1. AF Basics for Office Visits Patient Education
NEW Patients with
Atrial Fibrillation and/or Atrial Flutter

2. Anatomy of the Heart The heart sits inside your chest.
It is made up of 4 chambers
2 upper (atrium)
2 lower (ventricle)
If you take a cross-section of the heart you will see that the upper and lower chambers are separated by valves.
There can be problems with the plumbing--
which effect the pumping of the heart Or
Problems with the electricity—leading to arrhythmias.

3. Normal sinus rhythm
In Sinus Rhythm the electrical impulse originates at the Sinus Node.
It activates the upper chambers to contract.
When it reaches the AV node it electrically stimulates the lower chambers of the heart to contract.
The heart beats as a 1:1 ratio in a coordinated way. 3

4. Atrial Fibrillation
In Atrial Fibrillation (AF) the electrical impulses originate in the pulmonary vein in the left atrium in a chaotic fashion.
These impulses can fire at a rate between bmp.
The upper chambers quiver.
Blood can pool in the heart and cause blood clots.
The AV node blocks most impulses to the lower chambers.
Consequently, the heart beat is irregular 4

5. Difference in EKG Strips
Normal Sinus Rhythm
Atrial Fibrillation

6. Predisposing Conditions
% Proportion of patients 60 57 50 40 29 30 23 20 20 16 16 11
AF is more likely to occur in the setting of underlying structural heart disease or as the initiation or conduction of electrical impulses may thereby be destabilized. Predisposing cardiovascular conditions exist in over 90% of patients with AF. The most common conditions associated with development of AF are hypertension or high blood pressure (HBP), congestive heart failure (CHF) and coronary artery disease (CAD). Other predisposing conditions observed in AF patients include arthritis, cardiomyopathy, peripheral vascular disease (PVD), depression, anxiety, diabetes and gastrointestinal (GI) disorders (Market Certitude 2002).
Population-based studies have shown that less than 12% of all AF cases are lone AF, i.e. no history of cardiopulmonary disease or predisposing conditions (Fuster et al 2001). 8 8 10 7
Hypertension
CAD
Hyper
thyroidism
Angina
PVD
CHF
CMP
Depression / Anxiety
Diabetes
Idiopathic
Market Certitude, LLC Atrial Fibrillation Patient Record Study July 2002

7. Stages of AF Paroxysmal: Persistent atrial fibrillation:
Episodes start and stop on their own
Usually last 7 days or less
Usually initiated by rapid electrical firing from the pulmonary veins.
Persistent atrial fibrillation:
Episodes last longer than 7 days
Requires medications and/or electrical cardioversion to achieve normal sinus rhythm
Electrical impulses can orginate in the pulmonary veins and areas in the left atrium
Permanent atrial fibrillation:
No longer respondent to medications and cardioversions

8. Goals of Treatment
Stroke Prevention
Symptom Management

9. Stroke Prevention Anticoagulation medication
Aspirin
Warfarin (Coumadin)
Dabigatran (Pradaxa)
Non-pharmacologically treatment
Watchman device (Left Atrial Appendage excusion device)

10. Calculating Stroke Risk
CHADS2
C ongestive heart failure 1
H ypertension 1
A ge ≥ 75 years 1
D iabetes 1
S troke/ TIA 2
CHADSVAS
C ongestive heart failure/LV dysfunction 1
H ypertension 1
A ge ≥ 75 years 2
D iabetes 1
S troke/TIA/TE 2
V ascular disease [prior MI, PAD, or aortic plaque] 1
A ge years 1
S ex category (female) 1
Guidelines
0- No anticoagulation needed
1- Anticoagulation up to discretion of patient and physician
2- Anticoagulation required
The CHADSVAS score is an enhancement of the CHADS2 score to help identify traditionally the “lower risk patients” to ensure that we decrease their stroke risk with the proper anticoagulation.

11. Asymptomatic or Symptomatic Atrial Fibrillation
Diagnosed with Atrial Fibrillation
Asymptomatic AF
No change in Functional Status or Quality of Life
Symptomatic AF
Palpitations
Fatigue
Exercise Intolerance
Shortness of breath
Heart Failure Symptoms
Vague Symptoms
Patient diagnosed with atrial fibrillation:
Asymptomatic patients – no change in functional status or quality of life
Some patient are vague with regards to symptoms
Offer DC cardioversion for asymptomatic patient and also to determine whether or not patient has symptoms associated with atrial fibrillation.
Symptomatic patient – may have palpitations, but not always. Patient may experience symptoms of fatigue, SOB, exercise intolerance or heart failure
Rhythm Control strategy – AADs and Cardioversion
DC cardioversion
Rhythm Control
Rate Control versus Rhythm Control

12. Rate versus Rhythm Rate Control Beta Blockers Metoprolol Atenolol
Calcium Channel Blockers
Diltiazem
Verapamil
Digoxin
Rhythm Control
Sodium Channel Blockers
Flecainide
Propafanone
Potassium Channel Blockers
Sotalol
Dofetilide
Multiple Ion Channel Blocker
Amiodarone
There are two approaches to treating patient atrial fibrillation:
Rate control – allows atrial fibrillation to persist in patient who are asymptomatic.
Rhythm control- attempting to restore and maintain sinus rhythm in symptomatic patient.
Symptomatic patients – may not always have palpitaitons, they may have
Exercise intolerance, heart failure symptoms
AFFIRM and RACE Studies – Clinical Implications:
Survival: Rhythm control offers no survival advantage over Rate control
Recommend anticoagulation therapy for both approaches
AFFIRM Investig., New Engl J Med., 2002 Vol. 347, No. 23 12

13. Important considerations for patient selection for PVI
Is there an indication for a PVI?
Symptomatic
Failed antiarrhythmics
Paroxysmal or persistent
Paroxysmal AF has a higher success rate than persistent AF.
Important in choosing ablation method (cryo vs RFA)
Physical limitations
Works best when left atrium is not excessively enlarged (greater than 55 mm).
Less effective and more challenging in patients with structural heart disease

14. PVI Typically done under general anesthesia. 4-8 hours in duration
24 hour admission

15. Atrial Fibrillation: Catheter ablation or PVI
Pulmonary vein isolation (PVI) is done under general anesthesia.
6-8 hours
Catheters are inserted into your groins and advanced up inside the heart.
The catheter is advanced to the left atrium.
The target area is the pulmonary veins.
The Physician burns in a dot-by-dot fashion to isolate the pulmonary veins.

16. Integrated MRI and Mapping to Guide AF Ablation
Picture of the dot-by-dot approach.
#155

17. Risk Associated with Ablation
Limited Complications
Perforation of the Heart (Cardiac Tamponade)
Guided imagery throughout case
Pulmonary Vein Stenosis
Monitor by CT scan or MRI after case
Stroke/TIA
Continue anticoagulation throughout procedure
Atrial-Esophageal Fistula
Monitor temperature throughout procedure in esophagus
MGH Statistics
Cardiac Tamponade 1.5%
Pulm Vein Stenosis 0.1%
Stroke TIA 0.6%
Comparative to worldwide survey investigating the methods, efficacy, and safety of catheter ablation of atrial fibrillation
Cappato et.al, Circulation, March 2005