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Surgery to treat arrhythmia


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Surgery to treat arrhythmia
Surgery for abnormal heart rhythms is uncommon and becoming even less common, thanks to the development of less invasive procedures such as catheter ablation. Surgery when selected is performed in patients where the risk of operation is acceptably low and the probability of success high. At times, surgery to correct an arrhythmia problem may be combined with other types of heart surgery.
During surgery, in most instances, the location of the pathways of the abnormal rhythms are identified (mapped). They are usually along the inside lining of the heart chamber walls. After they are identified, they can be cut or be damaged by heat (cautery) or by freezing (cryosurgery) so that they no longer carry the electrical impulses of the abnormal rhythm. These pathways may have been present since birth or they may have resulted from heart problems developed later in life (heart attack, for example).
Today, there is less need for surgical treatment of arrhythmia, since many of the abnormal pathways can be diagnosed during Electrophysiologic Study and eliminated (ablated) by sending small bursts of radiofrequency energy through a wire to the pathway location. This does not involve surgical incision or the other risks and complications of surgery that even in the best treatment centers can be substantial. If possible, in most cases, catheter ablation is therefore preferred.
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It seems that doctors, especially cardiologists, “can’t wait for the words to be spoken” and often use abbreviations instead. This can be very confusing at times for anyone not familiar with this “verbal shorthand.” For quick reference, here are some common abbreviations, followed by a Glossary of Words.

  • Glossary of Abbreviations

AF- (or A. Fib) Atrial Fibrillation

AICD- Automatic Implantable Cardioverter Defibrillator

BBB- Bundle Branch Block

CAD- Coronary Artery Disease

ECG- Electrocardiogram (the English equivalent of EKG, which is derived from the German “Elektrokardiogram”)

EPS- Electrophysiologic Study

MI- Myocardial Infarction (the medical term for heart attack)

MVP- Mitral Valve Prolapse

PAC- Premature Atrial Contraction

PAT- Paroxysmal Atrial Tachycardia

PCD- Pacemaker-Cardioverter-Defibrillator

PSVT- Paroxysmal Supraventricular Tachycardia

PVC- Premature Ventricular Contraction

RBBB- Right Bundle Branch Block

SSS- Sick Sinus Syndrome

SVT- Supraventricular Tachycardia

VF- Ventricular Fibrillation

VT- Ventricular Tachycardia

WPW- Wolff-Parkinson-White

  • Glossary of Words

Ablation (ay-blay’-shun)- the process of damaging (ablating) a part of the electrical system of the heart in order to correct an irregular rhythm.
ACE inhibitors- drugs in common use for high blood pressure and heart failure. Because they work by relaxing the blood vessels they are called vasodilators. They cause some conservation of potassium and magnesium and can therefore in certain patients reduce arrhythmias secondary to low potassium and magnesium.
Angina (an-jine’-ah or anj’-in-a)- chest discomfort that results from too little blood flow (oxygen) to the heart muscle.
Antiarrhythmic (anti-ay-rith’-mic)- a medication or device that controls or corrects abnormal heart rhythms (arrhythmia).
Anticoagulant- medication that prevents the blood from clotting quickly.
Arrhythmia (ay-rith’-me-a)- an abnormal or irregular beat of the heart.
Arteries- blood vessels that carry oxygen-rich blood away from the heart and to the body.

Atherosclerosis- (ath’ero-skli-rosis) (also referred to as arteriosclerosis or “hardening of the arteries”) – the process of plaque build-up (clogging) in the arteries of the body, causing reduced blood flow.

Atria (ay-tree-a)- the two upper chambers of the heart, named right atrium and left atrium.
Atrial Fibrillation (or A. Fib)- a common abnormal heart rhythm in which the electrical activity of the top of the heart is chaotic, fast and disorganized. It is seen in various types of heart disease and at times when no cause is apparent.
Atrial Flutter- an abnormal heart rhythm in which the top chambers of the heart beat at approximately 300 beats/minute. Only some of the impulses get through the middle of the heart (AV junction) to the bottom of the heart (ventricles).
Atrial Tachycardia- one of the most common “fast” abnormal heart rhythms. Often occurring in paroxysms (episodes) causing the heart to beat 150 to 250 beats per minute. This condition is also called Paroxysmal Atrial Tachycardia (PAT).
AV node (or atrioventricular node)- part of the “Junction” in the middle of the heart. Sometimes called the “second pacemaker” of the heart because it can cause an electrical impulse if the natural pacemaker (SA node) fails, it also acts to slow impulses as they travel from top to bottom heart chambers.
Block- a slowing or interruption of an electrical pathway.
Bradycardia- a slow heart rate, usually less than 60 beats per minute.

Bundle Branch Block- Often misunderstood because of the name, bundle branch blocks have nothing to do with blocked arteries that cause chest pain (angina) and heart attacks; rather, they refer only to delay or interruption in the passage of electrical impulses along the pathways (or bundles, as they are called) extending from the junction to the ventricles. There are two pathways (bundles)- one on the right and one on the left.

Bundle of His- a part of the electrical pathway that makes up the “Junction” in the middle of the heart.
Cardiac- referring to the heart.
Cardiac Arrest- occurs when the heart stops pumping blood (usually as a result of Ventricular Fibrillation).
Cardiac Catheterization- an invasive test of heart function.
Cardiac Detection Monitor (also known as an Event Recorder)- a device that can record the heart’s rhythm during symptoms. It is used to determine whether symptoms are caused by abnormal heart rhythms.
Cardiomyopathy (card’ee-oh-my-opathy)- heart muscle disease of any type.
Cardioversion- a procedure that uses electrical current to “shock” or “reset” the heart back to regular rhythm.
Congestive Heart Failure (CHF)- a sluggish or reduced circulation resulting from the heart’s poor pumping capacity.
Coronary Arteries- the arteries supplying the heart itself with blood.
Coronary Artery Disease (CAD)- plaques or blockages in the coronary arteries (which supply the heart) resulting from atherosclerosis (“hardening of the arteries”).
Diastole- the relaxation part of the heart’s normal pumping cycle, as distinguished from systole, which is the contraction phase.

Dyspnea- (diss’nee-a or dissp’nee-a)- the medical term for breathlessness.
Dysrhythmia- another medical term for arrhythmia, or abnormal heart rhythm
Ectopy- any abnormal beats of the heart (also called “ectopic beats”).
Echocardiogram- a noninvasive ultrasound test of the heart.
Ejection Fraction- the percentage of blood pumped out of the heart (left ventricle) with each beat.
Electocardiogram- a noninvasive test measuring the heart’s electrical activity.

Electrophysiologic Study (EPS)- a diagnostic test using flexible thin wires passed from an arm or leg vein to inside the heart for the purpose of studying the heart’s electrical system from within.

Exercise Stress Test (also referred to as a treadmill stress test or bicycle stress test, depending on the type of exercise)- a test to determine the heart’s response to exercise work.
Extrasystole- refers to extra beats or premature beats.
Heart Block- a delay or interruption in the passage of electrical impulses through the junction causing slow heart rates. Heart block can be mild requiring no treatment or severe, at times, requiring a pacemaker.
Holter Monitor- a portable device for recording the heart’s rhythm continuously.
Ischema (iss-keem’ee-a)- the name for the imbalance that is produced when too little blood flow goes to any part of the body.
Mitral Valve Prolapse- a common abnormality of the mitral valve, affecting approximately 4% of the population. It is believed to be a cause of arrhythmias, although it is often difficult to prove. In patients with severe degrees of prolapse or complications such as valve leakage (regurgitation), infection or heart failure, more serious arrhythmia problems have also been reported.
Myocardial Infarction- the medical term for a “heart attack” (sometimes called a “coronary”). It means that a scar will replace heart muscle in the area of damage.
Myocardium (my-oh-card’ee-um)- heart (cardiac) muscle
Nitroglycerin- a common medication for treating chest pain from the heart (angina). The rapid way this drug works to relax blood vessels can result in low blood pressure, causing lightheadedness, headache, dizziness, flushing and palpitations as the heart rate speeds up in response to it. Occasionally it can cause a patient to faint, especially if taken when the patient is standing.

Pacemaker- a small, battery-powered device that is surgically placed under the skin of the chest or abdominal wall. It is connected to flexible wires placed in the heart that provide an electrical impulse, causing the heart to beat when the patient’s own heart rate is too slow.

Palpitations- the symptom of being aware that the heart is beating (most often, forcefully, irregularly, rapidly or slowly).
Premature Atrial Contraction (PAC)- an early abnormal beat from the top (atrium) of the heart.
Premature Ventricular Contraction (PVC)- an early abnormal beat from the bottom (ventricle) of the heart.
Proarrhythmia- causing new abnormal heart rhythms or making those already present worse (sometimes called “arrhythmia aggravation”).
Pulmonary- pertaining to the lungs
Risk Factors- aspects of an individual’s make-up or behavior that can increase the likelihood of having heart or vascular disease.
Sick Sinus Syndrome- symptoms that arise from an abnormally functioning sinus or SA node (natural pacemaker) often involving rapid as well as slow heart rhythms, at times treated with a pacemaker.
Sinus Node- (or SA Node)- the heart’s natural pacemaker that produces an electrical impulse, starting the heart muscle contraction.
Sinus Tachycardia- a normal (regular) rapid heart beat faster than 100 beats per minute.
Stroke (also called cerebrovascular accident or CVA)- refers to damage that leads to loss of brain tissue. Most strokes are caused by blocked arteries leading to the brain (just as heart attacks are caused by blocked arteries leading to the heart).
Sudden Death- death that occurs without warning (sometimes referred to as “unexpected”) as opposed to death that is culmination of a long and serious illness.
Supraventricular Arrhythmia (also called Atrial Arrhythmia)- abnormal heart rhythms that occur in the upper chambers of the heart, including atrial tachycardia (PAT), atrial flutter or fibrillation (A. Fib or Atrial Fib)
Syncope (sin’cope-ee)- the medical term for fainting or “black-out.”

Tachycardia- any fast heart rate, but generally above 100 beats per minute (bpm).

Vascular- referring to blood vessels.
Veins- blood vessels that carry blood back to the heart.
Ventricles- the two lower chambers of the heart. The left ventricle or LV is the major pumping chamber of the heart.
Ventricular Fibrillation (VF)- a very rapid and chaotic electrical activity of the bottom of the heart (ventricles) that results in a total failure of the heart to pump blood. This is a life-threatening arrhythmia.
Ventricular Tachycardia (VT or V-Tach)- an important abnormal heart rhythm that causes the heart to beat at 100 or more beats/minute. Although it may occur without a person’s awareness, it can cause important problems such as lightheadedness, fainting or collapse, and usually will require treatment.
Wolff-Parkinson-White Syndrome- an abnormality in which electrical impulses can get from the top to the bottom of the heart by way of an electrical short cut (Bundle of His). It is associated with irregular fast rhythms that may cause various symptoms, sometimes needing treatment.

A personal message

  • This guide has been a success if you:

    • Have gained some insight into the causes and types of arrhythmias.

    • Have become better informed about approaches and tests your doctor may use to diagnose your palpitations, skipped beats or heart fluttering.

    • Have incorporated some of the information from this guide into your daily activities.

    • Have learned some of the principles behind the treatments being used today in treating arrhythmias.

    • Now better understand your doctor’s recommendations.

It is our hope that the benefits provided by the knowledge you have acquired will enhance your physician’s efforts - and your own – in keeping you healthy and fit. Arrhythmias are a common problem, and today more than ever it is clear that they can be and are being managed well. They need not cause anxiety because of a lack of understanding. There is every reason to strive for control of bothersome symptoms, better use of medications and prevention of serious complications.

Together with your doctor, we hope that you stay well and that the knowledge you have gained will bring you reassurance and confidence. We wish you every success, and we trust that the beneficial results you experience will continue to motivate and inspire you.

Thank you,

Robert DiBianco, M.D.

Maggie Shand, R.N.

About the authors
Robert Dibianco, M.D.
Robert Dibianco, M.D., is the Director of Cardiology Research, the Risk Factor Reduction Center and Heart Failure Clinic at the Washington Adventist Hospital in Takoma Park, Maryland, where he is a practicing cardiologist and member of the hospital-based cardiology group, Cardiovascular Consultants, P.A. Dr. DiBianco is also a cardiology consultant at the Shady Grove Adventist Hospital in Rockville, Maryland, and an Associate Clinical Professor of Medicine at Georgetown University in Washington, D.C.
Dr. DiBianco graduated from Brooklyn College of the City University of New York and was awarded his M.D. degree at the State University of New York at Buffalo, School of Medicine. He completed his cardiology fellowship at Georgetown University in 1977.
In addition to his involvement in clinical cardiology and research, Dr. DiBianco reviews articles for publication in cardiology journals and has authored over 100 articles on heart disease, many dealing with new drug treatments for heart problems. His work has been published internationally as well as in leading journals in this country. He is a Fellow of the American College of Physicians, the American College of Cardiology and the Council on Clinical Cardiology of the American Heart Association.

Maggie Shand, R.N.

Maggie Shand, R.N., is a graduate of Castleton State College in Castelton, Vermont, where she received her Nursing degree in 1971. She earned her advanced critical care certificate through the Advanced Critical Care Program at Providence Hospital in Holyoke, Massachusetts, and Tufts University, Boston, Massachusetts.

Ms. Shand has extensive experience as a critical care nurse. She was the Clinical Research Coordinator at the Institute for Clinical Research in Washington, D.C., where she coordinated research in new treatments for patients with cardiac arrhythmias. These efforts culminated in several original contributions to the medical literature.
Ms. Shand is presently working in the pharmaceutical industry and continues to share her knowledge and enthusiasm for continuing medical education with physicians and the medical community.

First, our thanks go to our patients, who have given us the questions and defined the areas needing more explanation, and for whom this booklet is written. We hope this effort meets your needs.
This booklet would not have been possible without the contributions of our dedicated colleagues at the Washington Adventist Hospital and Shady Grove Adventist Hospital, who have taught us many lessons about the treatment of arrhythmias. To them we extend our deepest gratitude. Among the many we would like to thank are (alphabetically):
David M. Brill, MD

Adele M. Brooks, RN, MSN

Ingrid Chambers, RN, BSHC

James L. Cockrell, Jr., MD

Rebecca B. Costello, MS

Dennis J. Donohue, MD

Judith A. Freitag, RN, MSN, CCRN

Veronica C. Gamboa, MSN, CRNP

Ann James, RN

Doreen M. Kezer, RN, MSN

Louis J. Larca, MD

Keith M. Lindgren, MD

Diane Litten, RN

Loretta Norton, RN

James A. Ronan, Jr., MD

Kay Sandow, BS, RD

Sheryl L. Sturm, RN

Helga Westphal-Noguiera, RN, MS

Special thanks to Mary Myers, RN, BSN for her assistance in the preparation of this booklet. Mary is an Advanced Cardiac Life Support Instructor affiliated with Howard University, Washington, DC. She is presently employed by a private cardiology practice in Bethesda, Maryland.

Also many thanks to Jeff Miller, medical illustrator and Mike Russell, copy editor.

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