Atrial Fibrillation

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Atrial fibrillation, (Afib or AF) is the most commonly diagnosed arrhythmia (cardiac rhythm disturbance), impacting more than 2.7 million Americans. The condition itself isn’t life-threatening, but if left untreated, can severely erode your quality of life and lead to complications such as blood clots, heart failure, or stroke. In fact, Afib can increase the risk of stroke by five times and may be responsible for up to 20 percent of all strokes.

Types of Afib

Atrial fibrillation is caused by abnormal electrical impulses in the atria (upper chambers of the heart). This can cause the atria to quiver (fibrillate) and beat fast and/or irregularly. It triggers the atria to beat out of coordination with the bottom chambers (ventricles) and blood isn’t able flow as well as it should.

• Paroxysmal afib (intermittent atrial fibrillation) is when episodes come and go. The heart returns to a normal rhythm by itself or with medicine, within seven days. People with this condition may have episodes only a few times a year or their symptoms may occur every day.
• Persistent afib (continuous atrial fibrillation) is when the heart stays out of rhythm for longer than seven days. The heart will not return to a normal beat on its own and requires some form of treatment.

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Afib Symptoms

Some people never have symptoms at all, while for others the symptoms can be debilitating:

• Fast, irregular heartbeat
• Fluttering, pounding or flip-flop feeling in the chest
• Weakness and fatigue
• Inability to exercise
• Lightheaded or dizzy feeling
• Shortness of breath or breathlessness
• Discomfort, pain or pressure in the chest*

*Chest pain or pressure is a sign you may be having a heart attack and you should call 911 immediately.

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Common Causes of Afib

Heart structural abnormalities or damage are the most common causes of atrial fibrillation. It is most commonly diagnosed in patients over 65 years old and is more frequent in men than women. It is also more common in people of Caucasian decent. Other common causes include:

• Family history of Afib
• Prior heart attack or heart disease
• Hypertension
• Congenital heart defects
• Heart valve issues
• Heart failure
• Heart inflammation conditions such as cardiomyopathy and pericarditis
• Prior heart surgery
• Hyperthyroidism (over-active thyroid)
• Sleep apnea
• Excessive caffeine or alcohol
• Smoking
• Chronic lung disease such as emphysema
• Viral infections

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Diagnosis

Your doctor will conduct a thorough physical exam and ask you about your symptoms. He or she will also review your health and family health history. Tests may also be ordered to confirm diagnosis:

• Electrocardiogram (ECG or EKG) to check for problems with the electrical activity of your heart
• Holter monitor or event recorder: Portable devices you wear at home to measure and records heart rhythm over several days
• Echocardiogram to take a motion picture of your heart as it beats in your chest
• Blood tests to help rule out thyroid problems or other substances in your blood that may cause arrhythmia

Learn more about electrophysiology tests.

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Afib Treatment

There is no one-size-fits-all approach to the treatment of Afib. At KCHRI, our cardiac electrophysiologists develop a personalized treatment plan to lessen or cure your symptoms and reduce your risk of stroke. Combined with experienced electrophysiologists and advanced technology, we are able to deliver the most cutting-edge care with the best possible results.

Your EP doctor will decide the best approach for long-term management and treatment based on your:

• Unique type of Afib
• Symptoms
• Stroke risk
• Heart function
• Medical history
• Risk factors
• Comorbidities
• Age
• Lifestyle

There are two general approaches to treatment and management:

1. A rhythm control strategy is used to restore your heart’s regular beat. Therapies may include:

• Antiarrhythmic drugs
• Catheter ablation
• Surgical ablation

2. A rate control strategy can include medications to slow the conduction of electrical impulses across the atrioventricular (AV) node to the lower heart chambers. (The AV node controls how quickly or slowly the heart beats.) Examples of these medications include:

• Beta blockers
• Non-dihydropyridine calcium channel blockers
• Digoxin

Most newly diagnosed symptomatic patients will need the rate of their ventricles (lower heart chambers) slowed. Atrial fibrillation can cause the lower chambers of the heart to beat too fast. This condition is called Afib with RVR (rapid ventricular response). This can cause serious complications and requires treatment with either medication or cardioversion. Patients will usually see a substantial improvement in their symptoms when the ventricular rate is slowed.

Medication is generally the initial treatment for Afib. Medication doesn’t cure the condition and may not be effective in all patients. In some patients, medications may lose their effectiveness over time.

Many patients also need to take blood thinners to prevent blood clots from forming and prevent stroke.

• Watch an educational video about Afib treatments

Cardioversion

Cardioversion is not a cure for Afib, but is used to bring your heart rate back into a normal rhythm using an electrophysiology procedure with an electric shock or medication. It can be performed in an emergency situation or can be scheduled as an outpatient procedure.

An electrophysiology procedure called electrical cardioversion has a high success rate and a low rate of complications.

Pacemakers

A pacemaker is not used to treat atrial fibrillation. Pacemakers are used to treat a slow heart rate. Sometimes, a person with Afib will have tachy-brady syndrome (slow and fast heart rates). If this is the case, a pacemaker may be implanted to stop the slow heart rate and prevent the patient from fainting. However, the fibrillation will still be present.

A pacemaker may also be used if a patient is on medication to slow their heart rate. Then a pacemaker may be needed to prevent the heart from beating too slowly.

Left Atrial Appendage Closure

An electrophysiology procedure called closure of the left atrial appendage occlusion is performed to reduce stroke risk in patients who are at a high risk for bleeding and cannot take blood thinners. During the procedure, the left atrial appendage is closed to prevent blood from pooling and forming clots. There are several left atrial appendage closure devices used:

• WATCHMAN – A minimally invasive, catheter-based procedure using a cap like device to seal the appendage from inside the heart
• LARIAT – A minimally invasive, catheter-based procedure using a lasso-like device to close the appendage from outside the heart
• AtriClip – A minimally invasive surgical procedure using a clip to seal the appendage from outside the heart
• Other investigational treatments are available through clinical trials

Results: Closure of the left atrial appendage occlusion has been shown to reduce the risk of stroke. Talk to your electrophysiologist about your individual stroke risk and the results you can expect.

Learn more about left atrial appendage closure.

Ablation for Afib

Atrial fibrillation is considered a complex cardiac electrophysiology arrhythmia. That means there is usually more than one site in the atria that is causing the irregular heartbeat. Complex ablation is considered one of the best solutions for this condition and may even be used as a first-line treatment.

Pulmonary Vein Isolation

Pulmonary vein isolation is a complex ablation procedure that is used to treat or cure Afib. It is painless, minimally invasive and low-risk. It is performed using catheters that are inserted through a blood vessel in the groin and guided up to your heart and into the upper left chamber. Energy is then used to cauterize the tissue around where the four pulmonary veins connect. This is a relatively new procedure that can offer patients symptom relief within just a few months.

Results: The vast majority of patients experience a significant improvement in their quality of life and substantially reduces their number of visits to the hospital. Many patients are able to stop taking their rhythm medications in about 2-3 months and their blood thinners in about 6 months. Talk to your electrophysiologist about the results you can expect.

AV Node Ablation

For patients who have not responded to rate control medication, atrioventricular (AV) node ablation may be an option. This is a minimally invasive, catheter-based procedure to control the ventricular rate of the heart. It is used to prevent the upper heart chambers from sending faulty signals to the lower heart chambers. However, the Afib is still present. This electrophysiology procedure requires the placement of a pacemaker either at the same time as the ablation or before.

Results: Many patients experience a significant improvement in their symptoms. The pacemaker will control the heart's electrical activity so there will not be a need for rate control medication. Blood thinners may still be needed to reduce the risk of stroke. Talk to your electrophysiologist about your expected results.

Learn more about cardiac ablation.

Maze Procedure

Maze is a surgical ablation electrophysiology procedure. It is for patients with Afib who need open heart surgery for a coronary artery bypass, heart valve repair or replacement, or corrective surgery for congenital heart disease. This surgery is performed in collaboration with a cardiothoracic surgeon.

During the electrophysiology procedure, ablation is used to create several lines of scar tissue which forms a new “maze” for electrical impulses to travel through. The left atrial appendage is also removed.

Results: The maze surgery can potentially cure atrial fibrillation. Patients report a significant improvement in quality of life following the electrophysiology procedure. Talk to your cardiac electrophysiologist about the results you can expect.

Mini-Maze Procedure

Mini-maze is a minimally invasive version of the maze surgery. This electrophysiology procedure involves several smaller incisions and there is no need to stop the heart.

Convergent Procedure

For more persistent, long-standing forms of atrial fibrillation, two minimally invasive electrophysiology procedures may be necessary to achieve the best outcomes. The first part of the convergent procedure is done by a cardiothoracic surgeon using minimally invasive laparoscopy. The surgeon uses ablation to eliminate the faulty electrical currents coming from the back wall of the heart and performs a left atrial appendage closure. This part of the procedure usually requires a two-night hospital stay.

About six to eight weeks later, after inflammation has gone down, a catheter ablation is performed by an electrophysiologist. They put the finishing touches on the ablation to achieve the most complete results. This part will usually require an overnight hospital stay for monitoring.

Results: This two-part electrophysiology procedure results in a more complete ablation with better outcomes.

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