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Answer:
Your story is a typical one for patients referred for surgery. You have failed medical therapy, and have significant symptoms. Since you are in persistent atrial fibrillation, we usually recommend a full Cox-Maze procedure. This can be performed safely with ablation devices. You certainly would not be at high risk for surgery, although your precise risk would need to be determined at an office visit. As far as management of your atrial fibrillation, there are some things that should be tried before considering surgery. I feel an attempt at cardioversion is reasonable after being begun on an appropriate antiarrhythmic drug. If this was successful, you would not need to proceed with any interventional therapy. If you remain in atrial fibrillation, then your choice is between catheter ablation and surgery. As a single procedure, surgery is usually more effective than catheter ablation in patients with persistent atrial fibrillation. However, catheter ablation certainly would be a consideration and you should discuss this with an interventional electrophysiologist. I agree with you that an AV node ablation should only be done as a salvage procedure in patients who are not candidates for either catheter or surgical ablation.
Answer:
Recurrences following the Maze procedure can be successfully treated. First of all, it is important to determine what is your recurrent arrhythmia. Patients can have either recurrent atrial flutter or atrial fibrillation. A recent study from the University of Alabama showed that many of these recurrences can be treated successfully with catheter ablation. I would recommend seeing an electrophysiologist and obtaining an EP study to determine the mechanism of your recurrence. As part of this, it would be important to determine what procedure you actually had in July, 2006. If you had pulmonary vein isolation, deceptively referred by some as a “mini-Maze”, you could then undergo a more complete surgical procedure if catheter ablation is not an option.
Answer:
The role of surgery compared to catheter ablation for paroxysmal atrial fibrillation has been addressed in the recent consensus statement (Heart Rhythm 2007; 4:816-861). Surgery is recommended for patients who have symptomatic atrial fibrillation and have failed medical therapy, and who have either failed one or more catheter ablation, are not candidates for a catheter ablation, or prefer a surgical approach. You should talk to your electrophysiologist to determine which procedure is right for you. It is important to point out that a “mini-Maze” is a deceptive term, and refers to surgical pulmonary vein isolation. I would question both your electrophysiologist and your surgeon as to their results and their morbidity, and then proceed from there.
Answer:
The role of surgery compared to catheter ablation for paroxysmal atrial fibrillation has been addressed in the recent consensus statement (Heart Rhythm 2007; 4:816-861). Surgery is recommended for patients who have symptomatic atrial fibrillation that has failed medical therapy, and who have either failed one or more catheter ablation, are not candidates for a catheter ablation, or prefer a surgical approach. I agree that you should talk to your electrophysiologist to determine which procedure is right for you. It is important to point out that a “mini-Maze” is a deceptive term, and refers to surgical pulmonary vein isolation. It is not a Maze procedure. I would question both your electrophysiologist and your surgeon as to their results and their morbidity, and then proceed from there.
Answer:
For recurrences following surgical pulmonary vein isolations (deceptively termed a “mini-Maze” procedure), there are a number of effective strategies. First of all, some patients can be controlled with drugs that were not successful prior to surgery. I would recommend the resumption of an antiarrhythmic drug you tolerate and then attempt a cardioversion. If this fails, you can proceed this time with a real Maze procedure, which can be done through a minimally invasive approach.
Answer:
The use of amiodarone has a number of side effects, however, it sometimes does not prolong QT interval as much as some other antiarrhythmic drugs. The prolongation of the QT interval has nothing to do with the long half life of amiodarone, but instead its effect on atrial refractoriness. If you do start amiodarone, your electrophysiologist will carefully check your EKG to monitor your QT interval.
Answer:
If your symptoms are better, I would recommend continuing with medical management and not considering an interventional procedure.
Answer:

Answered By :Dr. Larry Chinitz
If you are well, asymptomatic, and living a normal life with rate control at 82 years of age, then you are better than most. No further intervention is required. Atrial enlargement by itself is of no concern to you and will not affect your life expectancy. The NYU Heart Rhythm Center is a comprehensive rhythm management and research institute that can be reached at 212-263-7149. We would enjoy discussing your situation.

Answered By :Dr. Damiano
As far as I know, there are no data to suggest that an enlarged atrium has any effect on your life expectancy. If you are not symptomatic and doing well, I would not consider an interventional procedure at the present time.

Answer:
We have not performed pulmonary vein isolation in any patient with heparin-induced thrombocytopenia. However, I do not think it would be a major risk factor, since we do not use heparin at the time of surgery. If needed, patients could be treated with other intravenous anti-coagulants in the postoperative period.
Answer:
I do think the surgical approach would have significant advantages over catheter ablation in someone like yourself who has had a previous stroke. This is because of the removal of the left atrial appendage during surgery. This recommendation would be strengthened if you had your stroke while on Coumadin. However, it sounds like you had your stroke before you were begun on Coumadin therapy. The advantage of the surgical approach in your situation is that you would have a better chance of discontinuing Coumadin compared to catheter ablation following a successful procedure.
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ISLAA 2022-Left Atrial Appendage
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Doctor

Dr. Dhanunjay Lakkireddy, MD, F.A.C.C, FHRS, The Kansas City Heart Rhythm Institute (KCHRI), KS, USA.

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