What to Expect: Heart Surgery
Heart Procedures to Expect When You Have Atrial Fibrillation
Find out about the techniques to control the heart condition atrial fibrillation when lifestyle change and medications alone fail.
By Mary Elizabeth Dallas
Medically Reviewed by Farrokh Sohrabi, MD
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Atrial fibrillation, commonly known as afib, is a type of irregular heartbeat that can increase your risk for stroke and heart failure. In afib, the upper chambers of your heart quiver or beat irregularly. An estimated 2.7 million Americans are affected by this condition. It causes symptoms like a rapid heartbeat, chest pain, sweating, fatigue, lightheadedness, and shortness of breath. Atrial fibrillation management often includes medication and lifestyle changes, like reducing stress and eating a healthy diet. But if these options fail to restore a normal heart rhythm, your doctor may recommend one of several procedures.
An electrical cardioversion is a procedure that uses a low-energy shock to restore a normal heart rhythm. "The shock is applied to the chest wall while a patient is asleep. The anesthesia lasts about 5 to 10 minutes, and the shock itself is very brief," explained David J. Wilber, MD, a professor of cardiovascular sciences, co-director of the Cardiovascular Research Institute, and medical director of clinical electrophysiology at Loyola University Medical Center in Chicago.
Cardioversion interrupts afib, which allows a normal rhythm to emerge, Dr. Wilber explained, but the procedure does not prevent more episodes from occurring. The success rate of electrical cardioversion is usually 75 percent or better. Some patients may undergo electrical cardioversion several times. Wilber added that because afib increases your risk for stroke, patients typically take blood thinners four weeks before and after the procedure. And, though it's possible that the procedure may worsen irregular heartbeats, serious side effects from electrical cardioversion are rare.
When medications or electrical cardioversion are ineffective or not an option, afib may be treated with catheter ablation. This is a highly effective procedure that works by creating scar tissue that, in turn, prevents irregular electrical signals from traveling through the heart.
Catheter ablation is a low-risk, minimally invasive procedure that takes two to four hours. It is done in an electrophysiology lab or a cardiac catheterization lab. Once the area of the heart that is triggering an irregular heartbeat is identified, radiofrequency, laser, or cryotherapy is used to destroy abnormal tissue and restore a normal heart rhythm. "During this procedure, a catheter is placed from the groin through the blood vessels into the heart," Wilber said. One common type of ablation for afib is pulmonary vein isolation ablation, or PVA. "Typically, the area that is the problem is the back part of the left atrium muscles that surround the pulmonary veins," he said, "so that tissue is ablated or destroyed." Wilber added that "several studies suggest the success rate of the catheter ablation is 70 percent with no recurrence and no medication." Another 10 to 15 percent of patients will gain control of their afib with the help of medication.
AV Node Ablation
Another type of ablation is known as atrioventricular node (or AV node) ablation. The AV node is where your heart's electrical signals pass from the upper chambers (the atria) to the lower chambers (the ventricles). During this procedure, a catheter is inserted through a vein in the leg or arm and directed to the AV node. Once in place, a low dose of radiofrequency energy is used to destroy a small area of tissue. The procedure requires your doctor to surgically implant a device called a pacemaker, which helps maintain a normal heart rhythm.
"AV node ablation is a last resort procedure, used when nothing else works," Wilber said. "The goal is not to eliminate afib but to prevent the rapid conduction of the afib into the ventricle. The procedure artificially induces heart block and, in that case, patients have a rhythm of their own, but only 30 to 40 beats per minute, so a pacemaker is required to provide an adequate rate for exercise and activity." AV node ablation is reserved for people who are in permanent afib, older patients who are weak or those who are not candidates for other forms of treatment.
Mini-Maze Minimally Invasive Surgery
A Mini-Maze procedure may provide an alternative to catheter ablation for some patients with afib. During this minimally invasive surgery, radiofrequency energy is used to cauterize specific areas of tissue to interrupt the abnormal electrical signals in the upper chambers of the heart. By creating a "maze" of scar tissue in certain areas of the heart, the procedure may help restore a normal heart rhythm.
Unlike Maze open-heart surgery, the Mini-Maze technique allows surgeons to access the heart through small incisions between the ribs. Wilber noted, however, that the benefits of the Mini-Maze procedure are not entirely clear. "A full Maze procedure is very effective, but opening the chest does have risks," he said. "The Mini-Maze is not as invasive as opening the chest, but it's not clear if this procedure adds more than what a catheter procedure can do."
Implantable Cardiac Defibrillator
People with atrial fibrillation who do not respond to medication may benefit from an implantable cardioverter defibrillator (ICD). Slightly larger than a pacemaker, an ICD is usually implanted under the skin below the collarbone. The device delivers an electric shock to the heart when it determines the heart rate is too fast. Wilber pointed out, however, that there are problems with the use of these devices to treat afib. "The shocks are painful," he noted. "Inside of the chest, the shocks can only be a tenth or 5 percent of the energy needed to do it from the outside. Still, this is perceived as painful." According to Wilber, this is an appropriate therapy in life-saving circumstances, but it's too painful to be used as a routine therapy.
Video: What to Expect-Open Heart surgery
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