Atrial Fibrillation

Atrial fibrillation is very common. There are many different causes to it and it can also be lifestyle-related. The treatment involves a stepwise approach. It starts with medication, then ablations and finally there is the possibility to implant a pacemaker.
Vorhofflimmern Patienten Herz Monitor

The most common Arryhthmia

Atrial fibrillationWith atrial fibrillation the heart beats very common. There are many different causes which can be lifestyle related. Mostly, the symptoms lead to a precise diagnosis. Unfortunately, sometimes it is only diagnosed after a firstmanifastation such as a stroke! Very often, however, atrial fibrillation is discovered by chance during a preliminary examination or check-up. 

When do you speak of atrial fibrillation?

The healthy heart rhythm is regular, unconscious but also variable and can be felt as a pulse wave that goes through the body. Normally, the beat starts as an electrical impulse from the sinus node in the right atrium and adapts very quickly to the physical requirements, as well as emotional and psychological stress (autonomous nervous system). The heart in its normal rhythm, is in the sinus rhythm. The heartbeat is controlled rhythmically by an electrical impulse, that originates from the sinus node. It is the heart's clock. With atrial fibrillation, this rhythm is disturbed and the heart beats irregularly.

A heart rhythm disorder (arrhythmia) is spoken of when the heart beats irregularly. With atrial fibrillation (absolute arrhythmia), the heart beats uncoordinated, whereby the small chambers no longer contract and only fibrillate uncontrollably. As a result, an uncoordinated heart action occurs, no longer clocked through the atria (the natural pacemaker of the heart) but with a chaotic ventricular heart rhythm. This can be seen in the electrocardiogram (EKG). The patients feel this very strongly. It is a medical diagnosis made by a doctor on an ECG showing the arrhythmia.

Who is commonly affected?   

Atrial fibrillation is the most common cardiac arrhythmia in adults worldwide. A widespread disease that is on its way to becoming an epidemic. The disease occurs especially in older age or in younger patients with certain risk profiles. But it is also common in older trained endurance athletes. Other diseases such as hypertension, heart valve problems, sleep apnoea, thyroid issues or infections can also cause atrial fibrillation. Often the uncontrolled heart rhythm is discovered by coincidence during an annual check-up.

What are the symptoms of atrial fibrillation?

The symptoms are very variable. There are patients who experience no symptoms, never notice the arrhythmia, and the diagnosis is made only after a complication, e.g. a stroke. Others notice it very strongly and are heavily affected by this condition. These can be related to the inappropriate pulse or the lack of cardiac power.

Common symptoms due to atrial fibrillation

Irregular heartbeat and pulse, stumbling, rapid heartbeat, palpitations, dizziness, sweating, shortness of breath, inner restlessness, feelings of anxiety, fatigue, tiredness, chest pain, exhaustion, reduced performance and stroke.

Common causes of atrial fibrillation

Age, high blood pressure, obesity, diabetes, alcohol, caffeine, drug abuse, overactive thyroid, consequence of heart failure, coronary artery disease, heart valve disease, postoperative, trained endurance athletes, pericardial diseases, asthma, COPD and sleep apnea syndrome.

Is atrial fibrillation dangerous?

If atrial fibrillation is treated correctly, it poses no acute danger. Those affected can either suffer from severe symptoms that reduce their quality of life or notice nothing at all. If left untreated, atrial fibrillation increases the risk of heart failure and stroke. That is why it is so important to initiate correct treatment early. Atrial fibrillation leads to a 5-fold increased risk of stroke. As a result of irregular heart activity, blood clots can form in the left atrial appendage, which can embolize into the body and clog smaller vessels. In the brain this leads to the feared stroke. .

The CHA2DS2-VASc score for patients with atrial fibrillation enables the calculation of the risk of a stroke, individually for each patient. A treatment recommendation with a blood thinner is then derived from this. Therapy is not recommended for patients with 0 points. For everyone else, more is better than less! A stroke can have devastating consequences. Therefore, blood thinning is necessary. For patients who cannot take a blood thinner (or who does not want to), the left atrial appendage can be closed mechanically offering an interesting alternative. An irregular and fast heartbeat, over a long period of time, can also lead to the development of a heart failure. Untreated atrial fibrillation leads to increased mortality, hospital stays and, of course, an impairment of the quality of life.

Where in the heart does atrial fibrillation happen?

The atrial fibrillation starts where the pulmonary veins enter the heart muscle fibers. This is where the misfires occur. These cause an electrical chaos in the small chambers. The heart rhythm is disturbed and is no longer routed regularly to the large chambers (ventricles). The cardiac rhythm is now dictated by the AV node which leads to an irregular heartbeat. The cornerstone of atrial fibrillation therapy is pulmonary vein isolation. This isolation can be created by a scar that prevents the triggers of atrial fibrillation in the pulmonary veins, from setting the heart into this chaos. An ablation is performed for this. This ablation is done with a catheter from the inside or surgically from the outside.

Classification of atrial fibrillation (AF)

Atrial fibrillation can be a one-time event secondary to another problem – or it can develop into a chronic condition. This varies from patient to patient. Depending on the occurrence, duration and reversibility of atrial fibrillation (af), it’s considered to be occasional and self terminating (paroxysmal), common (persistent) or permanent (permanent): 

  • Paroxysmal AF
    The seizure-like (paroxysmal) AF occurs like a seizure, but usually disappears by itself within minutes or maximum 24 hours. This form is self-limiting, usually comes and goes by itself. Patients mostly have a normal sinus rhythm and atrial fibrillation occurs only sporadically. Paroxysmal atrial fibrillation occurs most frequently in the left atrium around the pulmonary veins and can be treated with the electrical isolation of the pulmonary veins from the atrium so that they no longer interfere with the electrical transmission in the atrium. Triggers that can setoff paroxysmal AF have recently become known. These are alcohol (especially excesses), obesity, caffeine, drugs (especially amphetamines and cocaine) and smoking. If these triggers are eliminated, AF will also decrease. The risks associated with AF are important in this form. Symptoms can be unnoticed or felt terribly. Treatment is generally catheter ablation unless an indication for stopping anticoagulants is present in which case a surgical ablation can be done.
  • Persistent AF
    Persistent (persistent) AF lasts for more than 7 days and/or can only be stopped with medical means (medication or electric shock (cardioversion)). This form is more complex to treat and requires a furthermore pronounced medical work-up. Persistent AF is associated with increased fibrosis in both small chambers. The triggers for this can be found in the pulmonary veins and perpetuating factors lead to the occurrence of rotors – which are organized electrical storms in the heart causing terrible symptoms. The treatment depends on the duration – if persistent AF is present for less then a year (early persistent) the catheter ablation may still help, otherwise we recommend a surgical approach or a hybrid procedure.
  • Permanent AF
    The permanent AF is a condition in which AF is accepted by patients and doctors. The strategy is a rate control strategy ensuring that the heart rate during the constant AF is well controlled – in general <80bpm in the mean. Symptoms are relieved by medication. If that is not possible or insufficient, a pacemaker implantation can be discussed (“pace and ablate”). In this situation a pacemaker is used to override the heart’s own dysfunctioning control mechanisms. The pacemaker adapts to the needs of the body and varies the heart rate in a seemingless fashion. Symptoms are very well controlled with this strategy. Effective stroke prevention with blood thinners or mechanical left atrial appendage closure must also be pursued.

How is AF diagnosed? 

It all starts with a consultation at your doctors when he asks you about symptoms and accompanying medical conditions. This is followed by further diagnostic procedures. AF is diagnosed with an electrocardiogram (ECG) or a long-term ECG. If atrial fibrillation occurs only occasionally, it is difficult to secure it with a snapshot (ECG). That is why long-term ECGs are carried out (24/48 hour Holter ECG). But there are even better ways to get a continuous ECG recording. The devices can be stuck on with a plaster, a microchip can be placed under the skin, or newly smartphones and special apps can also be used to see the atrial fibrillation.

Once the diagnosis is confirmed, all other cardiac causes of AF must be excluded. For this purpose, the cardiologist performs blood sampling, echocardiography (cardiac ultrasound) and ergometry (stress test). In addition, your cardiac specialist can arrange for a CT scan (computed tomography) or a cardiac catheterization (Coronary angiogram).

Typical ECG of normal sinus rhythm  

The heart current curve is composed of various waves and spikes that make the course of the electrical impulses in the heart visible. 

ECG with a healthy heart rhythm - the sinus rhythm. The big peaks are the QRS complexes and follow each other very regularly. The small humpe before every QRS is called the P-Wave and marks the atrial activity. The bump after the QRS is the T-Wave and demonstrates the depolarization of the ventricle. P-QRS-T is the regular order of normal sinus rhythm. Any abnormalities in this sequence, the spacing between, or the vertical aberrations are signs of a problem.

EKG-Kurve gesunder Herzrhytmus

ECG with atrial fibrillation

The big peaks (QRS) as well as the baselines are completely irregular. The small humps between the QRS complexes are chaotic and seemingless unconnected to the QRS complexes.

EKG-Kurve mit Vorhofflimmern

Increased quality of live and less medications thanks to modern treatments of AF – A Heartteam decision 

The aim of our treatments is to improve the quality of life, reduce the symptoms and to prevent the risks of untreated atrial fibrillation, heart failure and stroke. Prevention of long term consequences follows naturally. 

Our modern methods enable the stopping of unwanted medication and, above all, the withdrawal of blood thinners after surgery. In the following section you will learn more about our different therapies. We tailor our approach in accordance to your needs in a true heartteam approach.

We are specialized on stubborn and complex atrial fibrillation

The Heart & Rhythm center specializes in the examination and treatment of atrial fibrillation, particularly for persistent or complex atrial fibrillation, such as in previously treated patients after one or more catheter ablations.

Surgical ablation was introduced more than ten years ago at the University Hospital Zurich by Prof. Salzberg and Dr. van Boven. Since then, numerous atrial fibrillation patients have been successfully treated with this method. In the patient videos with Prof. Salzberg you will learn more about the results of surgical ablation with atrial fibrillation.

In modern cardiac medicine, the interdisciplinary team work of cardiologists and cardiac surgeons as a HeartTeam, plays a key role in the diagnosis and treatment of cardiac arrhythmias. This is also specified by the current guidelines of the large specialist societies. Our team is composed of Prof. Salzberg and Dr. van Boven two internationally renowned surgeons with expertise in surgical ablation. Dr. Zerm is our Electrophysiology partner who leads one of the largest cath labs in Germany and is a high volume operator for EP procedures. He comes once or twice a month to Zurich to do the catheter and hybrid ablation together with us.

Redommended course of action with atrial fibrillation

If you are affected by atrial fibrillation, we recommend that you schedule an examination with your family doctor or cardiologist. First, the causes of atrial fibrillation must be clarified and secondly, a first attempt at therapy must be made. If you are already at this stage and need further support, please feel free to register for a consultation with us.

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Common causes of atrial fibrillation

Age, hypertension, obesity, diabetes, alcohol consumption, drug abuse, hyperthyroidism, sequelae of heart failure, coronary artery disease, valvular heart disease, postoperative, trained endurance athletes, pericardial disease, asthma.

Is atrial fibrillation dangerous?

Atrial fibrillation (a form of absolute arrhythmia) is not immediately life-threatening, but if left untreated can result in the risk of heart failure and stroke.

What are the most common symptoms of atrial fibrillation?

There are patients who experience no symptoms and only get the diagnosis through a complication, such as a stroke. Others clearly perceive atrial fibrillation: unadjusted pulse, lack of cardiac output, severe shortness of breath or panic attacks.
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