Atrial Fibrillation: Surgical Treatments (cont.)

GILLINOV:
No.

MEMBER QUESTION:
Since onset of my AF I have felt so terribly bad, with inability to have an interest in anything or to have any initiative. This seems to be the fibrillation with reduced output plus effect of beta blockers. Does this type of symptomology, which is really important, at any time amount to an indication for ablation?

GILLINOV:
Yes, it can. If the person is in reasonably good shape otherwise, and the medicines are not tolerated, then it is worth considering minimally invasive approaches to ablation.

MEMBER QUESTION:
I was recently diagnosed with AF (2 weeks ago), but my cardiologist believes I have been in and out of AF since I had viral myocarditis 11 years ago. Is there a certain time period to let the medications work? I am 53 and don't want to be on Lanoxin, Cardizem, Coumadin and aspirin therapy any longer than necessary. But obviously, I have a tendency to go back in AF. Your opinion?

GILLINOV:
We think that somebody should try medications for at least six months before considering surgery. If a low dose of medication taken daily eliminates the problem, meaning the atrial fibrillation, we would recommend continuing that strategy. On the other hand, if after six months after trying multiple medicines a person is still not controlled, it would be advisable to think about minimally invasive approaches to cure fibrillations.

"The physical characteristics of an ideal patient include normal body weight, good cardiac function, and a left atrium that is less than six centimeters in diameter."

MEMBER QUESTION:
Who is the ideal candidate for surgery?

GILLINOV:
The ideal candidate for surgery is the person who has the most to gain by cure of atrial fibrillation, so the ideal candidate would be highly symptomatic or would have had side effects from drugs or would have had a stroke. The physical characteristics of an ideal patient include normal body weight, good cardiac function, and a left atrium that is less than six centimeters in diameter. In addition, patients who require heart surgery for other reasons, like bypass surgery or valve surgery, who also have atrial fibrillation, undergo correction of both problems at the Cleveland Clinic.

MEMBER QUESTION:
I have heard about a procedure called Micro-Maze which is used to correct AF. What can you tell me about it and does the Cleveland Clinic offer this procedure?

GILLINOV:
There are a variety of terms used to describe the minimally invasive approaches. I am not certain what Micro-Maze refers to, however the minimally invasive approaches in use include those with endoscopes and those with keyhole type incisions. All of these are offered at the Cleveland Clinic.

MEMBER QUESTION:
What about radio frequency catheter ablation of the smooth muscles in the pulmonary veins? What is cure rate versus having to stent the veins due to scarring?

GILLINOV:
One ablation approach for atrial fibrillation involves the use of catheters placed inside the heart by an electrophysiologist. Through the catheters, radio frequency energy is delivered to create scar tissue inside the heart. The scar tissue blocks abnormal conduction of atrial fibrillation. This catheter-based procedure is challenging and time consuming. It is available in a few major medical centers. One risk of the procedure is damage to the pulmonary veins. Damage to these veins is a serious complication that can occur. With the minimally invasive surgical approaches, we have not had this complication.

MEMBER QUESTION:
If AF is corrected would it make heart failure conditions better?

GILLINOV:
AF is common in patients with heart failure. Cure of the atrial fibrillation in heart failure patients usually does improve their clinical course.

MEMBER QUESTION:
Is minimally invasive surgery the same as cardioversion?

GILLINOV:
No. Cardioversion is the use of electrical stimulation to restore normal heart rhythm. Cardioversion is what you see on TV when somebody says, "Give me the paddles." Then they yell, "Clear." That is different from minimally invasive surgery or catheter-based ablation.

"In most people with atrial fibrillation, Coumadin is far more effective than is aspirin in preventing stroke."

MEMBER QUESTION:
In the UK, so I heard on a radio doctor's show, the primary blood thinner prescribed for AF is aspirin as opposed to Coumadin, supposedly due to the pressure of socialized medicine. What are the increased risk factors to prescribing aspirin instead of Coumadin?



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