Cardiac specialists with the Washington University and Barnes-Jewish Heart & Vascular Center are one of the few groups in the country to routinely perform hybrid ablation for the treatment of atrial fibrillation.
Limitations of the Traditional Treatment Path
Despite the fact that atrial fibrillation is the most common heart rhythm disorder, it remains complicated to treat. Depending on the severity and type of atrial fibrillation, the traditional treatment path has been to achieve rhythm control with medication, to interrupt internal electrical discharges by catheter ablation or to structurally alter the heart through surgical intervention.
Today, many patients are referred for catheter ablation when medications fail. The goal of ablation therapy is to create scar tissue that isolates the irregular electrical signals and blocks them from spreading over the heart and causing fibrillation. Nearly 70 percent of patients remain free of symptoms one year after a catheter ablation procedure.
Although success rates for catheter ablation are better than medication, catheter ablation does not always work. Some patients may require a second or third procedure to achieve a successful result. “The heart is a remarkable organ,” says Philip Cuculich, MD, a Washington University electrophysiologist at Barnes-Jewish Hospital. “In time, it can heal and reconnect across those ablation lines.”
Part of the physician team that performs hybrid ablation therapy (from left to right): Hersh Maniar, MD; Ralph Damiano Jr., MD; Mitchell Faddis, MD; and Phillip Cuculich, MD.
In the past, the next step for these hard-to-treat patients was the Cox-Maze surgical procedure, developed at Washington University in 1987 by James Cox, MD, and refined by Ralph Damiano Jr., MD, chief of cardiac surgery at Barnes-Jewish Hospital. The refined Cox-Maze procedure is effective in 90 percent of patients.
But some consider it too invasive to treat atrial fibrillation alone.
“If my patient is having cardiac surgery, such as bypass surgery or valve surgery, and he or she has atrial fibrillation, it makes sense to employ the Cox-Maze procedure at the same time,” Cuculich says. “But many patients have just atrial fibrillation, and even though it may be persistent enough to affect their quality of life, cardiac surgery may not offer the best option for them.”
Using the Best of Both Worlds for Successful Treatment
To better help the patients who are at high risk for ablation failure, and for people who have had a failed catheter ablation procedure, a new hybrid procedure combines a minimally invasive version of the Cox-Maze with the latest advances in catheter ablation. The goal is to achieve the success rates of the open Cox-Maze with less risk and shorter recovery times.
This combined approach could improve success rates for patients with long-standing, persistent atrial fibrillation who want a minimally invasive treatment option.
The key is blocking signals that cause the erratic rhythm from both inside and outside the heart at the same time. Because catheters enter though a vein, electrophysiologists only have access to the inside of the heart. A surgeon, in contrast, can provide access to the outside of the heart.
“By applying the energy to make scars from both the inside and outside of the heart, we’re better able to achieve a full-thickness ablation,” says Hersh Maniar, MD, a Washington University cardiothoracic surgeon at Barnes-Jewish Hospital who performs the new hybrid procedure and the Cox-Maze. “A complete scar that encompasses the full thickness of the heart wall will more permanently block atrial fibrillation signals.”
According to Maniar, the goal of the hybrid procedure is to develop a minimally invasive, yet highly effective procedure that reduces the risk of stroke and allows more patients with atrial fibrillation to be treated effectively with a single procedure.
A clinical trial will compare the hybrid procedure to catheter ablation alone in patients who have not done well historically with catheter ablation—those with an enlarged left atrium and those with persistent atrial fibrillation. Outside the clinical trial, the procedure is available to any patient with atrial fibrillation after consultation with his or her doctor.
For more information about the trial or procedure, call 314-454-7698 or 314-362-7431. Watch a video about the procedure here.