HeartBeats Episode 2: Atrial Fibrillation (Part 2) Surgical Treatment for Afib

Welcome to HeartBeats. I’m Cathy Murtagh-Schaffer and I am your host for this episode of HeartBeats. This podcast is brought to you by Shipley Cardiothoracic Center - an educational series dedicated to providing our patients and the community with information and education about our Cardiothoracic Surgery program.

Today is the second part of a 2-part series on atrial fibrillation and we again have Dr. Paul DiGiorgi, a heart surgeon with Shipley Cardiothoracic Center and an expert in the surgical treatment of atrial fibrillation. Welcome back Dr. DiGiorgi, so glad you are able to be with us again to discuss this very important disease process.

1. Last time we talked a little bit about what atrial fibrillation is; would you mind just giving a brief synopsis of what afib is again please?

Atrial fibrillation is extremely common cardiac arrhythmia that essentially results in an irregular beating of the heart. There is a certain part of the heart, the Atria, which fibrillate instead of beat, that causes a host of problems including inefficient beating of the heart, it can cause leaky heart valves, it can cause congestive heart failure and cause stroke but it boils down to having certain chambers of the heart not beating correctly as well as called atrial fibrillation.

2. I think the big question on our listener’s minds is besides medicinal therapy and ablation what surgical therapies are available to treat atrial fibrillation?

When we talk about surgery for atrial fibrillation were essentially talking about a surgical version of what is done via the catheter ablation just on a larger scale. So, the original operation for atrial fibrillation was developed surgically and that is the original ablation, which was called MAZE procedure. The MAZE procedure was developed in the late 80s, essentially blocks all the areas in the heart that can generate atrial fibrillation. We talked about there being basically 6 areas, 3 on the left side 3 on the right side of the heart but the MAZE procedure is an ablation it’s done in the operating room by a heart surgeon and essentially creates an environment where the heart can restore itself to normal sinus rhythm and you block the areas that are trying to generate atrial fibrillation to heart.

(host) it's like putting up stop signs for the electrical current that goes through the heart is wrong direction

That's correct you're setting up a maze for virtual current flow properly without the interference of these rotors so to speak that are the cause of atrial fibrillation. They can still be there but there kept up at bay cause of the ablation lines that are essentially walling it off.

3. Approximately how many MAZE procedures has the team at Shipley done? Does Shipley have any outcomes data for the procedure and its success rate at terminating atrial fibrillation?

So here at the Shipley Cardiothoracic Center we’re one of the only centers that actually follows the outcomes of long-term in both MAZE patients and catheter ablation patients together. Together over the last four to five years we have done upwards of 1500 ablations for atrial fibrillation, probably in order of 800 catheter ablations and over 700 surgical ablations for atrial fibrillation. That's a large number and we also track those outcomes so I can tell you what our success rates are in day to day bases. We bring our patients back in and their information is put into our system. It's very unique to have both cardiologists and cardiac surgeons work so closely together on something like atrial fibrillation but our success is really predicated on our collaboration so that we understand what each of us brings to the table and we can provide the patient with what suits them best.

(host) Again I think this is just one of the wonderful concepts of Shipley Cardiothoracic and their team approach to care and without that I think your collaboration with the cardiologist and the surgeon and the group is a significant factor in the success rate you’ve had with your afib program.

It's true and in medicine in general as medicine gets more and more specialized every year we end up finding ourselves in smaller and smaller silos and it really does a disservice to the patient because you don't know what's happening next door. It's only through teamwork and collaboration that we can put together what we each of us bring to the table to best serve the patient.

(host) We talked a little bit about your outcomes data and the success rate of terminating afib. What follow-up is needed after the MAZE procedure?

So the follow up for the MAZE procedure is very important. It is one of the major determining factors of staying out of atrial fibrillation because people need to be checking on these things for you. So, typically what will happen is if you come in for surgery or catheter ablation you’ll be followed up on soon afterwards in the doctor’s office for your first post op check or follow up check. It is after that the longer term follow-up is very important and that's where you get into follow ups at three months and six months and annually with us because I'm definitely checking up on you in 12 months.

(host) so you follow these folks and through their lifetime Correct

(host) That's pretty significant. Yeah it's important for us to follow them because we can help with their treatment plans especially when it comes to come off blood thinners and we can know how good of a job that we're doing.

4. So at what point would patients come to you for a surgical consultation?

indications for surgery are for patients who have a symptomatic atrial fibrillation, that have failed both medicine and catheter ablation's or the patient failed medicine and they prefer to have surgery. Those are typically indications for surgical ablation.

(host) What if a patient just doesn't want to be on blood thinners? If the patient doesn't want to be on blood thinners they can seek out a watchman device, their EP cardiologists can insert those in their heart in the left atrial appendage. If there is the situation where the Watchman will not fit the patients will not be a candidate for Watchmen. Oftentimes, those patients are sent to us for left atrial appendage occlusion, which we do from the outside of the heart with a clip.

5. The clip sounds like it's a pretty important piece to all of this in particular I know it's significant in reducing strokes is the clip any better than the Watchmen Watchmen have more superiority over the clip? is there data to support that?

There is plenty of data out there to support both devices actually, the clip and Watchmen are similar in that they are both designed as devices to exclude the left atrial appendage, which is a blind sack on the back of the heart where strokes come from in atrial fibrillation. The Watchmen is unique in that it goes in over a wire from the leg into the heart without any incisions on the chest and it is deployed on the inside of the heart. That requires a certain period of blood thinners before and afterwards and follow up echo’s on those patients to make sure it's in place correctly and functioning way it needs to be that is the Watchman device. The clip that we put on the heart is a device we put on the outside of the heart surgically and it does require surgery all be it, usually a short stay for a day or so, but we go in through the chest not from the leg we deploy the clip on the outside of the heart. That clip is basically like paper clip that excludes the appendage from the outside. The important difference therapeutically for those patients is that it doesn't require any blood thinners before, during or after surgery and so in patients who are really at high risk for being on blood thinners, someone who had a life threatening bleed whether it was in their brain or GI track, they are usually the patients that are sent for clips over Watchmen typically because we know that we have a therapy that doesn't require any blood thinners that is very effective and so usually people get more comfortable trying to avoid another bleed in those situations.

6. The left atrial appendage clip seems to be a very important advancement in the prevention of stroke. Can you tell our listeners what a clip is and do you advise people who are having heart surgery to have a clip placed even if they don’t have atrial fib?

For some patients yes, it does reduce the risk of stroke in patients who have afib no question about that. We've looked at our own data and we had a fivefold reduction stroke in patients who had a clip placed. It's a tremendous reduction in stroke. If you look at the published data about clips in patients who have no history of atrial fibrillation that data has not been as robust and mainly because many of those patients are going to ever have atrial fibrillation in the first place. So, you're making that call at the time of surgery, deciding if this patient is at high risk potentially for afib afterwards, then those patients it is appropriate because it’s a lot easier to do it in 10 second while you’re there than to bring the patient back again for another procedure. So what surgeons will typically do is in patient who has no history for atrial fibrillation but they either feel they are at high risk for atrial fibrillation post op that may persist or in patients who they deem is not a good candidate for blood thinners postoperatively for whatever reason then they will prophylactically put on a clip so that if they do have afib and we feel that there's a higher chance they will have afib they can be protected both from stroke and from bleeding by not eating any blood thinners after surgery.

(host) It's a 2 for one and in that regards correct so the data is clear on patient that have atrial fibrillation it is associated with reduction of stroke and death long term and it is also felt prophylactically to be very helpful in patients who are high risk for stroke, afib and or bleeding.

7. This actually brings up a further question regarding the Left Atrial Appendage clip – if a patient with atrial fib were to only have a clip placed, would there be a need to continue blood thinners?

No, not for atrial fibrillation anyway. There are other reasons why people need blood thinners, if there is some sort of peripheral vascular disease problem or pulmonary embolism, many other reasons why patients would be candidates for blood thinners but as far as atrial fibrillation is concerned once that clip is on and the left atrial appendage is obliterated by any means, then the need for blood thinners obviated.

(host) Wow that's a pretty huge significant advance in the way we treat atrial fib and stroke risk I can remember when I first became a PA that that didn't exist per say, it wasn't something that we had data support. Well we have the data to show both almost all the strokes in afib come from the left atrial appendage, which is that little out patch in the back of the heart and we have increasing the robust data set to show that by getting rid of left atrial appendage will dramatically reduce risk of stroke in patients.

8. Is there anything else that you think our listeners should know about the MAZE procedure or atrial fib in general well?

Again treatment is never gone and there is always options for patients with atrial fibrillation and patients who are on blood thinners or have problems with blood thinners for any reason or have a stroke on blood thinners, there are options to get off of blood thinners and they should aggressively pursue those options whether they are presented to them initially or not. (host) I think that's a great message for us to send out is don't give up and keep searching.

Dr. DiGiorgi thank you so much for being here today – this has been such an eye-opening discussion. For our listeners please check out part 1 of our afib series and look for our other podcasts as well.

I’m Cathy Murtagh Schaffer and this has been HeartBeats, Shipley Cardiothoracic Center’s podcast dedicated to bringing research, innovation and education to our patients and the community.