Atrial fibrillation is the most common cardiac arrhythmia. Common symptoms include palpitations, fainting, chest pain or congestive heart failure. One of the most common indicators of atrial fibrillation is fatigue, which is not necessarily easy to diagnose. However, in some people atrial fibrillation may not cause any symptoms.
Atrial fibrillation is more common in older adults, but can affect both men and women at all ages. It is estimated that 11 percent of Americans over the age of 80 have atrial fibrillation. Approximately five percent of Americans above age 70 have atrial fibrillation. Atrial fibrillation has been seen in patients as young as 20 and sporadically in 30, 40, 50 year olds.
“It’s a huge problem and it’s incredibly common,” said Robert Salley, MD, executive director of Cardiovascular Services for Saint Joseph Hospital, part of KentuckyOne Health.
“Approximately five million American are affected by atrial fibrillation today, and an estimated 15 million will be impacted by the year 2050 due to our aging population,” said Ted Wright, MD, a cardiothoracic surgeon with Saint Joseph Cardiothoracic Surgical Associates.
Atrial fibrillation is particularly dangerous because it increases the risk of stroke. By some reports, the degree of stroke risk can be up to seven times that of the average population, depending on additional risk factors.
“Atrial fibrillation overall is still challenging to treat, but we have multiple methods available,” said Sameh Lamiy, MD, an electrophysiologist with Saint Joseph Cardiology Associates.
There are two categories of treatment for atrial fibrillation: rate control and rhythm control. Sometimes physicians are too quick to treat symptoms, but Lamiy proposes a different set of guidelines for determining which category of treatment to pursue.
“If the patient does not have symptoms or doesn’t feel the atrial fibrillation, I suggest using a rate control strategy,” said Lamiy. “Rhythm control is usually best applied for patients who experience symptoms from atrial fibrillation.”
While rate control treatments work to lower the heart rate and maintain it within a normal range, rhythm control treatments seek to convert the heart rhythm from atrial fibrillation to a normal rhythm.
“If a patient has no symptoms, we will not be aggressive in treatment other than rate control and anticoagulation standard treatment, if indicated,” said Jeffrey Schoen, MD, director of Electrophysiology at Saint Joseph Hospital. “If a patient has significant symptoms and is unresponsive to medical treatment, then we will pursue the goal of achieving and maintaining sinus rhythm.”
Sometimes atrial fibrillation can lead to slow alternating with fast rhythm, called brady/tachy syndrome. Often medications and a pacemaker will effectively treat this problem. If rate control is unresponsive to medications, then AV node ablation can be effective for rate control.
“As doctors, we seek to treat atrial fibrillation patients with symptoms,” Schoen, added. “Atrial fibrillation can present different ways and can fool doctors. Especially when treating older people. They often slow down, and stop doing as much as they once did. The atrial fibrillation can escape being detected because they just stop doing physical activity.”
Schoen says it is important for physicians to explore symptoms further. “The longer the patient is in atrial fibrillation, the less chance we have to get that rhythm straightened out,” Schoen said.
New Techniques Lessen Risk, Increase Success
Therapies for treating atrial fibrillation range from medication to electrophysiology or ablation, and minimally invasive surgery to open-heart surgery.
“We have many tools, including antiarrythmic medications, electrical cardioversion, catheter and surgical ablation,” said Schoen.
“For patients with short-standing atrial fibrillation, they are typically best treated using medication,” said Wright.
If medication is ineffective or it is determined the patient needs a higher level of therapy, often the next step is ablation, which involves a catheter inserted into a specific area of the heart. A cardiac electrophysiologist works to disconnect the source of the abnormal rhythm from the rest of the heart.
Atrial fibrillation ablation by cardiac electrophysiologists via catheter ablation techniques have improved significantly within the last five years, improving outcomes and reducing complications.
In patients with paroxysmal atrial fibrillation (episodes lasting less than seven days) ablation by the Saint Joseph EP team shows very promising results over the last two years, with a complete success rate of 90 percent.
Patients with persistent atrial fibrillation (greater than seven days and less than one year duration) are more challenging catheter ablation cases. Data from the Saint Joseph EP team showed complete success was achieved in 76 percent of cases and additional partial success in 20 percent of cases. These patients were satisfied with their clinical outcomes not necessitating additional procedures.
Overall, catheter ablation at Saint Joseph Hospital over the last two years has yielded an 80 percent complete success rate. Catheter ablation complication rates at Saint Joseph have been low, around two percent.
The surgical team at Saint Joseph Hospital recently started a minimally invasive surgical approach for atrial fibrillation ablation.
Recent developments have lead to ablation procedures being performed using cameras and radiofrequency energy sources that are very safe while remaining effective. This technique uses small incisions on both sides of the chest.
“We now have minimally invasive approaches so the amount of surgery a patient is exposed to is dramatically less, includes very little risk and high success rates,” said Salley.
“This approach has been a nice addition to our program for catheter ablation failure and some of the more longstanding cases of persistent atrial fibrillation as first treatment,” said Schoen. “Our goal is to provide clinical benefit to our atrial fibrillation patients by the optimal treatment available at Saint Joseph Hospital.”
For patients with persistent atrial fibrillation or persistent, longstanding atrial fibrillation, surgical ablation is more likely to be part of the treatment plan. Therapies such as the mini maze procedure may be used. The mini maze procedure uses radiofrequency ablation techniques with small incisions, and is most often used in patients with atrial fibrillation that do not have additional heart problem, such as valve issues or coronary artery disease.
In recent years, advancements in technology have led to less invasive mini maze procedures being performed on patients with lone or sole atrial fibrillation.
The maze procedure is more invasive and performed with a sternotomy.
“Approximately 75 percent of patients who undergo the classic maze procedure via sternotomy are free from arrhythmia and medical therapy,” said Wright. “We hope to improve upon this using a hybrid approach.”
Another newer development is hybrid ablation, which continues to be studied for treatment of persistent and longstanding, persistent atrial fibrillation. Hybrid ablation uses a dual approach. An electrophysiology cardiologist ablates from inside the heart and a cardiothoracic surgeon ablates on the outside of the heart. This combined approach provides these patients with a minimally invasive treatment option.
Clinic Provides One-Stop for Diagnosis and Treatment
Saint Joseph Hospital is currently working to establish an atrial fibrillation clinic model where patients have access to multiple doctors using a multidisciplinary approach. Cardiologists and surgeons work to evaluate patients and identify the best treatment option for each individual.
“The best way to treat atrial fibrillation patients over the long term is with a multidisciplinary approach that includes general cardiologists, electrophysiology cardiologists and cardiothoracic surgeon,” said Wright. “That is how we can best identify the appropriate therapy at the appropriate time.”
The clinic approach provides patients with options very quickly, without various doctors’ visits, and gives them a complete therapeutic plan. This allows patients to select the therapy that they feel is best for them.
The clinic is modeled after centers across the country that have been very effective in both raising awareness in their communities and given patients the tools they need to get effective treatment. The clinic at Saint Joseph hopes to provide patients with a single phone number and educational materials to access the multidisciplinary approach. A nurse coordinator will work one-on-one with patients and lead them through the care process.
“Over the long term, the best way to serve this population of patients is through directed care by a center of excellence using a multidisciplinary approach,” said Wright.
Patients will be able to call directly for an appointment, or be referred by their cardiologist or primary care physician. The keys are to identify the problem and begin therapy as soon as possible.
“I have treated patients who have had atrial fibrillation for years but were not diagnosed,” said Lamiy. “Many patients are able to do things they could not once their atrial fibrillation is treated.”
HYBRID ABLATION USES A DUAL APPROACH. AN ELECTROPHYSIOLOGY CARDIOLOGIST ABLATES FROM INSIDE THE HEART AND A CARDIOTHORACIC SURGEON ABLATES ON THE OUTSIDE OF THE HEART.