Atrial fibrillation: Difference between revisions

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List of terms related to Atrial fibrillation

	Atrial fibrillation;
	The P waves, which represent depolarization of the atria, are irregular or absent during atrial fibrillation.
ICD-10	I48
ICD-9	427.31
DiseasesDB	1065
MedlinePlus	000184
eMedicine	med/184 emerg/46

VisualWikitext

Revision as of 15:27, 15 June 2009

Conduction
Sinus rhythm	Atrial fibrillation

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

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Synonyms and related keywords: AF, Afib, fib

Overview

Epidemiology

Diagnosis

Overview

Classification

Etiology and Differential Diagnosis

Treatment

Pharmacological Treatment

Invasive Treatment

Surgical Treatment

Surgical treatment of atrial fibrillation

Maze procedure

James Cox, MD, and associates developed the Cox maze procedure, an open-heart surgical procedure intended to eliminate atrial fibrillation, and performed the first one in 1987. "Maze" refers to the series of incisions made in the atria, which are arranged in a maze-like pattern. The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macro reentry) that AF requires. This procedure required an extensive series of endocardial (from the inside of the heart) incisions through both atria, a median sternotomy (vertical incision through the breastbone) and cardiopulmonary bypass (heart-lung machine). A series of improvements were made, culminating in 1992 in the Cox maze III procedure, which is now considered to be the "gold standard" for effective surgical cure of AF. The Cox maze III is sometimes referred to as the "traditional maze", the "cut and sew maze", or simply the "maze".^[1]

Minimaze surgery is minimally invasive cardiac surgery similarly intended to cure atrial fibrillation. The "Minimaze" procedure refers to "mini" versions of the original maze procedure. These procedures are less invasive than the Cox maze procedure and do not require a median sternotomy (vertical incision in the breastbone) or cardiopulmonary bypass (heart-lung machine). These procedures use microwave, radiofrequency, or acoustic energy to ablate atrial tissue near the pulmonary veins.

Prognosis

Follow up & Secondary prevention

Risk factors for ischemic stroke or systemic embolization in patient with non valvular atrial fibrillation

Numbers represents relative risks^[2]

Advanced age (continuous, per decade) 1.4
History of hypertension 1.6
Heart failure or impaired left ventricular systolic function 1.4
Coronary artery disease (CAD) 1.5
Diabetes mellitus (DM) 1.7
Previous stroke or Transient Ischemic Attack (TIA) 2.5

Clinical Trial Data

Results from the Pulmonary Vein Antrum Isolation versus AV Node Ablation with Bi-Ventricular Pacing for Treatment of Atrial Fibrillation in Patients with Congestive Heart Failure (PABA-CHF) study suggest that pulmonary-vein (PV) isolation leads to better morphologic and functional results than atrioventricular (AV) node ablation with biventricular pacing for congestive heart failure (CHF) in patients with atrial fibrillation.

In this prospective, multicenter study, 41 patients were randomized to PV isolation and 40 to AV node ablation with biventricular pacing. At 6 months, patients in the PV isolation group had higher mean ejection fractions (35% vs 29%, p<0.001), greater 6 minute distances walked (340 vs 297 meters, p <0.001), and better quality of life scores as determined by the Minnesota Living with Heart Failure questionnaire (60 vs 82, p<0.001, where lower scores indicate better quality of life) than those in the AV node ablation arm.

These PABA-CHF study findings thus suggest the potential advantages of performing PV isolation over AV node ablation with biventricular pacing for this patient population.

Noted limitations of the study include using sites with extensive experience in performing ablations, an unblinded study design, and a relatively short follow-up time. (NEJM by Mohammed N. Khan, et al.)

Guidelines: Diagnosis and Management of Atrial Fibrillation

External links

EKG Examples of atrial fibrillation

External EKG Sources

References

↑ Cox JL, Schuessler RB, Lappas DG, Boineau JP (1996). "An 8 1/2-year clinical experience with surgery for atrial fibrillation". Ann. Surg. 224 (3): 267–73, discussion 273-5. PMID 8813255.
↑ Estes NAM 3rd, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJW, Waldo AL, Wyse DG. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with non valvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Performance Measures for Atrial Fibrillation). Circulation 2008; 117:1101–1120

@@ Line 42: / Line 42: @@
 ===[[Atrial fibrillation invasive treatment|Invasive Treatment]]===
 ===[[Atrial fibrillation surgical treatment|Surgical Treatment]]===
-==Invasive treatment of atrial fibrillation==
-====Radiofrequency ablation====
-In patients with AF where rate control drugs are ineffective and it is not possible to restore sinus rhythm using cardioversion, non-pharmacological alternatives are available. For example, to control rate it is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the [[atrioventricular node]] - which regulates heart rate, and to implant a [[artificial pacemaker|pacemaker]] instead. A more complex technique, which avoids the need for a pacemaker, involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate, or creating more extensive lesions in an attempt to prevent atrial fibrillation from establishing itself.<ref name="pmid16908781"/>
-[[Ablation]] is a newer technique and has shown some promise for cases of recurrent AF that are unresponsive to conventional treatments. [[Radiofrequency ablation]] (RFA) uses radiofrequency energy to destroy abnormal electrical pathways in heart tissue. The energy emitting probe ([[electrode]]) is placed into the heart through a [[catheter]] inserted into veins in the groin or neck.  Electrodes that can detect electrical activity from inside the heart are also inserted, and the electrophysiologist uses these to "map" an area of the heart in order to locate the abnormal electrical activity before eliminating the responsible tissue.
-Most AF ablations consist of isolating the electrical pathways from the [[pulmonary vein]]s (PV)<ref>[http://www.clevelandclinic.org/heartcenter/pub/atrial_fibrillation/pulmonaryvein_ablation.htm The Cleveland Clinic]</ref>, which are located on the posterior wall of the left atrium. All other veins from the body (including neck and groin) lead to the right atrium, so in order to get to the left atrium the catheters must get across the atrial septum. This is done by piercing a small hole in the septal wall. This is called a transseptal approach. Once in the left atrium, the physician may perform ''Wide Area Circumferential Ablation'' (WACA) to electrically isolate the PVs from the left atrium.<ref>[http://www.medscape.com/viewarticle/532503_2 Medscape] </ref>
-Some more recent approaches to ablating AF is to target sites that are particularly disorganized in both atria as well as in the [[coronary sinus]] (CS). These sites are termed ''complex fractionated atrial electrogram'' (CFAE) sites.<ref>{{cite journal | author= Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. | title=A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate | journal=J Am Coll Cardiol | year=2004 | pages=2044–53 | volume=43 | issue=11 | pmid= 15172410 | doi= 10.1016/j.jacc.2003.12.054}}</ref>. It is believed by some that the CFAE sites are the cause of AF, or a combination of the PVs and CFAE sites are to blame. New techniques include the use of [[cryoablation]] (tissue freezing using a coolant which flows through the catheter), microwave ablation, where tissue is ablated by the microwave energy "cooking" the adjacent tissue, and high intensity focused ultrasound (HIFU), which destroys tissue by heating. This is an area of active research, especially with respect to the RF ablation technique and emphasis on isolating the pulmonary veins that enter into the left atrium.
-Efficacy and risks of catheter ablation of atrial fibrillation are areas of active debate.  A worldwide survey of the outcomes of 8745 ablation procedures<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref> demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of patients becoming asymptomatic with addition of an antiarrhythmic medication.  In 27.3% of patients, more than one procedure was required to attain these results.  There was at least one major complication in 6% of patients.  A thorough discussion of results of catheter ablation was published in 2007<ref>{{cite journal | author=Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. | title=HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation | journal=Heart Rhythm | year=2007 | volume=4 | issue=6 | pages= 816–61 | pmid=17556213}}</ref>; it notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of antiarrhythmic therapy, and in experience and technical proficiency.
 ==Surgical treatment of atrial fibrillation==

v t e Electrocardiography
Overview	History of the EKG • EKG interpretation basics • Normal sinus rhythm
EKG Complexes	P wave • QRS complex • ST Segment • T wave • T wave alternans • Tombstone T wave • U wave Osborn wave • H wave • K wave • Delta wave NSSTW changes
EKG Intervals	PR Interval • QRS Interval • ST Interval • QT Interval
Conduction System & Bradycardia	Cardiac pacemaker • SA node • AV node• Bundle of His • Purkinje fibers • Sinus bradycardia • First Degree AV Block • Second Degree AV Block • Complete or Third-Degree AV Block • Concealed conduction • AV Junctional Rhythms • LBBB • LAHB • LPHB • RBBB • Trifascicular block
Atrial Arrhythmias	Sinus tachycardia • Premature Atrial Contractions (PACs) • Ectopic Atrial Rhythm • Paroxysmal Atrial Tachycardia (PAT) • Paroxysmal Atrial Tachycardia (PAT) with Block • Multifocal Atrial Tachycardia (MAT) • Atrial Flutter • Atrial Fibrillation • Wandering atrial pacemaker
Ventricular Arrhythmias	Differential Diagnosis of Tachycardia with a Wide QRS Complex • Accelerated Idioventricular Rhythm • Ventricular Parasystole • Premature Ventricular Contractions (PVCs) • Ventricular tachycardia • Ventricular Fibrillation • Sudden cardiac death
EKG Abnormalities in Disease States	Hypertrophy & Dilatation • Right atrial enlargement • Left atrial enlargement • Biatrial enlargement • Left Ventricular Hypertrophy • Right Ventricular Hypertrophy • Biventricular Hypertrophy • Acute myocardial infarction • NSTEMI • STEMI • Tombstone ST elevation • Right ventricular myocardial infarction • Atrial infarction Pre-excitation Syndromes • Wolff-Parkinson-White Syndrome • Lown Ganong Levine Syndrome • Mahaim Type Preexcitation Cardiomyopathies • Arrhythmogenic Right Ventricular Dysplasia • Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy Drug Effects on the EKG • Adenosine • β-blockers • Digitalis • Quinidine • Procainamide • Disopyramide • Lidocaine • Tocainide and Mexiletine • Phenytoin • Encainide, Flecainide and Propafenone • Amiodarone • Bretylium • Ca Channel Blockers • Phenothiazines • Tricyclic Antidepressants • Lithium Congenital Heart Disease • Dextrocardia • Atrial Septal Defect • Ventricular Septal Defect • Tetralogy of Fallot • Conjoined Twins or Siamese Twins • Congenital heart block Electrolyte Disturbances • Hyperkalemia • Hypokalemia • Hypercalcemia • Hypocalcemia • Nonspecific Changes Other Heart Diseases • Pericarditis • Myocarditis • Tamponade • Heart Transplantation • Sick Sinus Syndrome • Long QT Syndrome Inherited Disease • Brugada Syndrome Systemic Diseases • CNS Disease • Cardiac Tumors Heart Transplantation • EKG Changes in patient with Heart Transplantation Exogenous Effects • Hypothermia • Chest Trauma • Insect Bites • Electric Injuries
Technical Issues and Potential Errors in Interpretation	Artifacts • Lead Placement Errors • The EKG in a Patient with a Pacemaker • EKG in athletes

Atrial fibrillation: Difference between revisions

Revision as of 15:27, 15 June 2009

Contents

Overview

Overview

Epidemiology

Diagnosis

Overview

Classification

Etiology and Differential Diagnosis

Treatment

Pharmacological Treatment

Invasive Treatment

Surgical Treatment

Surgical treatment of atrial fibrillation

Maze procedure

Prognosis

Follow up & Secondary prevention

Risk factors for ischemic stroke or systemic embolization in patient with non valvular atrial fibrillation

Clinical Trial Data

Guidelines: Diagnosis and Management of Atrial Fibrillation

External links

See also

EKG Examples of atrial fibrillation

External EKG Sources

References

Further Readings

Navigation menu


Atrial fibrillation
The P waves, which represent depolarization of the atria, are irregular or absent during atrial fibrillation.
ICD-10	I48
ICD-9	427.31
DiseasesDB	1065
MedlinePlus	000184
eMedicine	med/184 emerg/46