My name is Paul Wang.
I'm Professor of Cardiovascular Medicine and Bioengineering by courtesy and I'm the Director
of the Arrhythmia Service at Stanford.
Patients with afib will come through several routes, typically.
Usually they've seen either their primary care physician or very commonly also a cardiologist,
and after the cardiologist has done their initial evaluation, they determined, oh, they
need to be treated.
They're looking for different options.
Can they come and see me to discuss what those options might be?
And that's the typical kind of environment.
Less commonly, we'll get someone more direct from the emergency.
There will be patients who actually have maybe –
been given the diagnosis and aren't really sure and they come self-referred.
So there's a wide range of patients that end up seeing an arrhythmia specialist.
The symptoms in atrial fibrillation are really varied, so we'll see patients that as far
as we can tell, they're asymptomatic, so there are those individuals and they often come
to us asking, "Well, I don't feel bad.
Do we need to do anything?"
And so we have a discussion of the various different both options and considerations.
On the other hand, there are people with progressively more symptoms and so it may be something fairly
non-specific and that might be fatigue, easily getting tired, sleeping more, those kinds
of things, or something really related to atrial fibrillation, racing heart rate with
associated chest pain or shortness of breath.
So that would be your very typical spectrum of symptoms.
once we decide the patient needs treatment for atrial fibrillation, then we decide, well,
is their current medical regiment appropriate?
That is, typically are their heart rates controlled?
Is it too rapid?
Do they have too much and now it's too slow?
And so we make that assessment.
Occasionally people might need pacemakers, those kinds of things, but generally it's
medications that we'll use to regulate the heart rate.
Now for some people, they in fact need additional medication and that is to try to either restore
normal rhythm or in fact maintain normal rhythm, and so sometimes that also includes a procedure
called electrocardioversion, where they get a shock to the chest that resets the heart
rhythm, so that may be an early step in which they have in terms of their treatment.
On the other hand, they may have already had that and they may come saying, "I'm still
pretty symptomatic.
I've done these initial steps.
I've tried –
these medications.
I may have even tried cardioversion.
I want to know what else is available."
Then we have the discussion in terms of the special procedure called catheter ablation,
and so by catheter ablation, we refer to catheters being tubes that we place inside the body
into the heart and that's the way in which we go about treating it.
Ablation then refers to killing cells that are felt to be responsible for atrial fibrillation.
In doing so, we hope to significantly reduce the likelihood that they'll have recurrent
atrial fibrillation, and that's why it's a major strategy in addition to medications
in terms of treating patients.
The tools we use are relatively simple – tools, by and large, and really the major breakthrough
is having very specialized tools that were designed specifically for atrial fibrillation.
Really as most procedures start, we try to use tools that we already have at our disposal,
and that's exactly what happened in terms of ablation for atrial fibrillation.
We use a standard catheter that was used for other arrhythmias and that's a single point,
we call it, catheter, which basically at one point at a time, you go through treating the
areas of the heart.
And so I use the analogy it's like a painter, so it's really like taking a small paintbrush,
putting a dot of paint on one place, and using that to paint the room.
Really we're doing that kind of a process.
On the other hand, people said, "Well, maybe there's a better way.
How can we create a system really designed to deliver the energy better?"
And so people had a variety of different approaches and the current major advances are in terms
of what we call balloon technology, and balloons –
are designed to actually sit around the structures called the pulmonary veins, and that is a
site from which we feel atrial fibrillation commonly originates.
And then by delivering energy through the balloon, we can then hope to block signals
from coming out of the pulmonary veins.
And so that's emerged as a standardized, well-accepted option in terms of the treatment of patients
as well, and so that's one other area.
Now there are other newer technologies that are also being developed to try to achieve
more efficient delivery of energy, having the ability to deliver a series of legions,
areas of ablation, at one time.
Rather than having to go point by point, maybe we can use more of a roller kind of effect
and paint a larger area at one point.
So those are the kinds of things that are trying to be advanced in terms of atrial fibrillation
ablation.