Atrial Fibrillation Surgery

Atrial fibrillation (AF or AFib) is the most common abnormal heart rhythm. Atrial fibrillation is an irregular, frequently rapid heart rhythm originating in the atria (top chambers of the heart). Instead of the normal situation (normal sinus rhythm) in which a single impulse travels in an orderly fashion through the heart, in AF many impulses begin simultaneously and spread through the atria, causing a rapid and disorganized heartbeat. .

At one time, atrial fibrillation was thought to be a harmless annoyance. However, atrial fibrillation is now recognized as a dangerous condition. Atrial fibrillation doubles the risk of death. It also increases the risk of stroke five to seven times compared to a person without atrial fibrillation. In addition, atrial fibrillation may cause congestive heart failure and uncomfortable symptoms related to a rapid heart rate). Advances in ablation (both minimal invasive surgical and catheter) offer the possibility of cure to a large number of patients.

Medical Management of Atrial Fibrillation

Initially, medications are used to treat atrial fibrillation. Atrial fibrillation medications may include:

• Rhythm control medications (antiarrhythmic drugs)
• Rate control medications (to slow the heart rate)
• Warfarin - an anticoagulant or blood thinner to prevent blood clots and stroke

Surgical treatment for atrial fibrillation is considered when:

• Medical therapy does not effectively control or correct atrial fibrillation
• Medications for atrial fibrillation are not tolerated
• Anticoagulants (Warfarin) cannot be taken
• Blood clots, including strokes, occur
• At the same time as other heart surgery

Almost all operations on the heart will be performed under general anaesthetic. Your anaesthetist will review you before the operation and discuss the anaesthesia and the risks involved. The anaesthetist will outline what lines will be used for the procedure but usually these involve:

• A drip in your arm to put you to sleep
• A radial artery pressure monitoring line in your wrist
• An endotracheal tube (breathing tube) to help your breathing under anaesthesia
• A line in your neck to administer drugs
• A Transoesophageal (TOE) probe to assess your heart during surgery
• A catheter in your bladder
• Pad protection for your eyes

Minimally invasive surgery is an option for many patients with atrial fibrillation. Surgical treatment for atrial fibrillation also may be considered when surgery is needed to treat a coexisting heart condition, such as valve or coronary artery disease.

When patients with AF have valve or bypass surgery, surgeons create a classic Maze lesion set on the heart using either radiofrequency energy or cryothermy. This generally adds 15 minutes to the operative procedure and does not increase operative risk. Sinus rhythm is restored in 75% to 85% of patients, depending upon patient characteristics.

Selected patients with valvular heart disease and atrial fibrillation may be candidates for a minimally invasive approach that enables treatment of both conditions.

Often a occlusion device or suture is used to obliterate a small sac in your heart called the left atrial appendage. This is where the majority of clot forms when AF occurs and therefore it is sensible to obliterate this area during the operation, which in turn, reduces the risk of stroke.

After your operation you will be moved to intensive care for close monitoring until you wake up. The intensive care staff will only wake you once they are satisfied that you are stable. When you wake up you will notice that you still have the various lines inserted by the anaesthetist at the start of the operation but not the TOE probe.

Pain is usually controlled with strong painkillers in the first 24-48 hours after the operation, but most patients find that the chest wound is comfortable after that with only paracetamol required to ease the discomfort.

You will also notice some drains at the bottom of your wound that help monitor any bleeding that invariably happens to a degree after heart surgery as the blood can be very thin and may not clot (stop bleeding) properly after surgery. Occasionally if there is excessive drainage from the tubes before you wake up, then the surgeon may decide to take you back to theatre to reopen the wound and wash out the area around your heart. Whilst the surgeon hopes not to have to do this, it is always safer to do this if needed. The drains are usually removed on the first or second day after the operation.

You may also notice thin wires near the drains called pacing wires. These are often placed onto the surface of your heart at the end of the operation to help regulate the heart rate. They are attached to a device called a pacing box which provides the electrical stimulus to regulate the heart rate during recovery. If they are no longer needed, then they are removed on the third or fourth day after surgery. Occasionally, if they are still needed after four or five days, a permanent pacemaker will be fitted before you leave for home. Your heart surgeon and cardiologist will discuss this with you if needed.

Once your condition is stable, you will be moved to the high dependency unit or the cardiac ward. You should be out of bed in a day or two and return home after a week, with full recovery after two or three months depending on your fitness, age and how complex the operation was.

The goals of treatment for atrial fibrillation include regaining a normal heart rhythm (sinus rhythm), controlling the heart rate, preventing blood clots and reducing the risk of stroke.

All of these reduce the risk of heart failure and may also mean a reduction in your medication usually required to control AF.

The risk of the additional operative time is usually negligible and does not increase the risk of the operation. You can always discuss these details with your surgeon.

In many hospitals, after a heart operation, a member of the cardiac rehabilitation team will see you on the ward to give you information about your condition and the treatment you have had.

They will talk to you about making lifestyle changes and how to reduce your risk factors (the things that increase your risk of heart disease) to help protect your heart in the future. You can also ask the rehabilitation staff any questions about your recovery.

There are a number of options for treating Atrial Fibrillation.

1. Medication – If you choose not to want any intervention on your heart then medication can help control a number of the symptoms. Medication may help your heart return to a regular rhythm, however, the longer you have had AF, then the more unlikely it is that medication alone will succeed in restoring a normal heartbeat. Many patients will however benefit from continuing with medication alone.
2. Catheter Ablation – This is a cardiology procedure where catheters are inserted inside the heart to ablate the abnormal electrical pathways in the same way that open surgery does. This is less invasive but does not address other heart problems such as valve disease.
   
   Often, people referred for AF surgery, have already had medication and catheter ablation but have been unsuccessful in having a normal heart rhythm restored.

DOCUMENT