Video Interview with Dr. Michael Argenziano About Atrial Fibrillation Surgery
August 5, 2009 5:21 AM CT
At the 2009 convention of the American Association for Thoracic Surgery, StopAfib.org had the opportunity to sit down and talk with Dr. Michael Argenziano, Director of the Surgical Arrhythmia Program at NY-Presbyterian/Columbia University Medical Center.
One interesting bit of trivia about Dr. Argenziano is that you may recognize the names of several of his colleagues, including Dr. Mehmet Oz, of Oprah fame and the YOU book series, and Dr. Craig Smith, who is well-known for doing Bill Clinton’s open-heart surgery.
In Part 1 of this video, Dr. Argenziano talks about the kinds of surgery they do for atrial fibrillation. They now do two types of procedures:
- Concomitant (simultaneously) with other heart procedures — this surgical ablation to eliminate afib can be either epicardial (outside the heart) or endocardial (inside the heart)
- Lone atrial fibrillation — where no other heart procedure is being done and the goal is strictly to get out of afib. This depends on the situation:
- For recent-onset paroxysmal atrial fibrillation and a normal heart, a minimally-invasive pulmonary vein isolation, with removal of the left atrial appendage, may be sufficient.
- For those with one or more failed catheter ablations, where the atria are pretty scarred, he favors a more extensive lesion set, such as a bi-atrial modified maze with lesions in the left and right atria and done from inside the heart. This is still minimally-invasive, but often requires the heart lung machine. It is like the Cox maze procedure lesion set, but without the incisions; he uses a variety of energy sources, and is currently favoring radio frequency energy.
He also talks about other considerations as to what procedures are best for certain patients.
- Patients with poor ventricular function, or who have an enlarged left atrium, may require more extensive procedures, such as endocardial (inside the heart) ablation, and maybe even an atrial reduction.
- Ganglionectomy can be done to remove abnormal nerve connections on the surface of the heart that can cause atrial fibrillation.
In Part 2 of this video, he talks about what else is new that afib patients should know about.
- He indicates that we are making lots of progress and have learned a lot. There are energy sources that are increasingly safe, and that are geared toward being minimally-invasive.
- There is, however, a great gap in our current level of knowledge about what really happens to patients after afib treatment. One trial that they are participating in involves implanting tiny subcutaneous (under the skin) monitors, like tiny pacemakers, that will provide continuous monitoring of the rhythm. Signals will be transmitted to the doctors (by phone), who can then monitor what patients are experiencing and determine if it’s atrial fibrillation, atrial flutter, bradycardia, or other, and then determine what to do about it. They will be able to monitor patients long term, and look at what patient rhythms look like five, ten, and even twenty years after surgery.
- Afib is finally getting the attention it has deserved for a long time, including for research funding.
View the videos:
- Dr. Argenziano on Atrial Fibrillation Surgery — Part 1
- Dr. Argenziano on Atrial Fibrillation Surgery — Part 2
Dr. Michael Argenziano is Director of the Surgical Arrhythmia Program at NY-Presbyterian/Columbia University Medical Center
For more about Dr. Argenziano, Dr. Oz, and Dr. Smith, read the fascinating book:
The Surgeons (my review of the book is there)
Mellanie: This is Mellanie True Hills with StopAfib.org. I’m at the American Association for Thoracic Surgery, and with me today is Dr. Mike Argenziano, of NewYork-Presbyterian/Columbia University Medical Center. He is the director of the surgical arrhythmia center. Dr. Argenziano, thank you for joining me today.
Dr. Argenziano: It’s my pleasure.
Mellanie: I appreciate you taking the time, and if you would, please tell patients about the kinds of surgeries that you do at NewYork-Presbyterian.
Dr. Argenziano: Well, for atrial fibrillation there are a number of procedures that we’ve developed over the years. We started in the late 1990s with standard open chest/open heart procedures where we used energy sources like radio frequency or cryothermy to supplement incisions that we made along the lines of the old Cox-Maze operation.
But as the years passed, we realized that patients needed a less invasive, less traumatic, and more advanced procedure, which would allow us to create the important lesions necessary for eradication of atrial fibrillation without creating the trauma and long recovery times associated with the traditional Cox-Maze operation. So along those lines, we’ve worked with a number of energy sources, including radio frequency, laser, microwave, high intensity focused ultrasound, and other energy sources, including chemical injection, to look for ways that we could create scars that could be effective, all the while trying to minimize the invasiveness of the procedure.
So currently, what we’ve evolved over more than ten years is that we perform really two types of procedures. For patients who are having other types of heart surgery—mitral valve surgery, coronary bypass, etc.—we do what you would call concomitant ablations, where we use either epicardial, from outside the heart, or endocardial, inside the heart, techniques to create the lesion sets that we feel necessary to treat the atrial fibrillation.
But, for the second group of patients, the patients who have what is known as lone atrial fibrillation, or atrial fibrillation that is not associated with other disorders requiring surgery, we do a whole different sort of operation. For those patients, we try to minimize the trauma of the surgery and the recovery time by making the incisions small, trying to avoid the heart-lung machine, but most importantly, we need to get those patients out of atrial fibrillation.
If you are a mitral valve patient, or a coronary bypass patient, getting out of atrial fibrillation can seem like an accessory goal, or a kind of icing on the cake, if you can get it. But if your problem is atrial fibrillation, and you have nothing else wrong with your heart, that’s not icing, that’s the goal—the goal is to get out of atrial fibrillation.
So for patients who come to me with lone atrial fibrillation, the operation I offer them depends a bit on their specific situation. If you are a patient with recent-onset paroxysmal atrial fibrillation, which means atrial fibrillation that doesn’t happen all the time, and you have an otherwise normal heart, then we might offer a pulmonary vein isolation, which we do minimally invasively on the beating heart without the heart-lung machine, and remove the left atrial appendage, which is the outpouching, a little sack, on the back of the left atrium, which may predispose people with atrial fibrillation to stroke.
On the other hand, if you are a patient who, like an increasing number of our patients, has gone through catheter ablation, and has had one, two, three, and even four failed catheter ablations, some with temporary success, some unfortunately with no success, then those patients are in a different category. Those atria are pretty scarred up after all those procedures, and in order to really give those patients the very best chance of getting out of atrial fibrillation I currently favor a more extensive lesion set, what we call a bi-atrial modified maze, where we create lesions in the left and right atria, and really the best way to do those lesions currently is do them from inside the heart.
So although I still do that operation minimally invasively, through a little 6 cm, or about 4 inch, incision in the side of the chest, in those cases we often do put the patient on the heart-lung machine, and open the heart, and do what is really very close to a complete Cox-maze lesion set, except without incisions, using a combination of radio frequency, cryo, or other energy sources, although most recently, radio frequency has been our favorite energy source.
Mellanie: Are there any other considerations that you’re making as to what procedures are best for which patients? You mentioned some of those, are there any other considerations as well?
Dr. Argenziano: There are some patients, for instance, who have poor ventricular function, you know, bad heart muscle function, or patients who have very enlarged left atria for whom more extensive procedures, including endocardial ablation and maybe even atrial reduction, where we make the atrium smaller to reduce the tension on the atrium, may be necessary.
And then finally, ganglionectomy—an adjunctive procedure that surgeons are increasingly using to remove some of the abnormal nerve connections on the surface of the heart that may promote atrial fibrillation—is another area we are actively pursuing.
Mellanie: What else is new? What are the things that you’re really excited about that are new that Afib patients should know about?
Dr. Argenziano: Well, I think Afib patients should be as encouraged as ever that we are making small, but regular, steps in the right direction. The tens of thousands of atrial fibrillation procedures that have been done over the last decade or so, since the new interest in surgical treatment of atrial fibrillation has been present, have taught us a lot of things.
We now have energy sources that are increasingly safe, efficient, easy to use, less expensive and therefore easier to adopt, and increasingly these devices and technologies are being geared toward minimally-invasive approaches, so as these devices are being developed, the idea of inserting them into a patient through a small incision is no longer an afterthought. It’s actually designed into the actual device.
But with everything that we know, and for all that we should be encouraged and excited about, there’s still so much to be learned. One of the things that I personally feel is a great gap in our current level of knowledge is what really happens to patients after afib treatment? We see publications that document six-month, twelve-month, and even twenty-four-month success rates, but how are those success rates being determined? In most cases, intermittent or spot-checks of rhythm are what are being used, and as any atrial fibrillation patient knows, they can be in and out of atrial fibrillation a hundred times in a day, or never over several months.
And so one trial that we’re involved in at Columbia involves, as a subcomponent of the trial, the implantation of small subcutaneous monitors, which are basically like tiny pacemakers, that we put under the skin, which will provide nearly-continuous monitoring of the rhythm. That then gets downloaded through a trans-telephonic system to a central database where we can actually ask the question, how often is this patient in atrial fibrillation? Is this patient having bursts of atrial fibrillation in the middle of the night, when they’re not aware, or are any funny symptoms that this patient is having correlated to atrial fibrillation? Sometimes patients are quite relieved to know that dizziness or funny feeling that they might have is actually not associated with atrial fibrillation, so they know that what they’re feeling is actually not something serious.
Mellanie: So you’re saying it will pick up things like atrial flutter, and that sort of thing, that could be rela
ted, but is not necessarily afib.
Dr. Argenziano: That’s right, or the consequence of treatment of atrial fibrillation. A very common problem for patients is bradycardia, a slowing of the heart rate, pauses in the heart rate. Sometimes, when a patient tells you, I feel a fluttering in my chest, or a funny feeling and I’m a little dizzy, it’s impossible to know, was that an episode of rapid atrial fibrillation, was that a sinus pause, was that atrial flutter? And if you know what it is, sometimes it’s as simple as just reducing beta blocker doses and getting those pauses to go away.
Mellanie: Right. How long do you think you’ll be able to leave those devices in for monitoring?
Dr. Argenziano: Well, the monitoring devices really require very little power, they’re small inert devices, and frankly once you have it under the skin, you can barely feel or see it, and I would say that it’s probably more trouble to go back in and remove it than not, so we actually feel those devices will have a utility for many years to come.
Remember, most afib patients have many, many years to live after their procedure, so focusing on the first year or two, although that may be very reasonable as a first question, is not enough in my opinion. I’d like to know what these patients look like five, ten, even twenty years later.
Mellanie: That sounds really promising to be able to have long term data about the results of these procedures. Is there anything else you’d like to add, for our audience of afibbers?
Dr. Argenziano: Right. Well, all I’d like to say is that atrial fibrillation is getting the attention it has deserved for a long time, and as our population ages, it is only going to get more attention as it is a disease that is associated with increasing age. For all these reasons, I think we now have enough attention on this, or at least more attention than we’ve ever had before.
In fact, as an example, the most recent NIH request for applications for the challenge grant program, which is a new program associated with the American Recovery Act, actually had an entire category for atrial fibrillation, which really indicates that the government and other third-party funders of research are paying attention.
Mellanie: Absolutely, that’s great news. Well, you guys at NewYork-Presbyterian are doing some great work. The audience may want to know that your colleagues include Dr. Mehmet Oz, who most people will know from Oprah fame and from the YOU book series, and Dr. Craig Smith, who is known for having done the open heart surgery on Bill Clinton, if I’m correct.
Dr. Argenziano: That’s correct.
Mellanie: You guys have an incredible team there at NewYork-Presbyterian, and I really appreciate you taking the time out of this important conference to share your wisdom for atrial fibrillation patients. Thank you so much, Dr. Argenziano.
Dr. Argenziano: Keep up the good work.