Arrhythmia surgery

Overview

An arrhythmia is a problem with your heart's rate or rhythm. It indicates that your heart is beating too quickly, too slowly, or in an irregular pattern. Tachycardia occurs when the heart beats faster than usual. Bradycardia occurs when the heart beats too slowly.

This "fluttering" of the heart may only cause mild symptoms in some people, but in others, it may be associated with more severe symptoms such as chest pain, shortness of breath, giddiness, and even blackouts. As a result, in some cases, your doctor may advise you to seek definitive treatment through surgical intervention.

Arrhythmia surgery has improved the clinical course of patients with and without congenital heart disease suffering from debilitating atrial and ventricular arrhythmias.

Standard arrhythmia ablation surgical techniques were used, including resection, isolation, and cryoablation of affected atrial or ventricular tissue.

Heart's internal electrical system

With each heartbeat, an electrical signal travels from the top to the bottom of the heart. As the signal travels, the heart contracts and pumps blood. With each new heartbeat, the process is repeated.

Each electrical signal originates in a cluster of cells known as the sinus node or sinoatrial (SA) node. The SA node is found in the right atrium, which is the heart's upper right chamber. At rest, the SA node in a healthy adult heart sends an electrical signal to start a new heartbeat 60 to 100 times per minute.

The electrical signal travels from the SA node through special pathways in the right and left atria. This causes the atria to contract and pump blood into the ventricles, the heart's two lower chambers.

The electrical signal is then transmitted to the atrioventricular (AV) node, which is located between the atria and the ventricles. The signal slows slightly here, allowing the ventricles to finish filling with blood.

The electrical signal is then released from the AV node and travels along a path known as the bundle of His. This pathway splits into two branches: a right bundle branch and a left bundle branch. The signal travels down these branches to the ventricles, which contract and pump blood to the lungs and the rest of the body.

The ventricles then relax, and the heartbeat cycle begins again in the SA node. An arrhythmia can be caused by any flaw in this process. For example, in atrial fibrillation, a common type of arrhythmia, electrical signals travel quickly and disorganizedly through the atria. The atria quiver instead of contracting as a result of this.

What is Arrhythmia?

Arrhythmia, in its broadest sense, refers to any abnormal heartbeat. Irregular heart rhythms are not uncommon, and many people, especially as they get older, feel a "fluttering" or that their heart "skips a beat." However, in severe cases, arrhythmia can be a dangerous condition that necessitates medical treatment such as surgery and/or medical devices to correct.

Electrical signals from within your heart control both the speed and pattern of your heartbeat. These signals cause the upper chambers of the heart (atria) to contract in order to move blood to the lower chambers (ventricles), and the ventricles to contract in order to move blood out to the lungs and the body. These electrical signals are generated and transmitted by special electrical cells known as the sinus node.

If these signals are disrupted, your heart may beat too quickly (tachycardia), too slowly (bradycardia), or irregularly (arrhythmia). When electrical signals are not sent or are blocked, a slow heart rhythm (bradycardia) develops, and blood cannot be pumped and moved properly throughout the body.

A fast heart rhythm (tachycardia) may develop if too many signals are sent. When signals are sent quickly and irregularly, the heart muscle may quiver and stop beating altogether, resulting in fibrillation. Fibrillation can occur in the atria (atrial fibrillation) or in the ventricles (ventricular fibrillation) (ventricular fibrillation). In severe cases, fibrillation can result in blood clots or cardiac arrest.

Who is at Risk for an Arrhythmia?

Arrhythmias affect millions of people in the United States. They are very common in older people. Atrial fibrillation, a common type of arrhythmia that can cause problems, affects approximately 2.2 million Americans.

The majority of serious arrhythmias affect people over the age of 60. This is due to the increased risk of heart disease and other health issues that can lead to arrhythmias in older adults.

Older adults are also more susceptible to the side effects of medications, some of which can cause arrhythmias. Some arrhythmia-treating medications can even cause arrhythmias as a side effect.

Arrhythmias of various types are more common in children and young adults. Young people are more likely to develop paroxysmal supraventricular tachycardias (PSVTs), such as Wolff-Parkinson-White syndrome. PSVT is characterized by a rapid heart rate that begins and ends abruptly.

Major Risk Factors

Arrhythmias are more common in people who have diseases or conditions that weaken the heart, such as:

The heart attacks
Heart failure, also known as cardiomyopathy, is a condition that weakens the heart and alters the way electrical signals move around the heart.
Too thick or stiff heart tissue, or heart tissue that has not formed normally
Heart valve leakage or narrowing, which causes the heart to work too hard and can lead to heart failure
Congenital heart defects are birth defects that affect the structure or function of the heart.

Arrhythmia Treatments

Treatment for arrhythmias is determined by the type and severity of the arrhythmia. There is no need for treatment in some cases of arrhythmia. Medication, lifestyle changes, invasive therapies, electrical devices, and surgery are all treatment options.

Arrhythmias can be treated with a variety of medications. Because everyone is different, it may be necessary to try a variety of medications and dosages before determining which one works best for you. Various types of drugs are used:

Anti-arrhythmic drugs are medications that are used to either convert an arrhythmia to sinus rhythm (normal rhythm) or to prevent an arrhythmia from occurring.
Heart-rate control drugs are medications that are used to regulate the heart rate.
Anticoagulant or antiplatelet therapy – drugs that reduce the risk of blood clots or strokes, such as warfarin (a "blood thinner") or aspirin.
Medications used to treat conditions that may be causing an irregular heart rhythm.

Surgical treatment for Arrythmia

Devices

A cardiologist inserts these devices during an electrophysiology lab procedure.

Pacemaker

A pacemaker is a device that is used to treat an abnormally slow heart rhythm. It is made up of a small, lightweight electronic device that is surgically implanted in your chest to provide long-term management. The pacemaker constantly monitors your heart rhythm to detect irregularities. When necessary, it generates an electrical signal that is similar to the heart's natural signals in order to keep your heartbeat at the proper rate.

Pacemakers can have one lead (wire) that ends in either the right atrium or the right ventricle, or they can have two leads, one in the right atrium and one in the right ventricle. Some pacemakers are rate-adaptive, which means they can help you adjust your heart rate to your level of activity.

Implantable Cardioverter Defibrillator (ICD)

An implantable cardioverter defibrillator (ICD) is a small electronic device that is surgically implanted in your body to continuously monitor your heart rhythm. However, unlike a pacemaker, the ICD is intended to slow down a fast-beating heart. It can pace your heart to slow the rhythm and, if necessary, shock your heart to restore normal rhythm. An ICD can be implanted in conjunction with a pacemaker, and some ICDs include a pacemaker that can be activated.

There are several ways the ICD can be used to restore normal heart rhythm:

When the heart beats too quickly, a series of small electrical impulses may be delivered to the heart muscle to restore a normal heart rate and rhythm.
Cardioversion/Defibrillation – When the heart beats dangerously fast or irregularly, a shock to the heart muscle may be delivered to restore a normal rhythm.
Anti-bradycardia pacing – most ICDs include backup pacing to prevent an abnormally slow heart rhythm.
Biventricular (B-V) pacemakers and defibrillators

Biventricular pacemakers and defibrillators are used in patients with heart failure who also have uncoordinated or asynchronous left ventricle contractions. These devices aid in the synchronization of the left ventricle's contraction.

In addition to the one or two leads placed in the right ventricle and right atrium by traditional pacemakers and defibrillators, bi-ventricular devices use an additional lead placed on the back or left side of the left ventricle. The additional lead is typically guided through the coronary sinus, a small vein on the back of the heart, to reach this area.

Catheter ablation

Cardiac ablation is a procedure used to treat irregular heartbeats. High-frequency electrical energy is delivered through a catheter to a small area of tissue inside the heart that causes the abnormal heart rhythm during an ablation. This energy "disconnects" the abnormal rhythm's pathway.

Most SVTs, atrial flutter, and some atrial and ventricular tachycardias can be treated with ablation. It can also be used to cut the electrical connection between the atria and the ventricles, which may be beneficial in people with atrial fibrillation. Ablation can be combined with other treatments to achieve the best results.

Risks

Possible cardiac ablation risks include:

Bleeding or infection at the site of catheter insertion
Damage to blood vessels
Valve damage in the heart
Arrhythmia that is new or worsening
Slow heart rate that may necessitate the use of a pacemaker to correct
Clots of blood in your legs or lungs
A stroke or a heart attack
Narrowing of the veins that carry blood from your lungs to your heart
Kidney damage caused by the dye used during the procedure
In rare cases, death occurs.

After cardiac ablation, the majority of people notice an improvement in their quality of life. However, there is a chance that your abnormal heartbeat will return. If this occurs, the procedure may be repeated, or you and your doctor may discuss other options. You may still need to take heart medication after a cardiac ablation depending on the type of arrhythmia you have.

Pulmonary vein isolation

Isolation of the pulmonary veins is a type of ablation that targets areas thought to cause atrial fibrillation in patients with frequent, paroxysmal, or persistent atrial fibrillation. The goal is to form scar rings that isolate the foci responsible for causing atrial fibrillation.

Surgical treatment of Ventricular Arrhythmia

Surgery for the treatment of ventricular arrhythmia has decreased dramatically since the introduction of implantable cardioverters/defibrillators (ICD) and percutaneous ablation. Surgical treatment of ventricular arrhythmias is still required, particularly in cases where ICD discharge occurs frequently or in patients with other surgical indications.

For malignant arrhythmias and right ventricular failure in patients with arrhythmogenic right ventricular dysplasia, surgical therapy may range from radiofrequency or cryoablation of a single focus (identified either intra-operatively or percutaneously) to more extensive surgical procedures such as surgical ventricular reconstruction with endocardial resection or even resection of the right ventricle and creation of a cavo-pulmonary circulation. However, the surgical procedure should be chosen based on the arrhythmia's pathomechanism.

This is significant because any incision in the left or right ventricle, as well as percutaneous ablation, can cause ventricular arrhythmia. When treating an arrhythmia, patients may require heart surgery for three reasons:

To treat heart disease that may be causing the arrhythmia
The Maze and modified Maze procedures are two surgical procedures used to treat atrial fibrillation that cannot be controlled with medications or non-surgical treatment methods. It is frequently used in conjunction with other types of heart surgery, such as valve surgery, but it can also be performed on its own in some cases.
Biventricular pacemaker leads can be implanted on the heart using minimally invasive or endoscopic techniques.

Maze Procedure

When other treatments (such as medication, cardioversion, and catheter ablation) have failed to correct the problem in severe cases of atrial fibrillation, your doctor may recommend a maze procedure. This open-heart surgery takes about three hours to complete, with a six to eight-week recovery period.

This novel procedure creates a "maze" of new pathways for electrical impulses to travel from the top of the heart to the bottom. It restores a regular, coordinated heartbeat, eliminates atrial fibrillation, and restores coordinated pumping to the heart's upper chambers.

Because the surgeon must actually work on the heart muscle, a maze procedure is much more difficult. The surgeon makes an incision down the center of the chest and splits the breastbone to gain access to the heart. Your heart will be stopped and cooled after being connected to a heart-lung machine so that the surgeon can make a number of incisions in the upper chambers of the heart. The heart is restarted and the patient is removed from the heart-lung machine once the procedure is completed. The incision has been closed.

Scars are formed in strategic locations in the atria as a result of the maze procedure. This results in a "maze" of scar tissue that the surgeon creates using cold energy (cryoablation). AFib can be treated with a maze procedure, which improves symptoms and quality of life. Furthermore, the maze can keep faulty electrical signals from causing AFib.

The maze procedure is effective in treating AFib in 60–70% of patients, who can often discontinue blood thinners several months after the procedure.

Why might I need a Maze procedure for AFib?

AFib can cause a variety of symptoms, including chest pain and shortness of breath. It can also lead to complications like blood clots and stroke. As a result, it is critical to diagnose and treat it.

The maze procedure is used to treat patients who do not respond to or tolerate other treatments. It's also a good option for people who need open-heart surgery for other reasons (such as mitral valve disease), because both procedures can be done at the same time.

The Maze procedure can be used to treat AFib, alleviate symptoms, and prevent complications. Your doctor will assist you in determining whether the procedure or another option is best for you.

How do I get ready for a Maze procedure?

To make sure you are healthy enough for this open-heart surgery, you may need some tests:

Blood tests
Chest X-ray
Electrocardiogram, to assess the heart rhythm
Echocardiogram, or echo, to assess heart structure and function

If you are scheduled for a Maze procedure, your surgeon will provide you with detailed instructions, which will include:

After midnight on the day of surgery, avoid eating or drinking anything.
Before the procedure, you must stop smoking.
Certain medications, particularly blood thinners, should be avoided prior to the procedure.

What happens during a Maze procedure?

Surgical Technique

Maze procedures vary according to the condition of the patients and other procedures that are taking place at the same time. However, in most cases, the surgery lasts several hours.

The surgical team will:

If necessary, shave the area where the surgery will take place.
Give you anesthesia so that you sleep deeply and don't feel any pain during the procedure.
Separate your breastbone by making an incision (cut) down the center of your chest.
Connect you to a heart-lung machine (cardiopulmonary bypass) that will perform the functions of your heart and lungs during the procedure.
Scar lines in the left and right atria can be created using cryoablation. The left atrial appendage may also be closed by the surgeon.
Remove you from the heart-lung machine, wire your breastbone back together, and stitch or staple the incision closed.

What are the Complications from a Maze procedure?

Complications can occur following any type of surgery, and they are more common in people who:

Are older
Are very overweight
Have multiple medical conditions
Smoke

Complications after the maze procedure are rare but may include:

Bleeding
Blood clots, which might lead to a stroke or heart attack
The need for a permanent pacemaker
Complications from anesthesia
Failure to control the abnormal rhythms
Infection
Kidney failure
Other abnormal heart rhythms

What happens after Maze surgery?

After the surgical ablation, you will be transferred to a recovery room, where you will be awakened from anesthesia. You will be a little sore, but not in excruciating pain.

You may have a breathing tube in your throat. You may also have a tube in your chest to drain excess fluids. Typically, the tubes are removed within two days of surgery.

Your health care team will:

Machines at your bedside monitor your heart rate and other vital signs.
Teach you breathing exercises to aid in the removal of fluids that may accumulate in the lungs during surgery.
Give you only liquids to drink at first, then gradually introduce food.
During the first day or two, encourage you to sit in a chair and walk with assistance.
Monitor your pain and provide you with medications and pain management strategies.
As you recover, remove the tubes.

After you leave the hospital:

For several weeks, avoid lifting anything heavy.
Follow all recovery instructions, including those pertaining to medications, exercise, diet, wound care, and driving.
Have someone assist you at home.
See the surgeon in seven to ten days for a follow-up appointment and to have any stitches or staples removed.
Over the course of several weeks, you will gradually regain your strength.

Conclusion

Surgery is sometimes used to treat arrhythmias. This frequently happens when surgery is already being performed for another reason, such as the repair of a heart valve. Maze surgery is one type of atrial fibrillation surgery. The surgeon performs this procedure by making small cuts or burns in the atria to prevent the spread of disorganized electrical signals.

Electrical cardioversion and catheter ablation are invasive procedures used to treat or eliminate irregular heartbeats. Your doctor will determine the best treatment for you and will go over the advantages and disadvantages of these therapies with you.

In patients with and without associated congenital heart disease, successful surgical therapy for atrial arrhythmias can be performed safely and with a high freedom from recurrence rate. Surgical ablation for ventricular arrhythmias has a lower success rate. The complexity of the underlying congenital heart disease, as well as hemodynamic status, may all contribute to arrhythmia recurrence or new onset arrhythmia manifestation.