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Most Commonly Asked Questions Regarding Atrial Fibrillation Ablation Surgery

By James P. Locher Jr., a member of Rockford Surgical Services and independent physician with the Regional Heart Institute.

How long will I be in the hospital?
A: The average hospital stay is approximately two days. The first night is spent in the ICU. This is so that we can monitor your heart rhythm and your vital signs closely. Our goal for the first postoperative day is ambulating some in the halls, as well as recovery of general overall strength. Again, our goal is a discharge on the second postoperative day.

When can I return to work?
A: A number of patients have been able to return to work in as little as the first week.

How long does the surgery take?
A: The surgery takes anywhere between two and a half to four hours to perform. The length of the surgery is somewhat determined by the complexity of the dissection and placement of the catheter around the base of the heart. Once this is done then the rest of the operation is consumed by time spent making the ablation lesions. Once the catheter is in place the rest of the operation is fairly uneventful and just requires time for the microwave device to do its work. I always stress to patients that we try to do the most complete and thorough job while in the operating room so as to give the patient the best opportunity for conversion to normal sinus rhythm.

When can I stop my heart medicines (antiarrhythmics) and Coumadin?
A: This is individualized based upon the patient. It is also individualized based upon the postoperative heart rhythm. The patients who have an extremely enlarged left atrium and right atrium, as well as chronic or permanent atrial fibrillation are more likely to need long term maintenance therapy with the anticoagulants, i.e., Coumadin and potentially heart medicines. Our goal is to see a sustained normal rhythm for a number of months prior to taking the patient off some of his medicines. I usually like to see sustained normal sinus rhythm for about three months prior to considering removing Coumadin. Our goal for all patients is to try to maintain normal sinus rhythm so that we can wean as many of the medicines down or remove them over a period of time.

What are the chances of success/or being cured from atrial fibrillation from this procedure?
A: Certainly the gold standard in years past for surgical treatment of atrial fibrillation was the COX MAZE-3 procedure for atrial fibrillation, which was a quite complex open heart operation that carried significant morbidity. Dr. Cox achieved approximately 94% success rate in conversion of patients to normal sinus rhythm. We try to replicate as much of what Dr. Cox did as we can using minimally invasive techniques and a microwave device. We have found that patients who have the highest rate of conversion to normal sinus rhythm are patients with paroxysmal (part-time) atrial fibrillation with normal or only slightly enlarged left atriums. We found that those patients have success rates with minimally invasive atrial fibrillation ablation of approximately 85-90%. Those that are least likely to be converted to normal sinus rhythm are patients that have permanent atrial fibrillation that have shown no signs of normal sinus rhythm for years and years. Also those that have massively enlarged left and right atriums. The success rate for those patients can be 50% or less. Many patients lie somewhere in between there and it is our job to stratify those patients and then give the patient an honest assessment as to their likelihood of conversion to normal sinus rhythm.

I have had previous open-heart surgery. Am I a candidate for minimally invasive atrial fibrillation surgery?
A: Patients that have had previous open-heart surgery have a significant amount of scar tissue surrounding their heart. This makes dissection of the two spaces behind the heart for placement of the catheter very difficult and potentially dangerous. For now, we are not offering minimally invasive atrial fibrillation surgery to patients who have had previous open-heart surgery.

What happens if I go back into atrial fibrillation shortly after the surgery?
A: I try to make it known to every patient that it is a possibility and potentially even a likelihood that patients will have bouts of atrial fibrillation immediately following the surgery and even for the first few weeks. The status of the atrial fibrillation prior to surgery can contribute to the likelihood of going back into atrial fibrillation following the surgery. Just from having the surgery itself and dissecting around the heart may make the heart even more irritable for the first few days or few weeks. For many patients that have been in paroxysmal atrial fibrillation this intermittent atial fibrillation the first few days or weeks is self-limited and will frequently subside as the inflammation around the heart subsides. For other patients, especially those that have chronic atrial fibrillation, the atrial fibrillation can be persistent and we usually plan to convert the patient in a normal sinus rhythm using a cardioversion after that period of inflammation subsides. That is frequently at approximately four weeks following the surgery.Thus, bouts of atrial fibrillation following the surgery are not seen as a failure, but rather as part of the expected course following the surgery.

What are the risks of the surgery?
A: I explain to every patient that even though this is minimally invasive through small incisions and through ports I still consider this a major operation. We are working around vital organs and structures, particularly the heart and the lungs. Certainly the risks of any kind of surgery involving the heart and lungs include infection and bleeding. There is also the risk of injury to any surrounding structures that we are working on. I always inform patients that have any form of minimally invasive surgery that there is always the chance that the procedure cannot be done in a minimally invasive fashion. The options in that event are to either terminate the procedure or proceed on with an even larger incision. This does not happen often, but certainly is something that each patient should be aware of. There is an infrequent occasion that a complete sternotomy incision (like a patient with open heart surgery would have) would be needed, especially in an emergent situation. Most operations, however, can be done again with a minimally invasive technique with small incisions and using a lighted scope. I also inform each patient, especially those that have a previous history of tobacco abuse or a smoking history, that certainly there is always the risk of having lun problems, including pneumonia, with any kind of thoracic or chest procedure. Again, this is not a common occurrence when utilizing small incisions. Overall the surgery is relatively sage and the overall operative risk is less than 1%.

Is there a lot of pain or discomfort from the surgery?
A: My response is that even though this is minimally invasive and involves the use of small incisions and a lighted scope, there is some discomfort following the surery. This is one of the reasons why we send our patients to the ICU so that we can be diligent in our attempts to control postoperative pain. I have found that the pain, however, is usually short lived. After a few days I have had many patients tell me that they have had no pain whatsoever. Certainly this is individualized to each person and theri own pain tolerance. Overall patients seem to recover from this very rapidly and are usually quite comfortable by the time they go home.

Are there any tests that I need to have performed prior to undergoing the surgery, or being considered to be a candidate for the surgery?
A: Yes, frequently there are two tests that we require prior to proceeding with the surgery. We frequently order a stress Myoview test, as well as an echocardiogram prior to scheduling the surgery. Each of these tests gives us differing information. The stress Myoview is a test that can elucidate whether there can be potential coronary artery disease and lack of blood flow to the heart. This is important to know prior to undergoing any form of heart surgery in that we would certainly like to minimize the risk of any cardiac complications following surgery. Certainly one of these complications could be a heart attack in the face of significant coronary artery blockages. Again we try to elucidate this prior to undertaking any minimally invasive surgery on the heart. The schocardogram is performed to look at overall heart function as well as the size of the upper chambers, as well as the overall valvular function. Once we perform these tests and see that the results are adequate then we can usually schedule the surgery quite promptly.

James P. Locher, M.D.
JPL / sd
7.31.06