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VCU Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University VCU Division of Cardiothoracic Surgery

VCU Division of Cardiothoracic Surgery

Atrial Fibrillation Program

Non-Surgical Treatments for AF

No single treatment strategy has been shown to be effective for all patients with AF. The choice of treatment depends upon the severity of the symptoms, the likelihood of response to a particular treatment, and consideration of the risks vs. benefits of treatment.

Historically, treatment of AF has taken one of four forms:

  • Medications to restore a normal heart rhythm and blood thinner to prevent stroke
  • Cardioversion to shock the heart back into normal rhythm
  • Pacemakers to prevent slow heart beating during AF, or caused by drugs used to treat AF
  • Catheter-based ablation to knock out the areas of the heart that are causing fibrillation

Treatment options tend to focus on three goals:

  • Reduce the risk of stroke
  • Manage or control atrial fibrillation
  • Try to cure atrial fibrillation
 

Medications

Anticoagulants (blood thinners) are prescribed to most AF patients to prevent blood clots that could lead to a stroke. Warfarin (Coumadin™) is the most commonly prescribed drug and has been show to reduce the risk of stroke by 68 percent compared to no treatment at all.

To achieve this level of protection, however, it is important to maintain the correct level of warfarin in the blood. Too little and clots can form; too much and severe bleeding problems can occur. Since many other drugs, as well as dietary supplements and foods, can affect warfarin levels in the blood, it is important for patients to follow their doctor's instructions closely and have blood levels checked regularly.

Rate control drugs control the heart rate during AF and rhythm control drugs (anti-arrhythmics) try to bring the heart back into normal rhythm. These drugs can offer some degree of success, but some people have problems tolerating their side effects or cannot use them because of interactions with other drugs they are taking.

Cardioversion

For most individuals with chronic atrial fibrillation, or those whose symptoms do not improve with medications, a normal heart rhythm can be restored by applying a controlled electric shock to the heart. This procedure, which breaks the pattern of abnormal electrical signals, is performed under careful medical supervision. Short-acting sedatives are used so patients do not feel pain or discomfort. It is also possible to restore the heart's normal rhythm using medications, but attempts at drug cardioversion are limited because of the potential for serious side effects.

Ablation of the atrio-ventricular node and pacemaker

A pacemaker is a small device implanted under the skin near the collarbone that monitors the heart's rhythms and sends a controlled electrical pulse to the heart muscle if it identifies a slow rate. A permanent pacemaker is only considered for patients who are unresponsive to medical therapy (i.e. drugs and cardioversion) and have significant symptoms. Placement of a pacemaker usually occurs in the electrophysiology lab. In some instances the therapy of choice will be to sever the atriio-ventricular node (AV) nodal impulses going from the atrium to the ventricle. This routine ablation procedure immediately slows the heart's rhythm. However, once the AV nodal impulses to the ventricle are cut, the heart rate will drop to about 40 beats per minute. Consequently, a pacemaker is implanted to establish a reliable, vigorous beat.

The whole procedure can be performed in an hour or two, and patients are usually symptom free as a result. Patients are required to see their caregiver regularly for a pacemaker check. Because of the special characteristics of the procedure most patients are not eligible for ablation of the AV node and pacemaker.
Even though the heartbeat is now regular, the upper chambers continue to fibrillate and the risk of stroke persists.

Catheter Ablation

Another treatment for atrial fibrillation is radiofrequency catheter ablation. During this procedure, one or more flexible catheters are inserted via X-ray into the blood vessel and directed to the heart muscle. Electrodes at the end of the catheter assist the doctor in detecting the faulty electrical sites that are causing the heart to beat irregularly and too fast.

A burst of heat in the form of radiofrequency energy destroys the tissues that create the abnormal electrical signals responsible for the irregular heartbeat. Sometimes the doctor may need to repeat the procedure. Catheter ablation can take four to six hours but on average only requires a 1-2 night hospital stay. When successful, catheter ablation ends the need for taking heart rhythm medications.

Our specialists have performed over 500 radiofrequency ablation procedures.

Cryoablation

Cryoablation is a new and safer method of treating and often eliminating the most common arrhythmias in both children and adults, with less chance of complications. This technique uses a freezing method, rather than heat, to disable arrhythmias permanently.

This freezing technique is also called cryotherapy. It involves threading a small catheter into the heart and freezing the tissue causing the heart to beat irregularly. Cryoablation does not cause patients pain.
Unlike current methods for treating arrhythmias, cryoablation allows cardiologists the advantage of testing the site for accuracy before carrying out the actual procedure. By threading a catheter through veins from the groin into the heart, cardiologists can map the heart's electrical impulses and freeze tissue suspected of creating a disturbance.

Physicians test potential ablation sites by temporarily chilling tissue in the target area. Cells that prove to be non-targets are returned to normal temperature and function before the physician repositions the catheter. Once the target site is pinpointed, the catheter tip is cooled to –75 degrees Celsius to freeze the affected tissue.

Cryoballoon Ablation

A promising new line of clinical research at Pauley Heart Center is Cryoballoon ablation therapy. When the pulmonary veins are thought to be the source of the electrical disturbance causing atrial fibrillation, cryogenic (cold) energy is applied to stop the transmission of the abnormal electrical signals. The technique is experimental.

Watchman

A new area of treatment at Pauley Heart Center involves use of the WATCHMAN®. This device is designed to keep harmful blood clots that form in the left atrial appendage from entering the blood stream and potentially causing a stroke. The WATCHMAN is designed to be permanently placed at the opening of the left atrial appendage.

Using techniques commonly performed in catheterization procedures, the doctor guides the WATCHMAN into the heart through a catheter (flexible tube) inserted through a vein in the upper leg. Once the catheter is in position, the doctor takes pictures of the heart in order to measure the left atrial appendage and determine which size WATCHMAN device to use. After the device is put into place, additional measurements and pictures are taken to make sure the device is in the correct position. Once the correct position is confirmed, the doctor releases the device to leave it permanently implanted in the heart.

Generally, this procedure requires an overnight stay in the hospital; recovery takes about 24 hours. It is hoped that the device will eliminate the need for blood thinners. It is experimental.

Stereotaxis Remote Catheter Navigation

The Stereotaxis Magnetic Navigation System allows for remote-control navigation of magnetically enabled catheters and guide wires for clinical ablation and electrophysiology device placement.

Stereotaxis provides pinpoint accuracy in placing electrophysiology catheters. The system uses two permanent magnets located on opposite sides of the patient table. The magnetically manipulated catheter is able to move in small increments with great precision, allowing physicians to more precisely map the treatment area.

With this method, our physicians can access difficult areas of the heart chamber quickly, safely and easily. This also enables us to perform more complex, successful, and time-efficient ablation procedures for atrial fibrillation in the cardiac catheterization laboratory.

 

 

 

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