Cleveland_Clinic_Host: Welcome Dr. Cummings and Dr. Gillinov and thank you for being with us today. Let's begin!

Speaker_-_Dr__Cummings: I am very happy to be here.

Pulmonary Vein Antrum Isolation - Ablation (PVI or PVAI)

heart24: What are the risks of pulmonary vein ablation and the rate of occurrence?

Speaker_-_Dr__Cummings: This is a relatively safe procedure with less than 1% chance of something bad happening. This includes death, heart attack, perforating the heart, emergency open heart surgery, esophageal fistula stroke or pulmonary vein stenosis or a serious vascular complication (bleeding problem where the IVs are placed in your leg). The rate of recurrence is what I think you meant. The success rate is about 80% after the first procedure. That means about 80% of people have no more atrial fibrillation and are on no medications after one procedure. There are certain characteristics (scar in the heart or large atrium or previous prosthetic valve surgery) that may increase your risk of recurrence.

 marybeth: If your atrium is enlarged, can pvi still be as successful? Is there a cut off that pvi wouldn't be offered?

Speaker_-_Dr__Cummings: We do not put a limit or finite number at which we do not offer an ablation. If the atrium is very enlarged it may affect the success or complication rate. I typically talk to my patients for a long time about their individual success rate and complication rate taking this type of number into consideration.

Speaker_-_Dr__Cummings: As an aside if the atrium is very very enlarged those patients may be a candidate for a surgical approach instead. That is why we do a team approach with Dr. Gillinov.

MMMontz: If a person taking digitalis and a beta blocker to curb a-fib wishes to try and correct a-fib by ablation or other procedures, under what conditions can a-fib NOT BE CORRECTED BY ABLATION?

Speaker_-_Dr__Cummings: Digitalis and beta blockers are good medicines for keeping your heart rate from being too fast in atrial fibrillation but do not really do much for preventing atrial fibrillation. There are other medications, depending on your individual characteristics, that can be tried. There are some characteristics of patients that decrease the success rate of ablation of atrial fibrillation. These characteristics include electrical scar found in the heart (the only way to know is to see it during an ablation) and prosthetic mitral valves with a very enlarged atrium. These affect the success rate a little bit depending on the patient - but are not absolute contraindications and we approach each patient individually when they come here.

Dipsydoodle: Your website states, "due to better treatment alternatives, AV node ablation is rarely used to treat atrial fibrillation." Question is: Would this be true if Cardiac Conversion, Cardiac ablation, and medications did not work?

Speaker_-_Dr__Cummings: AV nodal ablation is rarely used anymore because this is not a cure of atrial fibrillation. This just makes a patient permanently pacemaker dependent and keeps the heart beat from going too fast. The atrium remain in atrial fibrillation after an AV node ablation, the heart rate is just controlled by a pacemaker. Once an AV node ablation is done there is no way to regain the AV node function. Very rarely is AV node ablation an ideal solution but it is still used rarely in some situations as a last resort.

Cleveland_Clinic_Host: Dr. Cummings, some patients who have had AV nodal ablation still have symptoms of atrial fibrillation. Can you comment on that?

Speaker_-_Dr__Cummings: If a patient is still having symptoms of the atrial fibrillation after an AV node ablation we would still consider doing a PVI/Atrial fibrillation ablation on them. Though the AV node ablation will keep their heart rate slow it may not alleviate the symptoms of the fibrillating atrium. In these patients we still proceed with the ablation, though they will continue to be pacer dependent.

MMMontz: If a person had a-fib all his/her life, and had the mitral and aortic valves replaced with artificial valves, and had worse a-fib after all that, can correction of a-fib be done?

Speaker_-_Dr__Cummings: Wow. That is a lot for one person to go through. Experienced centers, like the Cleveland Clinic, are sometimes more comfortable performing an ablation on more complicated patients. We do atrial fibrillation ablations on patients with prosthetic valves - both mitral and aortic. The approach we use is through the septum so we can still do the procedure. These patients tend to have scar in their heart so their success rates are a little lower depending on their other characteristics. Here, we do not stop coumadin for the procedure so that is not a concern with the prosthetic valves. Sometimes even though AF ablation may have a lower success rate in these patients, often they are much better controlled and kept in sinus rhythm on medications that had previously not worked.

sensiblegirl: When do you know if you can have an ablation? Do you need to be on medications first for atrial fibrillation before you get one?

Speaker_-_Dr__Cummings: If you have atrial fibrillation and you are symptomatic, I would advise coming and speaking to an electro physiologist so they can go over all your options. Some more experienced centers are more comfortable doing procedures on more complex patients. Some insurance companies require people to try medications first and I often recommend trying at least one or two medications first. If you are intolerant of the medicine or it doesn’t work then ablation should be considered.

MMMontz: Are there any new advances to fixing a-fib or minimizing it better and what are they?

Speaker_-_Dr__Cummings: We are continually doing research to advance technology to curing atrial fibrillation. We actually received a grant from the state of Ohio to help us find new and innovative ways to do this called the Atrial Fibrillation Innovation Center. These innovations are growing rapidly and I always encourage people to keep tuned in for all these great advances. Already procedures are safer and more effective because of these innovations in both catheters and mapping technologies.

afibMichigan: I have had prior 2 PVI ablations for atrial fibrillation. The afib is returning again. Is this normal? Does PVI only last so long? Can you have too many ablations? Can the atrium be damaged from too much ablation scarring?

Speaker_-_Dr__Cummings: Unfortunately this is where it is difficult to make global statements for individual patients. About 20% of patients need to have a second procedure. It somewhat depends when your PVIs were done (because technology and our knowledge has improved over the years). Our data for PVI success rates are over several years of data now and have held firm at about 80% success rate. It would be important to go to a very experienced center to be evaluated and go through your individual experiences and procedures to really talk to you about your chances of success. Sometimes people need three or more procedures for success (but that is rare) - and occasionally these people can be considered for a surgical procedure.

SEAPANDA: following pulmonary vein-ablation for atrial fibrillation is , or how is anatrio-esophageal fistula ruled out?

Speaker_-_Dr__Cummings: Atrio-esophageal fistula is very rare with only 20-30 cases reported in the world. It typically presents a couple weeks after the procedure with fever and chills as well as stroke or heart attack. We do many different things during the procedure to make the procedure safer. Occasionally if someone has symptoms that are concerning we do a CT scan or an MRI to evaluate the esophagus. Using a EGD or large camera is not advised in these patients though there are small capsule cameras that are swallowed that can also be used in some patients that are symptomatic.

MMMontz: If a person has a lot of scar tissue in his heart, has an enlarged heart, has two artificial valves, is correction of a-fib possible?

Speaker_-_Dr__Cummings: I think this question must have come before my last answer? Though more complicated, yes correction of AF is possible.

marybeth: I read in your 2006 outcomes about Superior Vena Cava Isolation with atrial fibrillation nests. How often is the SVC included? What are Atrial fibrillation nests?

Speaker_-_Dr__Cummings: We include the SVC in all our atrial fibrillation ablations.

Speaker_-_Dr__Cummings: The concept of an atrial fibrillation nest is a little different. There are some studies that have found areas of tissue that may be considered "nests" that may participate in inducing atrial fibrillation. These nests can also be ablated. These are typically targeted in addition to a normal PVI in patients that are chronic or unsuccessful the first time.

MMMontz: If a heart ecg shows incomplete right bundle branch block, left anterior fascicular block, digitalis affected ST and T wave abnormality. and abnormal ECG, can a-fib be minimally or permanently fixed?

Speaker_-_Dr__Cummings: The right bundle and left anterior fascicular block along with the other findings on the ECG do not have any bearing on success with an ablation of AF.

Surgical ablation for atrial fibrillation

afib: When is surgical ablation indicated?

Dr__Gillinov: Surgical ablation is indicated in particular circumstances. If a patient is having valve or bypass surgery and also has atrial fibrillation, surgical ablation is indicated at the time of the other surgery. In patients without other indications for cardiac surgery, surgical ablation is indicated if 1) Drugs and catheter ablation have failed or 2) The patient has a history of stroke from atrial fibrillation or 3) There is a blood clot in the heart.

afibquestions: What is the Maze procedure?

Dr__Gillinov: The Maze procedure is an operation designed to cure atrial fibrillation. It is a type of ablation. It can be performed minimally invasively as a stand-alone procedure or along with other heart surgery.

atrialfib: What is the success rate of surgical ablation or a Maze procedure?

Dr__Gillinov: It ranges from 70% to 95%, depending upon patient characteristics.

aftermaze: I had a maze procedure but had atrial fibrillation in the first week after surgery. Is this a sign?

Dr__Gillinov: Early atrial fibrillation after ablation is very common, occurring in almost half of patients. It is almost always gone by 2 to 3 months after surgery.

atrialfibrillation: Can I have a surgical Maze procedure and will it work?

Dr__Gillinov: Yes. We have performed Maze procedures on many patients if a trial of catheter ablation was unsuccessful. The risk is very low, and the chance of success is greater than 80%.

Speaker_-_Dr__Cummings: Once again I think that because we have an Atrial Fibrillation Center where the electrophysiologists and the surgeons work together - it makes these kind of decisions and interactions easier.

aftermaze: What if I have atrial fibrillation 2 years after my Maze procedure?

Dr__Gillinov: We recommend a trial of drug therapy if this occurs. If troublesome atrial fibrillation recurs, catheter study and possible ablation are indicated.

atrialfibrillation: What sort of minimally invasive surgical approaches are available for ablation?

Dr__Gillinov: Currently available approaches include 1) A small right-sided incision (2-4 inches), 2) Small incisions on both the right and left sides, or 3) A small incision in the middle of the chest. The precise approach chosen with a patient depends upon the particular patient and what is most likely to be successful.

Left atrial appendage

stovskb: I have heard the left atrial appendage is important. Can you explain more? Do surgeons treat the left atrial appendage?

Dr__Gillinov: The left atrial appendage is a source of strokes in people with atrial fibrillation. During surgical ablation or a Maze procedure, the left atrial appendage is removed or excluded, reducing the life-time risk of stroke

marybeth: I understand that the left atrial appendage is thought to be a catalyst to the possibility of stroke. I know this can be removed in a surgical procedure. What options are there interventionally? ( I have heard of the watchman study. )

Speaker_-_Dr__Cummings: As Dr. Gillinov said, the left atrial appendage is a source of thrombus (blood clot) that can lead to stroke. In addition to what he mentioned above about removing them at the time of surgery, there are other ways to exclude the left atrial appendage. One way is through a minimally invasive clip put on the out side through a very small incision that is currently under investigation. The watchman study looked at a way to place a balloon like structure within the appendage from the inside of the heart to prevent blood clots from forming. The study is now closed to enrollment and we eagerly await the results.

Atrial Fibrillation and Atrial Flutter

shannon : What is the difference between atrial fibrillation and atrial flutter? are they treated the same way?

Speaker_-_Dr__Cummings: Atrial fibrillation is a very chaotic atrial beat and atrial flutter is a rapid but organized atrial beat. For the patient it often feels the same. They are treated the same in that they can increase your risk of stroke and cause rapid irregular heart beats. They often go hand in hand. They are a little different in how and where your doctor ablates within your heart to find them.

starlight: Can atrial fibrillation turn into a dangerous arrhythmia such as ventricular fibrillation?

Speaker_-_Dr__Cummings: Atrial fibrillation can very very rarely lead to ventricular fibrillation only in some patients with another condition called Wolf-Parkinson-White which allows for the rapid atrial fibrillation waves to conduct very rapidly to the ventricle through an accessory pathway. (Not even all patients with WPW are at risk) so this is a very rare phenomenon.

Medications and Atrial Fibrillation

richard: Some medications have a lot of side effects. What are the best medications to treat atrial fibrillation with the least side effects?

Speaker_-_Dr__Cummings: There are several medicines out there that treat atrial fibrillation. However they do have side effects. There is no “best” medicine for everybody in that some people may or may not be good candidates for some medicines. Some people respond differently than others to different medicine.

billc: If you have a-fib, can you take aspirin or do you need to take coumadin?

Speaker_-_Dr__Cummings: There are guidelines published by the ACC/AHA about which anticoagulant is acceptable for each patient. For young patients with no co-morbidities aspirin may be considered. However if a patient has even just high blood pressure as well as other risk factors for stroke coumadin should be considered. These guidelines are on the web for general access if you wish.

GI problems and atrial fibrillation

sunshine: I have heard that GI problems and reflux can cause atrial fibrillation or is connected to atrial fibrillation in some way? Can you comment on this? If you treat the reflux will you get rid of the atrial fibrillation?

Speaker_-_Dr__Cummings: No. Though, there have been reports of association of reflux and atrial fibrillation, there have been no real reports of curing atrial fibrillation by eliminating reflux.

Diet and atrial fibrillation

kovacsv: can diet help to reduce atrial fibrillation?

Speaker_-_Dr__Cummings: Though many people advocate certain supplements and dietary changes for atrial fibrillation, there are no large studies to confirm these reports. There are some studies that are evaluating omega 3 Fatty acids and atrial fibrillation, but that data is still pending.

Cleveland_Clinic_Host: Thanks for joining us everyone. If you missed any part of this chat, please check back soon for the full transcript at www.clevelandclinic.org/heart/webchat. And join us for our next chat with Dr. Lars Svensson discussing Aorta Surgery on July 11th. See you next time!

Speaker_-_Dr__Cummings: Thank you for having me.

Dr__Gillinov: It was my pleasure to be here.

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