Anesthesiology

Surgery for cardiac arrhythmias/atrial fibrillation surgery

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What the Anesthesiologist Should Know before the Operative Procedure

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance in the United States. It affects more than 2.5 million adults with a projected increase to 5.6 million by year 2050. Although AF per se is rarely a life-threatening condition, it is associated with significant morbidity and mortality. The significant morbidity and mortality are attributed to three detrimental sequelae: (1) palpitations that can cause significant anxiety and discomfort, (2) loss of synchronous atrial-ventricular contraction leading to hemodynamic compromise and ventricular dysfunction, and (3) stasis of blood flow in the left atrium, resulting in thromboembolism and stroke.

AF is classified as paroxysmal, persistent, long-standing, or permanent. Paroxysmal AF is defined as at least two episodes of AF that terminate spontaneously within 7 days. Persistent AF occurs when the duration of AF is longer than 7 days or lasts for any duration but requires pharmacologic or electrical cardioversion. Long-standing AF has a duration of more than 1 year. In permanent AF, a decision has been made not to attempt restoration of sinus rhythm but rate control and anticoagulation will still be achieved.

AF is common in patients presenting for mitral valve surgery or other forms of cardiac surgery. AF is present in up to 50% of the patients undergoing mitral valve surgery and in 1% to 6% of patients undergoing coronary artery bypass graft or aortic valve surgery. In patients with mitral valve disease, AF is a sign of advanced cardiovascular disease and is associated with increased mortality and morbidity. Mitral valve surgery alone may correct AF in about 80% patients in whom AF has been present for 3 months or less; however, 70% to 80% of patients with AF for 6 months or more, and who undergo mitral valve surgery alone, will have persistent AF in the postoperative period.

The goals for atrial fibrillation treatment include prevention of stroke (thromboembolism); rate control, resulting in symptom relief and prevention of tachycardia-induced cardiomyopathy; and rhythm control. Therapies focused on converting AF to sinus rhythm and maintaining sinus rhythm with antiarrhythmic drugs have proven to have minimal long-term efficacy and high rates of adverse events. Therefore, based on the the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) trial, medical therapy is more focused on attaining adequate rate control.

Surgery for AF is indicated for patients with symptomatic AF who are undergoing concomitant elective cardiac surgery or for selected asymptomatic patients undergoing concomitant elective cardiac surgery with low operative risk. Based on the Heart Rhythm/European Heart Rhythm Association/European Cardiac Arrhythmia Society expert consensus, stand-alone AF surgery should be considered for symptomatic patients who prefer the surgical approach, have failed one or more attempts at catheter ablation, have contraindication to catheter ablation due to mural thrombus, or have contraindications to anticoagulation.

Surgical ablation can be employed for ablation of persistent ventricular tachycardia (VT) in patients with VT circuits that are inaccessible to percutaneous techniques. Sustained ventricular arrhythmia is a common cause of sudden cardiac death in patients with ischemic, dilatative, or hypertrophic cardiomyopathies.

Surgical ablation, either endocardial or epicardial, can also be employed in patients with preexcitation syndromes for the division of accessory atrioventricular pathways.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Surgical ablation for cardiac arrhythmias, whether it is performed in conjunction with other cardiac surgery procedures or not, is an elective procedure. Given the prevalence of comorbidities in this patient population, a thorough preoperative evaluation will allow risk assessment and help devise a safe anesthetic plan. Risk assessment combines information obtained by documentation of existing conditions with the anticipated physiologic disturbance of the planned surgery (and accompanying anesthetic).

2. Preoperative evaluation

Preoperative evaluation will include the following:

  • Identification and documentation of existing conditions

- Presence and nature of the symptoms; clinical type of AF; previous attempts at conversion to sinus rhythm (cardioversion, catheter ablations). Underlying conditions in AF include valvular heart disease (mitral valve disease is the most common cause in younger patients), coronary artery disease/myocardial infarction, left ventricular systolic dysfunction (most common cause in older patients), hypertension (especially if left ventricular hypertrophy is present), restrictive cardiomyopathy, cardiac tumors, myocarditis, post cardiac surgery, sick sinus syndrome, preexcitation syndrome, cardiac trauma, pericarditis.

Other noncardiac conditions may include pulmonary embolism, pneumonia, acute hypoxia, metabolic disorders (hyperthyroidism), alcohol binge drinking or drugs. Underlying conditions in patients with ventricular arrhythmias may include cardiomyopathy (ischemic, dilatative, restrictive), electrophysiologic abnormalities (Brugada syndrome, Long-QT-syndrome), intoxications (digoxin), or electrolyte disturbances.

  • Additional diagnostic studies

- These will be customized based on the patient's underlying conditions and symptomatology, and may assist in risk modification and influence decisions regarding anesthetic procedures. The various diagnostic studies will be discussed in detail below.

3. What are the implications of co-existing disease on perioperative care?

N/A

b. Cardiovascular system

Coronary artery disease (CAD) is one of the underlying conditions in AF. In patients undergoing surgical ablation for lone AF or surgical ablation for AF concomitant with mitral or aortic valve surgery, preoperative testing aims at identifying patients with CAD, significant enough to warrant revascularization.

Preoperative testing may include pharmacologic stress testing; the two most common tests being used are radionuclide myocardial perfusion imaging (MPI) and dobutamine stress echocardiography (DSE). MPI involves visualization of a radiopharmaceutical that is distributed throughout the myocardium in proportion to coronary blood flow. The vasodilators used for pharmacologic MPI are adenosine, regadenoson, and dipyridamole. The vasodilator agents should be avoided in patients with resting hypotension, sick sinus syndrome, or high degree atrioventricular block in the absence of backup pacing. In addition, adenosine and dipyridamole should not be used in patients with bronchospastic airway disease. DSE is preferred in patients with bronchospastic lung disease and in those with severe carotid disease. It also provides information about right and left ventricular function and valvular heart disease.

Patients who will undergo mitral and aortic valve surgery may undergo left and/or right heart catheterization to exclude CAD and to identify pulmonary hypertension.

Acute conditions such as acute myocardial infarction or unstable angina should be stabilized before considering surgical ablation of AF.

c. Pulmonary

Preoperative evaluation of patients with pulmonary disease allows for optimization, risk stratification, and designing of strategies for reduction of postoperative pulmonary complications. The most important components of preoperative assessment of patients with known pulmonary disease are a thorough history and comprehensive physical examination. Pulmonary function tests (PFT) may be useful to assess severity of disease and adequacy of bronchodilator therapy in patients in whom it is difficult to elicit this from history or physical examination. Arterial blood gases may be used to evaluate the degree of pulmonary disease and provide a baseline for subsequent clinical decisions.

Identifying underlying pulmonary disease becomes even more important in patients undergoing surgical ablation for lone AF, in whom lung isolation and one-lung ventilation may need to be employed for optimal surgical exposure. The presence of either obstructive or restrictive components will lead to customization of the ventilation strategies during one-lung ventilation.

Cigarette smoking increases the risk for pulmonary complications even in the absence of chronic lung disease. The risk of pneumonia is twice as high in smokers as in nonsmokers and the development of hypoxemia in the postoperative period occurs more frequently and more severely in smokers and compared with nonsmokers.

d. Renal-GI:

Patients with preexisting renal disease are at increased risk for developing acute renal failure, especially if undergoing surgical ablation of AF, in conjunction with valvular replacement/repair or coronary artery bypass graft. Causes of baseline renal insufficiency include, but are not limited to, atherosclerosis of the renal arteries, diabetic nephropathy, hypertension, and depressed myocardial function. Contrast-enhanced imaging studies performed before surgery also alter renal function by both a direct toxic effect and a hyperosmolar-induced diuresis that reduces the intravascular volume. Intravascular volume expansion before, during, and after the angiographic study minimizes renal effects.

Fluid restriction in the setting of one-lung ventilation for the surgical ablation of lone AF may also predispose patients with preexisting renal disease to worsening renal function. Nonsteroidal ant-inflammatory drugs (e.g., ketorolac) for postoperative pain control should be avoided in these patients.

e. Neurologic:

N/A

f. Endocrine:

Hyperthyroidism represents a potentially reversible cause of atrial fibrillation; therefore, thyroid function tests should be part of the preoperative evaluation.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

N/A

4. What are the patient's medications and how should they be managed in the perioperative period?

Patients presenting for surgical ablation usually have a complicated treatment plan, including medications for:

  • Coronary artery disease

  • Antihypertensive medications

  • Congestive heart failure

  • Metabolic syndrome

  • Atrial fibrillation and associated risks

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Treatment options in AF aim at preventing thromboembolic events, rate-control, and conversion and maintenance of sinus rhythm.

The American College of Chest Physicians has established guidelines for anticoagulation in nonrheumatic atrial fibrillation. All patients with any single risk factor associated with increased thromboembolism (prior stroke or transient ischemic attack, systemic hypertension, recent congestive heart failure, or left ventricular dysfunction) should be placed on warfarin with the dose adjusted to an international normalized ratio of 2.0 to 3.0.

All patients older than age 65 (in the absence of risk factors) should be placed on warfarin with careful monitoring to avoid bleeding complications. Patients with no risk factors who are younger than 65 years old are considered low risk and should take one aspirin daily. Aspirin also is suitable for patients with a contraindication to warfarin therapy. The efficacy of other antiplatelet agents has not been studied in patients with atrial fibrillation.

Oral anticoagulation is generally stopped 4 to 5 days before the ablation procedure. Bridging therapy may be administered with heparin (either low-molecular-weight heparin or unfractionated heparin) until the day before the ablation procedure.

Rate control aims at limiting symptoms and reducing the risk of tachycardia associated cardiomyopathy. Rate control target is a ventricular rate of ≤80 beats per minute at rest and a maximum of <110 beats per minute during a 6-minute walk or an average heart rate of <100 beats per minute during 24-hour ambulatory monitoring, with no heart rate >110% of the maximal age-predicted exercise heart rate.

Beta-blockers, nondihydropyridine calcium channel blockers, and digoxin are the usual pharmacologic agents used for rate control. Beta-blockers are preferred as an initial atrioventricular blocking agent when there is left ventricular dysfunction associated with AF. Calcium channel blockers, verapamil, and diltiazem in a sustained released form often are well-tolerated by patients who have bronchospastic disease. At times, it is useful to give smaller doses of two classes of drugs to minimize adverse effects.

In patients with AF due to preexcitation syndrome (e.g., Wolff-Parkinson-White), intravenous procainamide and amiodarone are used to slow conduction across the accessory pathway. Intravenous beta-blockers and calcium channel blockers could result in hypotension and accelerated conduction over the accessory pathway and are contraindicated in this setting. Digoxin also is contraindicated in this setting because of concerns of accelerated conduction over the accessory pathway and the paradoxical effect of increased ventricular rates from atrioventricular node blockade.

Although restoration of sinus rhythm may seem desirable, clinical studies have not shown significant differences in clinical outcome between rhythm control and rate control. Rhythm control may be appropriate in younger symptomatic patients, newly diagnosed patients who have lone AF, and patients who have AF believed to be secondary to a precipitating event.

Selection of antiarrhythmic drugs is based on a safety-based approach. The initial choice of an antiarrhythmic medication in patients who have structurally normal hearts and normal 12-lead ECGs is flecainide, propafenone, or sotalol. In the presence of LV hypertrophy (>1.4 cm), amiodarone is the preferred initial therapy because of the perceived potential for proarrhythmia with other agents.

The preferred agents in patients with heart failure are amiodarone and defotilide. Patients who have ischemic heart disease usually are given sotalol or dofetilide as an initial agent. Sotalol and dofetilide are excreted through the kidneys and should be avoided in patients who have significant renal dysfunction.

As surgical ablation does not involve activation of the arrhythmia for mapping purposes, antiarrhythmic medication can be continued into the perioperative period. However, if a hybrid approach is considered (thoracoscopic epicardial ablation concomitant with catheter-based endocardial ablation), antiarrhythmic drugs should be discontinued for 48 to 72 hours (longer in the case of amiodarone) to facilitate activation mapping.

i. What should be recommended with regard to continuation of medications taken chronically?

  • Cardiac:

- Antihypertensive medication is continued into the perioperative period. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are a cornerstone of therapy for congestive heart failure and are important in the therapy of hypertension and coronary artery disease. In the perioperative setting, induction of general anesthesia in patients with angiotensin blockade may result in significant hypotension, requiring the administration of vasopressors. Withholding angiotensin blockade for 10 hours or more before surgery may result in less intraoperative hypotension.

  • Pulmonary

- It is paramount to continue pulmonary treatment, including in the morning of surgery to ensure stable pulmonary function.

  • Antiplatelet agents

- Continuation of antiplatelet drug therapy depends on individual patient risk factors (presence and type of stents, lapse of time since the stent placement, presence of peripheral vascular disease, etc.). After bare-metal stent placement, elective surgery should be postponed for 4 to 6 weeks for proper dual antiplatelet therapy (aspirin and clopidogrel) to allow stent endothelization and reduce the risk of coronary stent thrombosis. For drug-eluting stents, the recommendation is that elective noncardiac surgery be delayed for at least 12 months due to delayed endothelization and risk for early and late stent thrombosis with premature discontinuation of dual antiplatelet therapy. Generally, if clopidogrel is discontinued, aspirin can be continued safely in the perioperative period.

j. How To modify care for patients with known allergies -

Prevention of anaphylactic reactions relies mainly on accurate documentation of previous reactions and avoidance of the incriminated drug. During the preanesthetic consultation, a detailed history should be taken with special emphasis on atopy, drug allergy, and allergy to latex. Neuromuscular blocking agents, latex and antibiotics are the most frequently involved drugs. Pretreatment with H1 and H2 receptor antagonists may reduce histamine-mediated adverse effects associated with muscle relaxant and vancomycin administration but may not obliterate completely the allergic reaction due to the release and presence of other dangerous mediators. No evidence of beneficial effects of the prophylactic administration of corticosteroids in allergic reactions to anesthetic drugs has been shown. Pretreatment with corticosteroids, antihistamines, or both does not reliably prevent immune-mediated reactions.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Latex-sensitive patients should be managed by complete avoidance of potential latex exposure. Patient care must be carefully coordinated among all professionals, including pre- and postoperative nursing and operating teams. Whenever possible, the patient should be scheduled for elective surgery as the first case of the day to reduce exposure to aerosolized latex particles. Warnings identifying a risk for latex allergy should be posted inside and outside the operating room and in perioperative care areas. Resuscitation drugs should be readily available.

l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]

N/A

m. Does the patient have a history of allergy to anesthesia?

N/A

5. What laboratory tests should be obtained and has everything been reviewed?

  • Electrocardiogram

- An electrocardiogram in atrial fibrillation shows irregular oscillatory waves replacing regular P-waves with irregular ventricular response. The ventricular response is usually rapid but depends on the myocardial conduction properties (especially AV node), vagal, and sympathetic tone, presence or absence of accessory conduction pathways, and drug actions.

Regular R-R intervals are possible with AV block or ventricular or AV junctional tachycardia. Irregular, sustained wide QRS complex tachycardia can be found in AF with conduction over an accessory pathway or in AF with underlying bundle branch block. If the ECG reveals a slow, regular ventricular response in the setting of atrial fibrillation, suspicion of digitalis toxicity or complete heart block should be raised

Electrocardiogram in ventricular arrhythmias shows tachycardia with broad (QRS >0.12 sec) monomorphic or polymorphic QRS complexes. Atrial and ventricular activation is uncoordinated. At slower ventricular rates, P-waves may be recognized but appear independent of ventricular activation.

  • Transesophageal echocardiography

- A transesophageal echocardiography provides information regarding presence of thrombus in the left atrium, morphologic and functional information on the atria, ventricles, and valves (e.g., left and right atria size, left ventricular size, wall thickness and function), estimation of pulmonary artery pressure.

  • Chest radiography

- A chest x-ray can identify abnormalities in cardiac silhouette, evidence of pulmonary congestion, or lung parenchyma disease.

  • Laboratory tests

- Laboratory tests should include a complete blood cell count, a metabolic panel and coagulation tests.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Whereas catheter-based ablation can be performed either under general anesthesia or under monitored anesthesia care, surgical ablation, whether or not concomitant with other cardiac surgical procedures (valve repair/replacement, coronary artery bypass graft), is performed under general anesthesia. When performed in conjunction with other procedures, surgical ablation is performed with the use of cardiopulmonary bypass (CPB). When surgical ablation is performed for lone AF, it is generally performed without the use of CPB, either through a full sternotomy or, recently, more frequently with a thoracoscopic/thoracotomy approach and the use of one-lung ventilation.

General anesthesia

General anesthesia ensures airway control and monitoring of ventilation, control of patient movement, and, possibly, improved catheter stability and ablation efficiency.

The influence of anesthetic drugs on the cardiac conduction and myocardial refractoriness is of little consequence during surgical ablation. However, during combined epicardial-endocardial, this may become significant. Mechanisms by which anesthetic drugs influence conduction include direct myocardial effects, neurally mediated changes in autonomic nervous system tone, and indirectly thorough changes in acid-base and electrolytes during controlled ventilation.

  • Volatile anesthetics

- There are indications that volatile agents (enflurane, isoflurane, halothane) increase refractoriness of accessory and atrioventricular pathways and enhance automaticity of secondary atrial pacemakers, relative to the sinoatrial node accounting for the occurrence of ectopic atrial rhythms. Sevoflurane seems to have no effect on the electrophysiologic nature of the normal atrioventricular or accessory pathway and no clinically important effect on sino-atrial node.

  • Neuromuscular relaxants

- These modulate autonomic tone through ganglionic stimulation or blockade, act directly at sympathetic terminals, or, though histamine release, cause vasodilation and reflex tachycardia. Succinylcholine can precipitate both brady- and tachyarrhythmias; pancuronium is vagolitic and may increase heart rate; vecuronium may be associated with bradycardia.

  • Opioids

- May have a central vagotonic effect with depression of the sino-atrial automatism or atrio-ventricular node conduction, resulting in bradycardia – especially when used in high doses.

  • Propofol

- This has no clinically significant effect on the electrophysiologic expression of the accessory pathway and the refractoriness of the normal AV conduction system. In addition, propofol has no direct effect on SA node activity or intra-atrial conduction.

In addition to the standard monitors routinely employed in general anesthesia, invasive arterial monitoring is usually used even during surgical ablation for lone AF, given the potential for hemodynamic instability during one-lung ventilation, injury to various mediastinal structures, and need for frequent sampling for arterial blood gas monitoring. Central venous access should be achieved to facilitate resuscitation in case of hemodynamic instability or injury to mediastinal structures.

Lung isolation, if required, can be achieved with either double-lumen tubes or single-lumen tubes with bronchial blocker. Selection of an appropriate inspiratory to expiratory (I:E) ratio and respiratory rate is important in cases of severe obstructive disease or significant restrictive disease. In severe obstructive disease, an I:E ratio of 1:4 with a low respiratory rate of 6 to 8 breaths per minute allows for maximal expiratory time, thereby minimizing the risk of auto-PEEP and dynamic hyperinflation.

On the other hand, in restrictive lung disease, equalizing the I:E ratio to 1:1 (or using inverse ratio ventilation) and dividing the minute volume by a higher rate of 10 to 15 breaths per minute help to maximize inspiratory time per volume breath, thereby reducing peak and plateau ventilatory pressures.

Although rare, hemodynamic instability can result from the elicitation of arrhythmias during ablation, right heart dysfunction due to hypoxia or hypercardia during one-lung ventilation, or injury of mediastinal structures.

6. What is the author's preferred method of anesthesia technique and why?

What prophylactic antibiotics should be administered?

According to the Surgical Care Improvement Project (SCIP) guidelines, patients should receive Cefazolin (1-2 gm), cefuroxime (1.5 gm), or cefamandole within 1 hour from incision. In case of β-lactam allergy, vancomycin (1-2 gm) or clindamycin (300-900 mg) should be used.

What do I need to know about the surgical technique to optimize my anesthetic care?

Since 1987 when the Cox-Maze procedure was first introduced by Dr. James Cox, the development of new ablation techniques has greatly simplified and shortened the Cox-Maze procedure. These technologies have resulted in new, simpler operations through minimal access and off cardiopulmonary bypass.

  • Ablation procedures

- Ablation procedures confined to the left atrium consist of isolation of the pulmonary veins either using the "enbloc" technique (a single ablation line encircling the four veins orifices altogether) or by separately isolating the right and left pulmonary vein cuffs. A "mitral line" usually completes this procedure by connecting the pulmonary vein to the mitral annulus and can be performed either endocardially or epicardially. Left atrial lesion sets are typically recommended for patients with recent-onset or paroxysmal AF who are undergoing elective surgery, and there is no reason to open the right atrium.

  • The bi-atrial procedures

- These may add to this set a cavocaval ablation line and other lesions directed though the coronary sinus, tricuspid orifice, and interatrial septum on the right atrial side. Amputation or isolation of the right/left atrial appendages may complete the procedures. These lesion sets are usually applied to patients with long-standing or symptomatic AF or components of atrial flutter, young patients, or those patients undergoing right heart surgery.

  • Pulmonary vein isolation

- This is only is an ideal choice for those patients who present with new-onset paroxysmal AF. Can be performed off-bypass and through minimal access.

Energy sources used to create these lesions include microwave, laser, radiofrequency, high-intensity focused ultrasound, or cryoablation. At present, laser and microwave energy devices are no longer on the market. The principal limitation of these devices is their inability to reliably create transmural lesions on the beating heart, which appears to be an important determinant of therapeutic success. The use bipolar radiofrequency or high-intensity focused ultrasound seems to have overcome this problem.

What can I do intraoperatively to assist the surgeon and optimize patient care?

  • When performing surgical ablation for lone AF using a thoracoscopic/thoracotomy approach

- Adequate lung isolation allows for optimal surgical exposure and may improve the quality of epicardial lesions of ablation.

  • When performing hybrid procedures

- Transesophageal echocardiography (TEE) can be used to assist the electophysiologist in performing the trans-septal puncture across the interatrial septum. TEE can be used to exclude the presence of pericardial effusion at the end of the procedure. If radiofrequency or high-intensity focus ultrasound is used, consider withdrawing the TEE probe in the upper esophagus to avoid esophageal injury.

Although no relevant studies have addressed this issue, administration of antiarrhythmic drugs in the perioperative period may optimize the results of surgical ablation.

What are the most common intraoperative complications and how can they be avoided/treated?

  • Cardiac tamponade

- Can present clinically as an abrupt fall in blood pressure, or more insidiously and gradually. Therefore, it is imperative to be vigilant as a delay in diagnosis may be fatal.

  • Pulmonary artery rupture

- Requires prompt resuscitation and may necessitate the emergent institution of cardiopulmonary bypass for adequate repair.

  • Acute lung injury and pulmonary edema

- May occur during hybrid procedures when patients undergo one-lung ventilation during epicardial ablation and then undergo endocardial radiofrequency ablation. The catheters used for endocardial ablation release 15 to 30 mL/min of normal saline to cool the myocardium, resulting in a total crystalloid administration of 3 to 5 liters for the entire case. Administration of furosemide may be required to aid in eliminating this significant volume of crystalloid.

a. Neurologic:

N/A

b. If the patient is intubated, are there any special criteria for extubation?

The aim is early postprocedural extubation. The patients should be hemodynamically stable, awake, comfortable, following commands, and with adequate respiratory parameters (tidal volume, respiratory rate, end-tidal CO2, maximum inspiratory force).

c. Postoperative management

What analgesic modalities can I implement?

  • Intravenous analgesia modalities

- Using opioids, low-dose infusion of ketamine, nonsteroidal anti-inflammatory drugs, acetaminophen.

Regional anesthesia modalities: intercostal or paravertebral blocks, which may be performed by the surgeons at the end of the procedure if a thoracoscopic/thoracotomy approach has been used.

What are common postoperative complications, and ways to prevent and treat them?

  • Esophageal injury/atrio-esophageal fistula

- The esophagus is close to the posterior wall of the LA and ablation procedures here can damage esophageal wall, or affect esophageal innervation or vascular supply. Usually presents 2 to 4 weeks after the ablation with fever, chills, and recurrent neurological events or, more acutely, as septic shock or death. Atrio-esophageal fistula has extremely high mortality, putting extra focus on very early detection and especially prevention.

  • Pulmonary vein stenosis

- Results from thermal injury to PV musculature. Symptoms of PV stenosis include chest pain, dyspnea, cough, hemoptysis, recurrent lung infections, and symptoms of pulmonary hypertension.

  • Postoperative atrial flutter, left atrial dysfunction, and sinus node dysfunction

- Resulting in the need for pacemaker insertion.

What's the Evidence?

Damiano, RJ, Voeller, RK. "Surgical and minimally invasive ablation for atrial fibrillation". Curr Treat Options Cardiovasc Med. vol. 8. 2006. pp. 371-6.

Padanilam, BJ, Prystowsky, EN. "Atrial fibrillation: goals of therapy and management strategies to achieve the goals". Cardiol Clin. vol. 27. 2009. pp. 189-200, x.

Poynter, JA, Beckman, DJ, Abarbanell, AM. "Surgical treatment of atrial fibrillation: the time is now". Ann Thorac Surg. vol. 90. pp. 2079-86.

Shen, J, Bailey, MS, Damiano, RJ. "The surgical treatment of atrial fibrillation". Heart Rhythm. vol. 6. 2009. pp. S45-50.

Yilmaz, A, Van Putte, BP, Van Boven, WJ. "Completely thoracoscopic bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation". J Thorac Cardiovasc Surg. vol. 136. 2008. pp. 521-2.

Bick, JS, Thompson, A, Hoff, SJ, Whalen, SP, Ellis, CR. "Initial anesthetic experience during combined epicardial-endocardial treatment of atrial fibrillation". J Cardiothorac Vasc Anesth. vol. 25. pp. e6-8.

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