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A 喵咪社区 cardiothoracic surgeon explains why epicardial ablation may be the right treatment for some patients with longstanding persistent AFib.

Atrial fibrillation (AFib) presents in different ways. Some patients are asymptomatic. Some have paroxysmal AFib, with arrhythmia symptoms happening for less than a week or so and then stopping either on their own or with intervention, for a stretch of time. Other patients have persistent AFib that lasts more than seven days but less than a year. Those with AFib for longer than a year are said to have longstanding persistent AFib. Symptomatic longstanding persistent AFib accounts for about 10%-20% of AFib cases.

Recommended treatments for AFib can vary depending on the type of physician a patient sees. They can include medication, endocardial ablation from an electrophysiologist or epicardial ablation from a cardiac surgeon.

One thing that鈥檚 important especially for patients with longstanding persistent AFib to know is that medication or endocardial ablation alone may not successfully resolve their problems. Surgery may be needed. Unfortunately, says Jonathan Praeger, MD, a cardiothoracic surgeon with the 喵咪社区 Cardiac and Vascular Institute, part of 喵咪社区, many patients 鈥� and even their physicians 鈥� know little about the surgical options for AFib and aren鈥檛 aware that it may be the best option for some patients.

Different treatments for AFib

Medications and/or endocardial ablations from an electrophysiologist are the most prescribed treatments for AFib. An internist might recommend medication to try to normalize a patient鈥檚 heart rate or rhythm. If this is unsuccessful or patients aren鈥檛 tolerating their medications, an electrophysiologist may use endocardial ablation to create scar tissue on veins or muscle tissue inside the heart that will hinder abnormal electrical signals. Techniques include cryoablation, radiofrequency ablation and pulsed field ablation.

Endocardial ablation is often quite successful in treating patients with paroxysmal AFib. It can, however, be unsuccessful in treating some patients with symptomatic longstanding persistent AFib.

鈥淒ata shows it doesn鈥檛 have great outcomes in getting these patients out of atrial fibrillation and helping them stay out of atrial fibrillation and get off antiarrhythmic medications,鈥� Praeger says.

For this reason, physicians should ensure that longstanding persistent AFib patients who may not be good candidates for endocardial ablation are aware there is another option 鈥� epicardial ablation.

A cardiac surgeon performs epicardial ablation on the heart muscle tissue from outside the heart. This procedure is minimally invasive. An ablation device is inserted into the pericardial space to target the origin of the arrythmia.

Including surgery in the discussion earlier on

Unfortunately, AFib patients and their physicians often don鈥檛 discuss surgery as a treatment option early on, Praeger says. 鈥淲hat usually ends up happening is that endocardial ablation from an electrophysiologist is tried multiple times to see if it will work for a patient with symptomatic longstanding persistent AFib. Surgery is only considered as a last resort.鈥�

After endocardial ablation is performed, evaluating its effects takes many months. There is, for instance, a 鈥渂lanking period鈥� of at least a few months required, only after which the electrophysiologist can start assessing whether treatment was impactful. While doctors wait to see whether endocardial ablation had an effect, longstanding persistent AFib patients continue to experience continual symptoms.

鈥淚t could take a year to complete two rounds of endocardial ablation, and during this time a patient would continue to be in AFib,鈥� Praeger says. Studies show the longer a patient remains in AFib, the lower the likelihood of treatment success, he points out. And, he adds, if a patient has already undergone multiple endocardial ablation procedures, it can be more difficult for a surgeon to operate later if previous procedures caused a lot of inflammation and scarring.

A better approach would be to ensure that treatment discussions, especially with symptomatic longstanding persistent AFib patients, address all alternatives, including medication, endocardial ablation and epicardial ablation surgery. Patients should be referred to a cardiac surgeon to learn about their surgical options directly, Praeger says. 鈥淚t at least warrants a discussion.鈥�

鈥淭o be clear,鈥� he continues, 鈥渨e鈥檙e talking about a specific subgroup of AFib patients. If someone could be treated with electrophysiology with equal success, I wouldn鈥檛 put them through surgery, even though both procedures are very low risk. I鈥檒l tell a patient if I think they should be referred to an electrophysiologist for endocardial ablation instead. A good surgeon will do their due diligence in determining whether a patient is truly an appropriate candidate for surgery.鈥�

Ideally, if needed, an electrophysiologist and cardiac surgeon can even take a hybrid approach, working on a patient concomitantly. 鈥淒ata has shown that if a patient has longstanding persistent atrial fibrillation, a hybrid approach has better outcomes over medication or endocardial ablation alone,鈥� Praeger says. In addition, if a cardiac surgeon is involved, they can evaluate whether a patient鈥檚 AFib is isolated or if there are other cardiovascular causes at hand, such as coronary or valvular disease, that should be surgically repaired.

Opening lines of communication

Moving forward, it鈥檚 important to educate not only patients (so they can make more informed treatment decisions) but also doctors 鈥� cardiologists, internists, ER doctors, 鈥渁ll doctors, to be honest,鈥� Praeger says. 鈥淚t鈥檚 a win-win for everyone because the likelihood of success for the patient is better.鈥�

Consulting a surgeon gives the patient the opportunity to ask the surgeon questions. 鈥淚t鈥檚 not uncommon for a non-surgeon to describe a procedure, but not in the right way, and the patient declines mostly because they didn鈥檛 receive accurate information,鈥� he says. 鈥淓ven physicians often don鈥檛 understand that the surgery we perform is minimally invasive, for instance. It鈥檚 not like the old days when you would have to do a sternotomy. I鈥檓 not trying to pull the wool over anyone鈥檚 eyes. But I can give you answers. I can tell you about what I do and don鈥檛 know. I鈥檓 talking about recommending surgery appropriately, including being straightforward about any risks.鈥�

Physicians might be surprised to learn how many longstanding persistent AFib patients might choose surgery if given the option.

鈥淣o questions asked, the AFib patients I鈥檝e treated who used to be symptomatic are the happiest patients I see. They say that surgery changed their life,鈥� Praeger says. 鈥淭hese are patients who just wanted their symptoms to end. They wanted to get off the medications if they were having trouble tolerating their medications. I鈥檝e had a couple of patients who were suicidal because of their AFib. It鈥檚 a miserable feeling for these people. It鈥檚 extremely life-limiting. Patients who want a long-lasting fix might jump at the opportunity for surgery if they know the option exists. At the end of the day, a lot of these patients are otherwise quite healthy people. They could be living an active life if it weren鈥檛 for AFib.鈥�

He concludes: 鈥淚n my opinion, it鈥檚 prudent to refer these patients to surgeons earlier in order to give patients all the alternatives that exist.鈥�

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Jennifer Grebow

Jennifer Grebow is the manager of editorial services at 喵咪社区.

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