PracticeUpdate Cardiology June 2019

EXPERT OPINION 14

Contemporary Treatment of Atrial Fibrillation in 2019 Interview with Douglas P. Zipes MD by Aman Shah MD

Dr. Shah: I’d love to get an overview from you on where we are in the treatment of atrial fibrillation as of today. Dr. Zipes: Atrial fibrillation is a major problem. The numbers keep escalating in terms of those individ- uals who have atrial fib, and when I sit down and talk with a patient about atrial fibrillation, I basically tell them that there are two critically important aspects. One is rate control, and the other is their risk for having a stroke. Rate control is generally easily man- aged, beta-blockers, calcium blockers, and so on, and now, with the new oral anticoagulants, the stroke risk can be significantly reduced at an acceptable treatment regimen for a patient. Gone, really, are the days of warfarin and getting protons and so on. So those are the two major aspects, and it’s impor- tant for the patient to realize that atrial fibrillation is not a trivial disease. We treated it very lightly years ago, but we now know there’s an increased risk of death, of sudden death, of heart failure, and obvi- ously, of stroke. So, it is something that it’s important that we address. Having suffered 2 or 3 episodes of atrial fib personally, I know that I prefer to be in sinus rhythm, and that is certainly a major goal. Drugs have been generally unsatisfactory. The most effective is amiodarone, but it comes complete with a long list of side effects, and you need to think twice about treat- ing a patient with atrial fib, particularly in a patient with heart failure or compromised lung function with a risk of pulmonary fibrosis. Ablation has been a major advance. Beginning with the surgical approach by Jimmy Cox, we then use catheters to try to replicate what he’s done, and in the best cases, restoration of sinus rhythm is in the 65% to 75% range. And that is most easily achieved in patients who have paroxysmal episodes because we know once atrial fibrillation lasts, it remodels the atrium electrically and anatomically, making it more difficult to restore sinus rhythm. So, one of the best candidates would be a young person who has par- oxysmal episodes, bothered by them, ineffectively treated by drugs, wants to get rid of the atrial fib. That patient is an ideal ablation.

Dr. Zipes is Distinguished Professor of Medicine, Pharmacology and Toxicology, and Director of the Cardiology Division of Krannet Institute of Cardiology at the Indiana University School of Medicine.

Dr. Shah: That makes a lot of sense. Any other patients who you might prefer for surgical therapy given all the data that we have? Dr. Zipes: Well, I think a patient who is going for sur- gery, mitral valve or whatever, the surgeon can concomitantly do a Cox approach and restore sinus rhythm in those individuals, and I think that certainly can be combined, and is in many centers. The patient not going for surgery, obviously, doesn’t want their chest opened, and there we fall back on a catheter approach. For some patients, ablating the AV node and then implanting some sort of a pacemaker device is effective, and it all has to be individualized with a particular patient. For the latter, the one that I just mentioned, par- ticularly if they have some degree of ventricular dysfunction, right ventricular apical pacing is not going to be appropriate. So, they either need biven- tricular pacing or...and this is a paradigm shift, His bundle pacing. This has been a dramatic “advance,” I think. I say advance in quotes because we tried to do that 20 and 30 years ago, but the technology with some very skilled operators has been success- ful more recently, and obviously, to put a single lead in to pace the His bundle after ablating that area would be far preferable than having a right and left ventricular pacing apparatus. Ideally, it is ablating in the atrium. The bedrock of what’s done is to isolate the pulmonary veins and

" I am an enthusiast for, in selected patients, an invasive approach to ablate and try to restore sinus rhythm. One needs to be selective with a particular patient. One needs to sit down with a patient, talk about pros and cons, complications, and so on, and if the patient is agreeable after all of that, I certainly would be in favor of an ablation approach. " PRACTICEUPDATE CARDIOLOGY