Atrial Fib. Noninvasive Treatment

dawngloves, BSN, RN · Nov 3, 2005

Hey Dinith--
I have to agree with you regarding the success rate with ablation. I can't tell you how many times I've seen a post CABG and/or Valve Pt who have had the Maze procedure--and postop they are still in Atrial Fib!! And ditto for the traditional ablations. I see ALOT of Aortic Valve replacements with postop Afib as well. Do you or anyone know the rationale behind that?
Also, are you familiar with AtriCure bipolar radiofrequency ablation? It's surgical ablation, however it's a minimally invasive procedure. The surgeons where I work are doing it. It obviously decreases the risks involved.

You guys are taking me back.Eight years ago I worked tele at a teaching hospital and we would ablate after Cardizem and carioversion failed to break Afib. We had about a 60% success rate. It was such a bummer to look at your monitors and see your post ablation pt was now back in afib! Back to the drawing board!

RN12345656 · Nov 4, 2005

Dinith--AtriCure is very similiar to Maze procedure except sternotomy and pump are avoided with just a thoracotomy approach. EP lab ablation is obviously less invasive than AtriCure.

qanik · Nov 4, 2005

Just had to post as last weekend while at anesthesia school felt this strange palpatations and got lightheaded. Went to the ED. Workup = nothing. Sent to 23 hour obs. 6 hours later went into rapid a-fib. Rate 180-190. Cardiologist happened to be in the next room (large teaching hospital) I maintained my BP. They put my on a continuous 12 lead and tried some adenosine 6mg and then 12 to see if it was SVT. It was so fast you couldn't tell. Got the cardiezem bolus slowed me to 120-130 and you could clearly see a-fib. Stayed on the drip that night and spontaneously broke in the A.M. the plan was cardioversion later that AM if I didn't break. I had a follow up echo then stress echo- all normal that day. Went home on 180 cardizem CD for a month. Things I learned- don't take your morning prednisone (myasthenic) with a venti Starbucks. You can cardiovert up to 48 hours after initial a-fib without thrombus worry. Criteria for anticoags- Over 65 years of age, HTn, recent stroke, LV failure, onset more then 48 hours, past clot hx. Anyway that was my fun for the weekend. A heart rate of 190 is something, it feels like it is going to jump out of your chest :lol2:

Qanik

papawjohn · Nov 4, 2005

Hey Y'all

Gosh, qanik--had the heart rate (Says P- J- who's been on the ol' treadmill and under the nuc med sensor hisself.)

When I worked in cardiac stepdown there were two BIG things I learned to watch for. The first and worst was a CVA. Presumably AFib would occur post op--or the time on pump, who knows--would produce a 'mural thrombus' in the Left Atrium. Restoring NSR would 'break a piece off' and the embolus would find its way into (usually) the Left Middle Cerebral Artery. The result was usually typical--Right side flaccid, aphasia, confusion.

The second and coolest was what we called 'post-open-heart-syndrome'. (I think it's actually Dresslers Syndrome?) Pericarditis leads to inflamatory myocarditis. Your Pt has a mild fever, develops a rub, converts to AFib. (It's what got yer ol' Papaw listening to heart sounds 25 yrs ago.) It's quickly reversed by NSAIDS or SoluMedrol and a Calcium Channel Blocker. You call the Cardiologist at 10pm, start the med by midnite, and you have a reversal by 0600. COOL!!!

Thinking what a great profession we've got

Papaw John

ceecel.dee, MSN, RN · Nov 4, 2005

Very educational thread for me!

Thank you very much!

RN12345656 · Nov 4, 2005

Dinith--AtriCure is very similiar to Maze procedure except sternotomy and pump are avoided with just a thoracotomy approach. EP lab ablation is obviously less invasive than AtriCure.

I'm sorry--it's a thoracoscopy approach (smaller incision than an actual thoracotomy) :)

Dinith88 · Nov 4, 2005

I'm sorry--it's a thoracoscopy approach (smaller incision than an actual thoracotomy) :)

Thanks a bunch for the info!

JustMe · Nov 8, 2005

Hey Again
OK...Here's the story if your Pt goes into a rapid atrial rhythm or SVT. Your role is to get them back into NSR as soon as possible. (Do I get extra credit for NOT saying NSR ASAP?)
There's two ways this happens. First, the Pt might say--"Wow, I've done it again." This is the time to use your nursing judgement and say: "What works for you at home?" Lots of people have this experience at home and they do all kinds of things: They dip their face into ice water. Or they rush to the toilet and try to have a BM.
Whatever works for them at home, help them.
If that doesn't help them in the hospital, you have to decide if they"re going to need something special. If the rhythm is really rapid and probably ventricular (I say this because at this point it's 0200 and your looking at the screen of the CodeCartMonitor) you say "bear down like you're going to have a BM!!"
Nine times outa ten, this doesn't work and you're on the phone to the MD very shortly after. (There are alternatives--carotid massage--but we're not gonna do that without an MD on hand giving verbal orders. And if he's on hand, make him DO IT.)
Then you give digitalis and/or cardizem. Then about 5 times outa 10 the Pt returns to NSR.
For the rest, see my previous post....
Papaw John

I agree with everything you said Papaw John--except if the patient has had an acute MI. Have you ever had a pt with AMI on the commode, bearing down? Watch them brady down?? Not pretty! If you want them to bear down, put them on a bedpan, otherwise you could have more than a code brown! :uhoh3:

papawjohn · Nov 8, 2005

Hey JustMe

Oh HONEY!!! There're a couple of hilarious 'nursing humor' stories that I'd prob'ly get in trouble for putting on this thread. They involve BedSideCommodes and Blue/Brown codes.

And yes, I have Atropine in my pocket and Adensosine drawn up and etc etc when this kinda thing happens. I'm the kinda guy that likes to have a few 10cc syringes of Saline for flushes nearby. I'm a 'just in case' kinda nurse. (If you have it in your pocket--you probably won't need it.)

Papaw John

JustMe · Nov 8, 2005

Hey JustMe
Oh HONEY!!! There're a couple of hilarious 'nursing humor' stories that I'd prob'ly get in trouble for putting on this thread. They involve BedSideCommodes and Blue/Brown codes.
And yes, I have Atropine in my pocket and Adensosine drawn up and etc etc when this kinda thing happens. I'm the kinda guy that likes to have a few 10cc syringes of Saline for flushes nearby. I'm a 'just in case' kinda nurse. (If you have it in your pocket--you probably won't need it.)
Papaw John

LOL!!:rotfl: Murphy's Law!!

rookreck · Dec 30, 2005

At my facility if the time of the onset is known and is a new occurence we anticoagulate and try to use drugs (IV Cordarone) to convert them. If the patient has been in afib for a long period of time we slow them down with Cardizem and Lopressor and anticoagulate them and send them home. After a period of time the patient is brought back in and placed on IV cordarone for 24 hours and if they don't convert to NSR then we cardiovert after the 24 hours and the patient is sent home on po cordarone.

TennRN2004 · Jan 6, 2006

And as far as a reason for a-fib from AVR's (and any other heart surgery...but especially from valves) is mostly from endocardial edema caused by the procedure itself (and compounded by electrolyte abnormalities, etc.). This 'irritation' can take upwards of a month to subside. As far as how long they typically keep these people on meds (post-op hearts triggering afib) to control it i'm unaware (meaning if they've converted...if still in afib they onbviously could be on them for life).Thats a good question for a surgeon (or cardiologist) i suppose...

We started using a beta blocker protocol at my hopsital (about a year ago I think) to try and prevent CAB post op AFib. I don't have the actual numbers, but one of our heart surgeons a couple of weeks ago said he thought the post AFib rates had went from 30% down to about 10% now with the use of Atenolol and Cordorone preop and postop. Of course, we do have the patients who have a history of AFib who still go into it post op and may or may not convert to NSR, and we also have those who pop in and out of Afib/SR- they stay on anticoags and usually drugs like Dig for rate control, but overall it seems to be a good protocol we use. The only problem is now all of our CAB pts (I was surpised some of our surgeons didn't put epicardial wires in their patients just in case anyway) come out with pacing wires in case they go bradycardic from the meds and need to be temp paced for a while, but the surgeons don't like that either.