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Surgical Therapy of Atrial Fibrillation  [PDF]
Martin Haensig,Ardawan Julian Rastan,David Michael Holzhey,Friedrich-Wilhelm Mohr,Jens Garbade
Cardiology Research and Practice , 2012, DOI: 10.1155/2012/149503
Abstract: Atrial fibrillation (AF) can be found in an increasing number of cardiac surgical patients due to a higher patient's age and comorbidities. Atrial fibrillation is known, however, to be a risk factor for a greater mortality, and one aim of intraoperative AF treatment is to approximate early and long-term survival of AF patients to survival of patients with preoperative sinus rhythm. Today, surgeons are more and more able to perform less complex, that is, minimally invasive cardiac surgical procedures. The evolution of alternative ablation technologies using different energy sources has revolutionized the surgical therapy of atrial fibrillation and allows adding the ablation therapy without adding significant risk. Thus, the surgical treatment of atrial fibrillation in combination with the cardiac surgery procedure allows to improve the postoperative long-term survival and to reduce permanent anticoagulation in these patients. This paper focuses on the variety of incisions, lesion sets, and surgical techniques, as well as energy modalities and results of AF ablation and also summarizes future trends and current devices in use. 1. Background Atrial fibrillation is defined as uncontrolled atrial electrical excitation at a rate of >300 beats per minute. The conduction to the ventricles is irregular and in variable frequencies, therefore resulting in the types of slow (bradycardiac), normofrequent, or fast (tachycardiac) atrial fibrillation (AF). Furthermore, AF can be divided into paroxysmal, persistent, and permanent (accepted) AF [1]. Paroxysmal AF is self-terminating, usually within 48 hours. Although AF paroxysms may continue for up to 7 days, after 48 hours the likelihood of spontaneous conversion is low, and anticoagulation must be considered. Persistent AF is an AF episode which either lasts longer than 7 days or requires termination by cardioversion with drugs or by direct electrical cardioversion. The persistent types of AF are frequently symptomatic and are, depending on the comorbidities, associated with an increased stroke risk. Persistent AF is added by the subtype of long-standing persistent AF (>1y), when it is decided to adopt a rhythm control strategy. Permanent AF is when the presence of the arrhythmia is accepted and a rhythm control is no longer pursued. Surgical treatment of atrial fibrillation should be considered as a stand-alone concept when patients do not get free of AF or symptoms despite multiple interventional ablations or when a contraindication for catheter ablation exists [1]. Furthermore, atrial fibrillation as a comorbidity
Paroxysmal atrial fibrillation: choice of cardioversion therapy  [cached]
B. A.Tatarskii
Rational Pharmacotherapy in Cardiology , 2007,
Abstract: Characteristics and classification of different patterns of paroxysmal atrial fibrillation are presented. Main indications to restoration of sinus rhythm are discussed. The features of main medications used to terminate of atrial fibrillation are given. The choice of antiarrhythmic drug is considerate. Necessity of individual approach to therapy tactics is proved.
Atrial Fibrillation Ablation: First-Line Therapy?
Atul Verma
Journal of Atrial Fibrillation , 2009, DOI: 10.4022/jafib.v1.i8.545
Abstract: Background: Ablation for atrial fibrillation (AF) is a widely-accepted treatment for this arrhythmia. Ablation is traditionally reserved for second-line therapy in patients who have failed drug therapy, but it may be ready for first-line treatment. Objective: This article outlines the rationale for using ablation as first-line therapy for AF. Findings: AF increases both morbidity and mortality. Unfortunately, drug-based therapy for AF is very ineffective and may contribute adversely to both patient morbidity and mortality. Ablation addresses the root causes of AF and thus may be curative. The technique for ablation has become quite consistent and the outcomes better than those with drug therapy. The complication risk is also acceptably low. There is even preliminary evidence to suggest that AF ablation is superior as first-line treatment compared to drugs. Conclusion: AF ablation is rapidly evolving towards becoming first-line therapy for some patients with this debilitating arrhythmia. Key Words: Atrial fibrillation, Pulmonary veins, Catheter ablation, Review
Antithrombotic therapy in atrial fibrillation: new data and new horizons  [cached]
M.Yu. Gilyarov,V.A. Sulimov
Rational Pharmacotherapy in Cardiology , 2011,
Abstract: New data and perspectives of antithrombotic therapy are highlighted in patients with atrial fibrillation. Factors of warfarin therapy efficacy, as well as the possibility of new antithrombotic drugs are considered. Special attention are paid to the direct thrombin inhibitors — dabigatran. Possibilities and usage prospects of dabigatran in patients with atrial fibrillation are discussed in detail in the light of new results of RE-LY trial.
Antithrombotic therapy in atrial fibrillation: recent approaches and near perspectives  [cached]
Ya.P. Dovgalevskiy,L.E. Kuvshinova,I.V. Graifer,N.V. Furman
Rational Pharmacotherapy in Cardiology , 2011,
Abstract: Recent data and perspectives of antithrombotic therapy in patients with atrial fibrillation (AF) are highlighted. The main statements of current Russian and international guidelines about thromboembolic events prevention in AF patients are presented. Special attention paid to new agents for oral anticoagulation therapy, last information about their efficacy, safety and potential of application.
Anticoagulant and Antiplatelet Therapy in Patients with Atrial Fibrillation and Coronary Artery Disease  [PDF]
Karl Mischke,Christian Knackstedt,Nikolaus Marx
Thrombosis , 2012, DOI: 10.1155/2012/184573
Abstract: Anticoagulation represents the mainstay of therapy for most patients with atrial fibrillation. Patients on oral anticoagulation often require concomitant antiplatelet therapy, mostly because of coronary artery disease. After coronary stent implantation, dual antiplatelet therapy is necessary. However, the combination of oral anticoagulation and antiplatelet therapy increases the bleeding risk. Risk scores such as the CHA2DS2-Vasc score and the HAS-BLED score help to identify both bleeding and stroke risk in individual patients. The guidelines of the European Society of Cardiology provide a rather detailed recommendation for patients on oral anticoagulation after coronary stent implantation. However, robust evidence is lacking for some of the recommendations, and especially for new oral anticoagulants and new antiplatelets few or no data are available. This review addresses some of the critical points of the guidelines and discusses potential advantages of new anticoagulants in patients with atrial fibrillation after stent implantation. 1. Introduction Both patients with coronary artery disease as well as patients with atrial fibrillation frequently require antiplatelet therapy or anticoagulation to reduce the risk of cardiovascular and cerebral events. Recently, a number of new antiplatelet drugs and new drugs for anticoagulation have been approved to expand the armory of the treating physician. The standard antithrombotic agent for patients with coronary artery disease is aspirin; usually a dual therapy with addition of clopidogrel or newer agents is required after stent implantation or acute coronary syndrome. In patients with chronic atrial fibrillation, oral anticoagulation with vitamin K-antagonists represents the mainstay of therapy. In patients presenting with both coronary artery disease and atrial fibrillation, the choice of medication is sometimes challenging, especially with respect to a possible increase in bleeding complications in patients treated with a dual or triple therapy. 2. Risk Assessment in Atrial Fibrillation The current guidelines of the European Society of Cardiology (ESC) for atrial fibrillation suggest risk stratification in patients with nonvalvular atrial fibrillation for the decision of implementing oral anticoagulation [1]. This risk stratification is based on the CHADS2- and CHA2DS2-Vasc-Score [1]. The CHA2DS2-Vasc-Score is depicted in Table 1. These scores can easily be implemented into clinical routine as they are simple, although they do not take into account other risk factors such as left atrial flow velocity or the
Non-Pharmacological Therapy for Atrial Fibrillation: Managing the Left Atrial Appendage  [PDF]
Sushil Allen Luis,Damian Roper,Alexander Incani,Karl Poon,Haris Haqqani,Darren L. Walters
Cardiology Research and Practice , 2012, DOI: 10.1155/2012/304626
Abstract: The prevalence of atrial fibrillation (AF) is increasing in parallel with an ageing population leading to increased morbidity and mortality. The most feared complication of AF is stroke, with the arrhythmia being responsible for up to 20% of all ischemic strokes. An important contributor to this increased risk of stroke is the left atrial appendage (LAA). A combination of the LAA's unique geometry and atrial fibrillation leads to low blood flow velocity and stasis, which are precursors to thrombus formation. It has been hypothesized for over half a century that excision of the LAA would lead to a reduction in the incidence of stroke. It has only been in the last 20–25 years that the knowledge and technology has been available to safely carry out such a procedure. We now have a number of viable techniques, both surgical and percutaneous, which will be covered in this paper. 1. Introduction Atrial fibrillation (AF) is the most prevalent arrhythmia seen in clinical practice with over 2.2 million people in the United States being affected [1]. Given the association of AF with advancing age, this figure is predicted to increase significantly over the years to come, in line with an aging population. By 40 years of age, the lifetime risk of a man developing AF is 26% and a woman 23% [2]. Although most patients with AF tolerate it well, in a significant proportion of patients the arrhythmia can lead to a substantial reduction in quality of life. The most significant complication, feared by both patient and medical staff, is that of stroke. A stroke in a patient with AF has a poorer prognosis than in a patient without AF [3]. The rhythm had been shown to increase a patient’s risk of an ischemic stroke by 4-5 fold [4]. Additionally, AF has been shown to be accountable for up to 20% of all ischemic strokes [5]. Oral anticoagulant therapy, most commonly with warfarin, has been used to reduce the risk of stroke in patients with nonvalvular AF who are at high risk of thromboembolism [6]. Overall, warfarin is underused in these patients mainly due to patient and health practitioner concerns about the increased risk of significant bleeding with aggressive anticoagulation. Clinical data has suggested that only 50–60% of patients who clinically should be prescribed warfarin are actually taking it [7]. Furthermore, clinical trials have demonstrated that a significant proportion of patients who are taking warfarin, are not adequately anticoagulated placing them at an increased risk of stroke. There are now alternative medications to warfarin, which are available. Apixaban
Anticoagulant and Antiplatelet Therapy in Patients with Atrial Fibrillation and Coronary Artery Disease  [PDF]
Karl Mischke,Christian Knackstedt,Nikolaus Marx
Thrombosis , 2012, DOI: 10.1155/2012/184573
Abstract: Anticoagulation represents the mainstay of therapy for most patients with atrial fibrillation. Patients on oral anticoagulation often require concomitant antiplatelet therapy, mostly because of coronary artery disease. After coronary stent implantation, dual antiplatelet therapy is necessary. However, the combination of oral anticoagulation and antiplatelet therapy increases the bleeding risk. Risk scores such as the CHA2DS2-Vasc score and the HAS-BLED score help to identify both bleeding and stroke risk in individual patients. The guidelines of the European Society of Cardiology provide a rather detailed recommendation for patients on oral anticoagulation after coronary stent implantation. However, robust evidence is lacking for some of the recommendations, and especially for new oral anticoagulants and new antiplatelets few or no data are available. This review addresses some of the critical points of the guidelines and discusses potential advantages of new anticoagulants in patients with atrial fibrillation after stent implantation.
Efficacy of class III antiarrhythmics and magnesium combination therapy for atrial fibrillation
Wang A
Pharmacy Practice (Granada) , 2012,
Abstract: Atrial fibrillation is a common cardiac arrhythmia, and has been a significant financial burden. Class III antiarrhythmics such as dofetilide, ibutilide, and amiodarone are indicated for rhythm control. Magnesium may possess intrinsic antiarrhythmic properties, and may potentially increase the efficacy of class III antiarrhythmics when used concomitantly. Objective: The purpose of this article is to review the literature on the efficacy of magnesium in addition to Class III antiarrhythmics, specifically amidarone, ibutilide, and dofetilide for the cardioversion of atrial fibrillation.Methods: Databases Pubmed and CINAHL are utilized along with the search terms amiodarone, dofetilide, ibutlide, magnesium, atrial fibrillation, conversion, rhythm control, and cardioversion. Results: One study on dofetilide and 5 studies on ibutilide were identified. No studies were found on amiodarone. Patients with atrial fibrillation who received dofetilide and magnesium had higher rates of successful cardioversion as compared to those who only received dofetilide. Conversion rates were similar between the 2 treatment groups for patients with atrial flutter. As for ibutilide, 4 studies have shown that the addition of magnesium significantly increases conversion rates for patients with atrial fibrillation or typical atrial flutter. Conversion rates were similar for patients with atypical atrial flutter. One study showed that addition of magnesium did not improve efficacy of ibutilide. Higher doses of magnesium (4 g) were associated with improved outcomes. Adverse effects of magnesium were mild and included flushing, tingling, and dizziness. Patients who received magnesium had shorter corrected QT intervals and smaller increase in corrected QT interval from baseline.Compare to previous studies, studies included in this review had higher conversion rates for dofetilide and ibutilide as well as dofetilide and magnesium or ibutilide and magnesium combination therapies. However, only 2 ibutilide studies and 1 dofetilide study reported baseline characteristics such as left atrial size, history of heart failure, and duration of atrial fibrillation, which are significant predictors of successful cardioversion. Therefore, differences in baseline demographics may have influenced the results. Conclusion: Magnesium may be used as adjunct for dofetilide and ibutilide due to potential improved efficacy and minimal toxicity. Dose ranging studies should be conducted in the future to establish the optimal dose and duration of therapy as well as the optimal serum magnesium concentration in
Antithrombotic therapy in nonvalvular atrial fibrillation: problems and prospects  [cached]
A.Y. Rychkov,N.Y. Khor'kova,A.A. Bliznyakov
Rational Pharmacotherapy in Cardiology , 2010,
Abstract: Appropriate use of warfarin is not in routine clinical practice despite convincing data of clinical studies on the possibility of effective reduction in frequency of thromboembolic complications associated with nonvalvular atrial fibrillation, particularly ischemic stroke. Confirmation of the efficacy and implementation of measures related to the effect on blood clotting and providing basically new possibilities to reduce the risk of ischemic events expected in the near future.
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