Montefiore - Einstein Heart Center

Atrial Fibrillation Surgery

Atrial fibrillation, an irregular, rapid heart rhythm, afflicts over 2.3 million Americans, with an annual incidence of 160,000.  More than half of patients with atrial fibrillation suffer from fatigue, shortness of breath, and chest palpitations. Many patients can be treated successfully with medication that thins their blood, reducing the risk of blood clots, and with drugs designed to regulate the heart rate.  However, In over 500,000 cases, medical therapy is not effective, leaving patients at risk for stroke and even heart failure.  However, new surgical techniques can correct the problem, giving patients a better prognosis.

At the Montefiore-Einstein Heart Center, a multi-disciplinary team consisting of cardiologists, electrophysiologists, and minimally invasive heart surgeons is using the latest surgical techniques to eliminate atrial fibrillation.  By blocking the faulty electrical signals that cause atrial fibrillation and, when possible, removing the atrial appendage where clots form, our surgeons are able to cure the disease in most patients.

What Causes Atrial Fibrillation?

Atrial fibrillation is caused by faulty electrical triggers coming from the pulmonary veins of the left atrium, resulting in wavelets of energy that establish an irregular and fast heart rate.

In the heart, blood is pumped from the upper chambers, or atria, to the lower chambers, or ventricles, where it is then pumped out of the heart to the rest of the body.  Two nodes in the heart coordinate the electrical impulses that regulate the split-second timing allowing the atria to contract just before the ventricles.

In the healthy heart, this electrical system runs like clockwork-one electrical impulse equals a single two-part heartbeat.  But in patients with atrial fibrillation, instead of the impulse traveling in an orderly fashion through the heart, many impulses begin and spread through the atria.  These conflicting messages leave the lower heart unsure about how to process the electrical information it is receiving, and the heart is unclear which message to forward to the atrioventricular node at the base of the right atrium, where the message to contract is passed on to the ventricles. 

Are there different kinds of atrial fibrillation?

Atrial fibrillation is termed "paroxysmal" if it occurs intermittently and "chronic" or "persistent" if it is present all the time.

At the Montefiore-Einstein Heart Center, our surgeons are highly experienced in treating both types of atrial fibrillation.  Individualized treatment plans are developed for each patient, offering not only a broad range of medical options but the following surgical interventions as well.

Catheter-Based Ablation

In patients with atrial fibrillation uncomplicated by other heart disease and with normal-sized atrial chambers, the pulmonary veins can be electrically isolated from the rest of the heart with radiofrequency energy.  Through vessels in the groin, the surgeon introduces two catheters into the heart and, guided by x-rays and electrical maps, creates what are called ablation lines:  very precise, localized scarring that prevents abnormal electrical impulses from passing through.  With catheter-based ablation, because the atrial appendage can not be removed, anticoagulant medications must be continued to prevent clotting.

Minimally Invasive Surgical Ablation

In this procedure, the surgeon uses a telescope, special minimally invasive instruments, which are inserted through three small holes on either side of the chest cavity, and, in some cases, robotic assistance.  The pulmonary veins are electrically isolated with either microwave energy or radiofrequency energy applied to the outside of the heart.  Multiple ablation lines are created if needed, and the left atrial appendage is removed.

Patients with paroxysmal atrial fibrillation are the best candidates for minimally invasive surgical ablation.   In selected patients, anticoagulant medications can be eliminated. 

Robotic Cox-Maze Procedure

The Maze procedure is the most comprehensive surgery for the treatment of all types of atrial fibrillation It is successful in 90 to 95 percent of patients. 

In this procedure, the heart must be stopped, so patients need to be placed on a heart-lung machine for the duration of the surgery.  With robotic assistance, the operation can be performed through a 5-cm incision between the ribs of the right chest cavity.

The surgeon uses a combination of incisions and ablation lines, which are applied using radiofrequency, microwave, or cryothermy (cold temperature) energy.  The localized scarring creates a maze-like network that blocks abnormal electrical impulses while creating corridors where the appropriate electrical impulses can travel.  In this way, communication between the nodes that control the heart rhythm is restored, and the heart returns to a normal beat.  During the procedure, the left atrial appendage is also completely removed, eliminating the need for medication to prevent blood clots.

Atrial Fibrillation Team:

Robert Michler, MD
Professor and Chairman
Department of Cardiothoracic Surgery

Joseph J. DeRose, Jr., MD
Director of Minimally Invasive and Robotic Cardiac Surgery
Associate Professor of Clinical Cardiothoracic Surgery
Department of Cardiothoracic Surgery