Answer:

Dear Samyukta, Thank you for your question. My answer does not have the benefit of actually reviewing a CT scan or MRI and is general in nature. A final determination would have to be made by the operative surgeon. If the benign mass is within the mediastinum or pleural space, a minimaze can be performed at the same setting. I would resect the mass first and ensure that the pulmonary veins were not compromised by the resection of the mass. If the mass s completely outside the pericardium (the sac around the heart) there would generally be no interference with completing a maze procedure once the mass was removed.

Answer:

There are a number of factors which contribute to the risk of both diaphragmatic paralysis and PV Stenosis. The choice of energy source and the delivery instruments play a role with respect to risk. Unipolar delivery devices which are a lasso may twist and expose the phrenic nerves to ablation may damage them and result in paralysis. Minimally invasive approaches may expose the phrenic nerves to stretch and as a result a palsy may develop in the diaphragm. Diaphragm problems may resolve in up to 6 months. If they do not and the patient is very symptomatic, a plication or reduction in size of the diaphragm may be necessary. Surgical ablation typically allows the surgeon direct access to the epicardial surface of the heart and the surgeon is able to avoid directly ablating the pulmonary veins but rather the atrial antrum so pulmonary vein stenosis is extremely rare from surgery.

Answer:

A traditional maze was pioneered by Dr. James Cox and involves making a series of lesions in the atria of the heart by cutting the atria into pieces and sewing them back together. With the advent of radiofrequency, microwave, and cryotherapy sources of energy, these lesions can be made without cutting the heart into pieces yet the lesions are the same pattern. With the advent of new surgical techniques and advances in technology the same lesions in a traditional maze can now be created with minimal or keyhole access. There is some debate about the efficacy of different energy sources and technologies and the ability to create intact linear transmural lesions. The ex-maze is another approach using a device inserted beneath the xiphoid process and utilizes insertion of a scope into the pericardium. The ability to make intact contiguous lesions is questioned. Catheter ablation involves passing a catheter from the groin and puncturing across the atrial septum. The operator has to then direct the catheter in making a series of connect the dot burns from inside the atrium directed out. The challenge lies in getting overlap of the burns and transmurality without puncturing the heart or injuring adjacent structures. This approach is typically limited to isolating the pulmonary Catheter ablation may need to be performed several times.

Answer:

This is an interesting problem for which there is little informations. I have discussed this question with the director of the EP lab at my institution. I think some attempt at ablation is warranted. Given the presence of the ASD patch, a transeptal puncture would be difficult if not hazardous. Our electrophysiologist was not keen on the option. Failure to heal the puncture, injury to other structures such as the aorta may be more likely to occur. A surgical ablation could be performed though this would be a redo and might not be able to be completed minimally invasively. We have successfully performed procedures on patients with prior heart surgery but you need to be prepared that it might not be able to be accomplished of the scarring is excessive. Typically these scars form between the breast bone and the anterior surface of the heart. A minimally invasive maze would approach the heart posteriorly and can often be accomplished for this reason. Thank you for your question.

Answer:

There are many experienced electrophysiologists in Southern California performing ablation with state-of-the-art technology. To obtain a referral to a specific physician, it’s best to ask your cardiologist or primary care doctor. Robotic catheter ablation systems are in development, and are available at a few centers across the country. They do not allow unskilled operators to perform ablation more safely or effectively, but are simply another tool that can be used in ablation procedures. The esophagus is always monitored during atrial fibrillation ablation, to prevent delivery of too much energy near the esophagus. This could lead to atrial-esophageal fistula, which can be fatal. Different techniques are used to monitor the esophagus. Here at UCLA, we use a combination of barium contrast in the esophagus, allowing it to be seen on X-ray, as well as a temperature probe in the esophagus, that tells us if any heating is taking place during ablation. These techniques are not meant to prevent PV stenosis, a different complication of atrial fibrillation ablation. Since the procedure can be done either with patients under light sedation or fully asleep under general anesthesia, the method of filling the esophagus with barium will be different. Awake patients can swallow the paste, while those under general anesthesia have the barium injected into a tube in the esophagus. PV isolation is the cornerstone of atrial fibrillation ablation, but some electrophysiologists do ablation in other areas as well (depending on the patient). Some of these include lines to the mitral valve, across the roof of the left atrium, or between circumferential ablation lesions. Although the pulmonary veins are the most common origin of ectopic beats that cause atrial fibrillation, other structures can also trigger the arrhythmia, including the Ligament of Marshall and the superior vena cava. Sometimes ablation will be necessary at some of these other sites in addition to the pulmonary vein area.

Answer:

Vagal atrial fibrillation describes a subset of patients whose episodes are triggered at times of high vagal output, such as while sleeping, swallowing, straining, vomiting, or occasionally from sudden stress or emotional upset. This is a minority of patients with atrial fibrillation. They probably have a susceptibility to atrial fibrillation that allows the changes in the autonomic nervous system caused by vagal episodes to trigger fibrillation. There has been no systematic study showing that treatments for vagal atrial fibrillation should be different from those used for other patients with atrial fibrillation, and ablation is an option if medical therapy has not been successful. Cryotherapy differs from the usual (radiofrequency) ablation in that it uses cold, instead of heat, to destroy abnormal tissue. Many electrophysiologists consider it to be safer, since there is a longer time between the beginning of each ablation lesion and the point at which the damage is irreversible. In theory, if a critical structure is damaged, cryotherapy can be stopped and no permanent effects may be seen. This is also a weakness of cryotherapy, since the damage to the area that we intend to ablate may not be permanent. Many physicians believe that the rate of arrhythmia recurrence is higher with cryoablation as compared to radiofrequency ablation.

Answer:

Your history of atrial fibrillation is very common. Often, it begins with short infrequent episodes that may become more sustained over time. Sometimes atrial fibrillation does not stop on its own and patients require medication or an electric shock to reset the rhythm back to normal. Your doctors have completed a thorough evaluation of your heart, and it seems that you are on good medical therapy. If you have significant symptoms from atrial fibrillation, you should ask your doctors about a treatment strategy that involves keeping you in normal sinus rhythm. This generally starts with antiarrhythmic drugs, such as sotalol, dofetilide, propafenone, or flecainide. If drugs are not tolerated, not effective, or not safe for you, another option for treatment of atrial fibrillation is catheter ablation.

Answer:

Atrial fibrillation is often triggered by extra beats from the top chamber of the heart, called premature atrial beats or ectopic beats. It is normal for the pulse rate to be slightly higher on standing upright. Exercise is good for the body and heart, but is not usually targeted toward changing the resting heart rate. Some people have episodes of atrial fibrillation that are triggered by exercise; this is more common than a compressed nerve triggering atrial fibrillation.

Answer:

There are many experienced electrophysiologists in Southern California performing ablation. To obtain a referral to a specific physician, it’s best to ask your cardiologist or primary care doctor. Robotic catheter ablation systems are in development, and are available at a few centers across the country. They do not allow unskilled operators to perform ablation more safely or effectively, but are simply one more tool that can be used for ablation.