Atrial Fibrillation (AF, AFib)

  • Medical Author:
    Daniel Lee Kulick, MD, FACC, FSCAI

    Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.

  • Medical Editor: Charles Patrick Davis, MD, PhD
    Charles Patrick Davis, MD, PhD

    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

Quick GuideAtrial Fibrillation: Heart Symptoms, Diagnosis, & Afib Treatment

Atrial Fibrillation: Heart Symptoms, Diagnosis, & Afib Treatment

Procedures for treating and preventing atrial fibrillation

After successful cardioversion many patients (up to 75%) may experience recurrence of AFib within 12 months. Therefore, many patients will need long-term treatment with medications to prevent a recurrence of the disease; however, medication(s) are effective only 50% to 75% of the time in preventing recurrence. Moreover, many people cannot tolerate the side effects of long-term medication. For these reasons, several procedures have been developed to treat and prevent recurrence of the condition to return the person to good health; they include:

  • Ablation of the AV node with implantation of a pacemaker
  • Implantation of a pacemaker
  • Implantation of an atrial defibrillator
  • Maze procedure

Ablation of the AV node with implantation of a pacemaker

Ablation of the AV node is a procedure that destroys the AV node so that the atrial electrical discharges cannot pass through the AV node to activate the ventricles. The procedure usually is performed in a cardiac catheterization unit or an electrophysiology unit of a hospital.

  • Procedure: For ablation of the AV node, individuals are given a local anesthetic to minimize pain and are mildly sedated with intravenous medications. Using X-ray guidance, a wire (catheter) is inserted through a vein in the groin to reach the heart. Electrical recordings from inside the heart help to locate the AV node. The AV node is destroyed (ablated) using heat delivered by the catheter. After successful ablation of the AV node, electrical discharges from the atria can no longer reach the ventricles. Destruction of the AV node (whether by catheter ablation or by disease that occurs with age) can lead to an excessively slow rate of ventricular contractions (slow heart rate). Therefore, a pacemaker is implanted in order to provide the heart with a minimum safe heart rate.
  • Benefits of ablation of the AV node: The benefits of ablation of the AV node and implantation of a pacemaker include:
    • Resumption of a regular heart rate (even though a pacemaker may be determining the heart rate)
    • Relief from palpitations, fainting, dizziness, and shortness of breath
    • Ability to stop medications and avoid their potentially serious side effects
  • Risks of ablation of the AV node: Potential complications of ablation of the AV node and permanent implantation of a pacemaker include bleeding, infection, heart attack, stroke, introduction of air into the space between the lung and chest wall, and death. Still, this technique has helped many patients with severe symptoms to live normally.
  • Candidates for ablation of the AV node: Candidates for ablation of the AV node are patients with AF who respond poorly to both chemical and electrical cardioversion. These patients experience repeated relapses of atrial fibrillation, often with rapid rates of ventricular contractions despite medications. Ablation also may be an option for patients who develop serious side effects from the medications that are used for treating and preventing AF.
  • Limitations of ablation of the AV node: Ablation of the AV node only controls the rate with which the ventricles beat. It does not convert AF to normal rhythm. Therefore, blood clots still can form in the atria and patients are still at risk for strokes. Thus, there is a need for long-term anticoagulation in addition to the permanent pacemaker.

Other procedures for treating and preventing atrial fibrillation

Permanent pacemakers

Permanent pacemakers are battery-operated devices that generate electrical discharges that cause the heart to beat more rapidly when the heart is beating too slowly. Recent studies suggest that some patients with recurrent paroxysmal AFib can benefit from the implantation of a permanent pacemaker. Although the reasons for this benefit are unknown, regular electrical pulses from the pacemakers may prevent the recurrence of AFib. Furthermore, newer pacemakers that can stimulate two different sites within the atria (dual site atrial pacing) may be even more effective than standard pacemakers in preventing AFib. Nevertheless, permanent pacemaker implantation cannot be considered as standard non-medication treatment for atrial fibrillation.

Implantable atrial defibrillators

Implantable atrial defibrillators can detect and convert atrial fibrillation back to a normal rhythm by using high-energy shocks. By detecting atrial fibrillation and terminating it quickly, doctors hope that these devices will prevent recurrences of AFib over the long term.

Atrial defibrillators are surgically implanted within the chest under local anesthesia. These devices deliver high-energy shocks to the heart that are somewhat painful. Atrial defibrillators are not useful in patients with chronic sustained atrial fibrillation and are suitable only for patients with infrequent episodic attacks of AFib.

Maze procedure

Many doctors believe that the atria cannot fibrillate if they are sectioned into small pieces so that the conduction of the electrical current through the atria is interrupted. During the Maze procedure, numerous incisions are made in the atria to control the irregular heartbeat and restore a regular rhythm.

  • Procedure: The Maze procedure is most commonly performed via open heart surgery. Some electrophysiologists (doctors specially trained to treat abnormalities of rhythm) are now attempting to perform the Maze procedure using catheters inside the heart that are passed through a vein in the groin without open heart surgery. Unfortunately, the success rate using the catheter is below 50% and complications (such as strokes) may occur.
  • Effectiveness of the Maze procedure: The Maze procedure done surgically (using open heart surgery) has been reported to correct atrial fibrillation in 90% to 99% of patients. Only 15% to 20% of the patients need a pacemaker after surgery, and there is only a 30% chance of requiring long-term medications to maintain a normal rhythm.
  • Risks of the Maze procedure: The surgical Maze procedure involves open heart surgery and the pumping of blood by an external bypass pump while the surgery is performed, much like patients undergoing cardiac bypass surgery. The complications are not insignificant and include stroke, bleeding, infection, and death. Therefore, doctors usually do not recommend a surgical Maze procedure for the treatment of atrial fibrillation unless the patient is undergoing open heart surgery for another condition (such as for coronary artery bypass or replacement or repair of a diseased heart valve).

What are the complications of atrial fibrillation?

  • Heart failure: If the heart is unable to pump an adequate amount of blood to the body, as in some people with atrial fibrillation, the body begins to compensate by retaining fluid. This can lead to a condition called heart failure. Heart failure results in the accumulation of fluid in the lower legs (edema) and the lungs (pulmonary edema). Pulmonary edema makes breathing more difficult and reduces the ability of the lung to add oxygen to and remove carbon dioxide from the blood. The levels of oxygen in the blood can drop, and the levels of carbon dioxide in the blood can increase, a complication called respiratory failure. This is a life-threatening complication. In patients with underlying heart disease, the development of AFib may result in up to a 25% decrease in the pumping function of the heart.
  • Stroke: Quivering of the atria in atrial fibrillation causes blood inside the atria to stagnate. Stagnant blood tends to form blood clots along the walls of the atria. Sometimes, these blood clots dislodge, pass through the ventricles, and lodge in the brain, lungs, and other parts of the body. This process is called embolization. One common complication of AFib is a blood clot that travels to the brain and causes the sudden onset of one-sided paralysis of the extremities and/or the facial muscles (an embolic stroke). A blood clot that travels to the lungs can cause injury to the lung tissues (pulmonary infarction), and symptoms of chest pain and shortness of breath. When blood clots travel to the body's extremities, cold hands, feet, or legs may occur suddenly because of the lack of blood.
Reviewed on 1/30/2017
References
REFERENCES:

Kumar, K., MD. "Overview of atrial fibrillation." UpToDate. Updated: Sep 21, 2016.
<http://www.uptodate.com/contents/overview-of-atrial-fibrillation>

Wann, Samuel L., et al. "2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 57.2 (2011): 223-242.

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