For Some AFib Patients, Minimally Invasive Surgery Should Be Discussed

A Keck Medicine of USC cardiothoracic surgeon explains why epicardial ablation may be the right treatment for some patients with longstanding persistent AFib.

Atrial fibrillation (AFib) presents in different ways. Some patients are asymptomatic. Some have paroxysmal AFib, with arrhythmia symptoms happening for less than a week or so and then stopping either on their own or with intervention, for a stretch of time. Other patients have persistent AFib that lasts more than seven days but less than a year. Those with AFib for longer than a year are said to have longstanding persistent AFib. Symptomatic longstanding persistent AFib accounts for about 10%-20% of AFib cases.

Different treatments for AFib

Medications and/or endocardial ablations from an electrophysiologist are the most prescribed treatments for AFib. An internist might recommend medication to try to normalize a patient’s heart rate or rhythm. If this is unsuccessful or patients aren’t tolerating their medications, an electrophysiologist may use endocardial ablation to create scar tissue on veins or muscle tissue inside the heart that will hinder abnormal electrical signals. Techniques include cryoablation, radiofrequency ablation and pulsed field ablation.

Endocardial ablation is often quite successful in treating patients with paroxysmal AFib. It can, however, be unsuccessful in treating some patients with symptomatic longstanding persistent AFib.

“Data shows it doesn’t have great outcomes in getting these patients out of atrial fibrillation and helping them stay out of atrial fibrillation and get off antiarrhythmic medications,” Praeger says.

For this reason, physicians should ensure that longstanding persistent AFib patients who may not be good candidates for endocardial ablation are aware there is another option — epicardial ablation.

A cardiac surgeon performs epicardial ablation on the heart muscle tissue from outside the heart. This procedure is minimally invasive. An ablation device is inserted into the pericardial space to target the origin of the arrythmia.

Including surgery in the discussion earlier on

Unfortunately, AFib patients and their physicians often don’t discuss surgery as a treatment option early on, Praeger says. “What usually ends up happening is that endocardial ablation from an electrophysiologist is tried multiple times to see if it will work for a patient with symptomatic longstanding persistent AFib. Surgery is only considered as a last resort.”

After endocardial ablation is performed, evaluating its effects takes many months. There is, for instance, a “blanking period” of at least a few months required, only after which the electrophysiologist can start assessing whether treatment was impactful. While doctors wait to see whether endocardial ablation had an effect, longstanding persistent AFib patients continue to experience continual symptoms.

“It could take a year to complete two rounds of endocardial ablation, and during this time a patient would continue to be in AFib,” Praeger says. Studies show the longer a patient remains in AFib, the lower the likelihood of treatment success, he points out. And, he adds, if a patient has already undergone multiple endocardial ablation procedures, it can be more difficult for a surgeon to operate later if previous procedures caused a lot of inflammation and scarring.

A better approach would be to ensure that treatment discussions, especially with symptomatic longstanding persistent AFib patients, address all alternatives, including medication, endocardial ablation and epicardial ablation surgery. Patients should be referred to a cardiac surgeon to learn about their surgical options directly, Praeger says. “It at least warrants a discussion.”

“To be clear,” he continues, “we’re talking about a specific subgroup of AFib patients. If someone could be treated with electrophysiology with equal success, I wouldn’t put them through surgery, even though both procedures are very low risk. I’ll tell a patient if I think they should be referred to an electrophysiologist for endocardial ablation instead. A good surgeon will do their due diligence in determining whether a patient is truly an appropriate candidate for surgery.”

Ideally, if needed, an electrophysiologist and cardiac surgeon can even take a hybrid approach, working on a patient concomitantly. “Data has shown that if a patient has longstanding persistent atrial fibrillation, a hybrid approach has better outcomes over medication or endocardial ablation alone,” Praeger says. In addition, if a cardiac surgeon is involved, they can evaluate whether a patient’s AFib is isolated or if there are other cardiovascular causes at hand, such as coronary or valvular disease, that should be surgically repaired.

Opening lines of communication

Moving forward, it’s important to educate not only patients (so they can make more informed treatment decisions) but also doctors — cardiologists, internists, ER doctors, “all doctors, to be honest,” Praeger says. “It’s a win-win for everyone because the likelihood of success for the patient is better.”

Consulting a surgeon gives the patient the opportunity to ask the surgeon questions. “It’s not uncommon for a non-surgeon to describe a procedure, but not in the right way, and the patient declines mostly because they didn’t receive accurate information,” he says. “Even physicians often don’t understand that the surgery we perform is minimally invasive, for instance. It’s not like the old days when you would have to do a sternotomy. I’m not trying to pull the wool over anyone’s eyes. But I can give you answers. I can tell you about what I do and don’t know. I’m talking about recommending surgery appropriately, including being straightforward about any risks.”

Physicians might be surprised to learn how many longstanding persistent AFib patients might choose surgery if given the option.

“No questions asked, the AFib patients I’ve treated who used to be symptomatic are the happiest patients I see. They say that surgery changed their life,” Praeger says. “These are patients who just wanted their symptoms to end. They wanted to get off the medications if they were having trouble tolerating their medications. I’ve had a couple of patients who were suicidal because of their AFib. It’s a miserable feeling for these people. It’s extremely life-limiting. Patients who want a long-lasting fix might jump at the opportunity for surgery if they know the option exists. At the end of the day, a lot of these patients are otherwise quite healthy people. They could be living an active life if it weren’t for AFib.”

He concludes: “In my opinion, it’s prudent to refer these patients to surgeons earlier in order to give patients all the alternatives that exist.”

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