or do you go straight to this thing, which we all hear about people having little pacemakers put in?

>> Oh yeah.

Pacemaker would be later.

So again, the first thing in terms of medications we would probably talk about would be anticoagulation or blood thinners.

Like Eliquis or Xarelto, or warfarin or Coumadin.

We're going to look at the ventricular rate.

So again the top chamber is beating hundreds of times a minute.

How fast is the bottom chamber beating.

We may use a medication like a beta blocker or metoprolol or a calcium channel blocker.

Or diltiazem to try to, because those act on that AV node as well and slow the conduction to bring the rate down.

That often will help with any symptoms.

The patients experiencing.

And then we're going to assess, you know, what kind of management strategy are we going to do for AFib.

And that's broadly we either do what's called rhythm control, where we're trying to put the heart back in normal rhythm, or we may do only rate control, which means we don't really make active efforts to put the heart back in normal rhythm.

We just control the rate and control symptoms that way.

And that's that's going to depend a lot on the patient in terms of what symptoms are they having, what's their overall health status, what their wishes are.

Oh, you know, and we we can do both.

>> We hear about cardioversion a lot.

What does that really mean?

>> So cardioversion, I call it hitting the reset button.

So we're we're just doing an electric shock.

And that that kind of whatever arrhythmia is going on, it's going to stop that arrhythmia and allow that sinoatrial or SA node to take back over the heartbeat and beat in a coordinated fashion.

It's important to understand, you know, I get a lot of questions about that in terms of it stops like atrial fibrillation, but it doesn't do anything to really prevent it from recurring.

Okay.

So so if, if you're, if you're trying to do something to reduce that, we have to talk about other medications or procedures like the ablation.

>> So okay, so what is ablation?

Since you've mentioned.

>> That, so, ablation broadly is just a procedure, an electrophysiologist is going to do to try to treat some heart rhythm issue.

And we do ablations for dozens of different heart rhythm issues.

And we're the broad principles that we're going to put catheters through the usually the veins in the legs, sometimes the artery, depending on what chamber we need to access, we're going to measure some of the electrical signals, determine, you know, what spot we want to ablate for that arrhythmia and then use a catheter to actually kill a little bit of the heart tissue.

Really.

>> Is it that you're getting the heart tissue or are you disrupting that nerve impulse?

The nerve transmission?

>> Well, it's yeah, frequently it's the electrical signals aren't in just discrete nerves.

So it is actually like the heart tissue.

There are certain situations we may ablate those specific fibers, but for, for something like AFib, we're not ablating any specific conduction fibers.

>> Tell me about pacemaker.

What is actually going on with the pacemaker.

>> So a pacemaker is an artificial electronic device implanted either under the skin or now even directly in the heart.

That gives a little electric pulse to usually elevate the heart rate for someone that has a condition that's causing a low heart rate.

>> And does it kick on automatically, or is it or is it just on all the time?

>> So they're usually set on kind of a demand basis.

So we, we tell them we don't want the heart rate to be less than usually, you know, 50 or 60.

And then they frequently have a component of response to activity called a rate sensor.

So they, you know, the patient may get up and walk.

They can elevate the heart rate in a natural manner for people that can't do that, either Brady or bradycardia.

>> And so this kicks in and says, okay, let me tell the.

Hard to.

>> Contract or be faster.

>> Now I seem to recall when Vice President Cheney.

Had an implantable defibrillator.

>> Yes.

He had a pretty severe cardiomyopathy.

He had a defibrillator.

And I believe he also ended up with something else called a left ventricular assist device.

>> But what is this defibrillator do?

I mean I mean, again, my idea of a defibrillator is TV.

When a guy goes to the emergency room.

>> With a.

>> Hangnail and they put.

>> So.

Well, there's truth to that.

So, you know, a common question or confusion, I would say I get in clinic, is there there is a difference between a pacemaker and a defibrillator.

Okay.

And it's kind of like those logic questions you got in school.

So all defibrillators basically have pacemaker function.

>> Okay.

>> But no pacemaker does what a defibrillator does.

And the difference is the defibrillator.

It's a larger device.

It has a bigger battery.

It has something in it called a capacitor, which is a device for storing up electricity.

So it's able to give a much larger shock.

So it's able to convert people.

So we might use that in someone that has ventricular tachycardia because that's a life threatening rhythm.

And if they go into it, they need to be cardioverted or shocked out quickly.

Or they can have sudden cardiac death.

And that's what a defibrillator does.

>> And that's what and this is implanted in the body also.

>> Yes.

Yeah.

So we have many varieties of pacemakers and defibrillators.

They're all implanted in the body, usually in the heart, you know, usually people are familiar with ones that are implanted on the chest.

>> Yeah.

>> And they have wires that go down to the heart.

And that's how they connect to the heart monitor, the electrical signals, and if needed, you know, give the pacing or defibrillation.

Yeah.

But we have other options now.

We put pacemakers called a leadless pacemaker, which is a little bit smaller than a triple A battery.

We put that directly in the heart muscle.

So the, the battery and computer and everything is contained in the heart.

You really have no evidence of anything externally.

And then.

>> How do you get it in there?

>> We go through the vein in the leg directly, directly into.

>> So how do you know you're in the right spot?

>> Well, we're using X-ray.

>> Okay.

>> So we're using X-ray to see where the catheter is, see where we are in the heart.

Sometimes we use ultrasound.

We look at the heart signal.

So we're measuring kind of the health of the tissue.

We're in contact with and how well the device is working with that tissue.

Yeah.

And that's kind of how we direct it.

>> Are these permanent fixes or will you have to come back and do something later?

>> Well, all these devices have batteries.

>> Okay.

>> And so, you know, the lifespan of the battery depends on the type of device, how much the patient uses it, the specific electrical function in that patient, you know, typically on the short end, it would be maybe 5 or 6 years with some of the leadless pacemakers and good performance.

We're seeing 15 up to 20 years, which has been amazing.

But eventually we'll have to come back and either implant another device or change the generator or some of the leadless ones we are retrieving now.

>> So.

So you got to go back in into the heart and pull that one out.

>> That is what we're doing for some of them.

>> That's quite a procedure, man.

Quite a procedure.

So if you would for me in the last minute or so that we have, what are the three big things that you think it's important for us to know about arrhythmias?

>> Yeah, I think the first thing would be, you know, don't ignore it.

Like if you have symptoms, you know, particularly like sustained fast heart rates, that that certainly could be something like AFib.

It's important to get checked out so that we can manage your stroke risk, you know, the, I think another thing I love saying in clinic is, is with the supraventricular tachycardia.

You know, I meet people that have suffered with that for years, really.

And they never really knew that there were treatment options available.

And it's, it's wonderful to treat it.

It's a curative procedure for those people.

And then with pacemakers, you know, I think it's important to discuss, like with your cardiologist, usually about all the different variety of devices we have and have someone that's familiar because we can offer you what's best for you.

>> So out of curiosity, if I'm concerned, you know, I find that my heart is beating or I can feel it beating heavy in my chest or something, or it feels irregular.

Do we contact you directly or do we go through our primary care providers?

>> It can be both.

I mean, it depends.

Usually I would say in my case, most of my patients are referrals from their primary care or even other cardiologists because we're a subspecialty of cardiology.

But, you know, it's important to talk to someone because you may need an EKG or a what's called a Holter monitor, which is a wearable, basically EKG for a few days.

And that's usually a good first step.

Yeah.

>> And that information then gets passed on to you.

And then from there.

>> Yeah, we will look at the EKG or the wearable monitor and, you know, communicate with the PCP.

And if needed, you know, you can get referral to clinic.

>> Well, thank you very much.

This has been a fascinating discussion, particularly about a leadless pacemaker.

Kind of scary actually, but that's great.

It sounds great.

Thank you.

Thank you for being with us today.

I hope that you have a better understanding of conductive disorders, of the heart, and in particular, the causes, presentations, and things that we can do to mitigate our chances of developing them.

If you wish to watch this show again or watch an archived version of past shows, please go to ket.org forward slash Health.

If you have a question or comment about this or other shows, we can be reached at KY.

[MUSIC] Health.

At ket.org.

I look forward to seeing you in the next Kentucky Health and please feel your pulse.

Listen to your heart.

If you have any kind of a question, talk to your primary care provider.

If you're a cigarette smoker, stop.

We've heard that that's something that can cause arrhythmias because we want to see you again next week on Kentucky Health.

>> Kentucky health is funded in part by a grant from the Foundation for a healthy Kentucky