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>> Atrial fibrillation is the
most common heart rhythm abnormality,
and it results in the upper chamber
of your heart beating extremely fast,
500, 600 beats a minute.
This causes an irregular rapid heartbeat.
It's very much of an age related problem.
It's rare before 50, by the time you're 80,
one in 10 people have Afib.
It's also more common if you have
other types of heart disease,
if you're very obese, sometimes it runs in families.
So it's a very common important problem affecting
about over five million adults in the United States.
Diagnosis of atrial fibrillation is by obtaining an EKG,
which will document atrial fibrillation.
And so this is something that your internal medicine doctor
may do, maybe picked up incidentally
when you're getting a routine checkup,
or you may have symptoms.
Your heart may be racing.
You may feel fatigued, know that something's not right,
an EKG is obtained,
and you're told you have atrial fibrillation.
The first thing you think about
with atrial fibrillation is stroke risk.
Because one of the most devastating complications
of atrial fibrillation is having a stroke,
which can change your life forever or even kill you.
So that's the most important management question.
Different patients have different risks of strokes.
Some have high risk of stroke.
Some have low risk of stroke,
but if you have atrial fibrillation,
your stroke risk on average is five fold increased.
So there's a number of different treatments we can do
to lower that risk of stroke.
And that's the most important treatment strategy.
We also think about medications
to control the atrial fibrillation
or procedures to cauterize the atrial fibrillation.
And there's other medications just to slow it down.
So it's a conversation that you'll have
to have with your physician
if you're diagnosed with this condition.
Atrial fibrillation on average increases your stroke risk
five fold, but some patients are
at very high risk of stroke, maybe 10% per year.
In other patients the risk of stroke is extremely low,
despite having atrial fibrillation.
The risk factors we think about are age,
age over 65 diabetes, hypertension,
a prior stroke or TIA, coronary disease.
Those are the things that we use to decide,
is a patient high risk, or is a patient low risk,
or are they somewhere in between?
If a patient has atrial fibrillation
and they have enough risk factors
where their stroke risk is we'll say 2% per year or higher,
then we wanna do something to lower that risk.
We can either use anticoagulants like Coumadin, warfarin,
the old drug that's been around for 40 years.
There's also newer anticoagulants where you don't have
to monitor your blood levels.
You don't have to adjust
how much salad you have and so forth.
We call those NOACs,
these new oral anticoagulation medications.
And then more recently there's been techniques developed
to lower stroke risk without having to take a medication.
And this is called appendage occlusion.
So out of patients who have Afib are at high stroke risk
and should be on a blood thinner,
only about 50% are because they have bleeding problems.
They may have nose bleeding or GI bleeding,
or they may be at risk of falls
where they can't be on a blood thinner.
And for these patients, the good news is,
there's a new approach
to lowering stroke risk called occlusion
of the left atrial appendage.
Now, this is a heart I brought with me
and it shows the left atrial appendage,
which is a little sock-like wind sock
that comes off the left atrium.
That's where the clots form that cause strokes
in patients with atrial fibrillation.
So there's a number of techniques
to either put a plug in this little wind sock
from the inside, or go from the outside under the sternum,
the chest bone, and tie it off or go in surgically
and put a little clip on that structure.
And that is as effective as blood thinners
at lowering stroke risk.
So it's an important new alternative
that we have for all these patients
that can't take blood thinners.
So as we said, this appendage is where the strokes form.
So there's a number of different techniques
to get rid of that appendage.
Either you can go in
with a minimally invasive surgical technique
through your chest wall
and put a little Barbie pin-like device on it,
clamp it down and get rid of it that way.
Or you can go in with a snare under the chest bone,
in a cath lab setting and tie it off, cinch it off,
using a percutaneous technique
that does not involve surgery.
Or the third way is to put a plug in
from the inside of the heart,
where we go up from the leg,
thread this plug into the chamber,
and then we just deploy it like an umbrella.
And that occludes the appendage
and lowers the stroke risk back to a more normal level.
So deciding which of these approaches is right
for a given patient is a major decision,
and it involves assessing a patient's anatomy.
What is this structure look like?
And we have a team at Hopkins of imaging cardiologists,
cardiac surgeons, cardiologists,
and we meet together to decide the right approach
for the right patient.
If someone's had prior chest surgery,
then they aren't a candidate for the technique
where we go into the chest or under the sternum bone.
And for them we would use the plug approach through the leg.
If someone can't be on a blood thinner,
then we would use one of the other techniques
where we go in through the chest
where you don't have to be on a blood thinner
for the first six weeks, which is the case
with the umbrella-like device we deploy from the inside.
So I think the important messages,
it's a big question of these devices is the right device
for a given patient.
And that's where we have this team
that will review your case and make a formal recommendation.
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