How Well Do You Really Understand Your Atrial Fibrillation?
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Atrial Fibrillation Video Series: Day One
I’m Mr. Inder Birdi, a Consultant Cardiac Surgeon at The Keyhole Heart Clinic. If you’re reading this, you or someone you care about may have encountered atrial fibrillation (AF). I know it can sound alarming, but I’m here to guide you through it step by step in this email series. Let’s start at the beginning: what is atrial fibrillation?Under normal conditions, your heart beats in a steady rhythm, controlled by an electrical signal from the heart’s natural pacemaker. In atrial fibrillation, those signals become disorganized in the upper chambers of the heart (the atria). Instead of a smooth, regular beat, the atria quiver rapidly and irregularly – imagine a drum player suddenly losing tempo. This chaos can make your pulse feel irregular or fast. The good news is that AF itself is not immediately life-threatening, but it does require attention because it can lead to other issues over time (more on that in a later email).
You might hear AF described as “arrhythmia” – that simply means an abnormal heart rhythm. It’s a common condition and, importantly, it’s manageable. Many people with AF continue to live full, active lives with the right care. In this series, I will walk you through everything from why AF happens to the treatments available. Whether you’ve been newly diagnosed, are a concerned family member, or even just someone who worries about their heart health, these emails are for you. You’re not alone, and understanding AF is the first step in taking control of your heart health.
Stay tuned: In our next email, we’ll discuss how common AF is and who is at risk, so you can see where you fit in and why this condition is getting so much attention nowadays.
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Atrial Fibrillation Video Series: Day Fifteen
In our last email, we introduced atrial fibrillation (AF) and what it means. Now, let’s put things into perspective: just how common is AF, and who can develop it? The short answer is that AF is one of the most common heart rhythm disturbances worldwide. Over a million people in the UK alone have been diagnosed with AF, and millions more are affected globally. So if you have AF, you’re certainly not alone – many others are going through the same thing, including some very healthy people you’d never suspect.
Who gets AF? While AF can happen to almost anyone, it becomes more common as we get older. It’s often seen in people over 60 or 70, but younger adults can develop it too. In fact, about 1 in 4 people will develop AF in their lifetime. Certain factors can make AF more likely:
- Age: Getting older increases your risk.
- High blood pressure: A history of hypertension can strain your heart.
- Heart conditions: Prior heart attacks, valve problems, or heart failure can predispose you to AF.
- Other medical issues: An overactive thyroid, sleep apnea, obesity, or diabetes can contribute.
- Lifestyle factors: Excessive alcohol consumption (“holiday heart syndrome”) or intense stress can trigger AF in some people.
- Family history: Sometimes AF runs in families, suggesting a genetic component.
It’s important to note that even healthy individuals can get AF. Athletes, for example, sometimes develop AF (often called “lone AF” when it occurs without other heart disease). So, having AF is not a moral failing or necessarily due to something you did wrong. It’s a medical condition, and it’s more common than people think.
The take-home message: AF does not discriminate – it affects men and women, young and old, the very fit and those with health challenges. Understanding that it’s common can be reassuring. It means we have lots of experience managing it, and a wealth of research is dedicated to it.
Coming up next: We’ll talk about how AF actually feels – the symptoms and how it can affect daily life. This will help you recognize AF and understand what others experience too.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
One of the most unsettling things about atrial fibrillation is how it makes you feel. What symptoms might you notice, and how can AF impact your daily life? The experience can vary greatly from person to person. Some people with AF feel absolutely nothing unusual – they only find out they have it during a routine check-up. Others, however, feel a variety of symptoms that can be uncomfortable or even scary.
Common symptoms of AF include:
- Palpitations: This is the sensation of a rapid, fluttering, or irregular heartbeat. It might feel as though your heart is flip-flopping or pounding, especially in your chest or throat.
- Shortness of breath: You might find yourself getting winded more easily, even during simple activities or when lying down.
- Fatigue or weakness: AF can make you feel unusually tired or weak, because an irregular heartbeat can reduce the heart’s pumping efficiency slightly.
- Dizziness or lightheadedness: The chaotic heart rate can sometimes cause blood pressure to drop, leading to feeling faint or woozy.
- Chest discomfort: Some people feel chest tightness or mild pain (always get chest pain evaluated by a doctor, as it can have other causes too).
These symptoms can come and go if your AF is intermittent (what we call paroxysmal AF – more on AF types soon). Episodes might last seconds, minutes, or hours. You could feel fine one day and have palpitations the next. This unpredictability can understandably affect your daily life. You might worry about exercising, or feel anxious being far from medical help. It’s also common to feel emotionally unsettled (afraid or frustrated) when symptoms strike – after all, your heart is literally skipping a beat and that can be alarming.
Here’s the reassuring part: Many of these symptoms improve or disappear with proper treatment and lifestyle adjustments. If you’ve been started on medication, for example, it might already be helping to steady your heartbeat. And remember, not everyone with AF has strong symptoms – absence of symptoms doesn’t mean AF is gone, so follow your doctor’s advice on regular check-ups.
Living with AF often means learning to listen to your body without living in constant fear. It might take some time to regain confidence in daily activities. That’s completely normal. As we explore treatment options in later emails, you’ll see that there are ways to control these symptoms so you can get back to doing the things you enjoy.
In our next email: We’ll discuss why treating AF is so important, even if you feel okay – specifically, the risks of leaving AF unchecked, like stroke and heart failure. This is a critical topic for your long-term health.
The Road Ahead: Personalised AF Care and Next Steps Read More - Palpitations: This is the sensation of a rapid, fluttering, or irregular heartbeat. It might feel as though your heart is flip-flopping or pounding, especially in your chest or throat.
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Atrial Fibrillation Video Series: Day Fifteen
We’ve talked about what AF is and how it feels. Now you might wonder: if I can live with the flutters, why not just ignore it? The answer lies in the hidden risks of untreated atrial fibrillation. AF is more than just an irregular heartbeat – over time, it can lead to serious complications. I don’t say this to scare you, but to empower you. When you know why treatment and monitoring are important, it all makes more sense.
The biggest risk associated with AF is stroke. When your heart’s upper chambers (atria) quiver instead of beating effectively, blood can pool there, especially in a little pouch of the atrium called the left atrial appendage. Stagnant blood is prone to clotting. If a clot forms and later gets pumped out, it can travel to the brain and cause a stroke. In fact, people with untreated AF are about five times more likely to have a stroke than those without AF. Many strokes that occur in AF patients could be prevented with appropriate treatment (like blood thinners – we’ll cover that soon). Stroke can be devastating, causing paralysis, speech difficulties, or even threatening life, so this risk alone makes AF something to take seriously.
Another risk is heart failure. If AF causes your heart to beat very fast for prolonged periods, the heart muscle can weaken. Picture yourself sprinting non-stop – eventually, you’d exhaust yourself. The heart is similar; a continuously fast, irregular beat can lead to a condition called tachycardia-induced cardiomyopathy (a type of heart failure). Symptoms of heart failure include breathlessness, swelling of ankles, and fatigue. Treating AF can help prevent the heart from getting to that exhausted state.
Beyond stroke and heart failure, uncontrolled AF can lead to other issues. These include a decline in exercise capacity (you just can’t do as much as before), frequent hospital visits for heart rhythm or rate control, and a reduced quality of life from anxiety or depression (which we’ll discuss later in the emotional impact email). There’s also a small risk of developing blood clots elsewhere in the body (for example, causing organ damage) due to AF.
The silver lining is that knowing these risks means we can address them. Medications and procedures exist to dramatically lower the chance of a stroke and to keep your heart strong. So if you’ve been diagnosed with AF, it’s crucial to work with your healthcare team on a plan – even if you personally don’t feel bad from the AF. Prevention is our best tool here.
Next up: How do we actually detect and diagnose AF? In the next email, I’ll explain the tests and tools doctors use to catch AF and understand your heart rhythm.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
By now, you know why taking atrial fibrillation seriously is important. But how do we actually find out if someone has AF? Many people are diagnosed only after a doctor runs some tests. Let’s demystify how AF is diagnosed and what you might expect during the process.
The most common and straightforward test is an Electrocardiogram (ECG). This is a quick, painless test where small sticky patches (electrodes) are placed on your chest, arms, and legs to record the electrical signals of your heart. It usually takes just a few minutes. On an ECG, AF has a distinctive signature: instead of neat, regular waves, it shows irregular squiggly lines for atrial activity and an irregular pattern of beats. One ECG can confirm AF if it’s happening at that moment.
However, AF can be sneaky – if it comes and goes (remember paroxysmal AF from earlier), it might not show up during a short doctor’s visit. If you have symptoms that suggest AF but a regular ECG doesn’t catch it, doctors may recommend longer monitoring. This could be a Holter monitor, which is basically a portable ECG you wear for 24-48 hours (or even up to a week). It continuously records your heart rhythm as you go about your daily life, increasing the chance of capturing an AF episode. There are also event recorders you can wear for weeks, which you activate when you feel symptoms, and even implantable loop recorders placed under the skin that can monitor for a year or more.
In recent years, technology has given us consumer devices too. Some smartwatches and phone apps can detect irregular pulses and have alerted people to possible AF. While these are not 100% diagnostic, they’re amazingly useful prompts to get a medical check. If your watch flags an irregular rhythm, a formal medical test like an ECG is warranted.
Alongside rhythm monitoring, your doctor will likely do a check-up and some other tests. Expect questions about your symptoms and medical history, and a physical exam (listening to your heart and lungs). You may have blood tests to look for triggers or risk factors (like thyroid function or electrolyte levels). An echocardiogram (an ultrasound of the heart) is also commonly done after an AF diagnosis – not to detect AF itself, but to see your heart’s structure and function. It helps identify any underlying heart disease (for instance, valve issues or enlarged atria) and it’s important for planning treatment.
Bottom line: Diagnosing AF might be as simple as one office ECG if you’re in AF at the time, or it might require some clever sleuthing with devices that track your heart over days or months. If you’re going through this process, hang in there – it’s worth the effort to know exactly what your heart is up to.
In our next email: We’ll discuss the different types of AF (paroxysmal, persistent, permanent) and why knowing which type you have matters for your treatment plan.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
Atrial fibrillation isn’t a one-size-fits-all condition. There are different types of AF, and understanding which type you have can help tailor the right treatment approach. You may have heard your doctor use words like “paroxysmal” or “persistent.” Let’s break down these terms in plain language.
- Paroxysmal AF: This type of AF comes and goes in episodes. The word “paroxysmal” essentially means sudden or sporadic. If you have paroxysmal AF, your heart will go into AF for a short time and then return to a normal rhythm on its own. Episodes can last anywhere from just a few seconds to as long as a week, but often they stop within a day. You might go days or weeks without any AF in between episodes. Many people with paroxysmal AF feel when it happens (palpitations or other symptoms from our last email), but some might not. It can be unpredictable – you could feel perfectly fine one moment and then suddenly notice your heart racing the next.
- Persistent AF: In persistent AF, the abnormal rhythm doesn’t self-correct. If your heart goes into AF, it will stay in AF until something is done to stop it. That “something” might be a medical intervention, like medications or an electrical cardioversion (a controlled electric shock to restore normal rhythm). The cutoff doctors use is that if an AF episode lasts longer than seven days (or if it’s shorter but requires intervention to stop), we call it persistent AF. Some people live in persistent AF for weeks or months until treatment is attempted. During that time, the heart is continuously beating irregularly. Many folks with persistent AF get used to the sensation over time, but it can still cause symptoms and risks as we discussed.
- Permanent AF (or Long-standing Persistent AF): This is when AF has been present for a long while and a decision is made not to try to restore normal rhythm anymore. In other words, the heart is in AF continuously and both the patient and doctor accept that this is the new baseline. Instead of trying to eliminate the AF, the focus shifts to controlling the heart rate and preventing strokes (because maintaining normal rhythm proved too difficult or not possible in that case). The term “long-standing persistent AF” is often used if AF has lasted over a year and rhythm control hasn’t been successful. “Permanent” means you and your healthcare team have agreed to manage it without further attempts at getting rid of AF itself. It doesn’t necessarily mean it can never be changed, but for now, it’s being left as is.
Why do these distinctions matter? They guide treatment strategy. For example, someone with paroxysmal AF might be a great candidate for certain medications or an early catheter ablation to nip it in the bud, whereas someone with permanent AF might skip those attempts and focus on rate control and stroke prevention. Persistent AF often prompts more aggressive efforts to restore normal rhythm (within weeks or months of onset, cardioversion or ablation can be considered). Also, some therapies (like a certain procedure or surgical approach) might be recommended more strongly for persistent AF than paroxysmal.
In summary, knowing your AF type gives context to what you’re experiencing and what approach your doctors might take. It’s a bit like knowing whether a fire is a bunch of sporadic sparks versus a steady flame – it influences how we try to put it out.
Next email, we’ll delve into treatment: specifically, medications used for AF – both to control your heart rate and to try restoring a normal rhythm. We’ll also touch on the importance of these approaches for different AF types.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
Now that we’ve covered the types of AF, let’s discuss one of the first lines of treatment: medications. Medications for atrial fibrillation broadly fall into two categories – those that control your heart’s rate and those that control its rhythm. It’s an important distinction that often confuses people, so I’ll explain the difference and why your doctor might choose one approach or the other (sometimes both).Rate control medications don’t necessarily stop AF; instead, they aim to slow down how fast the heart beats during AF. When you’re in atrial fibrillation, your heart rate can be quite rapid. Rate control drugs help ensure that your pulse stays in a reasonable range (often aiming for something like below 100 beats per minute at rest). Common medications in this category include beta blockers (like bisoprolol or atenolol) and calcium channel blockers (like diltiazem or verapamil), and sometimes digoxin. If your AF is permanent or persistent and we’re not trying to get rid of it, controlling the rate can reduce symptoms like palpitations and prevent the heart from wearing itself out (remember the heart failure risk we talked about). These medications can make a big difference in how you feel day-to-day, making AF more “background noise” than a front-and-center problem.
Rhythm control medications, on the other hand, aim to get your heart back into a normal rhythm (sinus rhythm) and keep it there. These are often called antiarrhythmic drugs. Examples include flecainide, sotalol, amiodarone, and dronedarone, among others. These medications work by stabilizing the heart’s electrical activity to prevent those chaotic AF signals. If you have paroxysmal AF, a rhythm control drug might help space out the episodes or stop them completely. If you have persistent AF, your doctor might use a rhythm drug to help maintain normal rhythm after a cardioversion or ablation. Each of these drugs comes with its own precautions and potential side effects, so doctors choose them carefully based on your heart’s structure, other conditions, and how well you tolerate them.
Sometimes, you might start on a rhythm control strategy (trying to keep normal rhythm), but if AF keeps coming back or the drugs cause side effects, the strategy might shift to rate control (just controlling the speed and not worrying about eliminating AF). Both strategies, importantly, should always be paired with stroke prevention (usually blood thinners, which we’ll cover in the next email) because even well-controlled AF can still pose a stroke risk if it recurs silently.
Your doctor may also advise other supportive measures: for instance, a one-time procedure called cardioversion might be done to jolt the heart back into rhythm, usually with sedation – this often pairs with starting a rhythm control drug. And let’s not forget lifestyle: avoiding excessive caffeine or alcohol, and managing stress can help reduce AF episodes, complementing the medications.
In summary, medications for AF either slow the heart rate or help maintain normal rhythm. The choice of strategy is personalized. Some patients even manage with just a pill “as needed” when an episode strikes (this is sometimes called a “pill-in-the-pocket” approach, often using flecainide or propafenone under guidance). Whatever the regimen, it should make you feel better and protect your heart in the long run. If it’s not achieving those goals, your doctor might adjust doses or switch strategies.
Next up: Perhaps the most critical piece of AF management – blood thinners and stroke prevention. In the next email, I’ll explain why blood thinners are so often recommended and address common concerns about them.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
If there’s one topic I urge all AF patients to understand, it’s stroke prevention. We touched on stroke risk earlier – now let’s talk about the main strategy to counter that risk: blood thinners (anticoagulant medications). Many people have reservations about these drugs, so it’s important to know why they’re recommended and how they help keep you safe.
As a quick recap, atrial fibrillation can lead to blood pooling in the atria (particularly in the left atrial appendage). When blood pools, clots can form, and those clots can travel to the brain and cause a stroke. We can’t reliably prevent those clots from forming just by controlling heart rate or rhythm; even someone with occasional AF episodes can form a clot during a brief episode. That’s where blood thinners come in.
What are blood thinners? They are medications that reduce your blood’s ability to clot. Common examples include warfarin (an older drug that has been used for decades) and newer ones like apixaban, rivaroxaban, edoxaban, or dabigatran (often referred to as NOACs or DOACs – novel/direct oral anticoagulants). If you’re on warfarin, you know it requires regular blood tests (INR checks) to keep the dosage right. The newer anticoagulants are more convenient – no regular blood tests in most cases – and have become very popular in AF management.
By thinning the blood slightly, these medications dramatically reduce the chance of clot formation in your heart. In fact, a patient with AF on a proper dose of a blood thinner can cut their stroke risk down by as much as 60-70% or more, bringing it closer to someone without AF. This is huge. Some studies have even shown that in people with AF, taking anticoagulants is far more effective at preventing stroke than, say, trying to maintain normal rhythm with medications or ablation. That’s why, for many patients, even if we “cure” the AF with a procedure, we might continue blood thinners if any risk factors for stroke remain.
You might be thinking: “But I’ve heard blood thinners can cause bleeding – is it worth it?” It’s true, any anticoagulant increases bleeding risk somewhat, because we’re intentionally making it harder for your blood to clot. The key is that doctors weigh your stroke risk vs. bleeding risk using guidelines and scoring systems (you might hear terms like CHA₂DS₂-VASc score for stroke risk, and HAS-BLED for bleeding risk). For most people with AF and additional risk factors (like age or high blood pressure), the benefit of preventing a stroke outweighs the bleeding risk. And the absolute risk of a major bleed on these medications is low if managed properly. We also take precautions – for example, controlling high blood pressure, protecting the stomach lining if needed, and being careful with concurrent medications – to minimize bleeding risk.
If you have minimal risk factors and your doctor says you don’t need a blood thinner, that means your stroke risk is low enough that it’s safe to watch and maybe use other measures (like aspirin was used historically, but nowadays aspirin is not very effective for AF-related stroke prevention and isn’t usually the first choice). Most people with AF will end up on an anticoagulant at some point, and it often becomes a long-term preventive measure.
In some special cases, if someone absolutely cannot take blood thinners (due to serious bleeding issues or falls, etc.), we have other options like procedures to block off the left atrial appendage (I’ll explain that in a later email about the appendage). But for the majority, a pill a day is the simplest and most effective safeguard against stroke.
Taking a blood thinner is a commitment – you need to take it regularly and let all your healthcare providers know you’re on it. But it’s a silent hero in your AF treatment plan, working in the background to protect you. Many of my patients have said the peace of mind knowing they’re protected from stroke outweighs the inconvenience of another daily medication.
Next email: We’ll switch gears to interventional treatments – starting with catheter ablation. What is it, how does it work, and who should consider it? If you’re curious about non-medication routes to treat AF, stay tuned.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
Up to now, we’ve mainly discussed medications and monitoring for AF. Now let’s talk about a more direct treatment option that you may have heard of or even been recommended: catheter ablation. In simple terms, catheter ablation is a minimally invasive procedure that aims to eliminate the source of the AF within the heart, rather than just managing it with medications. It’s an important option for many patients, especially if symptoms persist despite meds or if you prefer to try to fix the problem at its root.
How does ablation work? In atrial fibrillation, the erratic electrical signals often originate in the areas where the pulmonary veins connect to the left atrium (these veins bring blood from the lungs into the heart). In a catheter ablation, a specialized heart doctor called an electrophysiologist inserts thin, flexible wires called catheters into your heart (usually via a vein in the groin, under local anesthetic). Once the catheters reach the left atrium, the doctor uses either heat (radiofrequency energy) or extreme cold (cryoablation) at the tip of the catheter to create small scars around the openings of those pulmonary veins. This is called pulmonary vein isolation. The scars act like roadblocks, preventing rogue electrical signals from those veins from spreading into the rest of the atrium and causing AF.
The procedure typically takes a few hours. You’re usually sedated or under light general anesthesia (so you won’t feel pain during it). Many patients go home the same day or after one night in the hospital. It’s worth noting that after an ablation, it’s normal to still have some irregular heartbeats as the heart heals – we usually give it about 2-3 months (a “blanking period”) to see the full effect.
Who is ablation for? Catheter ablation is often recommended for people with symptomatic AF who haven’t had enough relief from medications or prefer not to stay on them long-term. It’s particularly effective for paroxysmal AF (episodes that come and go) – success rates in maintaining normal rhythm for at least a year or more after a single ablation can be quite good in this group (often quoted around 70-80% success for one procedure, potentially higher with multiple). For persistent AF, ablation can still help, but success rates are a bit lower and sometimes multiple procedures or additional strategies are needed. Ablation is usually not the first option for permanent AF, because once AF is long-established it’s harder to completely eradicate.
It’s important to have a discussion with an electrophysiologist to understand the risks and benefits in your specific case. Ablation is generally safe, but like any procedure, it carries some risks – these can include bleeding where the catheters go in, or rare but more serious complications like stroke, heart damage, or an injury to the esophagus due to the heat (these are uncommon in experienced hands, but they are why we carefully consider who really needs an ablation).
The big benefit of successful ablation is the potential to live free of AF (or with much less AF), which can greatly improve quality of life. Some patients are able to reduce or stop certain medications after a successful ablation (for example, coming off an antiarrhythmic drug). However, many patients will still need to continue blood thinners, because AF can recur silently and stroke risk might still be present.
In short, catheter ablation is like fixing faulty wiring in the heart. It doesn’t involve any large incisions – just needle punctures – and for the right patient, it can make a world of difference.
In the next email: We’ll explore another route: surgical AF ablation via keyhole (VATS) surgery. This is different from catheter ablation and can be a great option in certain scenarios. I’ll explain why a surgical approach might be used and how it works.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
We just covered catheter ablation, which is done by cardiologists using wires from the groin. Now let’s discuss another powerful treatment option: surgical atrial fibrillation ablation, specifically done via a minimally invasive (keyhole) approach. As a cardiac surgeon, this is an area I’m deeply involved in, and I want to explain it in a patient-friendly way. You might wonder, “Why would someone need surgery for AF if catheter ablation exists?” It’s a great question.
Surgical ablation for AF often comes into play for patients who either did not get a successful result from catheter ablation, or who have more advanced AF that might benefit from a comprehensive solution. It’s also considered if someone is already having heart surgery for another reason (we’ll talk more about that in a later email about valve surgery and AF).
The keyhole surgical approach, often done via VATS (Video-Assisted Thoracoscopic Surgery), means the surgeon doesn’t open the breastbone or stop the heart. Instead, we make a few small incisions (cuts about 5-10 mm long) between the ribs on the sides of the chest. Through these ports, a tiny camera and instruments are inserted to reach the heart’s surface. The goal, like catheter ablation, is to create scars that block the abnormal electrical circuits causing AF. In surgical ablation, we often use a device that clamps around the areas where the pulmonary veins connect to the left atrium, delivering energy to create a continuous line of scar. This achieves a very thorough isolation of those pulmonary veins. Because it’s done under direct vision (the surgeon can see the heart’s surface with the camera), we can ensure lesions (scar lines) are placed accurately and completely.
One big advantage of surgical ablation is that we can address the left atrial appendage (LAA) at the same time. The LAA is the small pouch where clots often form in AF (remember the stroke discussion?). In a keyhole surgical ablation, we can place a clip on that appendage from the outside of the heart, effectively sealing it off so it can’t create clots. This is a major plus for stroke prevention, potentially reducing reliance on long-term blood thinners if successful (though that decision is made on a case-by-case basis).
Surgical ablation tends to have high success rates, especially for persistent or long-standing AF where catheter ablation alone might struggle. Some studies show that a standalone surgical ablation (without any other heart surgery) can restore normal rhythm in a large percentage of patients who had stubborn AF. However, it is more invasive than catheter ablation. It typically requires general anesthesia, and a short hospital stay (a few days) to recover from the incisions and chest tube (a temporary tube to drain fluid that’s often placed for a day or two). The risks are low but include things like bleeding, infection, or fluid around the lungs (because we’re working in the chest).
For many patients, the idea of “surgery” can be intimidating, but keyhole techniques have made it much less daunting than traditional open-heart surgery. There’s no big scar down the middle of the chest and recovery is quicker (weeks rather than months). It’s an option to discuss if you’ve had unsuccessful catheter ablations or if your doctor thinks you’re a good candidate due to the nature of your AF. In my practice, I’ve seen patients who struggled for years with AF finally get back to a normal rhythm after a keyhole ablation – it can be life-changing.
Next email: Sometimes, the best approach is combining both catheter and surgical ablation in what’s called a convergent or hybrid procedure. I’ll explain how that works when cardiologists and surgeons team up to battle AF together.
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Atrial Fibrillation Video Series: Day Fifteen
We’ve looked at catheter ablation and surgical ablation separately. Now, let’s discuss an approach that blends the best of both worlds – often referred to as a convergent procedure or hybrid ablation. As the name suggests, it’s a convergence of cardiology and cardiac surgery expertise to treat atrial fibrillation, particularly useful in more persistent cases of AF.
What is a convergent procedure? In a convergent approach, a cardiac surgeon and an electrophysiologist (heart rhythm cardiologist) work together, either in the same operation or in stages. The surgeon performs a minimally invasive ablation on the outside of the heart, and the electrophysiologist uses catheters to ablate from inside the heart. By doing both, we aim to create a more extensive and thorough set of ablation lines than either approach alone might achieve.
Here’s how it often works: the surgeon uses a small incision, typically under the breastbone or between the ribs (sometimes even via a tiny incision just below the sternum), to access the outside of the left atrium. Through this, the surgeon can create strategic lesions on the heart’s outer surface – for instance, isolating the pulmonary veins or creating lines on the back wall of the atrium, and usually closing off the left atrial appendage as well. Then, either in the same session or a few weeks later, the electrophysiologist will perform a catheter ablation inside the heart. The EP can then test the electrical signals and touch up any gaps in the lesion lines or address areas that can’t be reached from the outside approach.
By combining forces, the convergent procedure addresses AF from both the epicardial (outside) and endocardial (inside) surfaces. This is especially helpful for long-standing persistent AF, where the atrial tissue may need a more extensive treatment. It reduces the chance that any “missed spots” will let AF recur. Studies have shown that this hybrid approach can improve success rates in difficult AF cases, achieving sinus rhythm in patients who had been in AF for years.
For the patient, a convergent approach may involve a bit more planning – potentially two procedures instead of one. Recovery from the surgical portion is usually quick (since it’s minimally invasive, not open-heart). By adding the catheter portion, we ensure fine-tuning of the results.
Who might be a candidate for convergent ablation? Typically those with persistent or long-standing AF, especially if prior catheter ablations have failed, or if the heart’s atria are enlarged and might need more extensive ablation lines. Your care team will consider factors like your overall health, how long you’ve been in AF, and if you can tolerate a short general anaesthetic, etc.
The idea of two procedures might sound like a lot, but when done in a planned way, many patients tolerate it well and are very satisfied with the outcome – the hope being a durable return to normal rhythm and possibly reducing the need for ongoing antiarrhythmic medications.
Modern AF care is increasingly a team effort. As a surgeon, I often collaborate with my cardiologist colleagues to decide what combination of treatments will give each patient the best shot at a life free of AF. Convergent procedures epitomize that collaborative spirit.
In the next email: We’ll focus on that little pouch we’ve mentioned a few times – the left atrial appendage. Why is it so notorious in AF, and what can we do about it aside from blood thinners? We’ll explore that topic next.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
Throughout this series, we’ve talked about the left atrial appendage (LAA) a few times, especially when discussing stroke risk and treatments like blood thinners or surgical ablation. Now, let’s give the LAA the spotlight for a moment. What exactly is this appendage, and why does it matter so much in atrial fibrillation?
The left atrial appendage is a little pouch or outpouching off the left atrium (one of the heart’s upper chambers). In people without AF, it’s a quiet, unremarkable part of the heart – blood flows in and out of it with each heartbeat, and it doesn’t cause any trouble. In fact, its original purpose is not entirely clear, but it might help regulate pressure or be a leftover from our development in the womb. However, in AF, the LAA becomes significant because blood can stagnate there when the atria are not contracting properly. As we know, stagnant blood can form clots, and clots in the LAA can escape and cause strokes. It’s estimated that in non-valvular AF (AF not due to a mechanical heart valve or rheumatic disease), over 90% of stroke-causing clots originate from the LAA. That’s why it’s often called the “usual suspect” in AF-related strokes.
The primary strategy to deal with LAA clots has been blood thinners (anticoagulants, which we discussed). These medications don’t remove clots that are already there, but they help prevent new clots from forming by altering the blood’s clotting ability. But what if someone can’t take blood thinners, or we want to secure protection without lifelong medication? That’s where LAA closure or removal comes into play.
There are a couple of approaches:
- Catheter-based devices: You might have heard of the Watchman device (one example of an LAA occlusion device). In this procedure, a cardiologist uses a catheter (through the vein, into the heart) to deploy a tiny umbrella- or plug-like device that sits in the mouth of the appendage, sealing it off from the inside. Over time, heart tissue grows over the device, permanently closing off the appendage so clots can’t escape. This is done under general anesthesia but is not open surgery. It’s a relatively common procedure now for AF patients who need an alternative to blood thinners.
- Surgical closure or removal: If you’re undergoing heart surgery for any reason (valve surgery, bypass, or a surgical AF ablation like we discussed), the surgeon can take the opportunity to address the LAA. This can be done by sewing it closed, cutting it out, or placing a clip on it from the outside. The surgical clip (often an item called the AtriClip) can close the appendage off securely. These surgical options are very effective and can be done as part of the main operation so you don’t even really notice an extra “procedure” from the patient’s perspective .
By neutralizing the appendage (closing or removing it), we dramatically reduce the risk of stroke from AF without needing ongoing anticoagulation in some cases. It’s important to note, though, that doctors will usually still have you on blood thinners for a short period after an appendage closure device until it’s well sealed, and even long-term if you have other reasons for stroke risk. The decision to stop blood thinners after an LAA closure is individualized and made by your cardiologist based on follow-up tests (like a special heart ultrasound called a TEE to check the device).
For many patients, knowing the LAA can be “dealt with” is reassuring. If you’re someone who cannot tolerate blood thinners due to bleeding issues or have a lifestyle that makes them risky (for example, frequent falls or high bleeding risk), an LAA closure might be a lifesaver by allowing protection against stroke without the daily medication.
In summary, the left atrial appendage might be small, but in AF it’s a big troublemaker when it comes to strokes. Thankfully, we have ways to disarm this little pocket – either by medication or by physically closing it off. If your doctor mentions the appendage in your treatment plan, you’ll now know why it’s such a focal point of AF management.
Next email: Many people with AF also happen to need heart surgery for other reasons, like a valve problem. We’ll discuss how AF is addressed during heart valve surgery and why it’s a great idea to tackle both issues together when possible.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
Atrial fibrillation often coexists with other heart conditions. One common scenario is a patient with AF who also has a heart valve issue – for example, a leaky or tight mitral valve – that requires surgical repair or replacement. You might be reading this and thinking of your own situation or someone you know. Let’s talk about the benefit of treating AF at the same time as valve surgery, a classic “two birds with one stone” opportunity in cardiac care.
If you’re undergoing heart surgery for a valve (or other issues like a bypass), the chest is already open and the heart can be directly accessed. This presents an ideal chance to perform a surgical ablation for AF (often a full Cox-Maze procedure or a variation of it) without much additional risk or invasiveness. The Cox-Maze procedure is considered the gold standard surgical treatment for AF. In open-heart surgery, the surgeon creates a series of precise scars on the atria (originally done with cuts and stitches, now often done with freezing or heat energy) that direct the electrical impulses to follow a “maze” to the AV node, preventing the chaos of AF. This can restore normal rhythm in a high percentage of patients long-term.
When combined with valve surgery, the surgeon can perform this ablation maze pattern on the heart after fixing the valve. They will also usually remove or close the left atrial appendage during the surgery (since we know that’s crucial for stroke prevention). So, in one operation, the patient gets their valve problem fixed and their AF addressed.
Why do it together? For one, it’s efficient – the patient only undergoes anesthesia and the surgical opening once. Secondly, treating AF can improve outcomes: an irregular heartbeat after surgery can make recovery harder (AF after cardiac surgery is common if you don’t address it, even in people who didn’t have it before). If a patient already has AF going into surgery, not treating it means they’ll come out of surgery still in AF, with all the attendant stroke risks and symptoms. Studies have shown that patients who get a concomitant (simultaneous) AF surgery with their valve surgery have better long-term rhythm control and stroke prevention than those who just have the valve fixed. In fact, current guidelines often recommend doing AF ablation during valve surgery if the patient has significant AF history.
From a patient perspective, adding an AF ablation to valve surgery doesn’t usually change the recovery time significantly. You might have a few extra temporary pacing wires or need to take an antiarrhythmic medication for a short while after, but the overall hospital stay and recovery tasks (like walking, rehab) are the same. The surgeon might discuss a slightly increased time on the heart-lung machine or cross-clamp (the time the heart is stopped) to do the ablation, but in experienced hands this is minimal.
So, if you or someone you know is heading into heart surgery and AF is part of the picture, it’s absolutely worth a conversation about addressing the AF during the operation. It could spare you from a second procedure down the road and increase the likelihood of enjoying a normal heart rhythm after you’ve healed from surgery. I always tell my patients: our goal is not only to fix the plumbing (valves, arteries) but also the wiring (rhythm) of the heart when needed, so the heart can function optimally.
Next email: We’ll shift gears from the medical and procedural side to the human side of AF. Living with atrial fibrillation can take an emotional toll. Let’s talk about the emotional impact of AF and ways to cope with it in our next discussion.
The Road Ahead: Personalised AF Care and Next Steps Read More -
Atrial Fibrillation Video Series: Day Fifteen
Up to now, we’ve focused on the physical aspects of atrial fibrillation – what it is, how to treat it, and so on. But as important as those things are, I know that AF can also affect your emotional well-being. Let’s talk openly about the feelings and mental health side of living with AF, and some strategies to cope.
Being told you have a heart condition like AF can be stressful. It’s not uncommon to feel anxiety – for instance, worrying “Will I have a stroke out of the blue?” or “What if my heart suddenly races when I’m alone or at night?” Many patients describe a sense of vulnerability, knowing their heartbeat is irregular. Fear of the unknown or of serious events can creep in, even if logically you understand that with treatment the risks are controlled.
Some people experience panic or anxiety attacks that can be hard to distinguish from AF symptoms. A racing heart from anxiety can feel like AF and vice versa, creating a vicious cycle of worry. It’s also normal to feel frustrated or down. You might think, “Why did this happen to me?” or feel anger at your heart for not behaving normally. If AF episodes are limiting your activities – say you stopped exercising because you’re afraid of triggering AF, or you avoid travel because of “what if” scenarios – this can lead to a sense of isolation or depression. You might mourn the loss of the carefree health you once felt you had.
First, I want to assure you that these feelings are valid and common. As a doctor, I care about your mental health as much as your physical health, because one profoundly affects the other. Here are a few approaches my patients have found helpful:
- Education and empowerment: Simply learning about AF (which you’re doing by reading these emails) can reduce fear. The more you understand what’s happening and how treatments reduce risks, the more in control you’ll feel. Knowledge really is power; it can turn that feeling of “time bomb in my chest” into “manageable condition that I’m actively treating.”
- Open communication: Talk to your healthcare providers about your fears. Sometimes a reassurance – like hearing “your risk of stroke is very low now that you’re on the blood thinner” or “many people live long lives with AF” – can ease an anxious mind. Don’t hesitate to mention symptoms like anxiety or low mood; we might involve a cardiologist, GP, or counselor to support you.
- Lifestyle and support: Light exercise (as approved by your doctor) can actually help anxiety and make you feel more robust. Practices like yoga or meditation can calm the nervous system and possibly even reduce AF episodes triggered by stress. Avoiding excessive caffeine or alcohol can also help both AF and anxiety. Connecting with others who have AF – perhaps through a patient support group or even a trusted friend with the condition – can relieve the feeling that you’re going it alone. Sharing experiences often lightens the emotional burden.
- Mental health support: If you find anxiety or depression is overwhelming, it might be worth speaking to a therapist or counselor. Cognitive-behavioral therapy (CBT), for instance, can provide tools to manage health anxiety. In some cases, short-term use of medication for anxiety or depression is appropriate and nothing to be ashamed of. It’s all about getting you to feel better and enjoy life.
Remember, treating AF isn’t just about controlling a heart rhythm – it’s about ensuring you have a good quality of life. Your mental outlook and emotional health are a big part of that equation. It might comfort you to know that many patients, as they go through treatment and start to feel improvements, also see their anxiety ease up. Confidence returns: they travel, exercise, and live life fully, with AF more in the background.
You have a team (including me, via these emails!) that understands the emotional side of this journey. We’re not just here to prescribe pills or do procedures; we’re here to listen and support you through the ups and downs.
In our final email of this series: We’ll talk about moving forward with personalized AF care – how to tie everything together and plan the next steps in your AF journey.
The Road Ahead: Personalised AF Care and Next Steps Read More - Education and empowerment: Simply learning about AF (which you’re doing by reading these emails) can reduce fear. The more you understand what’s happening and how treatments reduce risks, the more in control you’ll feel. Knowledge really is power; it can turn that feeling of “time bomb in my chest” into “manageable condition that I’m actively treating.”
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Atrial Fibrillation Video Series: Day Fifteen
We’ve reached the final part of our educational series on atrial fibrillation. By now, we’ve covered a lot of ground – from the basics of AF to its treatments and even the emotional challenges. For this last email, let’s focus on where to go from here. How do you take all this information and apply it to your own life? What are the next steps in your personalised AF care?
Firstly, remember that atrial fibrillation is highly individual. Some people have infrequent episodes that never get worse, while others might have persistent AF that requires multiple treatments. There is no one-size-fits-all approach. The best thing you can do is work closely with a heart specialist (and often a team, including your GP, a cardiologist, possibly an electrophysiologist, and maybe a surgeon if needed) to map out a plan tailored to you.
Here’s a general roadmap for moving forward:
- Follow-up appointments: Make sure to keep regular follow-ups with your doctor. AF often requires tweaking of treatment over time – maybe adjusting a medication dose, or repeating a heart monitor to see how things are going. Regular check-ins will help catch any changes in your condition early and keep you on the best therapy.
- Lifestyle measures: Take stock of your lifestyle and see if there’s anything that can be optimized. This includes managing high blood pressure, maintaining a healthy weight, treating sleep apnea if you have it, and moderating alcohol and caffeine. These changes can significantly improve AF and overall heart health. Think of it as giving your heart the best environment to stay in rhythm.
- Medications and adherence: If you’re on medications (whether for rate control, rhythm control, or blood thinners), take them as directed and communicate about any side effects. Don’t stop anything abruptly without consulting your doctor. Over time, there might be opportunities to reduce or change meds, but that should be done thoughtfully and usually under monitoring.
- Considering advanced treatments: Depending on how you’re doing, you might consider treatments like ablation (catheter or surgical) if not already pursued. There’s no need to rush into procedures if you’re well-controlled on meds and not bothered by AF. However, if AF is still impacting your life or posing risk, it’s worth discussing these options. Keep an open dialogue – what was not necessary a year ago might become a reasonable choice if circumstances change (for example, if paroxysmal AF becomes persistent and troublesome, you might revisit the ablation discussion).
- Education and support: Continue learning and asking questions. Guidelines and technologies evolve – for instance, new drugs or device therapies for AF may appear in the coming years. Stay informed through reputable sources (your care team can recommend some). And don’t underestimate the value of support groups or patient networks. They can keep you motivated and make you feel part of a community that understands what you’re going through.
- Know the plan and emergency signs: Work out with your doctor what you should do if you have an AF episode or symptoms worsen. Some patients have a plan like taking an extra dose of medication or a pill-in-pocket approach for episodes. Know when to go to the hospital (for example, if you have symptoms of stroke – sudden weakness, speech trouble – or chest pain, or very prolonged palpitations with feeling faint). Having a clear action plan can remove a lot of anxiety because you won’t be second-guessing when to seek help.
Finally, as you move forward, keep in mind that you are more than your AF. It’s something you have, not who you are. Many people with atrial fibrillation go on to do incredible things – climb mountains, run marathons, enjoy retirement travels, play with grandkids – whatever it may be for you. With the right care plan, AF can be managed to the point where it’s a small part of your life’s story, not the headline.
I hope this series has helped you feel more informed and empowered. It’s been my pleasure to share this journey with you. If there’s one thing I want you to take away, it’s that atrial fibrillation is treatable, and you have a growing number of options and strategies to live your life to the fullest. You’re not alone on this path, the medical community (myself included) is continually working to improve AF care, and we’re by your side to guide you through it.
Thank you for reading along, and I wish you the very best in your health journey ahead. Stay positive and proactive…….. you’ve got this!
The Road Ahead: Personalised AF Care and Next Steps Read More - Follow-up appointments: Make sure to keep regular follow-ups with your doctor. AF often requires tweaking of treatment over time – maybe adjusting a medication dose, or repeating a heart monitor to see how things are going. Regular check-ins will help catch any changes in your condition early and keep you on the best therapy.
