Post-Operative Atrial Fibrillation, Valvular Afib, and the AtriClip — Video Interview with Dr. Ralph Damiano
March 6, 2013
- Summary: Video interview with Dr. Ralph Damiano discussing post-operative atrial fibrillation, valvular afib, and the AtriClip for afib stroke prevention
- Reading and watching time is approximately 9½ minutes
In this video interview, Dr. Ralph Damiano explains why post-operative atrial fibrillation is still among the most common complications of cardiac surgery. He also discusses valvular afib, which can be addressed during valve surgery. Dr. Damiano also talks about his experience with the AtriClip, which he believes is a huge advance in stroke prevention for atrial fibrillation.
View the video interview with Dr. Damiano (approximately 9 minutes)
About Ralph Damiano, MD
John M. Shoenberg Professor, Surgery
Chief of Cardiac Surgery
Washington University School of Medicine
Dr. Damiano’s Profile
Atrial fibrillation resulting from surgery
Dr. Damiano: Post-operative afib is one of the most vexing problems in cardiac surgery. We’ve been doing cardiac surgery since the early 60s, and post-operative afib remains the most common complication following cardiac surgical procedures. And it complicates about 30% of our procedures. It’s more common as you get older; it’s more common in valve patients; and in certain patient subsets — for instance, if you were having a double valve replacement, the incidence almost gets up to 50%. So patients who are undergoing cardiac surgery should know that. It can be upsetting to people, particularly they may have had friends in afib who have had complications, but post-operative atrial fibrillation is generally a more benign problem than the atrial fibrillation you get if you were just walking around and then went into atrial fibrillation.
We’ve done research on it in our laboratory, and others around the world have done it. And it turns out that it’s probably more of an inflammatory response, similar to a bruise you would get if someone punched you. Imagine that this is a bruise on your atrium, and the atrium responds to that inflammation by being more vulnerable to atrial fibrillation. As you get older, the incidence of post-operative atrial fibrillation gets higher and higher.
The good thing about post-operative atrial fibrillation is that it almost always goes away — about 98% of the time by a month, it’s gone. Its peak incidence is at two or three days, and usually by a few weeks it’s gone. So you generally only have to be treated for that first month, and then we would often treat patients with both anticoagulation — usually Coumadin, or now Pradaxa, Xarelto, or one of the newer drugs — and usually an antiarrhythmic drug. But after a month we’d stop all of that. So it’s usually benign and self-limiting.
That said, if you get post-operative atrial fibrillation, what we worry about is that it increases your chance of having a post-operative stroke. So that’s why it’s really important, if you have that, to be put on some type of anticoagulation, particularly if you’re an elderly, more high risk patient. Interestingly, but despite having lots of research on the area, we still don’t have a good treatment for that. When we looked at our own incidence of post-operative atrial fibrillation, we found that it has not changed since the 1980s — there’s been some feeling that using beta-blockers would help prevent it, but in the real world that doesn’t seem to be the case. And a recent big multi-center trial we participated in showed that really none of the drugs we use, even antiarrhythmic drugs, seems to have a big impact on the incidence of post-operative atrial fibrillation
Valvular afib (starts 2:57)
Damiano: Valvular atrial fibrillation doesn’t receive the kind of attention that it should. Worldwide, if you look at the worldwide burden of atrial fibrillation, by far the most common reason people are in afib is from valvular heart disease, and when you go to countries like India and China and a lot of southeast Asia, where they still see a lot of rheumatic valvular disease, it is a huge healthcare burden. When we’ve looked at our own series, and other people, about a third of patients who have mitral valve problems have atrial fibrillation associated with it.
So if your mitral valve leaks or is stenotic, often your left atrium increases, and that makes people prone to atrial fibrillation. You know, the exact mechanism hasn’t been well defined — we’re actually trying to do some animal studies to help try to define that — but we definitely know it’s a big problem, usually associated with your left atrium getting bigger, and higher pressures in the left atrium, and that seems to make people more prone to atrial fibrillation. Interestingly, it’s also a problem in about 1 in 5 patients with aortic valve disease.
The treatment — and I’d really recommend for patients who have valvular disease and atrial fibrillation to really go to a surgeon who knows how to cure your atrial fibrillation, because you should really take advantage of the opportunity when they do the valve procedure. If you need valve surgery, absolutely go to a surgeon who’s skilled in surgical ablation for atrial fibrillation because there is a very high cure rate, between 80% and 90%, particularly if you do a full maze procedure. Some patients are even candidates for lesser ablation procedures, but it’s a great opportunity to have both the valve fixed and the atrial fibrillation taken care of at the same time.
AtriClip (starts 4:56)
MTH: tell us about the AtriClip and your experience with that.
Damiano: So, the AtriClip is a new device that allows surgeons to be able to occlude the left atrial appendage without having to cut it, in which you almost have to be on bypass if you cut it off, or to staple it, which had a lot of complications with tearing. If you can imagine, it’s like a hair clip, that at the time of ablation procedures — or we even do it sometimes just in patients who need their appendage off because of the risk of stroke — it can be put on. It does not require going on the heart lung machine, or even an incision – it can be put on thoracoscopically. And I think it’s a big advance in the field.
As you know, the big complication of atrial fibrillation is stroke. And most of those strokes come from the appendage; maybe as much as 95% of the clots you get with atrial fibrillation are in the appendage. And we have thought, as you know, we’ve been doing atrial fibrillation surgery for a long time in St. Louis, and always we’ve felt strongly that if you’re going to have an atrial fibrillation procedure, the appendage should be taken off. And historically we’ve had to cut if off, more recently with the stapler, but I think certainly these new clips, which are very minimally invasive, are a big advance, and particularly for patients who are even having a thoracoscopic approach, or aren’t going on a heart lung machine, are by far in my opinion the safest. The early clinical trials with the clip have shown that it is both safe and very, very effective — over 95% effective — at getting rid of your appendage.
AtriClip alone, without a Maze procedure (starts 6:52)
Damiano: When you look at using the AtriClip as just a procedure alone, to just take your appendage that is still not a common procedure. The reason for that is probably multifactorial — one of the big reasons is that it is not reimbursed by any insurer, and that is a bit of a problem, and yet we still do it because there are some times when it’s the right thing to do.
So let’s say you’re a patient who has chronic atrial fibrillation, you’re elderly, and probably can’t really tolerate a major procedure for your afib, but you’ve had a stroke and then you develop a contraindication to anticoagulation. That’s often due to some kind of bleeding problem — either in your head, or your GI, gastrointestinal bleeding is common. Your risk of stroke is very high — maybe as much as 10% a year — and it’s our feeling in those patients that a clip of the appendage is actually a really good procedure. The reason it’s still not reimbursed is that there’s not a lot of trials which have really shown that that reduces the risk of stroke, but we feel that pretty much everything we know about our thirty-year experience with the maze procedure and general surgical ablation, and also the efficacy of removing the left atrial appendage at the time of valve surgery, that that’s probably a good thing to do. And there is a steady, though small, stream of patients that get referred to that. So I think one of the thing’s you’ll see in the next decade is that’s going to become more common, and I would predict we’ll be reimbursed. I think it’s a good option for patients that are really at high risk of stroke and really can’t take Coumadin.
MTH: Thank you for sharing with us, Dr. Damiano, about some of the things you’ve presented here at Boston AF as well as other conferences. Thank you so much.
Damiano: Thanks Mellanie.