Innovative treatment for most difficult cases of atrial fibrillation

Cardiologists and heart surgeons at Stanford Hospital are honing a new technique to treat the most difficult cases of atrial fibrillation.

Joining forces in the operating room, they are seeking to deliver a one-two punch to the source of the abnormal heart rhythm by using minimally invasive surgery and an intravenous catheter to get at the problem-causing tissue on both sides of the left atrial wall.

Stanford is one of a handful of institutions worldwide doing this combination of surgical and catheter ablation at the same time. “After reviewing the medical literature, we didn’t think surgical ablation alone was achieving the success rates that we would like to have with the most advanced patients,” said Paul Wang, MD, a Stanford Hospital cardiologist and professor of cardiovascular medicine who is at the forefront of the technique. “So our rationale was that if you could combine the surgical and catheter components, maybe you could get better results. It’s a logical hypothesis, and now we’re testing it."

About 2.2 million Americans suffer from atrial fibrillation, in which rogue electrical impulses in the heart’s upper chambers, the atria, disrupt the normal cardiac rhythm. Some patients suffer from an intermittent, or paroxysmal, form of the disease. For others, it’s persistent. Medication, cardioversion (an electrical shock to the heart) and either catheter or surgical ablation are common treatments. But for patients who do not respond to these treatments because they have such heart characteristics as a large atrial cavity or thick atrial tissue, the new procedure could offer some relief.

In the past, only select hospitals have offered combined surgical and catheter ablation, breaking it up into two separate operations over the course of about a week. Stanford Hospital, however, is one of the first to do both procedures at once. This means patients do not need to endure two separate preparation and recovery periods. And because the two sets of specialists are in the same room at the same time, they can immediately consult with one another about the specific case — making it easier, for example, for the cardiologist to target the locations needed to complete the ablation.

The surgeons operate first, making fingernail-sized incisions to insert a tiny camera, which guides their work, and a small instrument that delivers cell-destroying energy to tissue on the left atrium’s outside wall. Then cardiac electrophysiologists guide a catheter from the femoral vein into the cavity of the left atrium, where they deliver energy to many of the same sections but from the opposite side. “The goal is to treat the full thickness of the tissue,” Wang said.

Robert Robbins, MD, chair of the cardiothoracic surgery at Stanford, said the technique is just one example of the trend toward more multidisciplinary treatment strategies in cardiac medicine at the hospital. “That we’re able to offer this treatment option to patients demonstrates the kind of innovative and pioneering spirit of Stanford medicine,” he said. “It also shows the efficacy of collaboration.

Gan Dunnington, MD, a Stanford cardiothoracic surgeon who has performed the procedure, agreed: “The hybrid approach has definitely shown some exciting early success in patients whom I feel had very little chance of success through the traditional routes of ablation.”

Wang, Robbins and Stanford cardiologist Amin Al-Ahmad, MD, are also developing technology to allow cardiologists and surgeons to ablate the same section of tissue simultaneously. “That’s the next frontier for this procedure,” Wang said.

Research into the new treatment is being supported by a grant from the National Institutes of Health and Stanford’s Department of Medicine.

John Sanford is a writer in Stanford Hospital’s communications office.