Deciding Between Surgical and Catheter-Based Ablation for Elderly Patients
Heart & Vascular Institute Physician eNewsletter - Fall/Winter 2013
New minimally invasive catheter-based and surgical techniques provide excellent treatment options for elderly patients with atrial fibrillation.
The surgical technique can also be used to exclude the left atrial appendage, thereby reducing the risk of thromboembolism and stroke.
Although AF is typically initially treated with anti-arrhythmic medications, long-term control of AF with drugs alone is successful in only about 50 percent of patients. In addition, many elderly patients with AF are at high risk for falls and bleeding, making treatment with anticoagulants a challenge.
“Ablation has been shown to be more effective than drugs alone. Ablation obviates the need for lifelong anticoagulation and its potential for adverse reactions,” says Cleveland Clinic cardiovascular surgeon Edward Soltesz, MD, MPH.
At Cleveland Clinic, the efficacy of a single radiofrequency catheter-based ablation is 77 percent for paroxysmal AF. When a second ablation is necessary, the success rate rises to 92 percent.
For patients with persistent AF, the success rate is 76 percent for a single treatment and 90 percent after the second treatment.
Eighty percent of patients with AF lasting more than one year are successfully treated with two catheter ablation procedures.
Thoracoscopic ablation is performed on a closed-chest, beating heart through four half-inch incisions. The thoracoscope guides bilateral pulmonary vein isolation and connecting lesions, along with autonomic testing and ablation.
The technology is safe and precise and eliminates the need for computer-enhanced imaging.
Thoracoscopic ablation allows the left atrial appendage (LAA) to be isolated and excluded with the AtriClip™ Gillinov-Cosgrove LAA Exclusion System, a low-profile atraumatic device invented at Cleveland Clinic. This process eliminates the most common site of AF-related intracardiac thrombus formation.
Following thoracoscopic ablation, warfarin is maintained until sinus rhythm can be documented at the four-week follow-up. If LAA occlusion is performed, anticoagulation can typically be stopped after six to eight weeks.
Making a choice
“Deciding between surgical and catheter-based ablation can be a challenge. Patients should be evaluated by both an electrophysiologist and a cardiothoracic surgeon,” says Dr. Soltesz.
Patients with longstanding persistent AF have better success with thoracoscopic ablation than with catheter-based ablation. Patients at high risk of stroke from AF and high risk of bleeding from anticoagulation are excellent candidates for minimally invasive ablation with LAA occlusion.
On the other hand, patients with severe chronic lung disease and a history of heart surgery are not good candidates for the thoracoscopic procedure.
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