Manual of Surgical Treatment of Atrial Fibrillation

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Rate control is an essential part of atrial fibrillation treatment in acute and chronic settings. It promotes hemodynamic function by slowing ventricular response, improving diastolic ventricular filling, reducing myocardial oxygen demand, and improving coronary perfusion and mechanical function. Given the challenges of achieving and maintaining normal sinus rhythm and the deleterious effects of antiarrhythmic drugs, most patients with atrial fibrillation are treated with rate control.

Beta blockers e. Beta blockers and calcium channel blockers are contraindicated in patients with preexcitation Wolff-Parkinson-White syndrome. Non-cardioselective beta blockers are also contraindicated in patients with acute heart failure, severe chronic obstructive pulmonary disease, and asthma.

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Digoxin is no longer considered a first-line agent or recommended as monotherapy, but it can be added to therapy with beta blockers or calcium channel blockers. It may also cause acute cardioversion, which could lead to a stroke if anticoagulation therapy has not been properly administered.

The main indication for cardioversion is unstable or poorly tolerated atrial fibrillation that is unresponsive to drug therapy. Electrical cardioversion is usually successful in the short term, but often not in the long term. If transesophageal echocardiography shows no thrombus in the left atrium, it is safe to omit pre-cardioversion anticoagulation. Electrical cardioversion delivers a direct-current electric shock in synchrony with the QRS complex to avoid triggering ventricular fibrillation. One or more shocks of to joules may be necessary.

Pharmacologic cardioversion uses intravenous ibutilide Corvert , flecainide, dofetilide Tikosyn , propafenone Rythmol , or amiodarone. In general, maintenance of normal sinus rhythm with oral medications is more successful in patients 65 years and younger with structurally normal hearts, as well as patients who have only recently developed atrial fibrillation. Electrophysiologic radiofrequency ablation is a nonoperative, catheter-based procedure used to isolate and possibly destroy abnormal foci responsible for atrial fibrillation. Specific foci that cause atrial fibrillation have been found at or near the pulmonary vein ostia in the left atrium; locating these sites allows targeted ablation.

Some trials have shown that radiofrequency ablation is superior to antiarrhythmics in selected patients, including patients with paroxysmal atrial fibrillation who are symptomatic but without structural heart disease, patients who are intolerant of antiarrhythmics, and patients with inadequate pharmacologic rhythm control. Ablation of the accessory pathway is the optimal treatment for patients with Wolff-Parkinson-White syndrome and atrial fibrillation. Atrioventricular nodal ablation with pacemaker implantation may be beneficial for older patients with tachycardia-induced cardiomyopathy and persons with refractory ventricular rate control despite maximal medical therapy.

Product | Manual of Surgical Treatment of Atrial Fibrillation

Surgical treatments for atrial fibrillation are invasive, high risk, and should be considered only in patients undergoing cardiac surgery for other reasons. The maze procedure aims to eliminate atrial fibrillation through the use of incisions in the atrial wall to interrupt arrhythmogenic wavelet pathways and reentry circuits.


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Two percutaneously inserted devices, the Watchman and the Amplatzer Cardiac Plug, can be used to achieve occlusion of the LAA, although the latter is not available in the United States. Both are non-inferior to warfarin Coumadin in stroke risk reduction. Anticoagulation is an essential part of atrial fibrillation management. It significantly reduces the risk of embolic stroke, but increases the risk of bleeding. Although the benefit of anticoagulation exceeds the risk of bleeding for most patients, discussions about stroke prevention vs. Tools to aid in the assessment of the risks of stroke and bleeding are available and are useful in making decisions with patients about therapeutic options.

For many years, the CHADS 2 congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled] scoring system has been used to estimate risk of stroke in patients with atrial fibrillation.

Anticoagulation is recommended for patients with a CHADS 2 score of 2 or more, unless a contraindication is present. Vascular disease prior myocardial infarction, peripheral artery disease, aortic plaque. Similar clinical tools are available to assess anticoagulation bleeding risk. Warfarin lowers the risk of thromboembolic events, 36 — 39 but it has a narrow therapeutic range, multiple drug and food interactions, and requires frequent blood monitoring of the international normalized ratio.

Direct oral anticoagulants, including a direct thrombin and several factor Xa inhibitors, are available. Their major drawbacks are higher costs, difficulty reversing their effect in emergency situations, and the lack of simple blood tests to check drug levels. A specific antidote for dabigatran is available, and factor Xa inhibitor antidotes are in the late stages of development.

The oral direct thrombin inhibitor dabigatran is as effective as warfarin in preventing stroke and systemic emboli. Major bleeding events were similar to those of warfarin, with fewer intracranial bleeds 0. These oral anticoagulants also have a slightly lower risk of intracranial hemorrhage compared with warfarin 0.

Table 4 compares some of the risks and benefits of direct oral anticoagulants vs.

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Atrial fibrillation ablation

Variable dose adjusted to international normalized ratio. Generic prices not available; brand price listed in parentheses. Educate patients and check for interactions. Anticoagulation in atrial fibrillation. Information from references 40 , 41 , 43 , 45 , and Although current practice has been to use heparin or low-molecular-weight heparin to bridge anticoagulation when patients taking warfarin need surgery or invasive procedures, a recent randomized trial in patients with atrial fibrillation who were undergoing surgery and who were at low or moderate bleeding risk found that these patients had worse outcomes if bridged than those who had their anticoagulation stopped during the perioperative period.

Patients with a very high risk of stroke or thromboembolism and those undergoing cardiac, spinal, or intracranial surgery were excluded from the study. The treatment of nonvalvular atrial fibrillation must be individualized to each patient's condition, which can change over time. Referral to a cardiologist is warranted for patients with complex cardiac disease; those who cannot tolerate atrial fibrillation despite rate control; those who need rhythm control, require ablation therapy, or may benefit from surgical treatment; and those who need a pacemaker or defibrillator because of another rhythm abnormality.

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Data Sources: A PubMed search was completed in Clinical Queries using the terms atrial fibrillation, rate control, rhythm control, ablation therapy on nonvalvular atrial fibrillation, and anticoagulation therapy for nonvalvular atrial fibrillation. The search focused on randomized controlled clinical trials, systematic reviews, meta-analyses, and reviews published since Search dates: January to June Already a member or subscriber? Log in. Reprints are not available from the authors. Eur Heart J. Stroke severity in atrial fibrillation. The Framingham Study. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates.

Am J Cardiol. Heart disease and stroke statistics— update: a report from the American Heart Association. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. A population-based study of mortality among patients with atrial fibrillation or flutter. Am J Med. Are cost benefits of anticoagulation for stroke prevention in atrial fibrillation underestimated? The intrinsic autonomic nervous system in atrial fibrillation: a review.

ISRN Cardiol. Atrial remodeling and atrial fibrillation: mechanisms and implications. Circ Arrhythm Electrophysiol. Is pulse palpation helpful in detecting atrial fibrillation?

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A systematic review. J Fam Pract. New oral anticoagulants and the risk of intracranial hemorrhage: traditional and Bayesian meta-analysis and mixed treatment comparison of randomized trials of new oral anticoagulants in atrial fibrillation. JAMA Neurol. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. J Am Coll Cardiol. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. Isolation of the PVs is the corner stone of catheter ablation strategies for AF treatment. However, ablation of persistent AF is more difficult and requires identification of additional ablation sites using a stepwise approach: 1 Circumferential PV isolation; 2 Ablation of complex fractionated atrial electrograms identified during electrophysiological mapping; 3 Identification and ablation of additional linear lesions.

These additional linear lesions may result in ablations along the posterior of the LA, along the roofline of the LA from the left superior PV to the right superior PV, and along the mitral isthmus line connecting the ostium of the left inferior PV to the mitral valve annulus; 4 Ablation of non-PV triggers, such as the coronary sinus, superior vena cava, and crista terminalis. Electrophysiological map of pulmonary vein ablation sites; red dots are the ablation site.