Although atrial fibrillation (“A-fib”) is a serious and even dangerous condition, it also happens to be quite treatable. Today’s heart doctors have multiple options for treating A-fib, either with medication or with surgery. In this article, we’ll focus on the surgical options for A-fib treatment.
Addressing stroke risk
Since having A-fib increases a person’s stroke risk by up to 500%, the first order of business for physicians treating the condition is to attempt to lower that risk. To do this, doctors will perform a careful assessment of your stroke risk. Most A-fib patients are then put on an anticoagulant drug, which helps prevent the formation of blood clots which are the cause of most strokes. Just taking anticoagulants can slash stroke risk by half or more.
If a person is unable to take anticoagulants, doctors may perform a surgery called a left atrial appendage closure. “Left atrial appendage” refers to a small pocket in the muscular wall of the left atrium (the upper-left chamber of the heart). This pocket is often the site of pooling and clotting in the hearts of people with A-fib. Doctors may sew shut the left atrial appendage, remove it altogether, or plug it up. Note that this procedure does not correct the heart’s rhythm. It merely reduces the risk of clotting, and thus stroke, caused by the irregular rhythm.
Two main A-fib treatment strategies
Once stroke risk has been addressed, your doctors will determine the best course for dealing with you’re A-fib. There are two main approaches here, and the path you and your doctors decide upon will be driven by your symptoms and the severity of your disease. Those two strategies are:
- Rate control. If you’re A-fib is not very severe and isn’t causing you troublesome symptoms, you and your doctors may decide that all that’s required (apart from anticoagulants or left atrial appendage closure to control stroke risk) is to get your heart rate into the normal range using medication. This means leaving the arrythmia (irregular heartbeat) untreated and focusing on slowing down the rapid heartbeat.
- Rhythm control. For more problematic cases of A-fib, the best course of action may be to restore the heart’s proper rhythm.
Correcting the heart’s rhythm
Procedures to re-establish a normal heart rhythm are not without risks of complications. Your decision about the right choice for restoring proper heart rhythm should be made after a thorough discussion of the advantages and potential risks of each.
- Catheter ablation. In this procedure, a catheter is inserted into the femoral vein in the groin of a sedated patient. At the end of the catheter is a device that produces either heat or cold (when the device uses heat, the procedure is called a radiofrequency ablation, and when it uses cold, it’s called a cryoablation). The catheter is threaded all the way up to the heart, where it destroys tissues, usually where the pulmonary veins enter the heart, that are responsible for producing erratic electrical activity. Catheter ablation is not usually a one-and-done procedure. Most people will need at least two ablations to get their A-fib under control. Catheter ablation is generally considered quite safe and minimally invasive, but like all surgeries it carries risks, which can include the buildup of fluid around the heart, blood-vessel damage, heart attack, and stroke.
- Maze procedure. The maze (sometimes called the Cox maze) gets its name from the labyrinthine path of scar tissue intentionally created by the surgeon on the areas of the heart’s surface where abnormal heart rhythms get their start—typically the left atrium and pulmonary veins. The scarring is done either by creating incisions or by using the same kind of radiofrequency utilized in a catheter ablation. The new scar tissue blocks the abnormal electrical impulses, thereby restoring a normal rhythm in the atria. Unlike catheter ablation, the maze procedure is quite invasive. It’s usually incorporated into an open-heart surgery being performed for some other reason and is, therefore, far less common than catheter ablation.
- Cardioversion. The goal of this procedure is to “reset” the sinus node, the part of the heart that sets its rhythm. While cardioversion may be done with medication, our focus here is a procedure in which electricity is used to restart the heart. The patient is sedated or placed under general anesthesia, and paddles or pads are placed on the chest, through which an electrical shock is delivered that briefly stuns the heart. When the heartbeat picks back up, the sinus node produces a normal rhythm, something like restarting your computer when it’s been acting up. Unfortunately, it’s not unusual for the fibrillation to return at some point after the cardioversion, so some patients must undergo the procedure multiple times in their lives. A risk of cardioversion is that, during the period after the shock when the heart is still recovering its rhythm, blood clots can form. Patients therefore take anticoagulant medication well before and well after the procedure. Some patients will also need to take antiarrhythmic medication indefinitely after cardioversion.
- AV node ablation. This is generally considered a treatment of last resort. The AV node is a cluster of cells located in the right atrium (upper chamber) that serves as the electrical connection between the upper and lower chambers of the heart. In a heart with atrial fibrillation, the AV node essentially passes faulty signals generated in the upper chambers down to the ventricles. During an AV node ablation, the cells of the AV node are destroyed using radiofrequency energy and the surgeon implants a pacemaker that will, for the rest of the person’s life, control the timing of the contractions of the ventricles. However, an AV node ablation does not correct the faulty rhythm of the atria, meaning that although the contractions of the heart’s lower chambers have been stabilized, the risk of stroke is still elevated and the patient will need to stay on anticoagulant medication.
Don’t avoid treatment for A-fib as it could lead to stroke. Doing everything that is within your control to reduce your risk is a great first step, but it is not enough. It’s important to meet with your doctor and follow his or her recommended treatment plan. Your life depends on it.
