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Tachycardia: Difference between revisions
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→Atrial Fibrillation
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* Long standing persistent atrial fibrillation: Persistent atrial fibrillation for more than one year. | * Long standing persistent atrial fibrillation: Persistent atrial fibrillation for more than one year. | ||
* Permanent atrial fibrillation: Accepted atrial fibrillation, no strategies of rhythm control are pursued. | * Permanent atrial fibrillation: Accepted atrial fibrillation, no strategies of rhythm control are pursued. | ||
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====Management:==== | |||
Atrial fibrillation can be managed with anti-arrhythmic medication or more invasive treatment strategies. Studies have shown no benefit of rhyhtm control over rate control, thus the selection of strategy is mainly dependent of patient and atrial fibrillation characteristics. Independent of the treatment strategy, proper anti-coagulation is important and necessary in patients with risk factors. | |||
* <B>Rate control:</b> In atrial fibrillation the ventricle can have a fast irregular rate that can be difficult to tolerate by a patient. On of the strategies in managing atrial fibrillation is to control ventricular rate <120bpm. In this strategy no attempt is made to achieve sinus rhythm. This is the only treatment option in patients with permanent atrial fibrillation. Due to the fast irregular ventricular rate a dilated tachycardiomyopathy can develop and proper rate control can revert these ventricular changes. Rate control can be achieved with beta-blockers, Ca-antagonist and digoxine. | |||
** <b>Invasive treatment:</b> | |||
*** <b>His-Ablation with pacemaker implantation: </b>Patients with accepted atrial fibrillation and complaints of a fast irregular ventricular frequency who do not tolerate medication can be helped with a targeted His bundle ablation with catheter ablation to induce complete AV-block. A implanted pacemaker can take over the ventricular firing frequency independent of the atrium. | |||
* <b>Rhythm control:</b> In rhythm control all efforts are made to achieve and maintain sinus rhythm. This can be done with anti-arrhythmic drugs. Most effective are the Class IC and III anti-arrhythmic drugs. Overall rhythm control is difficult and anti-arrhythmic drugs have many (pro-arrhythmic) side effects. Therefore prescription of these drugs should occur with caution. | |||
** <b>Invasive treatment:</b> | |||
*** <b>Catheter ablation:</b> Medical therapy is not always sufficient to maintain sinus rhythm. In the last decade of 20th century it was discovered that atrial fibrillation is triggered from the pulmonary veins and that selective ablation of these trigger sites can reduce atrial fibrillation recurrence. As this technique evolved it is now common to ablate an area around the pulmonary veins to isolate them from the atrial tissue. The left atrium is approached through the inter-atrial septum and with the use of imaging and electrocardiographic signals a 3D map is made to navigate the atria. The pulmonary vein isolation can be performed with multiple energy sources. This is a difficult and long procedure, that depending on the technique used has (severe) complications. The success rate of the procedure varies on the experience of the operator (40-60%). Often the success rate can be increased by performing multiple procedures. | |||
*** <b>Surgical treatment:</b> Surgery is a more invasive, but more effective modality to treat atrial fibrillation. The classical cut and sew Maze procedure is a open chest procedure that requires extra-corporeal circulation. In this procedure the atrium is cut and sewn again to compartmentalize the atrium en therefore prevent the atrium maintaining atrial fibrillation. In recent years a less invasive procedure has developed to treat atrial fibrillation. This minimal invasive surgery is performed through thoractomy or thoracoscopy and is performed on a beating heart. A pulmonary vein isolation is performed with a clamp and if patients have persistent atrial fibrillation additional left atrial lessions are made on the atrium to compartmentalize the atrium. Finally the left atrial appendage is removed to reduce the occurrence of stroke. This procedure has a success rate of 68% after one year. | |||
* '''Anticoagluation treatment:''' Proper anti-coagulation is important in patients with atrial fibrillation to reduce the occurence of stroke. In patient with atrial fibrillation the indication of anti-coagulation is based on certain risk-factors a patients has. A score is created to fascilitate this descision making. The CHADS<sub>2</sub>VASc2 score incorporates the following risk factors. If a patient has 2 minor points or 1 major point anti-coagulation with coumarins is indicated. If a patient has no indication for coumarins no anti-coagulation is necessary. | * '''Anticoagluation treatment:''' Proper anti-coagulation is important in patients with atrial fibrillation to reduce the occurence of stroke. In patient with atrial fibrillation the indication of anti-coagulation is based on certain risk-factors a patients has. A score is created to fascilitate this descision making. The CHADS<sub>2</sub>VASc2 score incorporates the following risk factors. If a patient has 2 minor points or 1 major point anti-coagulation with coumarins is indicated. If a patient has no indication for coumarins no anti-coagulation is necessary. | ||