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Atrial Fibrillation

Treatments

The right solution to treat your Afib

atrial fibrillation treatmentsTreatment goals of atrial fibrillation:

  • Restoration of a normal heart rhythm or effective control of the heart rate
  • Decrease the  risk of blood clot complications associated with atrial fibrillation
  • Decrease the risk of long term complications (eg heart failure)
  • Relieve symptoms caused by atrial fibrillation

Why do people with Afib travel to Geisinger? Because the experts at Geisinger offer treatment options that others don’t. We also offer a wide variety of options, so that there’s a treatment that will meet your unique medical needs.

At Geisinger, fellowship trained electrophysiologists work closely with cardiac surgeons. Geisinger patients benefit from this unique approach, because the physicians can intimately communicate to determine the correct treatment. Your electrophysiologist will review with you your medical history, symptoms, and objective cardiac testing to individualize the best treatment option for you.    

All effective treatment options including anti-arrhythmic medication, monitoring, electrical cardioversion, catheter ablation and the surgical Maze procedure are available at the Geisinger Atrial Fibrillation Center. During your consultation, your electrophysiologist will discuss appropriate treatment options with you and provide evidence based recommendations.  Geisinger’s team will work with you to answer all your questions.

Please take a moment to learn more about the treatment options available at Geisinger’s Atrial Fibrillation Center. For more information, call us at 1.800.GWV.AFIB. Treatments available at Geisinger’s Atrial Fibrillation Center include:

Medications

Medications utilized in managing atrial fibrillation have three primary treatment goals:

  • Reduce the stroke risk associated with blood clot formation in the heart. The use of anticoagulants such as warfarin (Coumadin) reduce but do not eliminate the risk of stroke.
  • Afib often causes rapid heart rates, requiring medications to slow the heart rate to a normal range. Medication classes include beta blockers (eg Metoprolol) or certain calcium channel blockers (eg Diltiazem)
  • Antiarrhythmic medications both increase the likelihood to restore, as well as sustain, normal sinus rhythm. The choice of appropriate antiarrhythmic medication for you is complex, dependent upon confounding factors such as, though not limited to, structural heart changes, coronary artery disease (CAD), heart failure, kidney disease and medication side-effect profiles. Your electrophysiologist will review these issues with you and suggest the right antiarrhythmic agent for your needs. Hospital admission is required for continuous electrocardiographic monitoring, typically for 2 to 3 days, during initiation of some of these medications to assure long term safety.

Most patients will require medications from each of the above groups to achieve their reattment their goals.  Individual patients will have variable results from these medications necessitating either a change in dose or change to another medication.

Synchronized Electrical Cardioversion

Electrical cardioversion is a procedure in which a controlled electric shock is delivered to the heart to restore normal sinus rhythm. The low-voltage electric current (of less than one second in duration) enters the body through conductive patches applied to the chest wall. The shock causes the heart’s electrical system to depolarize, permitting a reset to a normal sinus rhythm. Brief anaesthesia is administered to ensure comfort. This is a safe procedure, with greater than 80% likelihood for a successful restoration of normal rhythm. Most often, cardioversion is used in conjunction with antiarrhythmic medications to enhance the likelihood of restoring and sustaining normal rhythm.

Your electrophysiologist will minimize procedural risk for stroke by either performing a transesophageal echocardiogram (TEE) to visualize with ultrasound whether there is evidence for clotting in the left atrium. Alternatively, ensuring that coumadin anticoagulation is within a safe and therapeutic range for approximately 3 to 4 weeks is equally effective. 

The complication risk for synchronized cardioversion is low, less than 1% for all complications. Stroke risk is minimized by following the procedures detailed above. Additional risks include arrhythmia, adverse reaction to anesthesia, or mild skin irritation (similar to a mild sunburn).

What to Expect Before the Procedure

  • An Atrial Fibrillation Center staff member will call you prior to the procedure. They will provide instructions regarding your medications and the time to arrive at the hospital. You should not eat or drink after midnight before the procedure, though you may take your medications with a sip of water as instructed.
  • After arrival at the reception area, you will be directed to the ‘cardiac procedure unit’ (CPU). There a nurse will review your history, medications, allergies, and planned procedure. An intravenous line will be initiated and blood work will be obtained as required.
  • Your electrophysiologist will advise you if a transesophageal echocardiogram (TEE) is required to ensure there are no blood clots present within the heart chambers. This procedure is performed under conscious sedation to ensure your comfort.
  • Two cardioversion electrode pads are applied to the chest wall.
  • Brief anaesthesia is administered before synchronized cardioversion so that you will not experience any pain or have recall of the procedure. The anaesthetic agent clears quickly, typically in about 5 to 8 minutes.

What to Expect After The Procedure

  • After the procedure you will be monitored in the CPU for approximately one to two hours, at which point you will be able to return home.
  • At discharge, a nurse will review your discharge medication regimen, including any additions or changes. Your Coumadin dosing will be reviewed, including a scheduled INR monitoring date (INR is used in determine the clotting tendency of blood).
  • You will be provided electrophysiology access phone numbers for concerns or questions.
  • You will be provided with an electrophysiology clinic follow-up appointment date and time.
  • You will not be able to drive for 24 hours after synchronized cardioversion, so you will need transportation home.
  • We recommend light activities for 24 hours after the procedure. You may return to work the following day.
  • You may experience some skin redness or irritation where the conductive patches were placed. This will be similar to a mild sunburn. It should resolve within a few days. If required, 1% Hydrocortisone topical cream will help with pain.

Catheter ablation

Treatment Overview
If medicine is not effective or not tolerated for atrial fibrillation, a nonsurgical minimally invasive procedure called catheter ablation may be chosen.  

In this procedure thin, flexible catheters are inserted into a vein in the groin and threaded up through the vein and into the heart. Some of these catheters provide for advanced imaging, incorporating X-ray, ultrasound and image integration to provide three dimensional mapping capability to visualize and safely guide the ablation catheter. The electrode at the tip of the ablation catheter emits radio waves creating heat which destroys the targeted heart tissue within the atria that either causes or sustains atrial fibrillation.   

Atrial fibrillation often originates from the pulmonary veins that connect the lungs to the left atrium. Circumferential pulmonary vein ablation is used to electrically disconnect the pulmonary veins from the left atrium. Sometimes, a doctor will use both focal and circumferential ablation.

Ablation procedures either try to cure atrial fibrillation (focal ablation, circumferential pulmonary vein ablation) or try to control your symptoms (AV nodal ablation).  

Ablation to cure atrial fibrillation
Focal and circumferential catheter ablations are used to try to cure atrial fibrillation. Focal ablation, also known as targeted ablation, is used to destroy the specific areas in the heart that are firing off abnormal electrical impulses and causing atrial fibrillation.  

A pacemaker is usually not needed when catheter ablation is done on the pulmonary vein or other targeted tissue. 
In some cases, catheter ablation may be done by applying radiofrequency energy to the outside or inside surface of the heart during open-heart surgery. This may be an option if you are already having heart surgery for another reason, such as coronary artery bypass or valve replacement surgery. 

Ablation to control symptoms of atrial fibrillation
Nodal catheter ablation, also known as AV node ablation, can control symptoms of atrial fibrillation when the cause cannot be stopped. You may need AV node ablation if targeted or pulmonary vein ablation did not stop your atrial fibrillation or if these procedures will not help you. With AV node ablation, the electrical bridge between the atrium and ventricle is disconnected. After the AV node is destroyed, the atrium can no longer send impulses to the lower chambers of the heart (ventricles) and thus cannot increase the heart rate. This controls atrial fibrillation symptoms.  

After AV node ablation, a permanent pacemaker is needed to regulate your heart rhythm. Nodal ablation can control your heart rate and reduce your symptoms, but it does not prevent or cure atrial fibrillation, so you will probably require anticoagulation therapy medication such as warfarin. 
The atrial fibrillation ablation procedure is performed under local anesthesia and deep sedation or under general anesthesia. A local anesthetic will numb the site where the catheter is inserted. At times, general anesthesia may be required. The procedure is done in a hospital where your health will be monitored carefully.

What to Expect Before the Procedure

  • An Atrial Fibrillation Center staff member will call you prior to the procedure. They will provide instructions regarding your medications and time to arrive at the hospital. You should not eat or drink after midnight before the procedure, though you may take your medications with a sip of water as instructed.
  • After arrival at the reception area, you will be directed to the ‘cardiac procedure unit’ (CPU). There a nurse will review your history, medications, allergies, and planned procedure. Intravenous lines will be initiated, and blood work obtained as required.
  • As the ablation procedure is performed under general anesthesia, you will be required to meet with anesthesiology staff
  • A transesophageal echocardiogram (TEE) will be performed under conscious sedation to ensure there are no blood clots present in the heart chambers.
  • Because the procedure can last up to six hours and a significant volume of intravenous fluid will be administered during the procedure, a Foley catheter will be placed in your bladder prior to the procedure. If there is a medical reason why you cannot have a catheter, please inform your nurse.

What to Expect After The Procedure

  • After the procedure you will initially be taken to the ‘post anesthesia care unit’(PACU) where you will be monitored until the effects of anesthesia resolve.
  • You will then transfer to the ‘cardiac stepdown unit’(CSU). During this time you will have to lie flat for an additional four to six hours. Nurses will monitor you closely and ensure your comfort.
  • Once in the CSU, your family and friends will be able to visit you during normal visiting hours.
  • Length of hospitalization is usually one to two days.
  • At discharge, the nursing staff will review your discharge medication regimen, including any additions or changes. Your Coumadin dosing will also be reviewed, including your scheduled INR monitoring date. (INR is used in determine the clotting tendency of blood).
  • You will be provided detailed instructions to help you recognize procedure complication symptoms, as well as a phone number so you can reach Electrophysiology for concerns or questions.
  • You will be provided with an electrophysiology clinic follow-up appointment.
  • We recommend taking one week off of work to permit recovery. During this time, you will not be able to lift heavy objects or participate in strenuous activity to allow healing of groin puncture sites.

Recovery from catheter ablation is usually quick. You may be hospitalized for one to two days so that your doctor can monitor your heart rate. After the procedure, you will need to take anticoagulation medicine such as warfarin for at least two to three months.

You might feel a flutter in your heart after the ablation procedure. The flutter usually goes away after your heart heals. If your flutter does not go away, you may need a second ablation procedure.

Why is it done?
Focal ablation - or pulmonary vein ablation that targets tissues that generate irregular electrical impulses - is often used for paroxysmal atrial fibrillation in people who have severe symptoms and who have not been helped by medications.

AV node ablation is sometimes used when chronic or paroxysmal atrial fibrillation does not respond to treatment with medication and symptoms continue to be bothersome. It is most often used in people who have difficult-to-control heart rates.

How well does it work?
Catheter ablation to cure atrial fibrillation (focal or pulmonary vein ablation, for example) is more successful in people with paroxysmal atrial fibrillation than in those with persistent atrial fibrillation. For people with paroxysmal atrial fibrillation, catheter ablation has proven successful in more than 7 to 8 out of 10 people. But for people with persistent atrial fibrillation, catheter ablation has proven successful in approximately 6 to 7 out of 10 people. 

If the first procedure does not get rid of atrial fibrillation completely, catheter ablation may need to be done a second time. Repeated catheter ablations have a higher chance of being successful. 

Risks
Catheter ablation to cure atrial fibrillation is an invasive procedure and has some serious risks. These risks include: 

  • Stroke. A stroke is a sudden disruption in blood flow to a portion of the brain. The disruption in blood flow is caused by a blockage or by bleeding of a blood vessel.
  • Puncture of the heart.
  • Pulmonary vein stenosis, or a narrowing of the pulmonary vein.
  • Phrenic nerve injury, which can cause paralysis of the diaphragm. The diaphragm is a large muscle that separates the chest cavity (containing the lungs and heart) from the abdominal cavity. It helps draw air in and out of the lungs.
  • Pericarditis. Pericarditis is inflammation of the sac (pericardium) that surrounds and protects the heart.
  • Cardiac tamponade. This is an emergency condition that can lead to death. It may require emergency heart surgery.
  • Atrio-esophageal fistula. In this life-threatening condition, a hole forms between the heart's upper chamber and the esophagus.
  • Bleeding from the puncture site.
  • New abnormal heart rhythms (arrhythmias).

The risks of catheter ablation of the AV node and pacemaker implantation may include:

  • Bleeding or bruising around the puncture site, lung collapse or bleeding around the heart.

After AV node ablation, you will need to take anticoagulant medicines because you will still be at risk for stroke.

Pacemaker for atrial fibrillation

Treatment Overview
A pacemaker is a battery-powered device about the size of a pocket watch that sends weak electrical impulses to “set a pace” so that the heart is able to maintain a regular heartbeat. There are two basic types of pacemakers.  

Single-chamber pacemakers stimulate one chamber of the heart, either an atrium or more often a ventricle.  

Dual-chamber pacemakers send electrical impulses to both the atrium and the ventricle and pace both chambers. A dual-chamber pacemaker synchronizes the rhythm of the atria and ventricles in a pattern that closely resembles the natural heartbeat. Dual-chamber pacemakers are usually used to treat a slow heart rate.  

All new pacemakers are rate-response, or physiologic, pacemakers. They can sense when your activity increases and respond by increasing your heart rate.
People with atrial fibrillation may require a pacemaker for a variety of reasons.  

With paroxysmal atrial fibrillation, you may need a pacemaker because you have a fast heart rate during episodes of atrial fibrillation and a slow heart rate when not in atrial fibrillation. These rates may be even slower than normal because of medications used to treat atrial fibrillation. This is called tachy-brady syndrome. In this case, you may need a dual-chamber pacemaker to make your heart beat as normally as possible. 

After catheter ablation of the atrioventricular node (AV node), a permanent pacemaker is needed. This pacemaker makes the lower chambers beat at a normal rate. (This pacemaker may be a single-chamber pacemaker).  

Permanent pacemakers are surgically implanted into the chest. The procedure to implant a pacemaker is considered minor surgery. It can usually be done using local anesthesia. The procedure takes about an hour. Permanent pacemakers are powered by batteries. The batteries usually last five to 10 years before they need to be replaced. 

Temporary pacemakers are attached to the heart by a wire threaded through a neck vein, a leg vein, or through the chest wall. Temporary pacemakers are most commonly used for a short time following heart surgery or when waiting for a permanent pacemaker to be implanted.

What To Expect After Treatment
Most people can go home one or two days after having a pacemaker implanted and can return to normal activities within two weeks. You should avoid driving or participating in vigorous physical activity that involves the upper body for several weeks after having a pacemaker implanted.

Why is it done?
Historically, pacemakers have been used to treat slow heart rates by sensing whether the heart rate falls below a certain rate and then pacing the heart to increase it to a set rate. However, newer rate-responsive pacemakers can alter the heart rate to a faster or slower rate based on your activity.
A pacemaker is always needed after AV node ablation (destruction of the AV node). After this procedure, the pacemaker is needed to generate a normal heart rhythm.

How well does it work?
Pacemakers stimulate the heart to speed up when it beats too slowly or reset the rate when the heart beats too fast. They can also substitute for the natural pacemaker of the heart (SA or AV node).

Risks
Few activities interrupt the signals sent by the pacemaker to the heart. Follow your doctor's specific instructions about care and precautions if you have a pacemaker.
Risks during the procedure to implant a pacemaker include:

  • Puncture of the heart
  • Bleeding
  • Difficulty breathing
  • Irregular heart rhythms
  • Infection
  • Blood clot
  • Pacemaker malfunction (wire breaks or device has sensing problems)

What do I need to consider in choosing a pacemaker?
Rate-responsive pacemakers are often the ideal choice for active people. These pacemakers closely reproduce natural heart rhythms and are able to raise the heart rate in response to physical activity. Your doctor can decide how fast the pacemaker should respond and how quickly your heart rate should return to a resting rate.

Strong electric or magnetic fields can interfere with your pacemaker. You can safely use most household and office equipment, and you can usually avoid electrical interference from magnetic or electrical sources by keeping certain things a few inches away from your pacemaker. You should completely avoid things like heavy electrical or industrial equipment.

You may walk through metal detectors (in airports or other security checkpoints) at a normal speed, but avoid standing near or leaning on these systems. Your pacemaker may set off a metal detector but the security archways will not damage the device. Your doctor will give you a pacemaker identification card to carry at all times. Before you pass through a metal detector, tell the security guards that you have a pacemaker, and show them your device identification card.

If you have a pacemaker, you will not be able to have an MRI (magnetic resonance imaging) test. Before you have any tests or surgery, tell all of the health professionals involved in your care that you have a pacemaker. You may choose to wear a medical alert bracelet that says you have a pacemaker. Experts are trying to make pacemakers that can work safely during an MRI test.

MAZE procedure

What is a maze procedure?
A maze procedure is a surgery used to control atrial fibrillation. If it can't be controlled by medication or other treatments, a maze procedure may be an appropriate treatment. It gets this name from the linear scars left on the heart's chambers post-surgery that resemble a maze.  

During atrial fibrillation, the electrical signal is splintered as though it is taking multiple routes through a maze, causing different areas of the atrium to contract at different times as each route takes a different length of time for the signal to travel through it. This fluttering effect, with different parts of the atrium contracting at different times, is called fibrillation.  

The maze procedure stops the electrical impulse from taking multiple paths and forces the signal into a single path. This allows the entire atrium to contract at the same time.  

Who Is a Candidate For a Maze Procedure?
A maze procedure is not necessary for the vast majority of atrial fibrillation patients. Medications or catheter ablation works well for most people. Patients who have failed catheter ablation or who are not candidates for catheter ablation may benefit from maze procedures. Also, maze procedures may be suitable for patients who undergo coronary or valve surgeries.

If you've looked into this option in the past, keep in mind that there are now newer and less invasive surgical ablation techniques that do not require the large chest incision and placement on the cardiopulmonary bypass machine, although this technology is still new and not offered at all hospitals.

How the Maze Procedure Works
The procedure can be done via open heart surgery, or via a minimally invasive procedure that uses small incsions or holes on the sides of the chest wall. The efficacy of different procedures may vary.

Signals are re-routed by traditional incisions or scarring by radiofrequency or cryo energy. The electrical impulse can’t cross severed or scarred pathways, so the surgeon uses either a scalpel, radio-frequency ablation (a type of heat) or cryonics (cold) to stop the electrical signal from traveling the unwanted pathways.