Surgical Treatment for Atrial Fibrillation

WebMD Live Events Transcript

Atrial fibrillation (AF) is the most common form of irregular heartbeat and affects about 2.2 million Americans. People with atrial fibrillation are at increased risk for life-threatening strokes. In addition, AF can damage the heart and lead to heart attack and heart failure. Cleveland Clinic heart surgeon A. Marc Gillinov, MD, joined us on Feb. 1, 2005 to discuss the latest surgical techniques for treating AF and restoring normal cardiac rhythm.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live Dr. Gillinov. Please begin by telling us about the Cleveland Clinic Heart Center.

GILLINOV:
The Cleveland Clinic is the largest cardiac surgery and cardiology surgery program in North America. We treat all forms of cardiovascular disease and have particular expertise in the treatments of atrial fibrillation (AF) and heart valve disease.

MEMBER QUESTION:
I have had persistent atrial fibrillation for one year, no other health problems and I am 81 years old. I do not like the effects of the medications. Does my age present a barrier to having the procedure (ablation, minimally invasive)?

GILLINOV:
Ablation is occasionally indicated in people over the age of 80. Such an individual should consider ablation only if the atrial fibrillation is very symptomatic or the patient has suffered a stroke from the atrial fibrillation.

"The natural history of untreated atrial fibrillation is that it becomes more frequent until it is present all the time."

MEMBER QUESTION:
What are the risks of ablation, and rates of occurrence?

GILLINOV:
Ablation is a general term used to describe a procedure to cure atrial fibrillation. The procedure may be performed with minimally invasive surgery or in some cases, with a catheter. The ablation procedure creates areas of conduction block in the heart. The success rate in people with intermittent atrial fibrillation is about 80%. The success rate for people who are in continuous atrial fibrillation is about 70%.

MEMBER QUESTION:
I am a 45-year-old male with occasional atrial fibrillation. I have had it for about 10 years. If it is occasional do I need to get it fixed surgically? I take no medicines for it.

GILLINOV:
If the atrial fibrillation only occurs occasionally and does not cause severe symptoms and has not caused a stroke, then it does not require an intervention like ablation. However, it would generally be wise to take aspirin in this instance.

MEMBER QUESTION:
Does atrial fibrillation get worse over time?

GILLINOV:
Yes. The natural history of untreated atrial fibrillation is that it becomes more frequent until it is present all the time. Atrial fibrillation decreases heart function and it is associated with a risk of stroke. The longer a person is in atrial fibrillation the greater the cumulative risks of decreased heart function and stroke.

MEMBER QUESTION:
When does a person decide that surgery is necessary to correct AF?

GILLINOV:
Surgery, which is usually minimally invasive surgery, should be an option when medical therapy has failed. So, if a person continues to have symptomatic atrial fibrillation or has a stroke on good medical therapy, it's time to think about other options. Another reason might be if a person does not wish to take lifelong medications. As we all know, these medications can have serious side effects, and it is often undesirable to be on such medicines for decades.

MEMBER QUESTION:
I am currently on medication for AF, including amiodarone. The more I read about it, the less I like it. I'm wondering if down the road sometime I will need some surgical procedure. Will having taken the amiodarone be a risk as it stays in your system, or can, for years?

GILLINOV:
Amiodarone is the most effective medication for treating atrial fibrillation. Unfortunately, it also has the greatest number of side effects. Long-term treatment with amiodarone, meaning over the course of years, is a very unfavorable situation. Being on amiodarone does not complicate the minimally invasive surgery, but being on amiodarone for years and years is almost certain to result in complications.

"You should only consider having an intervention for the atrial fibrillation if the atrial fibrillation is causing a problem for you."

MEMBER QUESTION:
Do you think medication should be tried and exhausted before ablation is performed?

GILLINOV:
We think that medication should be tried before ablation. However, if a patient fails two or three different medicines, we would then consider going on to ablation. A person need not try every single medicine before considering curative therapy.

MEMBER QUESTION:
I am anxious about having anything done to fix my atrial fibrillation; scared might be more accurate. Can you offer any advice to ease my fears?

GILLINOV:
Yes. You should only consider having an intervention for the atrial fibrillation if the atrial fibrillation is causing a problem for you. If you are having symptoms or cannot tolerate the medicines or have had complications like a stroke, then you should think about a form of ablation. On the other hand, if you are asymptomatic and tolerating Coumadin or another anticoagulant, it is reasonable to consider this continued medical therapy.

MEMBER QUESTION:
If you have the ablation, should you be able to stop taking the medications?

GILLINOV:
If a person has ablation and at six months after the procedure we document no atrial fibrillation, then we stop the medications.

MEMBER QUESTION:
What do you mean by minimally invasive surgery?

GILLINOV:
The minimally invasive surgery is performed with scopes or keyhole type incisions. It does not require a large incision, nor does it require use of the heart/lung machine.

MEMBER QUESTION:
Is it likely that surgery will become a first line of defense against atrial fibrillation, to cure it, instead of being on meds forever? I'm 47 and don't want to take warfarin and Tambocor the rest of my life for my occasional AF.

GILLINOV:
Many people are now considering earlier minimally invasive surgery. It is always appropriate to try medicines first, but for the reasons we reviewed earlier, many people are now leaning toward earlier curative procedures.

"Atrial fibrillation has many risk factors for its development."

MEMBER QUESTION:
What is your opinion of flecanide as a long-term treatment?

GILLINOV:
Flecanide is an appropriate medical treatment for atrial fibrillation and is successful in many people. It has an acceptable risk profile for long-term use.

MEMBER QUESTION:
Could atrial fibrillation be caused or worsened by a person being overweight most of their life?

GILLINOV:
Atrial fibrillation has many risk factors for its development. Obesity alone is usually not an important risk factor. Advanced age, high blood pressure, heart failure, and valvular heart disease are more common in patients with atrial fibrillation.

MEMBER QUESTION:
If the atrium stretched out due to being overweight for 20 years, will becoming thin relieve the atrial fibrillation?

GILLINOV:
Being overweight does not cause the atrium to stretch out. Losing weight will probably not make the atrial fibrillation go away, but of course there are a lot of good reasons to get in shape.

MEMBER QUESTION:
Have you seen an association with low-carb diets and atrial fibrillation?

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?

GILLINOV:
In most people with atrial fibrillation, Coumadin is far more effective than is aspirin in preventing stroke. Only selected patients with atrial fibrillation should receive aspirin alone.

MEMBER QUESTION:
What are the downsides of minimally invasive approaches (if any) which are not present on open heart (Maze) procedures for AF?

GILLINOV:
The Maze procedure is the most effective curative treatment for atrial fibrillation, and we have one of the world's largest experiences with this operation. However, the Maze procedure is open heart surgery and requires use of the heart/lung machine. It takes four to six weeks to recover fully from the operation. Of course, after recovery, most patients have a lifetime of normal heart rhythm. All of the minimally invasive approaches are slightly less effective than the Maze procedure, but they are also less invasive. It is important for a person with atrial fibrillation to go to a center where all of these options are available.

MEMBER QUESTION:
How many ablations does Cleveland Clinic do each year?

GILLINOV:
Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques. This includes people having Maze procedures, minimally invasive surgery procedures and catheter based procedures.

MODERATOR:
Can you describe what you do during a minimally invasive procedure?

GILLINOV:
Depending upon the patient, we will choose one of two minimally invasive approaches. One approach is performed completely with endoscopes, and therefore has only very small incisions. The left atrial appendage is removed with a special stapler. In the other minimally invasive approach, small keyhole incisions are made, one on each side of the chest, and the ablation performed. The left atrial appendage is removed with this technique as well. Currently only surgical approaches enable removal of the left atrial appendage. This is important because strokes in people with atrial fibrillation come from blood clots in the left atrial appendage.

"Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques."

MEMBER QUESTION:
I have premature ventricular contractions (PVCs) and my doctor is recommending ablation and/or mexiletine. The medicine concerns me because I read where side effects could be seizure. I was concerned about the ablation because I didn't know if the scar tissue would cause any hardness on the heart. My PVCs are back to back.

  • I have had an angiogram - no blockage
  • I have had the vein Doppler - no blood clots
  • I have had an MRI - no congenital disease
Regarding the PVCs, the doctor said that the bottom part of my heart was jumping in before the top part could finish its beat.

GILLINOV:
PVCs are different from atrial fibrillation (AF). PVCs arise in the ventricles rather than the atria. If PVCs are asymptomatic or minimally symptomatic they generally require no treatment. If the PVCs are symptomatic, medical therapy is appropriate before considering ablation. Mexiletine and other drugs are appropriate options.

MODERATOR:
We are almost out of time, Dr. Gillinov. Before we wrap things up for today, do you have any final words for us?

GILLINOV:
At the Cleveland Clinic we are committed to the development and implementation of new cures for atrial fibrillation. We have a multidisciplinary team of cardiac surgeons, cardiologists and nurses that examines every patient carefully and chooses the best treatment option with that patient. For more information you can contact us at www.clevelandclinic.org/heartcenter or our toll free number is 1-866-289-6911.

MODERATOR:
Our thanks to A. Marc Gillinov, MD, for joining us today. And thanks to you, members for your great questions. I'm sorry we couldn't get to all of them.

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?

GILLINOV:
In most people with atrial fibrillation, Coumadin is far more effective than is aspirin in preventing stroke. Only selected patients with atrial fibrillation should receive aspirin alone.

MEMBER QUESTION:
What are the downsides of minimally invasive approaches (if any) which are not present on open heart (Maze) procedures for AF?

GILLINOV:
The Maze procedure is the most effective curative treatment for atrial fibrillation, and we have one of the world's largest experiences with this operation. However, the Maze procedure is open heart surgery and requires use of the heart/lung machine. It takes four to six weeks to recover fully from the operation. Of course, after recovery, most patients have a lifetime of normal heart rhythm. All of the minimally invasive approaches are slightly less effective than the Maze procedure, but they are also less invasive. It is important for a person with atrial fibrillation to go to a center where all of these options are available.

MEMBER QUESTION:
How many ablations does Cleveland Clinic do each year?

GILLINOV:
Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques. This includes people having Maze procedures, minimally invasive surgery procedures and catheter based procedures.

MODERATOR:
Can you describe what you do during a minimally invasive procedure?

GILLINOV:
Depending upon the patient, we will choose one of two minimally invasive approaches. One approach is performed completely with endoscopes, and therefore has only very small incisions. The left atrial appendage is removed with a special stapler. In the other minimally invasive approach, small keyhole incisions are made, one on each side of the chest, and the ablation performed. The left atrial appendage is removed with this technique as well. Currently only surgical approaches enable removal of the left atrial appendage. This is important because strokes in people with atrial fibrillation come from blood clots in the left atrial appendage.

"Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques."

MEMBER QUESTION:
I have premature ventricular contractions (PVCs) and my doctor is recommending ablation and/or mexiletine. The medicine concerns me because I read where side effects could be seizure. I was concerned about the ablation because I didn't know if the scar tissue would cause any hardness on the heart. My PVCs are back to back.

  • I have had an angiogram - no blockage
  • I have had the vein Doppler - no blood clots
  • I have had an MRI - no congenital disease
Regarding the PVCs, the doctor said that the bottom part of my heart was jumping in before the top part could finish its beat.

GILLINOV:
PVCs are different from atrial fibrillation (AF). PVCs arise in the ventricles rather than the atria. If PVCs are asymptomatic or minimally symptomatic they generally require no treatment. If the PVCs are symptomatic, medical therapy is appropriate before considering ablation. Mexiletine and other drugs are appropriate options.

MODERATOR:
We are almost out of time, Dr. Gillinov. Before we wrap things up for today, do you have any final words for us?

GILLINOV:
At the Cleveland Clinic we are committed to the development and implementation of new cures for atrial fibrillation. We have a multidisciplinary team of cardiac surgeons, cardiologists and nurses that examines every patient carefully and chooses the best treatment option with that patient. For more information you can contact us at www.clevelandclinic.org/heartcenter or our toll free number is 1-866-289-6911.

MODERATOR:
Our thanks to A. Marc Gillinov, MD, for joining us today. And thanks to you, members for your great questions. I'm sorry we couldn't get to all of them.

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?

GILLINOV:
In most people with atrial fibrillation, Coumadin is far more effective than is aspirin in preventing stroke. Only selected patients with atrial fibrillation should receive aspirin alone.

MEMBER QUESTION:
What are the downsides of minimally invasive approaches (if any) which are not present on open heart (Maze) procedures for AF?

GILLINOV:
The Maze procedure is the most effective curative treatment for atrial fibrillation, and we have one of the world's largest experiences with this operation. However, the Maze procedure is open heart surgery and requires use of the heart/lung machine. It takes four to six weeks to recover fully from the operation. Of course, after recovery, most patients have a lifetime of normal heart rhythm. All of the minimally invasive approaches are slightly less effective than the Maze procedure, but they are also less invasive. It is important for a person with atrial fibrillation to go to a center where all of these options are available.

MEMBER QUESTION:
How many ablations does Cleveland Clinic do each year?

GILLINOV:
Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques. This includes people having Maze procedures, minimally invasive surgery procedures and catheter based procedures.

MODERATOR:
Can you describe what you do during a minimally invasive procedure?

GILLINOV:
Depending upon the patient, we will choose one of two minimally invasive approaches. One approach is performed completely with endoscopes, and therefore has only very small incisions. The left atrial appendage is removed with a special stapler. In the other minimally invasive approach, small keyhole incisions are made, one on each side of the chest, and the ablation performed. The left atrial appendage is removed with this technique as well. Currently only surgical approaches enable removal of the left atrial appendage. This is important because strokes in people with atrial fibrillation come from blood clots in the left atrial appendage.

"Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques."

MEMBER QUESTION:
I have premature ventricular contractions (PVCs) and my doctor is recommending ablation and/or mexiletine. The medicine concerns me because I read where side effects could be seizure. I was concerned about the ablation because I didn't know if the scar tissue would cause any hardness on the heart. My PVCs are back to back.

  • I have had an angiogram - no blockage
  • I have had the vein Doppler - no blood clots
  • I have had an MRI - no congenital disease
Regarding the PVCs, the doctor said that the bottom part of my heart was jumping in before the top part could finish its beat.

GILLINOV:
PVCs are different from atrial fibrillation (AF). PVCs arise in the ventricles rather than the atria. If PVCs are asymptomatic or minimally symptomatic they generally require no treatment. If the PVCs are symptomatic, medical therapy is appropriate before considering ablation. Mexiletine and other drugs are appropriate options.

MODERATOR:
We are almost out of time, Dr. Gillinov. Before we wrap things up for today, do you have any final words for us?

GILLINOV:
At the Cleveland Clinic we are committed to the development and implementation of new cures for atrial fibrillation. We have a multidisciplinary team of cardiac surgeons, cardiologists and nurses that examines every patient carefully and chooses the best treatment option with that patient. For more information you can contact us at www.clevelandclinic.org/heartcenter or our toll free number is 1-866-289-6911.

MODERATOR:
Our thanks to A. Marc Gillinov, MD, for joining us today. And thanks to you, members for your great questions. I'm sorry we couldn't get to all of them.

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?

GILLINOV:
In most people with atrial fibrillation, Coumadin is far more effective than is aspirin in preventing stroke. Only selected patients with atrial fibrillation should receive aspirin alone.

MEMBER QUESTION:
What are the downsides of minimally invasive approaches (if any) which are not present on open heart (Maze) procedures for AF?

GILLINOV:
The Maze procedure is the most effective curative treatment for atrial fibrillation, and we have one of the world's largest experiences with this operation. However, the Maze procedure is open heart surgery and requires use of the heart/lung machine. It takes four to six weeks to recover fully from the operation. Of course, after recovery, most patients have a lifetime of normal heart rhythm. All of the minimally invasive approaches are slightly less effective than the Maze procedure, but they are also less invasive. It is important for a person with atrial fibrillation to go to a center where all of these options are available.

MEMBER QUESTION:
How many ablations does Cleveland Clinic do each year?

GILLINOV:
Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques. This includes people having Maze procedures, minimally invasive surgery procedures and catheter based procedures.

MODERATOR:
Can you describe what you do during a minimally invasive procedure?

GILLINOV:
Depending upon the patient, we will choose one of two minimally invasive approaches. One approach is performed completely with endoscopes, and therefore has only very small incisions. The left atrial appendage is removed with a special stapler. In the other minimally invasive approach, small keyhole incisions are made, one on each side of the chest, and the ablation performed. The left atrial appendage is removed with this technique as well. Currently only surgical approaches enable removal of the left atrial appendage. This is important because strokes in people with atrial fibrillation come from blood clots in the left atrial appendage.

"Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques."

MEMBER QUESTION:
I have premature ventricular contractions (PVCs) and my doctor is recommending ablation and/or mexiletine. The medicine concerns me because I read where side effects could be seizure. I was concerned about the ablation because I didn't know if the scar tissue would cause any hardness on the heart. My PVCs are back to back.

  • I have had an angiogram - no blockage
  • I have had the vein Doppler - no blood clots
  • I have had an MRI - no congenital disease
Regarding the PVCs, the doctor said that the bottom part of my heart was jumping in before the top part could finish its beat.

GILLINOV:
PVCs are different from atrial fibrillation (AF). PVCs arise in the ventricles rather than the atria. If PVCs are asymptomatic or minimally symptomatic they generally require no treatment. If the PVCs are symptomatic, medical therapy is appropriate before considering ablation. Mexiletine and other drugs are appropriate options.

MODERATOR:
We are almost out of time, Dr. Gillinov. Before we wrap things up for today, do you have any final words for us?

GILLINOV:
At the Cleveland Clinic we are committed to the development and implementation of new cures for atrial fibrillation. We have a multidisciplinary team of cardiac surgeons, cardiologists and nurses that examines every patient carefully and chooses the best treatment option with that patient. For more information you can contact us at www.clevelandclinic.org/heartcenter or our toll free number is 1-866-289-6911.

MODERATOR:
Our thanks to A. Marc Gillinov, MD, for joining us today. And thanks to you, members for your great questions. I'm sorry we couldn't get to all of them.

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?

GILLINOV:
In most people with atrial fibrillation, Coumadin is far more effective than is aspirin in preventing stroke. Only selected patients with atrial fibrillation should receive aspirin alone.

MEMBER QUESTION:
What are the downsides of minimally invasive approaches (if any) which are not present on open heart (Maze) procedures for AF?

GILLINOV:
The Maze procedure is the most effective curative treatment for atrial fibrillation, and we have one of the world's largest experiences with this operation. However, the Maze procedure is open heart surgery and requires use of the heart/lung machine. It takes four to six weeks to recover fully from the operation. Of course, after recovery, most patients have a lifetime of normal heart rhythm. All of the minimally invasive approaches are slightly less effective than the Maze procedure, but they are also less invasive. It is important for a person with atrial fibrillation to go to a center where all of these options are available.

MEMBER QUESTION:
How many ablations does Cleveland Clinic do each year?

GILLINOV:
Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques. This includes people having Maze procedures, minimally invasive surgery procedures and catheter based procedures.

MODERATOR:
Can you describe what you do during a minimally invasive procedure?

GILLINOV:
Depending upon the patient, we will choose one of two minimally invasive approaches. One approach is performed completely with endoscopes, and therefore has only very small incisions. The left atrial appendage is removed with a special stapler. In the other minimally invasive approach, small keyhole incisions are made, one on each side of the chest, and the ablation performed. The left atrial appendage is removed with this technique as well. Currently only surgical approaches enable removal of the left atrial appendage. This is important because strokes in people with atrial fibrillation come from blood clots in the left atrial appendage.

"Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques."

MEMBER QUESTION:
I have premature ventricular contractions (PVCs) and my doctor is recommending ablation and/or mexiletine. The medicine concerns me because I read where side effects could be seizure. I was concerned about the ablation because I didn't know if the scar tissue would cause any hardness on the heart. My PVCs are back to back.

  • I have had an angiogram - no blockage
  • I have had the vein Doppler - no blood clots
  • I have had an MRI - no congenital disease
Regarding the PVCs, the doctor said that the bottom part of my heart was jumping in before the top part could finish its beat.

GILLINOV:
PVCs are different from atrial fibrillation (AF). PVCs arise in the ventricles rather than the atria. If PVCs are asymptomatic or minimally symptomatic they generally require no treatment. If the PVCs are symptomatic, medical therapy is appropriate before considering ablation. Mexiletine and other drugs are appropriate options.

MODERATOR:
We are almost out of time, Dr. Gillinov. Before we wrap things up for today, do you have any final words for us?

GILLINOV:
At the Cleveland Clinic we are committed to the development and implementation of new cures for atrial fibrillation. We have a multidisciplinary team of cardiac surgeons, cardiologists and nurses that examines every patient carefully and chooses the best treatment option with that patient. For more information you can contact us at www.clevelandclinic.org/heartcenter or our toll free number is 1-866-289-6911.

MODERATOR:
Our thanks to A. Marc Gillinov, MD, for joining us today. And thanks to you, members for your great questions. I'm sorry we couldn't get to all of them.

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?

GILLINOV:
In most people with atrial fibrillation, Coumadin is far more effective than is aspirin in preventing stroke. Only selected patients with atrial fibrillation should receive aspirin alone.

MEMBER QUESTION:
What are the downsides of minimally invasive approaches (if any) which are not present on open heart (Maze) procedures for AF?

GILLINOV:
The Maze procedure is the most effective curative treatment for atrial fibrillation, and we have one of the world's largest experiences with this operation. However, the Maze procedure is open heart surgery and requires use of the heart/lung machine. It takes four to six weeks to recover fully from the operation. Of course, after recovery, most patients have a lifetime of normal heart rhythm. All of the minimally invasive approaches are slightly less effective than the Maze procedure, but they are also less invasive. It is important for a person with atrial fibrillation to go to a center where all of these options are available.

MEMBER QUESTION:
How many ablations does Cleveland Clinic do each year?

GILLINOV:
Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques. This includes people having Maze procedures, minimally invasive surgery procedures and catheter based procedures.

MODERATOR:
Can you describe what you do during a minimally invasive procedure?

GILLINOV:
Depending upon the patient, we will choose one of two minimally invasive approaches. One approach is performed completely with endoscopes, and therefore has only very small incisions. The left atrial appendage is removed with a special stapler. In the other minimally invasive approach, small keyhole incisions are made, one on each side of the chest, and the ablation performed. The left atrial appendage is removed with this technique as well. Currently only surgical approaches enable removal of the left atrial appendage. This is important because strokes in people with atrial fibrillation come from blood clots in the left atrial appendage.

"Overall, at the Cleveland Clinic, we perform about 1000 ablation procedures using all available techniques."

MEMBER QUESTION:
I have premature ventricular contractions (PVCs) and my doctor is recommending ablation and/or mexiletine. The medicine concerns me because I read where side effects could be seizure. I was concerned about the ablation because I didn't know if the scar tissue would cause any hardness on the heart. My PVCs are back to back.

  • I have had an angiogram - no blockage
  • I have had the vein Doppler - no blood clots
  • I have had an MRI - no congenital disease
Regarding the PVCs, the doctor said that the bottom part of my heart was jumping in before the top part could finish its beat.

GILLINOV:
PVCs are different from atrial fibrillation (AF). PVCs arise in the ventricles rather than the atria. If PVCs are asymptomatic or minimally symptomatic they generally require no treatment. If the PVCs are symptomatic, medical therapy is appropriate before considering ablation. Mexiletine and other drugs are appropriate options.

MODERATOR:
We are almost out of time, Dr. Gillinov. Before we wrap things up for today, do you have any final words for us?

GILLINOV:
At the Cleveland Clinic we are committed to the development and implementation of new cures for atrial fibrillation. We have a multidisciplinary team of cardiac surgeons, cardiologists and nurses that examines every patient carefully and chooses the best treatment option with that patient. For more information you can contact us at www.clevelandclinic.org/heartcenter or our toll free number is 1-866-289-6911.

MODERATOR:
Our thanks to A. Marc Gillinov, MD, for joining us today. And thanks to you, members for your great questions. I'm sorry we couldn't get to all of them.



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Last Editorial Review: 3/10/2005