585
edits
Tachycardia: Difference between revisions
→Long-Term Management:
| Line 99: | Line 99: | ||
** <b>Invasive treatment:</b> | ** <b>Invasive treatment:</b> | ||
*** <b>His-Ablation with pacemaker implantation: </b>Patients with accepted atrial fibrillation and complaints of a fast irregular ventricular frequency who do not tolerate medication can be helped with a targeted His bundle ablation with catheter ablation to induce complete AV-block. A implanted pacemaker can take over the ventricular firing frequency independent of the atrium. A pacemaker might be indicated if rate control leads to a iatrogenic bradycardia. | *** <b>His-Ablation with pacemaker implantation: </b>Patients with accepted atrial fibrillation and complaints of a fast irregular ventricular frequency who do not tolerate medication can be helped with a targeted His bundle ablation with catheter ablation to induce complete AV-block. A implanted pacemaker can take over the ventricular firing frequency independent of the atrium. A pacemaker might be indicated if rate control leads to a iatrogenic bradycardia. | ||
* <b>Rhythm control:</b> In rhythm control all efforts are made to achieve and maintain sinus rhythm. This can be done with anti-arrhythmic drugs. Most effective are the Class IC and III anti-arrhythmic drugs.<cite>Lafuente</cite> Overall rhythm control is difficult and anti-arrhythmic drugs might have (pro-arrhythmic) side effects, if patients have contra-indications.<cite>Echt, | * <b>Rhythm control:</b> In rhythm control all efforts are made to achieve and maintain sinus rhythm. This can be done with anti-arrhythmic drugs. Most effective are the Class IC and III anti-arrhythmic drugs.<cite>Lafuente</cite> Overall rhythm control is difficult and anti-arrhythmic drugs might have (pro-arrhythmic) side effects, if patients have contra-indications.<cite>Echt, Roy1</cite> Therefore prescription of these drugs should occur with caution. | ||
** <b>Invasive treatment:</b><cite>Calkins</cite> | ** <b>Invasive treatment:</b><cite>Calkins</cite> | ||
*** <b>Catheter ablation:</b> Medical therapy is not always sufficient to maintain sinus rhythm. In the last decade of 20th century it was discovered that atrial fibrillation is triggered from the pulmonary veins and that selective ablation of these trigger sites can reduce atrial fibrillation recurrence.<cite>Hais</cite> As this technique evolved it is now common to ablate an area around the pulmonary veins to isolate them from the atrial tissue. The left atrium is approached through the inter-atrial septum and with the use of imaging and electrocardiographic signals a 3D map is made to navigate the atria. The pulmonary vein isolation can be performed with multiple energy sources (cryo-cooling, radiofrequent energy). This is a complex procedure, that depending on the technique used has a minor chance of (severe) complications, primarily caused by damage of the surrounding structures. The success rate of the procedure varies on the experience of the operator and is 57-71% after one or more procedures.<cite>Calkins2,Cappato</cite> Catheter ablation is suitable for patients with a with drug-refratory rhythm control strategy.<cite>Nielsen</cite> Certain selected patients with heart failure might benefit from catheter ablation, although success are lower.<Cite>Khan,Hsu</Cite> | *** <b>Catheter ablation:</b> Medical therapy is not always sufficient to maintain sinus rhythm. In the last decade of 20th century it was discovered that atrial fibrillation is triggered from the pulmonary veins and that selective ablation of these trigger sites can reduce atrial fibrillation recurrence.<cite>Hais</cite> As this technique evolved it is now common to ablate an area around the pulmonary veins to isolate them from the atrial tissue. The left atrium is approached through the inter-atrial septum and with the use of imaging and electrocardiographic signals a 3D map is made to navigate the atria. The pulmonary vein isolation can be performed with multiple energy sources (cryo-cooling, radiofrequent energy). This is a complex procedure, that depending on the technique used has a minor chance of (severe) complications, primarily caused by damage of the surrounding structures. The success rate of the procedure varies on the experience of the operator and is 57-71% after one or more procedures.<cite>Calkins2,Cappato</cite> Catheter ablation is suitable for patients with a with drug-refratory rhythm control strategy.<cite>Nielsen</cite> Certain selected patients with heart failure might benefit from catheter ablation, although success are lower.<Cite>Khan,Hsu</Cite> | ||
*** <b>Surgical treatment:</b> Surgery is a more invasive, but effective modality to treat atrial fibrillation. The classical cut and sew Maze procedure is a open chest procedure that requires extra-corporeal circulation. In this procedure the atrium is cut and sewn again to compartmentalize the atrium en therefore prevent the atrium maintaining atrial fibrillation.<cite>cox1,cox2</cite> In recent years a less invasive procedure has developed to treat atrial fibrillation. This minimal invasive surgery is performed through thoractomy or thoracoscopy and is performed on a beating heart.<cite>wolf</cite> A pulmonary vein isolation is performed with a clamp and if patients have persistent atrial fibrillation additional left atrial lesions are made on the atrium to compartmentalize the atrium. Finally the left atrial appendage is removed to reduce the occurrence of stroke. This procedure has a success rate of 68% after one year.<cite>boersma,krul1,lameir</cite> Recently hybrid surgical procedures have been described that combine the minimal invasive thoracoscopic surgery with (epicardial or endocardial) elektrophysiological measurement. Patients with a large left atrium (diameter>45mm) or a failed catheter ablation are eligible for AF surgery.<cite>Krul1, Pison</cite> | *** <b>Surgical treatment:</b> Surgery is a more invasive, but effective modality to treat atrial fibrillation. The classical cut and sew Maze procedure is a open chest procedure that requires extra-corporeal circulation. In this procedure the atrium is cut and sewn again to compartmentalize the atrium en therefore prevent the atrium maintaining atrial fibrillation.<cite>cox1,cox2</cite> In recent years a less invasive procedure has developed to treat atrial fibrillation. This minimal invasive surgery is performed through thoractomy or thoracoscopy and is performed on a beating heart.<cite>wolf</cite> A pulmonary vein isolation is performed with a clamp and if patients have persistent atrial fibrillation additional left atrial lesions are made on the atrium to compartmentalize the atrium. Finally the left atrial appendage is removed to reduce the occurrence of stroke. This procedure has a success rate of 68% after one year.<cite>boersma,krul1,lameir</cite> Recently hybrid surgical procedures have been described that combine the minimal invasive thoracoscopic surgery with (epicardial or endocardial) elektrophysiological measurement. Patients with a large left atrium (diameter>45mm) or a failed catheter ablation are eligible for AF surgery.<cite>Krul1, Pison</cite> | ||
Studies have shown no benefit of rhyhtm control over rate control, thus the selection of strategy is mainly dependent of patient and atrial fibrillation characteristics. This means that, since rate control is easier to achieve, rate control should be the initial strategy in all patients, especially in old patient and patients with no or few symptoms of atrial fibrillation. The target heart rate to achieve in rest is <110 beats per minute. In patients with persistent complaints of atrial fibrillation rhythm control can be initiated on top of rate control. Young patients with paroxysmal atrial fibrillation and no underlying heart disease might benefit from early (invasive) rhythm control to halt progression of the disease. However, independent of the treatment strategy, proper anti-coagulation is important and necessary in patients with risk factors.<Cite>Camm2012,Camm2010</Cite> | Studies have shown no benefit of rhyhtm control over rate control, thus the selection of strategy is mainly dependent of patient and atrial fibrillation characteristics.<cite>Carlsson, Hohnloser, Opolski, VanGelder1, Wyse, Ogawa, IonescuIttu</Cite> Patients with AF and heart failure have limited medical options of rate control, as most anti-arrhythmic drugs are contra-indicated, and no benefit of rate vs rhythm control was detected in studies.<cite>roy2,shelton</cite> This means that, since rate control is easier to achieve, rate control should be the initial strategy in all patients, especially in old patient and patients with no or few symptoms of atrial fibrillation. The target heart rate to achieve in rest is <110 beats per minute.<cite>VanGelder2</Cite> In patients with persistent complaints of atrial fibrillation rhythm control can be initiated on top of rate control. Young patients with paroxysmal atrial fibrillation and no underlying heart disease might benefit from early (invasive) rhythm control to halt progression of the disease.<cite>Camm3</cite> However, independent of the treatment strategy, proper anti-coagulation is important and necessary in patients with risk factors.<Cite>Camm2012,Camm2010</Cite> | ||
* '''Anticoagluation treatment:''' Proper anti-coagulation is important in patients with atrial fibrillation to reduce the occurrence of stroke. In patient with atrial fibrillation the indication of anti-coagulation is based on certain risk-factors a patients has. A score is created to facilitate this decision making. The CHADS<sub>2</sub>VASc2 score incorporates these risk factors. A patient has no indication for anti-coagulation if there is a low-risk of thromoembolic complications.<cite>lip1,lip2</cite> These patients are defined as males or females <65 years old with no other risk factors. This translates is a CHADSVASc score of 0, or a CHADSVASc score of 1, where 1 point is based on the female sex. In all other cases anti-coagulation with coumarins or other new anticoagulation drugs (dabigatran, rivaroxiban, apixaban)<cite>Connolly, Patel, Granger </cite> is indicated if no strong bleeding-risk exist. It is important to note that anti-coagulation is independent of the underlying rhythm. | * '''Anticoagluation treatment:''' Proper anti-coagulation is important in patients with atrial fibrillation to reduce the occurrence of stroke. In patient with atrial fibrillation the indication of anti-coagulation is based on certain risk-factors a patients has. A score is created to facilitate this decision making. The CHADS<sub>2</sub>VASc2 score incorporates these risk factors. A patient has no indication for anti-coagulation if there is a low-risk of thromoembolic complications.<cite>lip1,lip2</cite> These patients are defined as males or females <65 years old with no other risk factors. This translates is a CHADSVASc score of 0, or a CHADSVASc score of 1, where 1 point is based on the female sex. In all other cases anti-coagulation with coumarins or other new anticoagulation drugs (dabigatran, rivaroxiban, apixaban)<cite>Connolly, Patel, Granger </cite> is indicated if no strong bleeding-risk exist. It is important to note that anti-coagulation is independent of the underlying rhythm. | ||