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Epicardial ablation emerges as AFib treatment alternative: this minimally invasive surgical technique may be used to correct an erratic heartbeat in selected patients who fail medical therapy.

For patients with atrial fibrillation (AFib), a condition in which the heart beats irregularly, medication can often return the heart to its normal rhythm. But when medication is ineffective, AFib may require ablation--a procedure that entails going into the heart and stopping the abnormal electrical impulses that create the irregular heartbeat. The most common method of performing this procedure is called catheter ablation, in which a catheter--a thin, flexible tube--is threaded to the heart through the femoral vein via a small incision in the leg or groin. However, for patients who are not candidates for the procedure or in whom it is not succesful, another method called epicardial ablation is emerging as an alternative.


"Patients with left atrial enlargement, long-standing persistent AFib, and anatomic barriers like abnormal veins in the leg are good candidates for epicardial ablation but not catheter ablation," says Marc Gillinov, MD, a cardiac surgeon at Cleveland Clinic's Heart & Vascular Institute. "While epicardial ablation is performed on a small percentage of people with AFib, it's a small percentage of a large number of people who otherwise have no treatment options."

The procedure

During an epicardial ablation, the heart is accessed through small openings in the chest wall. "A camera and a light and instruments are inserted through three small ports in the chest," explains Vigneshwar Kasirajan, MD, a cardiothoracic surgeon at the Virginia Commonwealth University Health System's Pauley Heart Center. "It's a closed-chest procedure, and images from the camera are displayed on a video monitor." The surgeon then uses an energy source such as radiofrequency to block electrical conduction at the sites emitting the irregular impulses.

"The goal is to offer a single procedure that is very effective and requires a short recovery time. After an epicardial ablation, patients are usually ready to go home in two to three days," says Dr. Kasirajan. He emphasizes that the success of epicardial ablation depends on the surgeon working closely with an electrophysiologist, who can determine whether the ablations have successfully stopped the erratic impulses. Longterm follow-up with an electrophysiologist is needed to determine success.

When epicardial ablation is an option

A patient with AFib may be a poor candidate for catheter ablation for several reasons. "In patients who are very obese, it is difficult to visualize the catheter and the dose of x-rays needed to see clearly may be high," says Dr. Kasirajan. Epicardial ablation is sometimes preferable for elderly patients because they have a slightly higher incidence of perforation of the left atrium (one of the top two chambers of the heart) with catheter ablation. Patients who have had one or more catheter ablations that failed to correct the AFib also are good candidates. And if a patient has had a stroke and is at high risk of another stroke, epicardial ablation is a good choice because the left atrial appendage--a small pouch of the left atrium where blood clots often form--can be removed.

For patients with paroxysmal Afib--when the irregular heartbeat occurs occasionally--epicardial ablation is successful at stopping the AFib for close to 80 percent of patients at one year, according to Dr. Kasirajan. And for patients with persistent AFib, the success rate is around 60 percent at one year, which Dr. Kasirajan says is much higher than the success rate with a single procedure of catheter ablation.

"While epicardial ablation is still being refined, its use is growing. And as technology improves, surgeons will be better able to navigate in the pericardial space and block the areas that will stop the AFib and increase the chances that it will not return," says Dr. Gillinov. "It's an opportunity for patients who cannot be treated with catheter ablation."
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Title Annotation:BREAKTHROUGHS
Publication:Heart Advisor
Geographic Code:1USA
Date:Feb 1, 2009
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