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CHOOSING A  Non-Drug TREATMENT FOR ATRIAL FIBRILLATION

 

Catheter Ablation, Cox Maze (Version IV),

Wolf Mini-Maze+Extended Lesion Set, Saltman Micromaze

[...last updated February 2010]

 

This section of the af-ideas.com  web site will help you to choose a treatment for Atrial Fibrillation (or "AF"). It will describe factors that can affect your choice, and it will help you to gather and organize information you obtain about different treatments and about the doctors who perform them.

 

Please note: Before proceeding here, you may want to look over General advice for new AF patients, which describes some things you can try besides or in addition to those that are most likely to be suggested by a doctor. You may also want to read Deciding whether or when to have a CA or surgery.

 

Conclusions from research and experience will change over time. Treatment for AF is a rapidly developing field – a “moving target”, as some have called it.   

 

Two implications of this inevitable and rapid change are:

 

1) Research or other materials that are as little as a year old or less may be out-of-date (see Resources  for ways to get the latest information);

 

2) Waiting for techniques to improve or for doctors to get more practice in performing a new technique may be a reasonable option.

 

In what follows, I am assuming that you have a general familiarity with the causes, symptoms, and treatment of AF (see Resources for help with this).

 

 

Abbreviations

*You may come across the term "PV antrum isolation" or "PVAI". This approach isolates a larger area around the PVs and may be safer and more effective than a PVI.

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TYPES OF ATRIAL FIBRILLATION

Here is the latest (2007) in the evolving process of determining the most useful classification scheme for AF:

Types of AF

Paroxysmal AF>>>>>

Recurrent AF that lasts for several hours up to seven days and then reverts to NSR without CV

Persistent AF>>>>>

AF that lasts for more than 7 days or that lasts less than 7 days but requires CV
Permanent AF>>>>> CV not performed or attempted; decision made not to attempt CA or surgery
   

 

The only distinction with implications for treatment, according to  Dr James Cox, is between AF that is intermittent -- “Paroxysmal” --, and AF that is present all the time -- “Continuous”.  For example, treatment of Continuous AF  has a lower success rate and usually requires a particular lesion set that is relatively straightforward in the case of Maze surgery, but that can be difficult to do in the case of CA (see the Audience and Panel Discussion section  of the Report of the 2006 Boston Symposium). 

 

This distinction is magnified when the duration of Continuous AF is very long -- generally, years instead of months. AF burden (frequency x duration) can affect the likelihood of treatment success because of the possibility of structural remodeling. The time for structural -- as opposed to electrical -- remodeling to have its effects varies widely, but usually takes many months or some years to develop. There is no method of assessing remodeling that is in widespread use; MRIs may be used in the future for this purpose

 

Lone AF is AF uncomplicated by risk factors such as hypertension, heart disease, thyroid problems, and sleep apnea. The possibility that AF previously considered "Lone" may also have risk factors is being explored. Risk factors should be treated where possible. Doing so can reduce AF burden (frequency x duration of episodes), and make treatment success more likely.

 

AF can also be "vagal" or "adrenergic", referring to the kind of events that can trigger AF (see here for more on types of AF and for differences in treatment).

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Alternatives to Medical Treatment

 

Approaches other than those offered by the medical establishment are getting more attention. A full discussion of these approaches is beyond the scope of this site, but here is a list and some references. It makes sense to give these serious consideration before proceeding to interventions that are more costly, both financially and in terms of side effects or complications.

 

Two main approaches are:

 

The use of supplements such as magnesium, potassium, and taurine, plus COQ10, d-ribose, acetyl-l-carnitine and fish oil. (An analysis of research on supplements is beyond the scope of this site.)

 

Detecting and avoiding triggers, such as caffeine, alcohol, excessive exercise, stress and anything inflammatory.

 

Dealing with AF risk factors such as high blood pressure, thyroid problems and sleep apnea.

 

For an example of stepwise consideration of these and other measures see General advice for new AF patients .

 

 

The Role of Individual Preferences

 

Personal preferences or other individual differences may affect your attitude towards various treatments for AF.

 

Should you base your actions on these feelings? Probably not. But acknowledging that you have them is a step reducing their influence.

 

For example, paying too much attention to the length and discomfort of the recovery period of more invasive surgical approaches at the expense of the success rate for your type of AF may be trading short-term comfort for long-term gain. In other words, a treatment should not be rejected only on the basis of its longer and more uncomfortable recovery period.

 

Important Assumptions about Treatment for Atrial Fibrillation

 

The ideas presented below draw on the conclusions presented in several articles.

 

Assumption #1: It is not healthy to remain in Continuous AF or to endure Paroxysmal AF whose AF burden is comparable to several months or years of Continuous AF.

 

For more information, see the above articles. You should read these articles if someone has told you either that AF is a benign condition or that medication is an effective long-term treatment for it.

 

Assumption #2: Medication is not a long-lasting solution for most people who suffer from AF.

 

An exception would be if you are rarely in AF (say, once a month or several times a year), and your ventricular heart rate and other unpleasant symptoms are controlled by a rate-limiting medication. Under such circumstances, you might decide to wait and see whether your AF becomes more frequent and or your symptoms more unpleasant; or, until new, more effective treatments are developed and doctors have time to become proficient in them. You should not wait until the total time in AF is likely to cause changes in your heart that will make treatment more difficult. (You can ask your doctor whether there are ways he can determine whether this has happened.)

 

Another exception would be a person whose rare occurrences of AF are converted to NSR with a "pill in the pocket" approach; that is, by taking a high dose of an AR medication such as flecainide (Tambocor) or propofanone (Rhythmol) when AF occurs, perhaps preceded by a beta blocker. Various doctors will have different protocols with regard medications and dosages, how long to wait between doses, or when to stop medication and to arrange for CV.

 

The problem with these scenarios is that AF can occur without the person's being aware of it ("silent AF"). Such asymptomatic AF carries the same risk of blood clots and changes in the electrical and physical characteristics of the heart as does symptomatic AF.

 

Silent AF can also occur in patients who have been "cured" by CA or surgery (see the remarks of Drs Calkins and Kottcamp in the Report of the 2006 Boston Symposium) .

 

There is ongoing discussion and research into the question of the clinical significance of silent AF. For example, if such episodes are of short duration (<48 hours), they are unlikely to give the blood enough pooling time to create clots that can cause stroke or to cause significant remodeling.

 

Drawbacks of different types of medication

 

>>> Rate-control medications (for example, beta-blockers and calcium-channel blockers) can control the rapid ventricular heart rate that results from AF and will reduce the strain on the ventricles. For some, they also reduce symptoms to a tolerable level.

 

... but these medications do not stop the fibrillation of the atria, and therefore would not be expected to prevent the formation of clots or other consequences of a high atrial rate. So, the problems created by an irregular fast atrial beat and inadequate filling remain.

 

 These include stroke risk from clotting of the blood in the atria (see below), as well as electrical and physical remodeling.

 

>>> Rhythm-control medications can prevent AF; however,  there is a 20-60% rate of AF recurrence at one year. The real recurrence rate is undoubtedly higher because an unknown amount of  AF is asymptomatic and undetected. Also, anti-arrhythmia medications can have serious toxic and unpleasant side effects. This is especially true of amiodarone (Cordarone) , which is also the most effective.

 

Several studies have reported that rate control medications are just as effective as anti-arrhythmia medications in terms of mortality and quality of life. This does not mean that both are effective in an absolute sense, or that it is not better to be in NSR without taking these medications.  

 

Here is the way the Bordeaux group puts it in the introduction to one of their 2005 studies:

 

"Antiarrhythmic drugs have been the mainstay of maintaining sinus rhythm for many patients with persistent atrial fibrillation (AF). However, their limited efficacy and potential for significant adverse effects has led to renewed interest in rate control measures. This concept has been strengthened by the publication of the "Atrial Fibrillation Follow-Up Investigation of Rhythm Management" (AFFIRM), the "Rate Control versus Electrical Cardioversion" (RACE), and the "Pharmacological Intervention in Atrial Fibrillation" (PIAF) trials, which suggested an equivalent outcome for pharmacological rhythm and rate-control strategies. However, emerging evidence suggests that these findings merely highlighted the fact that the benefits of sinus rhythm can be negated by the deleterious effects of antiarrhythmic drugs. Indeed, a further analysis of the AFFIRM results demonstrated that sinus rhythm was associated with a 47% lower risk of death, while the use of antiarrhythmic drugs significantly increased mortality risk by 49%. Thus, the restoration and maintenance of sinus rhythm is of potential benefit if it can be achieved without the use of antiarrhythmic drugs."

 

Coumadin (warfarin), an anticoagulant, is worth special mention, as it is the medication of choice for AFer's with additional risk factors for stroke. Many people with AF will meet these criteria, but there is anecdotal evidence that some who do not will be placed on warfarin anyway.

 

Problems presented by using warfarin include risk of internal bleeding, artery calcification, which is an important risk factor for heart attack, and possibly osteoporosis

 

The best compilation of information for sophisticated lay people on their options for dealing with their risk of stroke and for reducing the negative effects of warfarin (if they must take it) is found in two references listed in the Resource section.

 

New medications on the way?

Drug companies and researchers are working hard to develop new medications that more precisely target the causes of different types of AF without short-term unpleasant- and long-term toxic side effects. Motivation comes from huge profits that can be made because of the large number of AF cases (estimated to be 3-6 million and increasing as the population ages).

 

Ask your doctor about dabigatran, a new anticoagulant (as of 2009) that has been shown to be equal or better than warfarin in Phase III clinical trials. Possible obstacles to approval are a slight increase in probability of myocardial infarction and the fact that there is no antidote to use when coagulation should not be compromised.

 

Be aware that positive announcements of new medications are sometimes premature. This has been the case of alternatives to amiodarone and warfarin. There can also be unforeseen long-term consequences of new medications.

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CHOOSING A TREATMENT AND AN EP OR SURGEON TO DO IT

 

So, you have decided to find out about CA or surgical approaches that may deal more effectively with your AF. What do you do next?

 

The short answer is this:

 

Find out the success- and complication rates for your type of AF for the EPs or surgeons that you are considering. They should have done at least 400 cases (the best known have done one-to-several thousand). Success rate should be 80-90+%, depending on your type of AF. The complication rate resulting from technique (that is, those are his fault and the not the result of a patient condition), should be <1%. You should also find out how he defines success.

 

Find out these statistics by calling or emailing several EPs or surgeons on the Doctors' List. See Questions for Doctors for suggestions on what to ask them.

 

Decide if an EP or surgeon's rates are acceptable to you by comparing his rates to those of others and by thinking about the risks you are willing to take. Decide if the risks of failure or complications are better than the risks of waiting, as discussed above. If you think you might proceed, then get on the waiting list. You can always cancel if you change your mind.

 

If at all possible, get on the waiting list for one of the top people from the Doctors List.  There is significant difference between the rates of the top practitioners and those who are less experienced or skillful (see here and look over the conclusions drawn from the patient surveys in the AFIB Report).  There may be a waiting list of a year or more, but this  should not ordinarily affect your decision. I know it is difficult to wait ...  Getting an appointment for a consultation shouldn't take as long, and having a plan can make the wait easier to bear.

 

Whom to choose?  For CA,  Dr Andrea Natale or the Bordeaux group in France (Drs Jais and Haisaguerre) will usually be mentioned first in any list of top EPs. The others on the Doctors List will also be worth questioning, especially if you have Paroxysmal AF , which is usually easier to treat than Continuous. If you have Continuous AF, you should take pains to question the EP or surgeon about his success rates for this type of AF. More EPs and centers will join the top echelon as they create good records and technology (i.e. robotics) shorten the learning curve.

 

Surgery is also an option, but the choice can be complicated, and there are pro's and con's depending on your type of AF --- but more about this later...

 

There are important details, of course. How do you choose between CA and surgery? What are the criteria that different doctors use for success? Exactly what complications can occur? What are the characteristics of a good procedure? ...and so on.  The rest of the article will cover these topics or refer you to information you can explore on your own.

 

Remember that the bottom line is what you find out about an EP or surgeon's success- and complication rates for your type of AF, and about his criteria for success.

 

Choosing between CA and Maze Surgery

 

The short answer is this:

 

If you have Paroxysmal AF, you can expect good results from CA. And because CA for this type of AF is relatively straightforward (a PVI of PVAI will do in many cases), the success rates among expert EPs (i.e. those on the List) will not differ a great deal or will be within the margin of error.

 

Paroxysmal AFers can also consider the Wolf Mini-Maze surgery. This are is a PVI with some additional features, and with some advantages and disadvantages when compared to CA. The outcome research on this approach has been based on small samples and has been, in most cases, disappointing. But recent changes in the technique raise hopes for significantly improved outcomes for both Paroxysmal and Continuous AF (as in the next paragraph).

 

If you have Continuous AF,  You should find an EP who is experienced in doing a "stepwise" CA procedure in which the EP can make lesions that are Maze-like, if necessary. Not every EP will do this because doing so takes more skill than doing only a PVI. I believe you must also consider new versions of the Mini-maze, with lesions in addition to those pioneered by Dr Wolf and are designed to have the same effects as the lines usually required in dealing with Continuous AF.  And of course there is Maze surgery itself, which is arguably the most invasive and is often done when open-heart surgery is done for other reasons, but is also done as a stand-alone procedure. So, the choice for those with Continuous AF is more complicated, as we shall see later on.

 

In the discussion that follows, it is important to note that the probability of the occurrence of some complications  will depend on skill and experience of the doctor and will be virtually absent from the records of some expert EPs; the same goes for surgeons.

 

But even the expert EP or surgeon can do only so much about long-term negative effects may be built into the procedure. Their risk is unknown because the necessary outcome studies have not been done, so we must depend on educated guesses based on the process. Examples would be the effects of extensive scarring in the case of CA, and problems resulting from the patient's time on the heart-lung machine in most Maze surgeries. Ask anyone you consult for their opinions on these factors ... 

You should also keep in mind that the effects of certain procedures will also depend on the your physical robustness. For example, having surgery that is more invasive or traumatic physically may not be a concern if you are young and strong.

 

You should always ask a doctor questions that about complications that can occur with his particular procedure and the rate that these occur in his own practice. The way he is doing the procedure or the technology he is using may take care of something  that can be a problem in other centers. Examples are: Using an approach with robotic arms that permits smaller incisions and more precise placement lesions or ablations, using an energy source that reduces the spread of device-tip temperature or one that permits targeting LA areas ordinarily blocked by blood vessels, or using an imaging system that gives a 3-D image of the inside of the heart, of the position of the esophagus and of catheter placement and pressure.

 

Technological improvements are occurring rapidly, so you should ask any EP or surgeon you are consulting if there are any special techniques or equipment he uses to increase the safety and effectiveness of his procedure. 

 

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Positive and Negative Features of Catheter Ablation and Surgery  

 

CA and Surgery: Coming together?

 

CA and surgery are developing in ways which may result in a merging of techniques, goals and results. For example:

 

For the present, there are some significant differences, which are discussed below.

 

Success Rates

 

It is difficult to evaluate success rates because follow-up assessments are not standardized. Some doctors define a patient who is in NSR and on medication as a success (for more discussion of criteria for success, see Curative procedures for AF and Success rates, competition, and commercial conflict of interest ... ). 

 

The duration of follow-up is often short: six months to at most a year or two. There are longer-term rates available for Maze surgery, but they are for early versions. And some practitioners depend on self report to determine the presence or absence of AF, while others require mechanical sampling using EKGs, or event-, or continuous monitoring. Also, the reliability and validity of success rates will depend on: the number of cases on which the rates are based; the type of AF; and on whether the practitioner was using his latest version of his procedure.

 

Also, any comparative success rates are continually changing because of developments, such as those described in CA stepwise CA procedures that do Maze-like lesions  and Totally Thoracoscopic Maze/Mini-maze approaches.

 

Remember, then, that you must ask the EP or surgeon whom you are considering for

Generally speaking, these days (2009), you should be considering practitioners with success rates in the 80-90% range. The figures for Paroxysmal AF will be higher than those for Continuous AF. Follow-up should be at least a year. It should also be based on hundreds or more of cases. You can decide whether success should be defined as "of all medications". Many patients will be much happier if their AF burden is decreased, even if they continue to take some medication. For example, after a CA, the PIP approach may work when it didn't before. So, you must decide for yourself what constitutes an acceptable Quality of Life. And remember that a second procedure (usually a "touch-up" ablation following surgery or a first ablation) can significantly increase success rates.

 

I should add that going to a reputable medical center is no guarantee of success because the records of different doctors at the same center will vary. So ask! The best doctors will give you their success and complication rates.

 

Catheter Ablation and Surgery: Some things to consider

 

Before proceeding, you may want to get an idea as to what is actually done by EPs and surgeons. To view webcasts of catheter ablation and surgery for atrial fibrillation, you can go to OR Live. And here is a fairly detailed description of  the surgical approach of  Dr Niv Ad  (as of 2005). It will also help if you take a look at the lesions sets of various practitioners.

 

CA is less invasive than Maze surgery. The incisions through the skin in the groin area are minor; the heart is not opened, and the heart-lung machine is not used. There is less pain during and after the procedure, and recovery time is always much less, the exact difference depending on the type of surgery. For example, after CA, the patient may spend the night in the hospital with recovery to full activity in a couple of weeks (depending on the details of the procedure, the robustness of the patient, and the type of activity). Recovery from " minimally invasive" PVI-Centered or relatively invasive Maze surgery will require 3-6 days (respectively) in the hospital and several weeks of gradual recovery at home.

 

If a CA is not successful, another can be done (a "touch-up" ablation), which will significantly affect the success rate. (In a report by the Bordeaux group, the success rate for CA of 60 patients with Continuous AF went from 87% to 95%.). Roughly 20-30% of ablatees will require a second ablation. Surgery can also be performed on a patient who has had a CA -- and a CA can be done on someone who has had surgery. A second surgery is not ordinarily recommended because scarring makes the work more difficult to perform. This means that a Maze procedure cannot be done after a Wolf Minimaze, even though the latter was mainly a PVI.   

 

CA can be tailored to individual differences in the location of circuits contributing to AF (“mapping”), as opposed to surgical lesion sets which are, at present, “one size fits all”.

 

The tools an EP uses are designed to ablate a point or small area from which is contributing to a patient's AF. Making lines that completely block an electrical current from passing though must be done by burning a series of dots without a break, whereas a surgeon can make such a line by using tools that makes longer lines with just one placement of the instrument. A break in a line can create atypical AFL in the LA, which may be difficult to ablate. In the future, the use of array catheters may deal with this problem.

 

The heart is beating during CA making exact placement and energy delivery difficult. In some surgery, the heart is stopped for part of it. Robotics has the potential to help with this problem, but the estimates of the time before robotics will be perfected to the point where it will be the treatment of choice varies from two to five years or so (as of 2009).

 

For both CA and surgery, there is a slight risk of stroke from clots broken loose by the procedure. This is prevented by making sure that any clots are detected and dissolved previous to the procedure. 

 

In CA, there is a risk of PV stenosis, in which scarring from ablation narrows or closes off the affected vein to the heart. This risk has been reduced by making sure to make ablations outside of the PVs themselves (as in a PVAI).

 

There is an extremely low but dangerous risk of an esophageal fistula (making a hole in the esophagus) and  of phrenic nerve paralysis. The latter is usually temporary. 

 

Stenosis and other negative effects caused by misplacement of energy are more probable in CA than in current Maze surgeries because the energy source is directed from the inside of the heart out in the direction of structures outside the heart (an “endocardial” approach) rather then from the outside in ("epicardial" approach).

 

The fact that the EP does not have a direct view of the operating field, as does the Maze surgeon, contributes to the above complications. Improvements in imagery are making this less of a problem for the EP.

 

As noted above, these complications are all but absent from the records of the top EPs. Improvements in imaging and the use of robotic techniques can help, as can the use of energy sources which are more focused or which do their work with less heat. (For a discussion of complications of surgery, see below.)

 

CA may create negative long-term effects, such as loss of function from scarring that results from extensive high-temperature ablation and de-bulking of the wall of the LA. No one knows for sure. EPs will try to ablate only those areas necessary to prevent them from being able to induce AF at the end of the procedure. They will also try to use tools (irrigated-tip catheters) and energy sources (cryo energy) to reduce the spread of heat from high tip temperatures.

 

CA can be long -- from 3-6 hours. Exposure to radiation (if flouroscopy is used) will be much less, but some believe is it significant. Any improvement in technique that makes CA faster -- such as the use of robotic arms -- will help, as will improvements in imaging.

 

In CA, the LA appendage – a small bit of elongated tissue extending from the LA that encourages clot formation on its surface -- is not removed (but there is controversy about doing so). There have been efforts to design devices that can prevent clots from leaving the LAA, but these have not yet been uniformly successful.

 

The 2007 HRS Society Guidelines attempt to comment on indications for surgery vs. CA. I do not find them particularly helpful for most cases. They do indicate the difficulty on reaching consensus on this topic:
 

"Based on the new 2007 Heart Rhythm Society Guidelines that are just being released the indications for a maze procedure are: 1. Symptomatic AF patients undergoing other cardiac surgery, 2. Selected asymptomatic AF patients undergoing cardiac surgery in whom the ablation can be performed with minimal risk. 3. Stand alone AF surgery should be considered for symptomatic AF patients who prefer a surgical approach, have failed one or more attempts at catheter ablation or are not candidates for catheter ablation." -- Dr Niv Ad 2007 Personal communication to LAF Forum (http://www.afibbers.org/lafforum.html) and a-fibcures ( http://health.groups.yahoo.com/group/A-fibcures/ )  Bulletin Boards."

 

So, you can ask your doctor for his opinion of the comparative advantages and disadvantages of CA vs. surgery for your type of AF.

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Surgery: The Cox Maze (Version IV) 

 

The goal of the Cox Maze surgeries is to channel aberrant electrical impulses into a pathway that results into a correct atrial-ventricular flow of current and coordination. This is done by making lesions using a one or more of several energy sources on the inside of the heart. The scar tissue formed when these lesions heal blocks electrical conduction.

 

Through the years, the lesion set has been reduced in the hope that the success rates of the original maze will still hold. The location and number of incisions has also evolved to the current the form of Cox Maze IV.

 

Complications of Maze surgery for AF

 

Possible Complications from Maze Surgery for AF

Complications of general anesthesia: 

Heart attack, stroke


... from making incisions: 

Infection, bleeding, pain


... from being on the heart-lung machine :

    

Stroke, bleeding, temporary or permanent cognitive problems


... from the Maze operation itself:   

Damage to blood vessels or the phrenic nerve; fluid in the lungs (easily drained but can be painful); blood sugar problems (reduced by using an insulin drip); damage to the AV node resulting in the need for a pacemaker.
   

 

You should ask the surgeon you are consulting about these risks in your particular case.

 

Confusion regarding the use of the word "maze" to describe surgical approaches

 

It is important to realize how versions of the Cox Maze differ from the PVI-Centered surgeries pioneered by Dr Wolf.

 

For more on how these surgeries differ from one-another, click here for an explanation by Dr Ralph Damiano and here for a description of the lesion sets of the various operations.  You will see that there are differences but that some surgeons have added Cox-Maze lesions to the Wolf set. The results of these attempts have not been determined but the hope is that success rates will approach those of the Cox Maze in a procedure which is much less invasive and safer.

 

Wolf PVI-centered surgery vs. CA for Paroxysmal AF

 

The choice between Wolf PVI-Centered surgery and CA for Paroxysmal AF is worth special consideration.

 

As described above, the Wolf  approach performs a PVI with an instrument that should ensure transmurality and a continuous lesion encircling the PVs. Additional work is done -- excision of the Ligament of Marshall, removal of the LAA and denervation of certain ganglionated plexi. None of this additional work is accomplished by a CA, except that, in the case of a PVAI, some ganglionated plexi may be affected because their location can be on the epicardial surface of the LA in the line of fire of the energy applied on the opposite endocardial surface.

 

On the other hand,, in PVI-centered surgery, additional areas involved in aberrant impulses will not be targeted, nor is there work done in the RA (specifically ablation of the cavotricuspid isthmus to prevent RA or typical AFL). And, as noted above, there is controversy over the wisdom of removing the LAA.

 

There is no easy answer to which is best. Again the bottom line must be the EP's or surgeon's answers to your questions about success- and complication rates.

 

Another way out of this dilemma is to accept the fact that more than one procedure may be necessary; either a CA followed by a "touch-up" CA,  or a Maze or Wolf-centered approach followed by a CA.

 

Hybrid (or "convergent") approaches combining surgery for a PVI plus other work, followed by a CA if necessary hold some promise, the assumption that this sequence maximize the potential advantages of each approach. Dr Richard Lee and Dr Andrea Natale are working in this area.

 

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>>> The next section will be useful if you get into a discussion with an EP or surgeon you are considering about his technique. Click here to skip this section.

 

Energy sources and device characteristics

 

A variety of devices using different energy sources have been used to make the lesions that isolate or otherwise deactivate the electrical sources of AF: bipolar and unipolar radio-frequency energy (“RF” energy); microwave (used in the Saltman Micromaze procedure); HIFU (high-frequency focused ultrasound), and cryo-ablation (freezing the troublesome areas as in the “Cryomaze”  or the Cryosurgical Maze procedures).  

 

Several characteristics of the device are may be important:

 

  • The makers of some instruments stress the importance of transmurality; that is, the ability to ensure that the scarring created by the lesion extends all the way through the atrial wall, making isolation of the source of aberrant circuits complete.  For example, the Atricure device using bipolar RF energy that is used by Dr Randall Wolf and others reportedly does this because the tissue is squeezed between the jaws of a clamp (transmurality happens when the resistance reaches zero).
  • The ability of the energy to pass safely through blood vessels, if making the necessary lesions requires it, (as does the Cox PV-mitral valve ring lesion he considers necessary for treating Continuous AF) would be advantageous. A relatively new energy source, HIFU has this characteristic, but is not in widespread use;
  • The delivery of energy that is localized to the target and doesn't affect nearby structures. Microwave and cryo energy  have this characteristic because they radiate less heat. The Wolf procedure also does this because the RF clamp squeezes out the blood from the area being ablated. (Blood acts as a heat sink, meaning that, in the presence of blood,  the temperature of the device must be higher to heat the tissue sufficiently for scarring.)
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So, if you decide on surgery, whom should you choose?

 

The answer to this question will emerge from your looking over the Checklist that follows immediately below, and then asking the Questions for Doctors of those on the List of Doctors.

 

What to do when you can't go to a top EP or surgeon

 

Here is the situation:

 

CA and surgery for AF is still "operator dependent"; that is, there are significant differences in outcome between those who are the best and those who are not the best.

 

Not everyone can go to the best, as defined by reliable reports of success-  and complication rates.

 

There are not nearly enough slots in the top centers to accommodate all those who need treatment. The waiting lists will get longer as people realize that they don't have to settle for a life on rate-limiting- or AR medication, and that they can choose the treatment procedure and the doctor to do it. (The advent of robotics will make treatment with outcomes approaching those of top practitioners much more available and inexpensive, as well as safer and more effective.)

 

Not all practitioners collect the data necessary to make these estimates because doing so takes resources that are most readily supplied by an institution who will use the results in journal articles or in reports at conferences.

 

There are presumably many potentially excellent EPs and surgeons who have not done enough cases on which to base these estimates.

 

Many patients will  be restricted by insurance or travel requirements or other practical considerations.

 

So, here are some things to consider when reliable estimates or success- and complication rates are not forthcoming from the practitioners from whom you must choose:

 

Let me repeat that going to the best --or as close to the best that you can manage-- is more crucial in the case of Continuous AF.

 

>> Look at the doctor's training. It will be in his favor if he has trained with one of the top people, or, better yet, if he has a recommendation from a top person. I believe that the Cleveland Clinic will give such recommendations; perhaps other doctors on the List  will, too.

 

>>Look at the technology the doctor is using. Certain energy sources may increase the effectiveness of ablations or lesions and reduce complications. Other technology (e.g. robotics) have the potential for increasing safety and reducing the effects of operator experience by making it easier to make precise lesions in just the right places with just the right pressure.

 

>>Other characteristics of the procedure will also become relatively more important when success and complication rates are not available. For example, you can make sure that the lesion set is appropriate for your type of AF. Your cardiologist may be able to help you with this, but finding this out may be mainly up to you.

 

 

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  A CHECKLIST FOR CHOOSING A NON-DRUG TREATMENT FOR ATRIAL FIBRILLATION  

 

The full Checklist follows below. It is a bit imposing so remember that its purpose is to help you to review what you have read so far and to put it terms of questions. It may also be helpful background if you happen to get into an extensive discussion with a doctor or EP or for further reading of research.

 

For a list of critical questions that you might actually ask a EP or surgeon you are considering, see Questions to email or ask prospective EPs or Surgeons.

 

The Checklist below and the list of Questions for Doctors* that is based on it can be used:  a) to collect information to use in making your choice of a  procedure and EP or surgeon; b) to report what you have learned about doctors and  procedures to others; and, c) to describe your experience of after undergoing a procedure.

 

* See the a-fib.com site for another list of questions to ask doctors .

 

Most of the most important questions in the Doctor’s level of experience and his success rates and Characteristics of the procedure sections. Questions in bold face should have priority.

 

Most questions are relevant to both catheter-approach ablation and surgery. Those that are not are so indicated.

 

If possible, you should schedule a consultation with the EPs or surgeons whom you are considering and take a list of questions with you. It can also help to have someone else there who can help you make sure that you ask everything you need to, that you get clear answers and that you remember everything the doctor says.

 

Remember that the doctor may feel pressed for time. He is one-up on you by virtue of his expertise and status. He may be trying to sell his approach so that he can gain experience or for other reasons. Of course you want to find a person you can trust, but I do not believe that bed-side manner should be a critical factor.

 

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CA vs. Surgery *

 

 

Advantages

Disadvantages

Catheter ablation

 

 

Surgery

 

 

 

 

 

Your choice, and the reasons for it:  

 

Contact Information

 

 

Name of  the procedure

 

 

Dr’s name

 

 

Web site address

 

 

Contact person

 

 

Address

 

 

Phone

 

 

Email

 

 

Other contact info

 

 

Waiting List

 

 

How long will you have to wait for the procedure

 

 

How long the wait would be for another doctor at the same center.

 

 

 Type of Patient Accepted or Preferred*

 

 

AF diagnosis: Are patients accepted who have your type of AF (Paroxysmal or Continuous AF):

 

 

Duration : Is there any limit to the time that a patient can have been suffering from Paroxysmal or Continuous AF:

 

 

Are there patient characteristics will result in being rejected for treatment [heart conditions such as valvular disease, coronary artery disease, scarring from previous heart surgery; or, other risk or contributing factors such as high blood pressure, thyroid problems, diabetes, lung disease]:

 

 

Is a trial period on medication required or recommended:

 

 

Are there other criteria for being rejected for this treatment:

 

* It is my impression that the criteria that follow are becoming less and less likely to be relevant, although doctors may decide to accept only those who need their help the most or with they are most likely to be successful.
 

The Doctor’s Level of Experience & His Success Rates

 

 

 

Description

Importance or Weight

Your Comments

 

Number of procedures (for your type of AF) he has done as the primary surgeon or EP, using his latest version of the procedure

 

 

 

 

Number of procedures as the assistant or while being mentored

 

 

 

 

Experience with other procedures what would transfer to the one he is currently doing

 

 

 

 

 

 

 

 

 

Success rates for your type of AF, off all meds (see here for complete breakdown)

 

 

 

 

 

 

 

 

 

Complications (number or % and type)

 

 

 

         

 

How was the presence or absence of AF determined on follow-up (monitoring or self-report)

 

 

 

         
  How long are patients followed      
         

 

 How common is it to have a second procedure, such as a touch-up ablation, after ablation or surgery

 

 

 

  What is the success rate when two or more procedures are done      
         
         

 

Your Comments and Conclusions about Success- and Complication Rates

 

 

 

 

 

Characteristics of the Procedure

                                                                                                                                      

 

Characteristic

Description

Importance or Weight

Your Comments

 

 

 

 

 

 

Duration of CA or Maze surgery

 

 

 

 

 

 

 

 

 

Invasiveness (surgery):

 

 

 

 

   Location, length & number of incisions

 

 

 

 

Time on the heart lung machine

 

 

 

  How the surgeon gains access to the heart      

 

Other features affecting comfort or recovery time

 

 

 

 

 

 

 

 

 

Lesion set

click for examples

 

 

 

 

Where do you ablate (CA) or make linear lesions (surgery or some CAs)

 

 

 

         
         

 

Device Characteristics:

 

 

 

 

Type of energy used to create lesions

 

 

 

 

Any particular device advantages or disadvantages:

 

 

 

 

 

 

 

 

 

 For CA: Do you any new or special techniques or technology:

 

 

 

 

Any special mapping  technique

 

 

 

 

Any special imaging technique

 

 

 

 

Is the procedure robotic or robot-assisted

 

 

 

 

Other special equipment used.

 

 

 

 

 

 

 

 

  SAFETY      
  What safety measures are taken to prevent complications      
         

 

Comments and Conclusions about the  CA or Maze surgery being considered

 

 

 

 

 

Pre- and Post-Operative Procedures

 

 

 

Description

Comments

 

What pre-op testing is done (CTs, MRIs for heart disease, blood clots, mapping):

 

 

 

 

 

 

 

The recovery period:

 

 

 

# of days in the hospital

 

 

 

What happens during

the hospital stay

 

 

 

How much pain will

there be and for how long

 

 

 

What activities are

possible, and when

 

 

 

 

 

 

 

Post-op medications:

 

 

 

Anti-arrhythmic medication: which one and for how long:

 

 

 

“Blood thinners” (Coumadin/warfarin), for how long

 

 

 

 

 

 

 

Other post-op procedures

 

 

 

 

 

 

 

Day-by-day schedule of pre- and post-op procedures

 

 

       
  Conclusions about Pre- and Post-op Procedures    

 

 

 

 

 

 

Miscellaneous

                                                                                              

 

Other doctor characteristics

 

 

What does the doctor do to help a patient whose procedure has failed

 

 

Does the doctor have commercial interests in the device used to create lesions that might conflict with the interests of his patients

 

 

What do the doctor’s patients say about the way the doctor relates to them. What are their “gut feelings” about him.

 

 

Has the doctor published a lot, lectured frequently, created innovative techniques or accomplished other things that enhance his reputation among his peers.

 

     

 

How experienced is staff at dealing with ablation or surgical patients

 

     

 

What is the infection record of the hospital where you will be staying

 

 

 

 

 

What are the pro’s & con’s of waiting until improved procedures are developed or until doctors get more practice with new procedures. What medications or procedures are in the pipeline?

 

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TREATMENT TRENDS and the IDEAL TREATMENT for ATRIAL FIBRILLATION

 

It may help you, the prospective patient, to be aware of some of the trends in the treatment of AF. You can also look over criteria for the ideal treatment for AF

 

You can have these in mind as you evaluate procedures and the EPs or surgeons who perform them.

 

What to do next

 

You can find out more about doctors and procedures by emailing or calling them with Questions for Doctors, which is based on this Checklist. You can use the email addresses for the well-known surgeons and EPs given in the List of Doctors. You can also look on the internet for more information on each specialist. The Resources sections will help you with this.

 

Once you make a choice...

 

You can do things like:

 

If you are going to stay at a hospital for a few days, you may find some parts of Planning for your hospital stay useful.

 

More and more people are choosing not to live with AF but rather to have surgery or a CA, and the procedures are getting better all the time. Actively participating in choosing a treatment will help you to feel much better in spite of your AF, while you wait.

 

There is a great deal of research activity on treatment of AF that is driven by the numbers of patients with this difficulty and the amount of money that will be spent on any treatment that is either more successful, safer, or less unpleasant than those that exist today. The next few years will undoubtedly bring great advances.

 

Looking back on the situation today, people ten years in the future will probably think, "How crude those procedures were! How did patients put up with them?" --  just as we shudder to think about surgery at the beginning of the last century. 

 

Good luck!

 

 

                                                          -- Dick Inglis

 

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RESOURCES

 

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