What triggers atrial fibrillation and what helps

Ready for the next procedure Heler Romero, a 70-year-old woman with atrial fibrillation. The cardiologist is still sitting in a control room, blue cassock, surgical uniform, surrounded by computer screens showing curves and numbers. You talk about diseases: stroke, heart failure, dementia, depression. “These are the most serious consequences that can be triggered by atrial fibrillation,” says senior doctor at Pankow Caritas Clinic Maria Heimsuchung. She will soon be standing next to the operating table, which can be seen from here through a large pane of glass. She will heal the woman’s heart, with catheter and cold – with an electrophysiological exam, EPU for short.

Atrial fibrillation is a widespread disease. The risk for a European of contracting it at some point in their life is high. That’s about 27 percent. “This is the risk of life,” says Romero. “Statistically, it affects one in three people.” With increasing age, the likelihood of contracting this more common type of cardiac arrhythmia increases.

Those affected often feel weak, impulsive, quickly exhausted, out of breath easily, and dizziness bothering them. Others feel restless, notice that something is wrong with their heartbeat, that it is too high, that it increases for no apparent reason. There may also be seizures, confusion, fainting. A long-term ECG brings clarity.

“However, a group of patients who are not quite small do not notice anything and have no symptoms. One third of all cases are presumed, “says Jürgen Meyhöfer, chief of cardiology, who joined his team in the control room.” However, we generally consider atrial fibrillation to be a very serious disease because it reduces life expectancy and the quality of life “.

It can cause serious damage. Mainly from stroke. According to the German Heart Foundation, at least 20% of these brain infarcts are due to atrial fibrillation. “Courses change in the heart,” Meyhöfer describes the problem. The atrium no longer contracts like in a healthy person. “The blood flows more slowly, clots form, which can enter the brain and block the vessels there.”

Atrial fibrillation: do genes play a role?

The rhythm is often disrupted because the veins emit electrical impulses that really shouldn’t: the so-called pulmonary veins. They carry oxygen-rich blood from the lungs to the heart. The first port of call is the left atrium. If the cells of the electrically active heart are lost there, they send out the fatal signals.

This is especially true for younger patients with no previous illnesses. “As we age, various diseases often appear,” says Meyhöfer. High blood pressure, diabetes, or heart failure increase the risk of atrial fibrillation. External influences such as smoking or excessive alcohol consumption can play a role, intensify or trigger the effect.

A genetic predisposition can also promote cardiac arrhythmia. This is indicated, among other things, by a US analysis, the results of which were published in 2004. Scientists followed 2,243 people for 20 years, all descendants of participants in what is known as the study of the heart of Framingam, a long-term study. They were twice as likely to have atrial fibrillation than usual if at least one parent had had the condition.

Effective treatment is possible, initially with drugs and, if these no longer work, with UPE. In the same procedure on the 70-year-old patient at Maria Heimsuchung, the pulmonary veins are blocked, literally, in four places that are electrically active when they shouldn’t be. “They will be isolated,” says Romero. The senior doctor will insert a catheter into the vein through the groin. Attached to it is a collapsed balloon that can be opened and filled with coolant. The freezing cold turns off the offending cell. If everything goes well.

Heler Romero moves the mouse of a computer back and forth, on the screen appears in front of him the 3D image of a heart belonging to the patient who was previously on the operating table, 50 years old, relatively young for the clinical picture. The heart shines with yellow, green, purple, red. Yellow represents electrical activity. They measured it with a probe, also inserted with a catheter.

Romero makes the picture, a yellow wave spreads like a small tsunami. “We had to stop the wave here,” says the doctor and uses the mouse to draw a circle around the point that should now be red. Red means: no electrical impulse. Electrophysiologists also achieve the same effect in heat as in cold. If it doesn’t work the first time, try this. In 80 percent of cases, however, the first attempt is successful.

“It’s now a very common procedure,” says chief physician Meyhöfer. At the Visitation of Mary, they just started doing it. They converted an area of ​​the hospital for electrophysiology, installing an X-ray machine that rotates around the patient to view her heart from different positions. Recording is performed continuously.

Romero and his team wore lead vests, including lead aprons, to protect themselves from radiation. The patient has now arrived and has been wired for ECG. He will fall asleep immediately after the effect of the anesthetic. The infusion is already in progress.

They treat four patients a week here with electrophysiology. “We want to double the number in the future,” says Meyhöfer. Although some Berlin hospitals now offer this type of therapy, it is needed and the demand is high. And she could go up. Due to the long Covid.

In a large-scale study, scientists accompanied more than 150,000 former U.S. Army members after surviving corona infection. They compared health data collected with people who had not been infected with Sars-CoV-2. Cases of atrial fibrillation have drastically increased in patients with Long Covid, by approximately 70-85%.

But even without the late effects of the pandemic, there has been a clear trend for 50 years. In the 1970s, it was mainly heart attacks that cardiologists had to treat in this country. But even then, prominent US cardiologist Eugene Braunwald warned that atrial fibrillation would become the main problem. He should be right. “The frequency,” says Heler Romero, “has increased significantly.”

One explanation lies in demographic change. In 1970, the average life expectancy in Germany was 67.2 years for men and 73.4 years for women, while in 2020 the statistical average had risen to 78.9 and 83.6 years. From the age of 65, the likelihood of developing atrial fibrillation increases significantly, with all possible consequences. Even those that a doctor would not initially associate with cardiovascular disease. For example: dementia.

Atrial fibrillation can trigger dementia

“Dementia in connection with atrial fibrillation is now the subject of more extensive research,” says Romero. Microembolias could be a trigger: blood clots that are too small to trigger a stroke but block the smaller vessels in the brain and thus lead to memory impairment. “Clots form in the left atrium,” says the senior doctor. And that’s where he went with a catheter.

A large screen above the patient shows the X-ray film, showing Romero placing a probe over the heart that measures electrical impulses and sends the data to the control room. A computer puts them together in a 3D heart, yellow, green, purple, red. A nurse monitors the procedure, checks the curves, reads the measured values ​​and transmits the information to Romero via a headset. “My co-pilot,” says the doctor.

Meanwhile, he made a tiny hole in the heart septum and pushed the balloon with a catheter, from the right to the left atrium, with pinpoint accuracy to the target. Now she opens it, the balloon, introduces the coolant, the temperature drops rapidly. This can be seen in one corner of the screen: minus 40 degrees, minus 45, minus 55. A clock counts the seconds up to 180. The surgery is finished at this point of the heart for the time being.

“In 20 minutes it will be checked again whether the surgery was successful,” says Meyhöfer. “If so, we assume that the problem has been fixed permanently.” An electrophysiological examination takes one to two hours. A long period in which Romero and his team must remain very focused. In which they also perform heavy physical work. Your X-ray protective equipment weighs twelve kilograms. Now they take off their lead armor, take the jacket and apron to a wardrobe.

The patient is taken out of the treatment room. She is conscious. She didn’t notice anything about the operation. But she can feel the result. A pleasant sensation with every heartbeat.

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