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Surgical Treatments for Atrial Fibrillation

Are there alternative treatments for Atrial Fibrillation for those with HCM?

Yes, Pulmonary vein ablation – or PVAI and MAZE procedures have been used with success in patients with persistent atrial fibrillation. The information below has been taken in part from the Cleveland Clinics website. 

 What is pulmonary vein antrum isolation?


Research has shown that almost all atrial fibrillation signals come from the four pulmonary veins. Pulmonary vein antrum isolation (PVAI), also called pulmonary vein ablation, is a treatment for atrial fibrillation. During PVAI, a doctor inserts catheters into the blood vessels of the atrium.
 
A special machine delivers energy through the catheters to the area of the atria that connects to the pulmonary vein (ostia). This energy (ablation) produces a circular scar that blocks any impulses firing from within the pulmonary vein, thereby “disconnecting” the pathway of the abnormal rhythm and preventing atrial fibrillation. In some cases, ablation also may be performed in other parts of the heart such as the superior vena cava.
 

How successful is PVAI in treating atrial fibrillation in HCM?

Success rates for PVAI are defined as restoring a patient’s normal sinus rhythm while not being dependent on medications to control the heart rhythm. In the general population pulmonary vein isolation has an 80 to 85 percent success rate with the first ablation. For those who have returned for further ablation, the success rate has been 95 percent. The success rate in the HCM population is less clear but believed to be significantly lower then the non HCM population.
 

What is a MAZE procedure and how is it done?


An incision is made along the sternum (breast bone). This may be a traditional incision, or in some cases, a minimally invasive incision may be used. The heart-lung machine oxygenates the blood and circulates it throughout the body during surgery.
Certain patients with isolated atrial fibrillation, especially continuous atrial fibrillation and/or enlarged atria, are candidates for the Maze procedure. This procedure can treat the atrial fibrillation and restore the atria to a more normal size.
 
During the Maze procedure, a series of precise incisions, or Cryoablation,  are made in the right and left atria to interrupt the conduction of abnormal impulses. This allows sinus impulses to travel to the atrioventricular node (AV node) as they normally should.
The Maze procedure has been very successful with a 98% success rate in “lone atrial fibrillation” patients and a 90% success rate overall. Post -procedure freedom from stroke has been over 99%.
For patients who require other forms of heart surgery, surgeons may perform either a classic Maze procedure or a modified Maze procedure. The classic Maze procedure cures atrial fibrillation in more than 90 percent of patients, but requires about one hour to complete. In most patients who are having additional heart surgery, the surgeon chooses to perform a modified Maze procedure.
 

Outcome:

  • Improvements in surgical techniques over the years have produced successful results in most patients:
  • Long-term freedom from atrial fibrillation
  • Decreased symptoms
  • Greatly reduced embolic events (such as blood clots or stroke)
  • Decreased atrial (top chamber of the heart) size in those with enlarged atria pre-surgery, particularly those who undergo Maze procedure with mitral valve repair procedure.
Success with the MAZE procedure in HCM patients has been seen however, the numbers are very small in any one center. 
 
Several HCM Centers have had successful MAZE in HCM, due to the relatively new data exact numbers are not available. If you have atrial fibrillation and are going to have a myectomy, discuss the Maze procedure with your surgeon to decide if it is right for you.  



Citations:

American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines.Maron BJ, McKenna WJ, Danielson GK, Kappenberger LJ, Kuhn HJ, Seidman CE, Shah PM, Spencer WH 3rd, Spirito P, Ten Cate FJ, Wigle ED; Task Force on Clinical Expert Consensus Documents. American College of Cardiology; Committee for Practice Guidelines. European Society of Cardiology.J Am Coll Cardiol. 2003 Nov 5;42(9):1687-713
Hypertrophic Cardiomyopathy for Patients, Their Families and Interested Physicians Second Edition: Maron and Salberg, Wiley publishing 2006
Effectiveness of atrial fibrillation surgery in patients with hypertrophic cardiomyopathy.Chen MS, McCarthy PM, Lever HM, Smedira NG, Lytle BL.Am J Cardiol. 2004 Feb 1;93(3):373-5
Five-year experience with the maze procedure for atrial fibrillation.Cox JL, Boineau JP, Schuessler RB, Kater KM, Lappas DG. Ann Thorac Surg. 1993 Oct;56(4):814-823
Substrate and procedural predictors of outcomes after catheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy.Bunch TJ, Munger TM, Friedman PA, Asirvatham SJ, Brady PA, Cha YM, Rea RF, Shen WK, Powell BD, Ommen SR, Monahan KH, Haroldson JM, Packer DL.J Cardiovasc Electrophysiol. 2008 Oct;19(10):1009-14
Usefulness and safety of transcatheter ablation of atrial fibrillation in patients with hypertrophic cardiomyopathy.Gaita F, Di Donna P, Olivotto I, Scaglione M, Ferrero I, Montefusco A, Caponi D, Conte MR, Nistri S, Cecchi F. Am J Cardiol. 2007 Jun 1;99(11):1575-81 
Efficacy of catheter ablation of atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy.Kilicaslan F, Verma A, Saad E, Themistoclakis S, Bonso A, Raviele A, Bozbas H, Andrews MW, Beheiry S, Hao S, Cummings JE, Marrouche NF, Lakkireddy D, Wazni O, Yamaji H, Saenz LC, Saliba W, Schweikert RA, Natale A.Heart Rhythm. 2006 Mar;3(3):275-80