Chapters Transcript Video The New Arrhythmia Playbook—Hybrid Ablation, LAA Management & AI Today we dive into the evolving landscape of cardiac arrhythmic care, spotlighting advanced approaches that are reshaping electrophysiology and surgical collaboration. We'll explore together expert voices from both sides of the table, electrophysiologists and cardiothoracic surgeons to discuss the nuances of hybrid procedures, procedural decision making, and interdisciplinary synergy. We'll also explore a transformative role of artificial intelligence, machine learning, emerging digital technologies, and enhancing precision outcomes and patient care. Welcome to Baptist Health. Doc, a podcast built for innovation and collaboration by physicians for physicians. Hello, I'm Doctor Tom Nguyen, a cardiac surgeon and chief medical executive at Baptist Health Miami Cardic Ambassador Institute. Joining us is Doctor Mario Pascual, electrophysiologist at Baptist Health Miami Cardic Ambassador Institute. With extensive experience in managing arrhythmias and Doctor Brian Tompkins, cardiac surgeon at Baptist Health Miami Cardiac Ambassador Institute, focused on structural heart treatments and collaborating on rhythm disorders. Thanks for joining us, Doctor Pascual and Doctor Tompkins. For the physicians out there, can you describe to us what are some typical disease processes that electrophysiologists and surgeons that are involved in that space might end up treating? Yeah, thanks for having me, Doctor Wen. It's always exciting to, to be here and talk, you know, with some colleagues, especially ones we work so closely with. So I appreciate your time and and having us on board, uh. You know, so electrophysiologists are essentially doctors of heart rhythm disorders, as you know, most know there'll be different portions of the heart. There's a structural portion, the coronary artery disease or obstructive disease, and uh what we specialize is in heart rhythm disorder. So most common arrhythmia in this country and worldwide will definitely be atrial fibrillation. And so that'll be the most common arrhythmia that we treat and You know, the uh treatment of atrial fibrillation has certainly gone through an evolution and especially in the last 20 years, and that evolution has been combined with CT surgery, collab collaboration, and as we kind of move on to the next stage, different forms of energy that we're using in order to treat Afib. So definitely an exciting time of for EP and especially in the space of atrial fibrillation. Can you describe a typical process that you treat, but most physicians might not realize that you treat? Maybe, maybe a untreated population that needs to be treated that most people not might not be as aware of? I think there's several in the EP space and um one would be the early referral of atrial fibrillation we many times see a very late referral patient that's been in atrial fibrillation for many years and we know our outcomes are just not good enough. So getting that early referral is extreme. extremely important to have the best outcome for that patient. And secondly, our PVCs. I think premature ventricular contractions are something that are severely undertreated in our community. We have many patients that are suffering either from cardiomyopathies due to PVCs or that are highly symptomatic from PVCs. Yet once again, there's a little bit of delay in diagnosis of what's causing this patient's symptoms and therefore they're not seeking the correct care with an electrophysiologist early on enough. I'll add to that. Thank you. Thank you for having me again. Thanks for joining us. Um, just to kind of bounce off what he, he was saying because he's absolutely right, Afib is, is really the number one thing that we do treat surgically. And we've come a long way, uh, from the cut and sew maze that, uh, Jim Cox used to uh taught us way back when where we would actually open the heart and actually make lines and incisions in the heart itself and then sewing them back up. It took hours. It worked very well, um, but you know, today's day and age, uh, you know, like Pascal mentioned, we now have newer energy devices. We do cryoablation, we do thermal ablation. Uh, a lot of Afib actually begets afib, which means it gets worse and worse, and therefore, as that left atrium starts to dilate, it can also affect valves like typically the mitral valve, the mitral valve itself can induce atrial fibrillation. So as surgeons. We have found that um we try to do a concomitant procedure if we're referred for a valve uh even for coronary work. If we referred for a valve and we're there looking at the mitral valve, we're gonna cryo late and we've found that if we can get people back into sinus rhythm, it actually improves their EF significantly through many surgical trials from 40% upwards of 55% post-op. Um, so, and then, and then furthermore, to take it one step further. Since we've been doing that in a concomitant space, now as a surgical ablation, For people who have long standing persistent and persistent afib, as you can imagine, as that left atrium dilates, more scar, uh, forms, more micro reentran, uh, patterns start to form, and it becomes harder for the electrophysiologist just to tackle it by themselves. So therefore, we as surgeons do minimally invasive procedures where we can go behind the heart and ablate it and also tackle the, the appendage while we're there as well so we can get them off of anticoagulation, get, get them off of chemicals. And then one last thing I was gonna say was that we um also uh are are as he was kind of mentioning the PVCs we do um intractable VA people will do sympathectomies for that as well we also help them in that sense as well. Can you both give us an idea of really the disease burden, you know, how many patients out there are afflicted by this and then and then just concrete tangible um results of it being treated, you know, maybe a mortality or morbidity, you know, feeling better, but just something that that we can better understand why do this? How big is the disease process and why even do this to begin with? Sure, absolutely. It's a great question. You know, if we say Afib is an epidemic, and there's many reasons for that, but if you look at the prevalence of Afib, there was in 2010, probably about 2 to 3 million people in the United States with atrial fibrillation that has exponentially grown to the point where by 2030 we expect about 13 to 14 million patients with atrial fibrillation in the United States. So it's just this epidemic growth. Reasons for that are multifactorial, you know, there's definitely an obesity epidemic. We're learning that there's more and more of a genetic input or causes of atrial fibrillation. Um, and so as obesity rates grow, diabetic, diabetes grows, the incidence of Afib. There's also some good reasons, you know, patients with structural heart disease and patients with uh any type of cardiovascular disease are living longer and age is definitely one of the main predictors. So if we look at. Incidents or prevalence in, in patients that are younger than 55, only 0.2% of the population will have Afib. But once you hit the age of 80, 85, that prevalence goes up to about 10 to 12%. So age is, is definitely a huge predictor of, of atrial fibrillation. We always say in terms of outcomes that the earlier we see atrial fibrillation, the better. And it's once again talking about that disease process. Early on in the disease process, we know that Afib is predominantly isolated to the pulmonary veins and triggers in the pulmonary veins, so. If we were, you know, get a patient with afib and kind of slice their heart, we can visualize these little diamond shaped structures what we call myocardial sleeves that sit inside of these veins that will be the main trigger for atrial fibrillation. So at first, when a patient is paroxysmal in atrial fibrillation. The procedure is quite simple. We can go in, we isolate the veins, we eliminate these triggers with different energies which we can speak of later, and we have success rates of about 90% of these patients as that disease progresses and they become more persistent, meaning longer than 7 days or long standing persistent, more than 1 year, then things really start to change because it's not just isolated to the pulmonary veins, but now the atrium itself is changing. There's a lot. More fibrosis, there's up regulation of certain genes that promote short in action potential durations of the atrium. So all these things in combination now all of a sudden makes Afib a lot more favorable, makes the errors we have to target a lot more extensive and unfortunately really decrease, you know, uh, makes outcomes much worse. So we're thinking about Afib, or persistent Afib outcomes are about 70% success out to 5 years. We have a drop from 90%. To 70% just because there may have been a little delay in the referral, a little delay in the procedure itself, um, we also say that Afib management is multidisciplinary. There's a lot of trials out there, um, you know, there's a beautiful trial out of Australia. It's called the Legacy trial where they took patients and offered them ablation within the first year and then put them in a very structured program. And there are 3 different categories of these patients, patients that lost greater than 10% of weight loss, kind of 3 to 10 to 9% and less than 3%. Those that lost over 10% of their body weight, 90% of them were in normal rhythm at 5 years. If you lost less than 3%, less than 50% were in normal sinus rhythm. So just pushing that multidisciplinary approach, you know, with our colleagues to really manage afib aggressively. Now I wanna, I wanna emphasize, uh, a couple of points to take home is that with a lot of disease processes, the earlier we treat the better and if we wait too long it's gonna be a lot harder to treat so so with Afib and a lot of other rhythm disorders it's so important for for physicians to send the patients in early and I think that's a potential. Untreated population, but, but can, can you both elaborate on, on why patients aren't coming in? Is it awareness? Is it the patients aren't feeling it? What can we do to help capture those early patients when they have that early disease to bring them in? I think, uh, if I don't mind, uh, a couple of things, um, as, as he was mentioning that, you know, unfortunately people may not feel anything. 12, they may feel it and not know why they feel crummy. And then number 3, there was the age old paradigm of maybe we should just treat this with antiarrhythmics, get their heart rate normalized under 100, and you know maybe put them on some Eliquis and and they'll be fine. And you know a lot of times they've uh you'll follow people out and and they're doing OK but again maybe their EFs dropping, maybe the, uh the left atrium still dilating maybe the mitral valve gets worse and maybe we don't get an echo on time. Um, and so for that particular reason, people who are in afib, now that we've found, as I mentioned before, that if we get them back into the sinus rhythm, they feel better, B reduce their incidence of stroke, and then C, their ejection fraction comes up. So therefore their risk of mortality goes down, um. And as Dr. Pascal was saying, a lot of these people are referred late, meaning, uh, probably more than 70% or so are not, are no longer paroxysmal when they see an electrophysiologist. From a surgical perspective, we have a few trials like the CCF trial or the convert trial that has shown that um although uh it's really hard to maybe tackle these patients from an endovascular standpoint alone. When you add a surgical ablation from the epicardium, you can get kind of back to the 80 to 90% success rate out to 18 months. And again, getting these people off of chemicals and getting their their appendage clipped is very important. That's why collaboration is extremely important. That's why they need to be referred early. And uh we can tackle this together. Furthermore, if, um, like he was saying he was isolating the triggers in a paroxysmal fashion, the drivers unfortunately become uh more active as that atrium dilates and you get over a year or so, and that scarring and that fibrosis really changes the whole landscape of that left atrium. So at that point, um, once we, uh, from a surgical perspective can really isolate that whole left, uh, atrial wall, and then EP as well can come back and we can map it and take a really good look to see what maybe triggers are now involved and they also can be isolated from endovascular standpoint we can really tackle this together in a in a holistic fashion, I think. Yeah, so again, so important if you have patients with rhythm disorders earlier is better and, and if we get the patients there we can treat them. Uh, let's talk about the consequences a little bit. So one of the consequences is possibly decreased ejection fraction, heart function. The other is stroke as well. Maybe let's talk about that and, and, and what are ways we could maybe manage and minimize the risk of patient having a stroke after uh if they have atrial fibrillation or or some other rhythm disorder, yeah, and I think this is a pretty complex question that we like to really simplify. Um, I think a lot of uh physicians and certainly patients think that if the atrium is fibrillating, then that's when their risk of stroke goes up. And unfortunately, it's a lot more complex than that than we know. Um, you know, there's a triad out there that everybody knows pretty well that promotes, you know, thrombus formation and, and the same lies true in Afib. It's not simply a fibrillating atrium that causes stroke, but you have to have the correct circumstances for it. No patients that with Afib have, you know, kind of inflammatory cytokines that make them prothrombotic. We know they have some endocardial dysfunction, and they have this little out pouching called the left atrial appendage that kind of gives, gives the perfectittis for, for thrombus formation because the sluggish flow, the endocardial disruption within the appendage and just that prothrombotic state. So the, the best thing we can do for AFIB patients, I always say is minimize the risk of stroke. Right now we have, um, you know, a risk calculator called the CASA score, which is, it's good. I mean, it's the best that we have and I think it's certainly it's doing a good job in preventing stroke in our patients, but I think it's not specific enough and I think if we sat down and, you know, another 5 years and had the same discussion, I bet we're gonna have something better than the CATSA score, something that's much more specific. But for the time being, it's what we have. It's a risk profile. If that Chad's VA score is greater than 2, we know that patient's risk of stroke is greater than 2% per year. And at that point, it's always recommended to start anticoagulation. Most likely the direct oral anticoagulant nowadays. Direct oral anticoagulants are fantastic. They work really well, but we know that up to 25% of patients after taking an direct oral anticoagulant will stop it within a year. And there's many reasons for that. I think once you tell patients they're gonna take a blood thinner, they get very anxious about it. In the United States Healthcare, um, these medications are extremely expensive, um, and you know at the end of the day, it's, it's hard to take a medication every single day, so adherence to medicines is also certainly an issue. So that's, that's a great point. So you know, stroke is one of these things that people fear more than death sometimes. It's very debilitating and what we can do to minimize that risk of stroke, I think is important. But in some patients have afib, atrial fibrillation, they don't want to be on a blood thinner, and there are things that we can maybe do to avoid them having to be on anticoagulant even though they have atrial fibrillation. Can you talk a little bit more about percutaneous options and possibly surgical options for managing, you know, the infamous left atrial appendage as you're alluding to. And, and you know, it's, it's funny. I do a lot of different procedures, but when you talk to a patient about a way to get off anticoagulation, they'll be the biggest smiles that you'll you'll receive all day. So I love it just for that reason. It's a huge patient satisfier truly is. And uh there's different options. There's you know, the Watchman device, um, there's the you know the surgical clips. There's multiple other percutaneous approaches that are coming out in the future as well that we're involved in research with that Back to South Miami Cariac and Vascular Institute. But they essentially have the same principle that left atrial appendage, that nitis where, you know, where you have blood stasis and it's a, you know, blind loop of blood flow you using some type of percutaneous approach to seal off communication between the left atrial appendage and the atrium. So we're getting access in the groin, going up, doing a transeptal puncture, and usually they guided by some type of echocardiography or replacing some type of plug within the appendage in order to minimize the communication. The beauty of that, it's percutaneous, recovery is quite quick. Um, but the left atrial appendage can also be a trigger for atrial fibrillation, and we know that with our percutaneous devices unfortunately we don't cause electrical isolation of the appendage. So it's one of the limitations of percutaneous left atrial appendage occlusion devices and that's where kind of handed off to Doctor Tompkins so he can, you know, discuss the beauty of that, that surgical clip, that atrial clip, yeah, if you could expand out to Tompkins, uh, in what scenarios would a watchman device uh or other device. Out there, uh, be, uh, a good ideal solution and, and what scenario would a surgical approach to ligating the left atrial appendage be a better solution and, and describe briefly on how you would do that. Yeah, sure. So number one, anybody who who another issue is if you can't tolerate anticoagulation. So if you can't tolerate anticoagulation and endovascular approach is not gonna work merely because they have to still be on anticoagulation for a short period of time after they get it occluded. Um, from a surgical perspective, um, you know, number one, if we're going in there for pericardial effusion to be drained, and number 2, if we're going in there because someone has persistent afib and, and we're treating the posterior wall and we're looking right at the appendage, we can clip it. Number 3, if we're gonna go do a concomitant procedure, meaning if somebody's already coming in with a valve disorder and we're gonna ablate them. Um, with a cryoablation or radio frequency ablation, whatever that, uh, that we can also not only put a clip there, we can also cut the appendage, we can sew the appendage off, um, and, and furthermore, while we're doing it, uh, just like our EP colleagues do the same thing, we're using, uh, you know, a TE we're using an echo to make sure from many different angles that that appendage is completely occluded because the last thing you want is any gap. Um, at all because then that's anotheritis for possible thrombus which we wanna get stay away from from a surgical perspective, um, when we're doing this minimally invasive, you know, like a convergent procedure, we're able to make this little tiny small incisions in the chest and through a thoracoscopic approach we'll open up the, uh, pericardium. The appendage will pretty much pop out towards us and we'll put a clip directly across it. It doesn't take much time at all. Like I said, it's gonna be under TE guidance and. Uh, once that's done, it's very minimal pain associated with that. Before, before we change gears and, and talk a little, uh, uh, uh, away from afib a little bit, let's talk about the flip side where your heart rate gets really slow, and that's something that I believe you all treat as well. So, so maybe describe uh the conditions that are often treated when you have a slow heart rate and how it's done and maybe potentially the unmet need there too where where they're. Patients out there who probably need it done, but they're not, they don't know they need it done. Yeah, yeah, definitely. So, you know, Afib can also present with other Brady arrhythmias or they can definitely have a tachycardia component, but it can have, you know, tachy Brady syndrome is, is actually something that's extremely common. So patients will be in afib and they'll go quite fast and then all of a sudden they'll convert to sinus rhythm and their sinus no just has a little bit of disease, so they'll have what's called sick sinus syndrome. And so those patients can sometimes be difficult to treat because they're extremely fast in atrial fibrillation, but on conversion back to sinus, all of a sudden they're extremely slow. Uh, and these patients, we always consider two options, and I think it depends on the, on the profile of the patient. But there's either an ablation which can have a really good chance to prevent that tachycardia, so you just can live with a little bit of sinus brady, or there's pacemakers that we can use in order to treat those Brady arrhythmias. Maybe the safer approach. Um, you know, pacemakers are minimally invasive procedures nowadays. There's two types of pacemakers out there now. There's a traditional or the trans venous leads, so getting access in the axillary vein. Passing leads into the heart, um, or there are, um, what we call leadless uh pacemakers out there nowadays. So the limitations of trans venous devices is that you know no lead will last forever. So usually with the pacing leads 25-30 years down the road at some point you're gonna have to start thinking extraction because you know the the leads are moving with the heart so they're moving and contracting 60 times a minute over 20-30 years these leads can definitely start to fracture, have issues with them. Device infections can also be, um, you know, a big problem in our, in our patients, about 2% per year. And so that's one of the reasons that Lila pacemakers have really, you know, caught a lot of attention. We think, um, you know, the risk of infection is much less than 1%, so it's extremely rare and it's a lot more comfortable to the patient. They don't have a pocket, they don't have arm restrictions after the pacemaker, something they definitely appreciate. Um, so it's definitely an evolving field. Um, there is now, uh, a type of pacemaker that's called conduction system pacing. So with pacemakers in the past, something we wrote about if you cause chronic RV pacing, you cause a lot of synchrony of activation between the right ventricle and the left ventricle and up to 20% of these patients would, you know, start to establish some heart failure. Now with conduction system pacing we have a specific lead that can bury itself deep into the septum and actually capture the left bundle and so if you're capturing the left bundle you're pacing the native conduction system of the heart and so you get these beautiful narrow QRS results and you essentially eliminate the risk of uh developing a, you know, dysynchronous heart and heart failure from chronic RV pacing so. Definitely, you know, pacemakers are something that we're just so flat and stable for, you know, many years, 30 years, and all of a sudden now we have needless pacemakers, we have conduction system pacing, we have advancing in biventricular pacing and it's just been, you know, become a lot very, very exciting, um, as well lately. Uh, just to add one thing to what he said, um, because the, the one interesting thing is that these pacemakers have been there for a while and they're gonna be there for a while, even after, you know, we have all these, these minimally invasive procedures that we can put in there, uh, because, uh, the point I wanted to bring up was if you see someone with a blood infection at all and they have a pacer and they have leads in it, they have to come out. That is a class one indication to remove them then we can go in and put another type of pacemaker if the patient. Uh, has the anatomy for it or has the physiology for it, uh, but it's very important that everyone's aware that, you know, if someone has a blood stream infection and they happen to have a pacer and a pacing lead in in in there, it should come out and we should contact us both for us to to take care of that, um, and, and furthermore, you know, you also, we also try not to leave too many leads in there because guess what you're, you're gonna end up having causing a fibrosis and then you're gonna have obstruction in the future you can have another issue. So just uh just a sidebar to what you were saying because I think it's important that everybody knows about these possible issues that we can come up with can arise in the future. Yeah, I think that's a great point, Doctor, you know, many times we'll see patients that are almost placed on 6 weeks of antibiotics hoping the infection goes away when they have indwelling devices and that's it'll never go away, right? You know, the staff. Aureus forms that biofilm strep streptococcus can form that biofilm, and as soon as the antibiotics are removed, the bloodstream infection comes right back and those patients get quickly septic. So it's a great point. You know, total system extraction is definitely the standard of care in these patients. And, and, and, and Duke actually just did a study that says that if you can extract these patients less than 6 days after they have a bloodstream infection. Their risk of mortality goes down so therefore they they live longer so that's also very important for them to know and get transferred to you know us as a center to be able to do this. What, what makes Baptist electrophysiology program different than others? What makes this special? Yeah. I think a couple of things. I think number one is, is our focus on outcomes. If we look at, you know, as an EP group when I sit down with my partners with, you know, Doctor Villas and Doctor Moner, the first thing we're looking at is, is our outcomes and, and how we're doing and how we're doing and, you know, in regards to comparison to national benchmarks and it's something that we take a lot of pride in because I think we beat a lot of those national benchmarks and so it's definitely something we're very proud of. I think we're, we're also, you know, Miami cardiovascular Institute has a world of, of innovation, and that started from, you know, the legend of Doctor Barry Katzen, and I think that, you know, Miami Cardivascular Institute we're always pushing for, for innovation. We're always looking to see where the field is going, where it's going next and trying to really push those limits to really optimize the care of our patients. Um, so I think those are the two main things that drive our program. We also believe in ease of access. We always say that there should always be room for patients to be seen electrophysiology within the first week of getting the call, um, and so it's something we put a lot of focus on, um, when we review our data at the end of each month. Well, I can attest to that because every time I reached out to you all, you, you see the patient properly and the patient is very happy and there's very little delay. I'm glad to hear that. Doctor Tompkins, what makes Baptist EP different? So I would say that our collaboration, you know, our ability that we reach out to, to, you know, just us being here today will tell you that, you know, from a testament from a surgical side from the EP side that we collaborate together and, and furthermore, there's, there's many other, uh, different people that we collaborate with, you know, so. I think that's #1 important number 2 that we see our patients quickly and and really number 3 is, is not our outcomes are absolutely important, but what makes our outcomes important also is what brings patients here is it makes them happy. So we want you to be happy not only that you're happy, you're happy because you got a good durable lasting outcome. How do we get patients to you? Describe to us the referral process. Yeah, yeah, so we have a main centralized number um that you can certainly call and we will call that number back within 24 hours if it's not immediately, you know, especially if it's after hours. We also have an email that we can certainly, you know, give out. So if you email the patient information, there's somebody on the other side of that, we'll call out and reach out to the patient. And I always say, you know, to the physicians out there, you know, my number is essentially a public number out there. Feel free to give me, send me a text, send me an email, and I'll definitely help arrange that visit. Um, the number would be 786-204-4201 for a centralized number if anybody wants it. Thank you, Doctor Tompkins on that? No. and not only that, but we have, uh, boots on the floor 24/7 at South Miami and at Baptist. So anytime you need to get a hold of one of us, one of our APPs will be there and available to answer that phone call then call us. And again, the same thing that we're also very much available through our, um, through our phone number and our email as well. So, uh, MCVI is is ready and open and available to you at any point in time. As you wrap up, I was hoping each of you can give some final comments and thoughts on. Uh, the program here and the direction of the program as we conclude, yeah, yeah, I think, uh, you know, Tom, uh, we've talked about it. We're very excited about EP, uh, at BAFTA South Miami Cardi and vascular Institute. I think we're, we're staged for growth. And um you know we see that we can make a huge impact in our community as we discussed earlier today there's there's definitely room for earlier patient access into our office um if we look at the um you know number of Afibs done in Miami-Dade County is actually below the national benchmarks um so there's definitely, you know, a lot of excitement for growth, um, within our community. And um you know, not just from a physician standpoint but also a patient, you know, patient uh standpoint to kind of improve the access to to our AP clinics. Dr. Tomkins, from you know our standpoint, we're also moving forward in the world of AI as well. I think it's actually very important, you know, we're introducing, you know, robotic approaches to ablate the, the uh the left atrium. Um, and, and, and why is that important? Well, because once you introduce an AI system, uh, for a couple of different reasons. Number one, it keeps you out of harm. It can map the heart better and make sure that you're getting and isolating those abnormal electrical impulses. And, and then furthermore, you know, uh, just another step further for your cardiologist or an internist who's getting an EKG, there's gonna be AI models and they already are AI models that have EKGs that may read to the eye normal. But a fib or any other arrhythmia may be buried deep in that. And I think that's where it needs to be explored. That's where they need to come to us. That's where they could come to him and get maybe a loop recorder or something involved to make sure that we're capturing this early. I wanna thank you both for joining us this uh this afternoon uh to talk about something that's really important, uh, Doctor Pascual, Doctor Tompkins, uh, and I want to thank the audience for, for joining us today. I think there's several really important take home points. The first is that. Uh, rhythm disorders is very prevalent across our community, especially here in Miami, but it's really undertreated. We know that Florida in general is a state that's growing, but in population that's aging, and those are the patient population that tend to have these rhythm disorders, and we know a lot of them aren't being treated and um and the earlier we treat them, the better. The second is that the consequence is important. You can have decreased heart function, you have a risk of stroke. And we can treat those as well, a lot of different technologies to treat that here at Baptist. The third is the collaboration that we have with electrophysiologists, surgeons, but also the collaboration with industry and technologies out there. That gave us access to different toys that a lot of other folks might not have access to. And the last point is that as a program here, we are readily available, the service side, if you want to send us patients, we have a number uh that you can call. You can even call Dr. Pascal's, you know. Mobile home number any time you want he'll be there and he'll answer it but we're really here to to serve our patient community and take care of our patients out there with rhythm disorders. So thanks for joining us and hopefully you'll join us next time. Thank you again. Thank you very much. Thank you. To find out more about the topics covered on Baptist Health. Doc, please visit physicianresources.baptisthealth.net. Created by
