Hi, and thank you for joining us at EmpowHER, women’s health online. I’m joined right now by Dr. Lishan Aklog; he is the Chairman of EmpowHER’s Medical Advisory Board. He is also the Director and Chief of Cardiovascular Surgery at the Heart and Lung Institute of St. Joseph’s Hospital and Medical Center in Phoenix, Arizona. Hi, Dr. Aklog.
Dr. Lishan Aklog:
That’s quite a mouthful, huh Todd?
Todd Hartley:
It sure is. Dr. Aklog, atrial fibrillation, as you know, is the most common cardiac arrhythmia; it’s an abnormal heart rhythm, but what is it that women don’t necessarily know about afib that they should know about today?
Dr. Lishan Aklog:
That’s an excellent question. I think there are lot of myths about atrial fibrillation or as you properly used the term ‘afib,’ which is what we commonly use. There’s a couple of myths; one of the myths is that, and probably the most important myth, is that it’s a relatively benign condition. I must say that that’s what I was taught in medical school and throughout my training that yes, somebody, people who have afib need to be on blood thinners and then, as long as they are on blood thinners everything will be fine and that’s clearly not the case and I think we have some time to delve in that a little bit deeper.
The other common myth, which goes hand-in-hand with that, is that afib can’t be cured; that once you have afib you’re stuck with it for life and that’s also simply not true.
Todd Hartley:
Well, let’s start with that one right there. Let’s say, how is afib corrected? Let’s say, a patient has it and comes to see a specialist like you, how do you take care of it?
Dr. Lishan Aklog:
Well, we take a very broad multidisciplinary approach with this. So when a patient comes to us, they come to not me as Dr. Aklog, heart surgeon, but to our atrial fibrillation clinic and we believe that’s important because for every patient there are variety of treatment options and it’s important that the treatment plan is tailored to their particular condition and that they have an opportunity to discuss all the options with the various specialists that would participate in that.
If you talk about the options for treatment there are really three main categories – the first category is medical treatment. So that’s treatment with a variety of different types of medication. The second category are catheter treatments where we are using a catheter from inside the heart that atrial fibrillation can be corrected, and the third broad category are surgical treatment – either minimally invasive surgery or more standard surgical treatments.
Todd Hartley:
Dr. Aklog, is atrial fibrillation something that the patient is responsible for? Did they do something wrong or is it something that they were born with?
Dr. Lishan Aklog:
It’s actually neither. They certainly are not responsible for it, unlike many different types of heart condition. Generally speaking, for things like, you know, coronary artery disease where you develop blockages there are a lot of variety of lifestyle factors that contribute to coronary artery disease.
For atrial fibrillation that’s really typically not the case. So typically, people develop atrial fibrillation as they get older as a result of some things that they can control like high blood pressure, and in some patients we never really know exactly why they develop it. It’s just something that can appear at an increasing rate as patients get older.
And it is, in and of itself is not something that you are born with. Patients who have other abnormalities, other congenital heart abnormalities can develop atrial fibrillation, but as an isolated condition, it’s not something that you are born with, it’s something that typically will show up later in life in middle age and then progressively as patients get older.
Todd Hartley:
Dr. Aklog, a woman anonymously, on the website, asked if an arrhythmia on the right chamber of the heart – the upper right chamber, could be classified as an atrial fibrillation?
Dr. Lishan Aklog:
That’s a good question and to answer, we have to delve a little bit into an anatomy lesson. So, what the writer is referring to is that the two upper chambers or receiving chambers of the heart – the atrium – there are two of them, one is the right atrium and the other one is that left atrium, and so when we talk about atrial fibrillation, we are really talking about both the right and the left atrium.
Now, there are a variety of arrhythmias that are not atrial fibrillation – things that are referred to as SVT or supraventricular tachycardia and a whole variety of other conditions with big long medical names that are not atrial fibrillation, and many of those can arise in an isolated way in the right atrium, and they can be treated using catheters in a very directed way in the right atrium.
Atrial fibrillation is really a condition that involves both the right and the left atrium and, in many ways, the dominant triggers for atrial fibrillation are actually more commonly found in the left atrium, but when the atrial fibrillation kicks in and the atrium are not beating in a synchronized way, they are just wiggling like a can of worms, that by definition involves both the right and the left atrium.
Todd Hartley:
Fascinating, okay. Now do you mind a couple of more questions from women on the site?
Dr. Lishan Aklog:
Yes.
Todd Hartley:
So ladies, if you are listening right now on EmpowHER, one of the great functions is if you want to ask a question to one of our experts like Dr. Lishan Aklog, you can just click the ‘ASK’ button and we will do our best to get that question asked while the show is going on. And another anonymous woman said, “Dr. Aklog, I have a lot of stress at work, does this cause or trigger my afib or is it something else that I might be feeling? Thank you.”
Dr. Lishan Aklog:
Another excellent question. So, although I said earlier that lifestyle thing, things that you can control in your life are not a direct cause of atrial fibrillation, so you are not going to get atrial fibrillation because you have a stressful life or other things, they definitely can exacerbate it. So, people who have atrial fibrillation, their heart is susceptible to triggers that are going to generally rev up the heart, the function of the heart and rev up the heart rate. So when you get stressed, your body produces burst of adrenalin and the effect of adrenalin on the heart in general and particularly on patients who have atrial fibrillation can be to either trigger a bout of atrial fibrillation or if you are in continuous atrial fibrillation it can make the heart race at a much faster rate. So, controlling stress is definitely a part of the short-term treatment for atrial fibrillation.
Todd Hartley:
Earlier in the conversation you had mentioned that medication can help, but do a lot of patients go on with medication and never have it corrected?
Dr. Lishan Aklog:
Yeah, so if you are talking about medication we should talk sort of in two categories – the first category are a pretty straightforward and those are blood thinners. So patients who have atrial fibrillation because the atrial chambers are not contracting properly there’s stagnation of blood and people are prone to developing blood clots. So, it’s absolutely mandatory that patients be on some type of blood thinner, preferably Coumadin or Warfarin to decrease, not eliminate, but to decrease the risk of blood clot formation and thus the risk of stroke.
Then, the other broad category of medications are a little bit more challenging and those are medications that attempt to treat the rhythm itself, and there are whole variety of medications that are utilized for that. The bottom line is however, that there are no medications that are shown to cure atrial fibrillation. The best we can do is, keep the rate down, which is important. You know, if you have atrial fibrillation it’s a lot more comfortable to have your heart rate at 60, 70, 80 than it is at 130, 140, 150.
So general, most we can get medications that will keep the rate down, but none of the medications actually can cure atrial fibrillation and in fact, many of them are potent medications, which any patient who has lived with atrial fibrillation for a while will know these names and very often when we see them cringe when we discuss them medications like Amiodarone, Rythmol, Flecainide and others, not only is their effectiveness, they are not that effective at keeping you out of them, they all carry their own, they have a cost associated with them in terms of, you know, sometimes quite severe and long-term side effects.
So it’s not something that generally in the long-term we like to keep patients on because they have really serious and sometimes even life-threatening side effects. So, the bottom line, Todd, is that medications do not cure atrial fibrillation. So patients who seek a cure have to be evaluated and considered for the other two categories, whether it’s catheter ablation or surgical procedures that we now know can cure atrial fibrillation.
Todd Hartley:
Dr. Aklog, I was lucky enough to be at your hospital one day when a presentation was being performed on different atrial fibrillation surgeries and procedures and one of the things that I watched, and I was totally impressed with this, was the mini-maze procedure. Is that what’s considered like the gold standard today?
Dr. Lishan Aklog:
Well, you know, I wouldn’t call it the gold standard because the reason it’s called the mini-maze procedure is because it’s a derivative of the full maze procedure and what it is, is less invasive version of the original full maze procedure which really is the gold standard. So let’s talk briefly about that first.
The full maze procedure was invented in the early 1990s by a doctor named Dr. James Cox in St. Louis, Missouri, and what the concept was, was actually one that we actually, that the patients can understand, which is that it’s called a maze procedure because that’s exactly what we are doing. We are creating a maze in the atrium which allows the heart, this jumbled, irregular heart activity to pass through in a, you know, like a maze typically has its one path that will get you from the beginning to the end – well that’s what we do. We basically create a maze on the chamber by creating these lines and forcing the electrical activity that go down a specific path.
So the success rate of a maze procedure when it was first conceived was and remains very high – it’s 90-95% effective. The mini-maze procedure was created because the full maze procedure is major open-heart surgery and a lot of patients who, where their only condition is atrial fibrillation were reluctant to undergo a full open heart operation. So over the past six to seven years we have developed this mini-maze procedure which allows us to create most of the lines of the maze procedure from the outside of the heart without having to go on the heart-lung machine and also allows us to do them through very small incisions in between the ribs and the armpit instead of going through the middle of the chest.
And so, it’s a lot less invasive and we have really much better technology now that let’s us create many of those lines that were part of the original maze procedure. The compromise is that because it’s so much less invasive the effectiveness is probably a bit less than it is for a full maze procedure. So we tend to quote patients a 90-95% effectiveness with a full maze procedure and more like an 80 to 85% effectiveness in the mini-maze procedure. So it’s somewhat less effective, but it’s still high enough that we’ve had good success with it and patients appreciate being able to get that, to be cured of their afib without having to undergo the full procedure, and then the final point is that, if there’s one of the unlucky 15 or 20% that mini-maze doesn’t work, we always have the option of doing the full maze procedure to try to salvage an even higher success rate.
Todd Hartley:
Well he is Dr. Lishan Aklog. He is the Chairman of EmpowHER’s Medical Advisory Board, and before we say goodbye on the atrial fibrillation in women’s subject, Dr. Aklog, what is it, how does atrial fibrillation affect women differently than men, does it?
Dr. Lishan Aklog:
It doesn’t. Unlike some other aspects of heart disease, it’s quite common in women and it is, but really at the end of the day, the symptoms and the treatments are fairly similar, but it is something that is quite common in women. Women tend to experience it quite negatively and it can have a significant impact on their quality of life and so it’s something women need to pay attention to, but most of the standard signs and symptoms and treatments are quite similar to what they are in men.
Todd Hartley:
Dr. Aklog, thank you so much for helping us empower women and their healthy hearts.
Dr. Lishan Aklog:
Thank you.