Episode Transcript
[00:00:01] Speaker A: The Michael Hatfield Remax team presents real estate and more.
[00:00:06] Speaker B: Bay Area real estate is different than all of America. And why? What's up with buyers? What's on sellers'minds? How is the market? And much, much more.
[00:00:17] Speaker C: Now here's your host, Michael Hatfield.
[00:00:20] Speaker A: Welcome to the Real Estate and more Show. I'm your host, Michael Hatfield. This segment I call the heart of the matter, as I believe angels are living among us. Our guest today is a man I deeply respect for his life's work in the field of cardiology and for helping others in need. Living in Phoenix, he speaks with other doctors in conferences all over the world on behalf of that very special place, the Mayo Clinic. In these conferences, he shares cutting edge techniques on the treatment of heart issues developed from research by America's number one medical institution. I will share that several friends and family he has helped with serious health issues. Regarded amongst his peers as a world class cardiologist. Everyone just calls him Dr. Sri. Welcome to the show, Dr. Kumandor Srivatsan.
[00:01:11] Speaker D: Thank you and glad to be here, Michael, and good to be with you.
[00:01:15] Speaker C: Oh, that's great. Before we get into the heart matter, would you mind terribly if I just ask you a few questions? I know you know about a lot of things, and the one that I'm mostly interested in at this second is how is the real estate in your home city of Phoenix?
[00:01:31] Speaker D: At the moment, it's doing extremely well. The prices are really on the higher side.
It's surprising considering the mortgage rates are in the seven and a half percent range. One would have normally expected the price to at least come down or be remaining stable, and the market will be less competitive from a seller standpoint. But that's not the case for several reasons. A 1.5 million Californians have moved into Arizona, and they all seem to have a bag of cash, so to speak, because they sell their homes at a much higher price point in California and find Arizona prices to be very significantly lower than their prices. The second thing is a lot of peopLe, the inventory is very low because they've checked their homes into low interest rate mortgages from several years ago, and they don't want to get out of it because if they have to move to a new house, the mortgage rates will be very high. So the inventory is really low. Third, the population is increasing, but the home stocks were really low because of the economic crisis that occurred about ten plus years ago. So I think a confluence of factors has led to very stable prices on the higher side for Arizona standards. Yeah. So I think it is a little surprising considering the mortgage rates of seven and a half percent. But still, that's where we are.
[00:03:10] Speaker C: Yeah, pretty much. Over the last four years, we've seen a. I will call it a thinning market, meaning that there's less transaction when you compare it to the prior year. I think that it's a crazy time that we live in, and yes, I'm sure that there have been a lot of California people move into the state and causing the values to be high, but they're still high here in the Bay Area, too, and they seem to be pretty stable despite the thin market and also the mortgage rates being higher. I was seeing that it was like 7.8% on one of the lenders just this week, and that's pretty high for a conforming 30 a year loan. So it sounds like you're lamenting some of the same things we are here also, so it's of kind. Interesting. So over time, are you expecting the values to continue to go up? Are you expecting to fall off there in Phoenix, or what's your crystal ball say?
[00:04:09] Speaker D: My speculative feeling is the first quarter 2024, the housing market will either completely stabilize a plateau or may even come down 5%.
I think the ten year bond rate breaching the 5% is likely to occur, which means the mortgage rates will probably be 7.8% to 8%.
I suspect there will be definitely a plateauing effect. I don't know about a 5% reduction as possible between the first quarter and second quarter. That's my crystal ball. I don't know how much you trust my crystal ball, but that's where I think the market is heading.
[00:04:57] Speaker C: Well, maybe we're all in the same boat with this crystal ball, because here I'm seeing a lot of the same thing.
One of the things that you mentioned earlier was that the inventory is very slim there in Phoenix. Here it's very slim also. And anytime that we can find that the buyers come to the marketplace in a greater amount, we're going to have those values push up even more without given inventory improvings. So I sure appreciate your thoughts on that, Dr. Sri, but let's talk about a subject of which you are infinitely familiar with. I bet this is a subject many of our listeners are interested in, as in this condition affects a large percentage of our population. Atrial fibrillation. What exactly, Doctor, is atrial fibrillation?
[00:05:48] Speaker D: Atrial fibrillation is abnormal and rapid incoordinated contraction of the upper chambers of the heart. Normally, the electricity starts in the upper chambers and goes down through an electrical junction box to the bottom chamber, the junction box, in medical terms called AV node. And usually there is a one to one response between the upper chamber contraction and the bottom chamber contraction. But when you have chaotic and irregular rapid rates in the 350 to 450 beats per minute in the upper chamber, the gate acts as a protector and only allows. The junction box only allows somewhere between 100 to 140 in majority of people. Some people with very young people can even mount 180 to 200 beats a minute. And very people with sick AV nodes or very elderly can have slower heart rate because the junction box doesn't open that often, and therefore, they may have 60 beats or 450 beats, well controlled beats. Now, what are the consequences of this Atal fibrillation? This rapid and incordinated heart rate can lead to reduced cardiac output, and that can lead to multiple symptoms.
So that's where this condition is very common today. It almost looks like an epidemic of atrial fibrillation at this point.
[00:07:16] Speaker C: Yeah.
[00:07:17] Speaker A: What percentage would you say of our.
[00:07:19] Speaker C: Population is affected by atrial fibrillation?
[00:07:23] Speaker D: The population of 70 years and older will have about 5%, and population older than 80 years, about 10% of atrial fibrillation. I have to say, Caucasian population has a higher risk for developing atal fibrillation. People younger than 60, the percentages are in the 1% to 2% range. So it's not as significant as compared to populations older than 70. But over one and a half million patients have recognized have Afib that are clinically documented. But if you go by apple Watch tracings, that may be much higher. So we're only seeing the patients who actually come to doctors.
[00:08:08] Speaker C: So, doctor, what actually causes atrial fib?
[00:08:12] Speaker D: In majority of the patients, it's either unrecognized high blood pressure, or it is blood pressure over time, 10, 15, 20 years that have been partially controlled or well controlled, but still leads to some kind of significant microscopic changes within the left upper chambers of the heart that leads to atal fibrillation. Now, any number of conditions can cause atrial fibrillation, such as valve or heart disease, like mitral valve regurgitation, which is fairly common. Or you can have hypertrophic cardiomyopathy, which is a genetic condition. You could have thyroid disease, which can cause atal fibrillation. So any number of conditions can cause atal fibrillation, but the most common one is high blood pressure over time.
[00:09:03] Speaker C: I see living in this American economy where everybody is having to work so hard to make ends meet, is not probably good for this particular outcome.
Coming up with this disease, how life threatening is this disease that many people have?
[00:09:24] Speaker D: Atrial fibrillation, by and large, is not a fatal condition. But having said that, if one has faster heart rates and does not seek any therapy, the faster heart rate can exhaust the heart muscle and can lead to cardiomyopathy or weakening of the heart muscle, and that can lead to congestive heart failure. And if unattended, eventually congestive heart failure can lead to death. So that is a very extreme scenario in the United States. Vast majority would go seek attention and would get some form of intervention. Now, the second major part, even if you're seeking therapy, atrial fibrillation can lead to stroke, which also can lead to quite devastating consequences, either in death or significant disability. That is very frustrating for the individual. So as soon as someone has the diagnosis of atrial fibrillation, it's better to seek medical attention and get the best treatment that is possible.
[00:10:29] Speaker C: When you said higher heart rates, are you talking about ones that are over 100 beats per minute, or are you talking about resting heart rates or what rate are you talking about there?
[00:10:40] Speaker D: Correct. So if at resting heart rate greater than 110 would be considered fairly significant, because it is like getting onto a treadmill and not getting out. And if you are consistently going to beat faster, the heart muscle exhausts the energy reserves it has, and eventually it starts eating on itself, so to speak. And that exhaustion eventually leads to weakening of the heart muscle fibers. So resting heart rate greater than 110, 120 would significantly result in cardiomyopathy. If you look at animal models, if you pace them 100 and 5160 beats, within 6 hours, the heart muscle becomes weaker. But in human beings, it takes probably several days, particularly probably weeks to months, because most people will go to sleep and then the heart rate will come down a little bit because the adrenaline drive increases the heart rate. So I think overall, faster heart rates are not good for you. The timing may depend upon the speed with which the heart is beating.
[00:11:52] Speaker C: Okay, so if anybody is having a faster heart rate and it's coming and going, isn't there a term that you use for that? It is faster sometimes, but other times it's not.
What's that term used for that type of condition?
[00:12:10] Speaker D: If you have very fast heart rate and very slow heart rate, it's called tachy Brady syndrome. But if you only have fast heart rate, it's just tachycardia. But if you have, tachycardia is a common term we use. And in fact, the resulting heart muscle dysfunction is tachycardia mediated cardiomyopathy. But if you have tachycardia and normal heart rate, you may have peroxysmalatal fibrillation, where you could go into Afib and then go back into regular rhythm. So any mixture of things. All this can be monitored on a continuous mobile monitoring today, and either a ultra monitoring or continuous mobile telemetry. And then the doctor will be able to make a diagnosis and give you the planned outline for therapy from then on.
[00:13:02] Speaker C: So, once a person has this diagnosis of atrial fibrillation, I think the first step in the playbook would be lifestyle changes, maybe medications and so forth.
[00:13:14] Speaker D: Yes, I mean, the first thing would be the doctor would request an echocardiogram or an ultrasound of the heart just to make sure the heart function is stable. You'll check the thyroid function, kidney function, and so on. If the person has gone back into regular rhythm, then he will talk about how to preserve regular rhythm, medications or other means, and then he will talk about blood thinners. The blood thinner would depend upon whether the person's risk factor for stroke, which is measured by an index called Chad's vasque score. But lastly, lifestyle is a huge and big, significant improvement. Weight loss, obesity is rampant, weight loss, sleep apnea, control of hypertension, and, of course, modulating lifestyle, all would play a very significant role if you don't want frequent episodes of atrial fibrillation.
[00:14:12] Speaker C: Interesting. I know. I read just recently that a very little known causal factor for AFIb could be from something as simple as strep throat.
[00:14:23] Speaker D: Yeah, strep throat, in the old days, used to lead to rheumatic fever. And the very famous statement by Sir William Boyd is, rheumatic fever licks the joint, but bites the heart. So it leads to significant valve heart disease, particularly rheumatic mitral stenosis and mitral regurgitation. Aortic stenosis. So the strep throat should not be taken lightly. Fortunately, in the United States, majority of the people have access to health care and they can get amoxicillin, which or any form of penicillin derivative will stop all these long term complications of the heart that can occur from a simple strap throat.
[00:15:12] Speaker C: Some years back, I'm aware that you.
[00:15:14] Speaker A: Conducted a clinical study and gained quite a bit of professional recognition from that study.
This was a study that looked at the connection between Heidal hernia and atrial fibrillation. I believe it involved something like 140,000 Mayo clinic cardiology patients. This study discovered that, indeed, that there were connections between atrial fibrillation and Heidal hernias.
[00:15:43] Speaker C: Would you share with us how did that study come about? And any conclusions from it, please?
[00:15:48] Speaker D: Yes, that's a very interesting study. We always were interested. A couple of my patients were telling me that I get a significant heartburn and all, you know, within a few hours, I'm in ATL fibrillation. And this was concerning. And yet initially, we didn't know. Then we told them, well, these two are not associated. But when few more patients were saying the same thing, we got intrigued. And then we thought, and a couple of them we investigated, actually had hiredal hernia. Then we decided, why not just look through the medical records and see what exactly is happening with higher discernia patients?
And we were able to collect over 100,000 patients, as you mentioned, about 140,000 patients. And we found the rate of AFIB in this population was much higher than age match controls because of the two common conditions, can coexist. And that's called an association and not a causal association. Causality will be on a regression analysis. So we did a lot of analysis and found that these two are related. And then we came up with this hypothesis that there's a shared nervous system between the esophagus and the heart, and anytime you have hydronia and acid reflux, there are some output that comes from the autonomic nervous system that is putting these patients into atrial fibrillation. In fact, we have since then done a lot of patients who have undergone ablation for atrial fibrillation with a decent amount of success. And we find this Hyatt hernia remains a major risk factor, and particularly esophageal conditions for precipitating atrial fibrillation.
[00:17:47] Speaker C: That's so interesting and such great work.
Exactly. What is an ablation? You mentioned ablation. What is ablation, and where does that actually stand in the playbook of treatment?
[00:17:58] Speaker D: Yeah. Ablation in literal terms means elimination through what we used to call incineration. But today we do.
Ablation is not necessarily heating. It can be by freezing, it can be by a new modality called pulse field. Ablation.
The seminal work from Bodeaux in France in 1998 showed that AFIB starts from the veins that bring blood back into the heart from the lungs, so called pulmonary veins. Pulmonary essentially means lung. These veins, wherever they're joining the mouth of these veins, have some unique cells which are able to beat so fast.
So pulmonary vein isolation, whether it was heat directed using radio frequency or freezing.
Now, pulse field, which is a form of high voltage, electric minute, electric shock that you don't even feel, are able to disrupt the circuit and not allow these cells to communicate with the rest of the atrium, and therefore stopping the atrial fibrillation at its tracks. And because ablation is a form of elimination of the problem, the term ablation is being used, and usually it's not necessarily incineration. It can be cooling, it can be pulse feel, as I mentioned earlier. Yeah.
[00:19:33] Speaker C: Are you familiar with the hybrid convergent ablation technique? Isn't that something new?
[00:19:39] Speaker D: Yeah, that's a very intriguing proposition.
It is a two stage procedure that we also, in Mayo clinic, actually do it. Convergence, meaning convergence of two separate procedures, which means, in general, they are done four weeks apart. The first procedure is done by a trained cardiothoracic surgeon who actually goes under the breast bone and puts a telescope, kind of a scope, under the heart, because the back wall of the heart, called the posterior wall, near the vertebral column, has a lot of electrical abnormalities and circuits which need to be eliminated. And they put something like a heating probe on the back. Forgive my language, but something like a branding iron. But the good news is, because the esophagus is moved away, it doesn't affect the esophagus. When you try to do this from endocardially inside the heart, you don't have control over the esophageal damage. And secondly, the pull thickness is not that easy to achieve from cauterizing from inside the heart. So this procedure, he does the entire back wall of the heart, then the cardiologist goes four weeks later and does it from inside of the heart, whatever portion that he has not done. The interesting thing is convergence procedure is reserved for persistent or permanent AFIB, meaning patients never go back into sinus rhythm on their own, so they always stay in AFIb. Convergence procedure has shown extraordinary success rate, between 65% to 70%, whereas previous catheter based ablations were showing 25% to 40%. So it is a huge leap forward in the treatment of long standing persistent atal fibrillation management.
[00:21:38] Speaker C: Amazing to hear this level of ability for this work to be done on a human being. Does the success rate of just an ablation, does it differ between medical institutions?
Like, if I were to choose Mayo Clinic as opposed to XYZ facility, is there a study that shows better success rates at Mayo Clinic?
[00:22:04] Speaker D: It'll be self serving of me to directly say that the Mayo Clinic, but in general, I can say high volume centers generally have a better outcome than low volume centers. And not only the efficacy is better, but also the complication rates are much lower when it is done. By an operator, was performed the procedure repeatedly and does three or four days a week and does two a day or something like that, and was done over 1500 to 2000. Should have an easier time doing the procedure and the patients benefit from it. But the Mayo Clinic in general has.
The one advantage in Mayo is that we don't have a lot of time constraint. So we actually remap our patient, meaning we obtain a map at the baseline condition for the patient. We do the ablation, we repeat the map and now find any leaks across these barriers that we created. We also test the durability of the barrier with administration of medications which promote conduction, such as adrenaline, light drug medication and adenosine. So these waiting extra time and doing these kind of tests definitely increases the durability of the procedure, and thus the patient doesn't have to come back for the same procedure again. But in general, all large volume centers do very well. There's nothing specific, and any very low volume centers generally have a somewhat of a lower outcome. And that is a nationally published data.
[00:23:55] Speaker C: Like you want a pilot to have a lot of takeoffs and landings, as opposed to just a few. I definitely understand that. When I first learned about the ablation surgical technique, the common practice was to access the heart through two different arteries in the growing area, I believe, growing area and one catheter for the physician to see what he was doing. And the other catheter was used to do the denerving of the faulty heart circuits. But I'm sure that's changed now, isn't it? How does it work now?
[00:24:25] Speaker D: Yeah, I mean, the cryoablation itself changed that. The cryoablation is basically a balloon which is inflated at the mouth of these veins, and the temperatures are taken down to -50 to -80 degrees, which freezes the water inside these cells and disrupts their cellular membrane. And in fact, we untaw it and refreeze it, so it does not reconnect at all. Now, through the balloon, in the central lumen of the balloon, you can advance a catheter, which is like a lasso, and that has electrodes and you can measure it. So a single catheter is all that is required to cross the septum that is able to both ablate and at the same time you're able to assess the same methodology has come under pulse field ablation. I've been talking about this pulse field a lot. What it effectually means is that when you give extraordinary amount of voltage difference from a catheter at the cellular membrane level, the cell membrane has lot of pores or holes through which molecules go in and out. But when you give extraordinary voltage, the holes become much larger, allowing all the ingredients of the plasma to get in, and that disrupts cellular function and the cell loses its function. The way the high voltage is delivered is in nanoseconds or microseconds. These are very short pulses.
And that same catheter which delivers it is able to measure whether the cell, whether electricity is able to cross that area. So a single catheter technique, 2.5 seconds application, and you have to rotate it four times, about 10 seconds. One vein is isolated, so these four veins can be done within 60 minutes. So this procedure, which used to be six hour procedure today with RF, shortened it to two and a half, 2 hours. Two and a half hours. Cryo shortened it to an hour and a half. And now pulse field ablation has shortened it to less than 1 hour. Procedure with very good efficacy. They, in fact remapped these patients and 85% to 90% of them remain disconnected electrically, which is a very good outcome considering the procedure is such a short duration. And it's also very safe because esophagus is immune to the amount of pulse field that is being used to the heart.
Not only the procedure is shortened, the efficacy is preserved, but the safety is improved with pulse field ablation.
[00:27:16] Speaker C: That is just absolutely amazing. As in a side note, I understand Mayo Clinic in the Scottsdale area has bought quite a bit of land and they are going to continue to add research buildings and facilities to their efforts dealing with medical issues of humans. Is that what you're getting now, too?
[00:27:38] Speaker D: Yes. Our hospital has doubled in size. Now we have 500 beds. There are multiple towers coming and research.
[00:27:46] Speaker A: We've been listening to one of the world's top cardiologists, Dr. KumOndora Shravatsen of the Mayo Clinic on real estate and more. We're going to take a real short break. Stay tuned. We'll be right back.
