Tag Archive - Texas Cardiac Arrhythmia Institute

TCAI Hosts First-Ever EPLive Symposium

April 2, 2012 in AFIB, Community Outreach with 0 Comments

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Normally, I try to keep this blog focused on issues that impact patients directly, like how to take your own pulse, or how to prevent heart disease. But this time, I want to toot TCAI’s own horn a bit.

Last week, we hosted a symposium called EPLive here at St. David’s Medical Center in Austin. The first of its kind, this conference brought together the heavy hitters of electrophysiology to discuss live and pre-recorded EP procedures. Over 100 physicians, nurses, EP technologists, and industry representatives attended the two-day symposium, which contained a total of nearly 40 case presentations. Faculty included world-renowned electrophysiologists from major EP centers in Boston (MA), Akron (OH), Philadelphia (PA), Chicago (IL), Rochester (MN), New York, Stanford (CA), Los Angeles (CA), and Lancaster (PA), as well as Hamburg, Germany and Venice, Italy.

TCAI broadcast six live cases from our EP Lab on each day of the conference. While one of our physicians was focusing on performing the procedure, another TCAI physician walked conference attendees through the procedure and fielded questions from the audience. This unprecedented format allowed physicians to watch, live, complex cases being performed in real-time on anonymous (but very real) patients, with real challenges, trouble-shooting, and results. The sessions focused on ablation of atrial fibrillation and ventricular arrhythmias, as well as cardiac devices (such as pacemakers and defibrillators) and new technologies in electrophysiology.

As the brain-child of Dr. Andrea Natale (TCAI’s Medical Director) and the course co-directors, Drs. Francis Marchilinski, Paul J. Wang, and Amin Al-Ahmad, the goal of EPLive was to use actual procedures as a tool for teaching electrophysiologists how to implement the latest technological and technical advances in the field. Many of the cases sparked lively debate about the best way to approach a certain aspect of the procedure, and all prompted thoughtful questions from experienced and novice electrophysiology professionals.

According to attendees, the first-ever EPLive symposium was a huge success. We hope to host the conference again here in Austin in 2014.

February is National Heart Month

February 14, 2012 in AFIB, Exercise, Heart, Heart Rhythm, Women with 0 Comments

Not everyone loves the sappiness and romanticism of Valentine’s Day.  But everyone has a heart, and we all have the ability to protect our hearts from heart disease and stroke.

In honor of National Heart Month, the Centers for Disease Control (CDC) has launched a national education and prevention initiative called Million Hearts™.  The goal of the campaign is to prevent 1 million heart attacks and strokes over the next five years.  Did you know that over 80,000,000adults, or 1 in 3 people, in the U.S. have some form of heart disease?  Or that more than 2 million Americans suffer heart attacks and strokes each year?  According to the CDC, cardiovascular disease is the leading cause of death in this country, and it accounts for more than $444 billion is health care expenses and lost productivity.  And here’s a staggering pair of statistics from the CDC:  on average, someone dies every 4 minutes of a stroke, and every 34 seconds, someone in the U.S. has a heart attack.

The good news is that most heart attacks and strokes are preventable.  The Million Hearts™ website is a great resource for information about prevention and treatment of heart attack and stroke, and provides practical instructions for how you can reduce your risk of these deadly conditions.  I’m a particularly big fan of the five-point action plan that CDC offers individuals for reducing their risk of heart attack and stroke:

  • Prevent heart disease and stroke in your family by UNDERSTANDING the risks.
  • GET UP and GET ACTIVE by exercising for 30 minutes on most days of the week.
  • KNOW your ABCS:
    • Appropriate Aspirin Therapy
    • Blood Pressure Control
    • Cholesterol Management
    • Smoking Cessation
  • STAY STRONG by eating a heart-healthy diet that is high in fresh fruits and vegetables and low in sodium, saturated and trans fats, and cholesterol
  • TAKE CONTROL of your heart health by following your doctor’s instructions for medications [and] treatment.

Cruise the Million Hearts™ website, and check out the My Life Check tool from the American Heart Association and the American Stroke Association for more practical, easy-to-use advice on how you can improve your heart health.  This February, skip the box of Valentine’s Day chocolates.  Instead, give yourself the gift of ensuring that you’re not one of the 2 million Americans who suffer heart attack or stroke this year. Your loved ones will thank you for it!

Guest Blogger: Matthew Dare, CEPS, on New Cardiac Ablation Technology Trends

January 25, 2012 in AFIB, Heart, Heart Rhythm with 0 Comments

This month, we welcome Matthew Dare, CEPS, as guest blogger on the TCAI blog.  Matt is Research and Technology Coordinator at TCAI and is our go-to guy whenever we have questions or issues with the high-tech equipment used in the EP Lab here.  Matt’s expertise is invaluable to the daily operation of the lab.  If you have questions for Matt, please feel free to contact him at matthew.dare@stdavids.com.

One of the things I have always loved about EP is the myriad of cutting edge technologies we use on a daily basis.  With technologies such as integrated control and video systems, 3D mapping, remote navigation, telepresence and a dizzying array of ablation technologies that include radiofrequency, cryo and lasers, a modern EP lab resembles something closer to a video game or mission control at NASA than an operating room.  And as a member of a generation raised on video games, I feel right at home.

Now, we didn’t get to this point of high tech integration overnight.  It has taken years and years of advances to get us to where we are now.  With that thought in mind, I’d like to look back on the advances of this past year and some promising pieces of technology we might see in the coming year.

  • New Irrigated Catheter Designs – Several companies are in the midst of studies new irrigated catheters that promise better lesion formation with more efficient cooling.  These more efficient designs allow for lower saline flow rates than those currently on the market.  This will help offset some the fluid overload issues we see with current catheters.  One thing to watch with these new catheters will be how lab practices change due to the lack of temperature feedback from the catheter.
  • Force Sensing Catheters – Contact force has always been a factor in creating good lesions, but up until now, physicians have not had a reliable way of determining how much force they are actually applying to the tissue.  That will change with the catheters currently being studied as both competing technologies, magnetic sensor based and fiber optic sensor based, will allow physicians to determine contact pressure down to one gram.  Ideally this should allow for better, more consistent lesion formation while also helping prevent complications from applying too much pressure.
  • Multielectrode RF – While this technology has been studied for several years, the EP community was able to see more data this year along with broader investigational use.  The idea of being able to create complex lesion sets with a single application is very intriguing.  Unfortunately, the current non-irrigated implementation of this technology has had difficulty in creating deep lesions.  In addition, several centers and studies have reported a significant rate of silent embolization in cases utilizing the current system.  The addition of irrigation electrodes has the potential to solve both of these issues.
  • Cryo Balloon – This year, the cryo balloon became just the second device to receive an indication for paroxysmal atrial fibrillation from the FDA.  Since receiving that indication, the cryo balloon has enabled many centers that were not previously equipped for AF ablations to perform this complex procedure.  As the device is limited to isolation of the pulmonary veins, it does have its limits, but it has the potential to be an important tool in the EP toolbox.
  • Laser Balloon – The laser balloon is another device that has been in studies for several years, but has recently gone through a redesign of the laser console and of the balloon itself.  These changes have made the system much more user friendly than previous iteration and even allow for one handed operation of the balloon by the physician.  While the laser balloon is similar to the cryo balloon in the fact that it is basically limited to isolating the pulmonary veins, it provides the physician with the ability to target specific regions around the pulmonary veins.  In addition to more localized ablation, the laser balloon also allows physicians to actually see where the lesions are being placed via an endoscope located within the balloon itself.
  • Radiometric Temperature Sensing Catheter – The last technology I want to mention is a newer system that allows for the measurement of actual tissue temperature.  This device integrates passive radiometric sensors into the tip of an irrigated ablation catheter rather than the traditional thermocouple or thermister found in most ablation catheters.  The systems works by detecting microwaves emitted from heated tissue during radiofrequency ablation.  This enables the physician to see the temperature of the tissue three millimeters from the tip of the catheter.  As I mentioned earlier, one of the drawbacks of newer irrigated catheter designs is that they provide no real temperature feedback during ablation.  This system has the potential to remedy that issue.

As you can see, this upcoming year promises to be another year filled with exciting advances in EP.  Hopefully these new technologies will allow the EP community to provide broader access and improved outcomes for our patients.  It will certainly be interesting to see what we think a year from now

Review: The AFib Educator iPhone App

January 3, 2012 in AFIB, Heart, Heart Rhythm with 0 Comments

I recently stumbled across a nifty smartphone app that aims to help patients visualize the electrical mechanism behind Afib, as well as what the disease does to the heart.  AFib Educator 2.0 is a free smartphone app developed by AFStat™: A Call to Action for Atrial Fibrillation.  According to the About AF Stat section of the app, AF Stat is “a collaboration of health care leaders and organizations working to improve the health and well-being of people affected by…AFib,” and is sponsored by a major pharmaceutical company, Sanofi Aventis U.S.  Despite its pharma roots, though, the app does not mention specific drugs used in the management of AFib.

Here at TCAI, our Atrial Fibrillation (AFib) Nurse Educators are always looking for new ways to educate AFib patients.  AFib is a complex disease that’s hard to wrap your head around as a patient, and the treatment and management options can be confusing.  The confusion is compounded by the fact that you can’t actually see AFib, and some patients don’t even feel symptoms of the disease.  Yet, AF increases the risk of stroke five times and accounts for about a third of hospitalizations for cardiac rhythm problems.  Apps like AFib Educator make it easier for visual learners (myself included) to understand this costly, often debilitating disease that affects more than 2.5 million Americans.

The app is broken down into four sections: About the App, Demo Videos, AFib Management Videos, and AFib Facts.  The first and last sections are, in this reviewer’s opinion, not particularly useful.  The user is likely to look at each of these sections once and never tap on them again.  The app is geared toward healthcare providers, who are likely already familiar with facts about AFib, though there is a handy “Send AFib Facts” button in the AFib Facts at your Fingertips section that allows the provider to e-mail the list of facts, ostensibly to the patient.

The real meat of the app lies in the middle two sections, the first of which features fantastic videos and real-time EKGs of the heart in normal sinus rhythm and AFib.  These digitally animated videos are realistic and detailed, and mesmerisingly capture what’s actually going on in the heart when it’s in regular rhythm versus AFib.  The AFib Management Videos section is equally as fascinating, depicting the heart’s inner workings after rate and rhythm control drugs are applied.  The most telling video here is the AFib & Stroke Risk clip, which shows a clot forming in the upper chambers of the heart and traveling to the brain, demonstrating the real risk of AFib to the patient.

What’s missing from this app?  Here is where its sponsorship by a pharmaceutical company is evident—nowhere in the app is there any mention of cardiac ablation—a promising course of treatment for many AFib sufferers.  It would be great to be able to show patients animations of the ablation process, since our AFib Nurse Educators are often educating patients prior to cardiac ablation procedures.  The app also fails to provide much information on anticoagulation, a big piece of the education process for AFib patients.

All told, though, AFib Educator is a useful app with beautifully-made videos that could serve as a very effective visual aid on a tablet or smartphone at the patient’s bedside or during a doctor’s office visit.

Holiday Heart Syndrome: The Gift you DON’T Want this Year

December 5, 2011 in AFIB, Community, Diet, Heart, Heart Rhythm, Holiday, Lifestyle Tips with 0 Comments

Ahhh, the holidays… the one time of the year we’re free to eat, drink, and be merry to our hearts’ content.  I don’t mean to be a wet blanket, but all of that merriment can do a number on your body.  Consider all the ways the holidays tend to assault our health:   there’s the extra pound of weight most of us gain during the holidays (which, sadly, rarely comes off the next year), the added salt and fat of those rich holiday goodies, the additional financial and family strain that are common this time of year, the workouts that fall by the wayside, and all those festive cocktails.   That last one can lead to what doctors call “Holiday Heart Syndrome,” a temporary disturbance in heart rhythm and/or function that usually occurs in folks who have no other health problems and is thought to be brought on by binge drinking.  So one minute you’re enjoying your third glass of champagne, and the next minute, your heart feels like it’s going to pound out of your chest.

The term Holiday Heart Syndrome was coined in the 1970s, when physicians began noticing an increase in heart rhythm disturbances in patients around the holiday season.  Most commonly, the sufferer of this syndrome is young, healthy, and does not normally drink in excess.  Imbibing a modest to large quantity of alcohol, though (which many of us do at holiday parties) can over-stimulate the electrical system of this otherwise healthy person’s heart and cause rhythm problems, most commonly Atrial Fibrillation.  Rhythm disturbances associated with Holiday Heart can also be caused by fluid overload, associated with all the salty foods we tend to eat during the holidays.  Luckily, most cases of Holiday Heart Syndrome go away on their own within 24 hours.  But some can persist or recur, increasing the sufferer’s risk of stroke or cardiomyopathy.

The most common symptoms of Holiday Heart Syndrome are palpitations, feeling like your heart is “jumping around” in your chest, and dizziness or fainting.  If you experience these symptoms, especially if you’re otherwise healthy and you’ve been back to the punch bowl a few times, your heart is telling you to stop drinking, sit down, hydrate well with water, and get some rest.  If the symptoms last for more than 5-10 minutes, it’s a good idea to go to the emergency room.  Even if they go away fairly quickly, though, it’s not a bad idea to tell your doctor; you could have a greater propensity toward heart rhythm disturbance in the future.

So how do we prevent Holiday Heart Syndrome?  According to one of TCAI’s Nurse Practitioners, D. Kay Zedlitz, ACNP, “the key is moderation.”  It’s okay to indulge in some festive food and drink, but don’t go overboard.  One alcoholic beverage per day for women and two for men is what’s widely considered moderate; if you go over your daily limit, consider abstaining the next several days to let your system rest.  Remember: alcohol is a toxin to the heart.  Try alternating alcoholic and non-alcoholic beverages (preferably water) at holiday parties, and limit your proportions of rich, salty foods.  Your heart will thank you for it.

[image credit]

TCAI Staff, Doctors Venture to Venice

November 17, 2011 in AFIB, Heart, Heart Rhythm with 2 Comments

What do you think of when you picture Venice, Italy?  Romantic gondola rides along the canal?  Check.  Towering cathedrals?  Yep.  Ornate glass masterpieces?  Got ‘em.  One of the largest annual conferences on cardiac arrhythmias in the world?  Huh?  Yes, that’s right, each year, experts in electrophysiology from across the globe convene in Venice to discuss the latest in arrhythmia treatment and research.  This year, three TCAI nurses, six physicians, several researchers, a technologist, and a former patient were all invited to speak at this 12th annual who’s who of electrophysiology.  Not only did they share with the world the great things happening at St. David’s Medical Center, they also brought back some great knowledge, and some ideas for improving patient care and education stateside.

Our allied health professionals (nurses and technologists) were tapped for some heavy-hitting sessions in Venice.  Barbara Thomas, the Director of Electrophysiology (EP) Services and the Atrial Fibrillation (AFib) center, was the co-chair of the allied professionals track at the meeting and served on a panel discussing the role of EP nurses in different national health systems.   Tami Metz, the Manager of TCAI’s EP Lab, spoke about ablation of ventricular arrhythmias.  Our resident Coordinator of EP Education, Matthew Dare, gave a presentation about new technology in the field.  Cindy Williams, one of our AFib Nurses, presented on the nurse’s role in AFib Ablation, touting our unique Nurse Navigator program, where AFib patients have a nurse follow them from initial through two years’ post-procedure.  One of our nurse practitioners, Kay Zedlitz, delivered her perspective on improving patient outcomes using Cardiac Resynchronization Devices.

TCAI physicians stole the show in Venice.  Doctors Gallinghouse, Canby, Sanchez, Horton, Natale, and Burkhardt all shared their expertise, experience, and research results on just about every subject in EP.  Dr. Andrea Natale, the Medical Director of TCAI, was co-president of the conference, participated in a lively debate about whether AFib ablation should be first-line therapy in caring for patients with AFib.  Based on studies conducted by TCAI, Dr. Natale came down on the “pro” side of the debate, explaining that, for patients with a normal heart, ablation can be an effective first tool that the physician reaches for in curing AFib.

Speaking of TCAI research, several of our research fellows presented abstracts and posters in the conference.  Dr. Luigi Di Biase, Senior Research Fellow, extended his stay in Italy so he could accept the prestigious Valsalva Award in Bologna, Italy.  The award, given by the Italian Institute for Cardiovascular Research, honors distinguished, young researchers who have made significant innovations in cardiovascular research.

So next time you think of Venice, think of all the great knowledge that’s gained and shared every October at the Venice Arrhythmias conference.  Because, how romantic can a gondola ride be when you’re in AFib?

image credit : Chiara Marra

How to Take Your Own Pulse: Something Everyone Should Know

November 1, 2011 in AFIB, ER/Urgent Care, Heart, Heart Rhythm, Lifestyle Tips, Men, Women with 0 Comments

As a nurse, I’m often surprised at the number of people who don’t know how to take their own pulse.  I have to remind myself that, for someone who doesn’t do it every day, it can be a little tricky.  By the time you finish reading this, you’ll know exactly how to take your own pulse.

But before we get into the how, let’s talk about the why.  Why is it important to know how to check your own pulse anyway?  If you have Atrial Fibrillation (AFib), checking your pulse is a quick and easy way to tell if you’re in or out of rhythm.  While many people feel terrible when they’re in AFib—palpitations, dizziness, shortness of breath, and decreased stamina, to name a few—some folks have no idea when they go into AFib.  This can be especially dangerous for people with undiagnosed AFib, since the heart rhythm disorder is one of the top causes of stroke.  If you don’t know you’re in AFib, you can’t take steps to protect yourself from its potentially debilitating effects.

And since AFib affects more than 3 million Americans, mostly over the age of 60, I would argue that everyone age 60 or older should take their pulse on a regular basis to (at the very least) see if it’s fast or slow, regular or irregular.

So here’s how to do it:

  1.  Turn your left hand so that your palm is face-up.
  2. With the index and middle fingers of your right hand, draw a line from the base of your thumb to just below the crease in your wrist.  Your fingers should nestle just to the left of the large tendon that pops up when you bend your wrist toward you.
  3. Don’t press too hard, that will make the pulse go away.  Use gentle pressure.
  4. Wait.  It can take several seconds—and several micro-adjustments in the placement of your two fingers on your wrist—to find your pulse.  Just keep moving your fingers down or up your wrist in small increments (and pausing for a few seconds) until you find it.
  5. Notice whether your pulse is regular (keeps time like a metronome) or irregular (more random, fast-slow, fast-slow).  An irregular pulse is a tell-tale sign of AFib or other heart rhythm disturbances.
  6. To take your pulse rate:
    1. Find a watch with a second hand and place it on your right wrist or on the table next to your left hand.
    2. After finding your pulse, count the number of beats for 20 seconds.
    3. Multiply by 3 to get your heart rate, or beats per minute (or just count for 60 seconds for a math-free option).
    4. Normal, resting heart rate is about 60-100 beats per minute.

Questions about what you find?  Speak to a Nurse Navigator by calling (877) 887-7737, or consult your physician.

October is National Sudden Cardiac Arrest Awareness Month!

October 18, 2011 in Heart, Lifestyle Tips, Outdoors, St. David's HealthCare with 0 Comments

October is National Sudden Cardiac Arrest Awareness Month!

Forget the witches, ghosts, and goblins, here’s something really scary: more than 250,000 people die each year from sudden cardiac arrest (SCA). SCA claims more lives than breast cancer, lung cancer, or AIDS annually.

Sudden cardiac arrest is exactly what it sounds like—one minute, a person is walking around, living their life, and the next minute, their heart stops and, if they don’t receive prompt treatment, they die. Victims suddenly collapse without warning, become unresponsive, and stop breathing. Sadly, more than 90% of SCA victims die before reaching the hospital, but this doesn’t have to be the case. Immediate treatment—in the form of CPR and, if available, use of an Automated External Defibrillator (AED)—can double the chances of survival.

So what can you do about SCA? Here are a few suggestions from the Heart Rhythm Society that could save a life (maybe your own!):

  1. Know the signs of SCA (sudden collapse, unresponsiveness, no breathing/gasping breaths)
  2. Call 911 ASAP
  3. Start CPR immediately.
  4. Use an AED if one is available
  5. Learn CPR—It’s easier than ever!

Hands-Only™ CPR is just as effective as traditional CPR with breaths. All you have to do is push hard and fast on the center of the chest. How fast is fast? 100 beats per minute—conveniently, the same bpm as the Bee-Gees tune, “Stayin’ Alive.”

Check out the American Heart Association’s awesome Hands Only CPR resources here.

Check out these other great resources for more info on SCA:

Have a safe and happy Halloween!

Jamie LaRue, RN

 

New Study Shows Lead Extraction Just as Safe When Done in EP Lab as Operating Room

October 5, 2011 in AFIB, Heart, Heart Rhythm, Lifestyle Tips with 2 Comments

We’ve talked in this blog about putting pacemakers and defibrillators in, but what about when they need to be taken out?  Lead extraction involves the removal of pacemaker or implantable cardioverter-defibrillator (ICD) leads from within the heart. Leads are thin, flexible wires that deliver energy to the heart muscle from a pacemaker or defibrillator to regulate the heart’s rhythm or deliver a shock if the patient is in a lethal heart rhythm.

Sometimes, the leads stop working properly or become obsolete and need to be taken out, usually to make way for new leads.  They can be difficult to extract because, over time, scar tissues grows over them.  During lead extraction, a sheath, or tube, is inserted threaded over the existing lead and inserted through a vein in the chest wall and into the heart.  The sheath helps free the lead from any scar tissue that may have developed around it, helping the doctor to gently pull the lead from the heart muscle.  Sometimes a laser is required to remove excess scar tissue that has grown around the lead.

Removing these adhered leads poses a risk of damaging the heart, which is why it used to be standard practice to do this complicated extraction procedure in the operating room (OR).   Nowadays, though, most high-volume Electrophysiology (EP) centers (TCAI included) do lead extractions in the EP Lab itself, with an OR and a cardio-thoracic surgeon (and his or her surgical team) on-call in case of emergencies.  A study published in the July 2011 issue Heart Rhythm, the journal of the Heart Rhythm Society (see full citation below), validated the safety of this approach.  The first of its kind, the study compared the safety and effectiveness of extracting leads in the OR versus the EP lab and found them to be essentially equal if a rapid-response surgical team is on-call to assist with any emergencies that might require surgery.

The study found that the most common complication associated with lead extraction was damage to blood vessels or chambers in the heart, which if it is serious enough, sometimes needs to be corrected with open heart surgery.  The major predictor of these complications during a lead extraction, according to the study, is age of the lead being extracted.  Older leads, have had more time to become adhered to other structures in the heart and are usually more difficult to extract.  Whether the extraction was done in the EP Lab by an electrophysiologist or in the OR by a Cardio-Thoracic Surgeon did not significantly impact the rate of complications, as long as there was a surgical team standing by to intervene in the EP lab in the event of complications.  We look forward to further study on this important matter—as the population of folks with cardiac devices ages, so will their leads.

REFERENCE: Francheschi, Frederic, MD, Dubuc, Marc MD, FHRS, Dharo, Jean-Claude, MD et al.  “Extraction of Transvenous Leads in the Operating Room Versus Electrophysiology Laboratory: A Comparative Study.”  Heart Rhythm, vol. 8, issue 11. July 2011.

September is Atrial Fibrillation Awareness Month!

September 7, 2011 in AFIB, Heart, Heart Rhythm with 1 Comment

It’s that time of year again! The Heart Rhythm Society (HRS), the professional society for electrophysiology, has designated September as Atrial Fibrillation (AF) Awareness Month. The Society has launched a new Public Service Announcement (PSA), gotten Congress to adopt an AF Awareness Resolution, and partnered with the American College of Cardiology to develop an online resource for health care professionals. But what’s the point?

More public education is desperately needed about this serious condition that affects more than 2.5 million Americans, most of them over the age of 60. As the U.S. population ages, the number of people affected by AF is expected to almost double—to 5.6 million—over the next 40 years.

So, AF affects a lot of people, but why is that such a big deal? AF can be debilitating, dangerous, and costly. The condition can cause a major deterioration in quality of life for its sufferers, causing fatigue, palpitations, pain, and sometimes fainting spells. More seriously, AF increases the risk of stroke five times, and according to HRS, AF “and is estimated to be responsible for 88,000 deaths and $16 billion in additional costs to the U.S. healthcare system.” AF accounts for about a third of hospitalizations for cardiac rhythm problems.

It is vital that the public knows the signs and symptoms of AF—palpitations, fatigue, an irregular heart rate, a feeling akin to “a fish jumping around in the chest”—so folks can tell their doctors and be properly screened. There is a wide variety of treatment options for the condition, ranging from “watch and wait” to invasive catheter ablation. Electrophysiologists, doctors who specialize in heart rhythm disturbances, will work with the patient to come up with the course of treatment that best suits his or her needs.

Visit www.MyAFib.org and the TCAI website for more information about Atrial Fibrillation.

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