正常心脏是一个肌肉泵，可以将含氧多的血液自左心室泵入主动脉，再经全身的动脉系统至全身，满足身体对血液所携带的氧及营养成分的需求。同时静脉系统自全身将已经消耗了氧和营养物质，而携带了组织代谢后生成的二氧化碳及废物的静脉血进入右房，右室，然后泵入肺动脉及肺，在那里血液可以获得充分的氧气，以后再经过肺静脉、左心房回到左心室。 心脏及大血管的主要结构是右心房、右心室、肺动脉、肺静脉、左心房、右心室、主动脉，心房与心室之间的房室瓣，右侧称三尖瓣，左侧称二尖瓣。主动脉与左心室之间，肺动脉与右室之间的瓣均为三个瓣叶，称半月瓣，或称主动脉瓣，肺动脉瓣。左右心房之间有薄的肌性隔，左右心室之间有厚的肌性隔，分别称房间隔及室间隔。 　　出生时就有心脏结构的异常称为先天性心脏病，如左右心房之间的隔有缺损称房间隔缺损，右心室与左心室之间的隔有缺损称室间隔缺损。各处瓣膜均可有狭窄或闭锁，如肺动脉瓣狭窄，主动脉瓣狭窄。心室亦可一侧发育不良或缺如，如左心发育不良、单心室。心脏各腔及动、静脉之间连接亦可以异常，如完全性大动脉转位，完全性或部分性肺静脉畸形引流。也可能多种畸形同时存在，如法乐氏四联症等。 　　先天性心脏病在正常人群中发病率大约1％(0．6％—1．2％)，这是一个不小的数字，按我国10亿人口计算，大约有1千万人患先天性心脏病。先天性心脏病不属于遗传性疾病，但有些家庭有多个子女患不同种的先天性心脏病，或多个堂兄弟姐妹患病。一般来讲一级亲属中有一个患先天性心脏病，则其他人患病的机率上升3倍，两个成员患病则机率上升为9％,如果三个成员患病，则其他成员患先天性心脏病的可能性上升至50％。 　　一些染色体异常的疾病常伴有先天性心脏病，如大家多见的先天愚型(唐恩氏综合征，即21三体综合征)约50％患先天性心脏病，其中心内膜垫缺损及室间隔缺损分别占32％及29％，其次为房间隔缺损占11％，法乐氏四联症占7．9％，动脉导管末闭占6．7％。18三体综合征约90％患先天性心脏病，主要为室缺、动脉导管末闭等。近来由于分子生物学的发展，发现越来越多的先天性心脏病有共同基因的缺失，如CATCH综合征，为第22对染色体之一短臂11位点缺失，可合并法乐氏四联症，室间隔缺损，主动脉干，主动脉弓中断等。单纯房间隔缺损大部分呈多基因规律，先症者同胞和子女的再显风险率为2．5％- 4.6％。少数家族中可见连续数代均有本病患者的情况。单纯室间隔缺损呈多基因遗传，先症者同胞的再患风险为 3．3％-4．4％，子女为3．7%—4％。先症者同胞中单纯室间隔缺损和室间隔缺损合并其他心脏畸形的发生率比一般人群高10—20倍，一致性病损为30％—60％。动脉导管未闭呈多基因规律，子女再患风险率为3．4％—4．3％，同胞为2.6％—3．5％。一致性病损占50％。法乐氏四联症为多基因遗传，患者子女的再显风险率为3.0％—4．2％，同胞为2.5％—3．0％。一致性病损小于50％。不一致的病损以室缺、肺动脉口狭窄和大动脉转位最常见。

心脏大血管外科的成就、动态和发展方向

      我国心血管外科萌芽于本世纪四十年代后期，至今已有半个世纪的历史。直至七十年代中期以后才得到迅速发展，部分病种的外科治疗水平达到国际先进水平。 一、先天性心脏病 在发达国家普及程度较高，大部分复杂和重症病儿可在新生儿期或婴儿期获手术治疗。我国在多数大中城市均已开展，一般先心病可在学龄前手术，但复杂先心病和婴幼儿重症心脏病外科治疗的普及尚有一定距离。以沈阳军区总医院心外科为代表的复杂先心病外科治疗，法乐四联症根治术从数量和质量上均达国际先进水平。其他如"单心室"、"完全性大动脉错位"、"三尖瓣闭锁"等病种的外科治疗均收到良好效果，受到国内外专家的重视。第四军医大学西京医院心外科在国内首先研制成功的右心带瓣管疲道，心尖--主动脉外通道等，对推动我国复杂先心病外科治疗的发展起到了积极作用。 二、风湿性心脏瓣膜病 国际上各类人工心脏瓣膜经过30余年发展，已在世界各国广泛应用并取得良好效果。上海第二军医大学蔡用之教授1965年6月将国产笼球瓣应用于临床并获成活27年的效果。目前国产侧倾碟瓣质量不断提高，生物瓣研制有新的突破，双叶机械瓣生产亦为期不远，换瓣手术死亡率约5%左右，各种人工瓣膜都存有自身的优缺点，近年对自身心脏瓣膜采用综合成形技术，是慢性心脏膜病患者的希望。第四军医大学西京医院研制的可塑性二尖瓣成形环及其测试系统，已在国内不少医院得到推广应用。同种组织瓣的应用近年发展较快，特别是观察到同种瓣在植入人体后可能保持活性而且耐久性优于其他生物瓣，更加受到人们重视。 三、冠心病外科 冠心病外科在欧美国家已非常普及，手术方法不断完善，手术适应症不断扩大，复合手术从数量和疗效上都有较大提高。目前我国冠心病外科尚限于部分设备条件较好的医院，数量和我国发病人数亦相差极远。近十多年来介入性治疗（球囊扩张，激光成形等）迅速发展，部分冠状动脉架桥手术为之取代，国内已开展多枝冠脉架桥手术、冠脉架桥同时行球囊扩张或激光成形手术，冠脉架桥同时瓣膜置换术。血管桥来源除大隐静脉外，乳房内动脉、胃网膜动脉亦被应用。急性心肌梗塞的"架桥"手术可改善心功能，降低医院内死亡率，目前国内开展不多。关于心肌梗塞合并症，如室壁瘤，乳头肌功能不全，室间隔穿孔等，手术治疗取得了好的效果。 冠状动脉介入性治疗近十年多来发展迅速，经皮穿刺冠状动腔内成形术（PTCA）、溶栓术、冠状动脉腔内激光成形术等，目前多采用综合性治疗措施，或溶栓加PTCA或介入性治疗后架桥，取得了更好疗效。

体外循环的基本概念

　　 体外循环是指用一种特殊装置暂时代替人的心脏和肺脏工作，进行血液循环及气体交换的技术。这一装置分称为人工心和人工肺，亦统称人工心肺、人工心肺装置或体外循环装置。 　　

         体外循环时，静脉血经上、下腔静脉引入人工肺进行氧合并排出二氧化碳，氧合后的血液又经人工心保持一定压力泵入体内动脉系统，从而既保证了手术时安静，清晰的手术野，又保证了心脏以外其他重要脏器的供血，是心脏大血管外科发展的重要保证措施，1953年Gibbon首例应用于临床。 　　

        体外循环基本装置：包括血泵、氧合器、变温器、贮血室和滤过器五部分（图6-20）。 图5-20 体外循环装置示意图 　　

        血泵，即人工心，是代替心脏排出血液，供应全身血循环的装置。根据排血方式分为无搏动泵和搏动泵两种。目前仍以无搏动泵应用较广泛，射出血液为平流，以滚压式泵为主，靠调节泵头转动挤压泵管排出血液。搏动泵排出血液为搏动性可分为与心脏同步和非同步两种。 　　

        氧合器：即人工肺。代替肺脏使静脉血氧合并排出二氧化碳。目前使用的有三种类型：①血膜式，血液散布在平面上形成血液薄膜，与氧气接触并进行气体交换，转碟式为其代表，可重复使用，但费时费力，目前国内已极少应用；②鼓泡式，血液被氧气（或氧与二氧合碳混合气）吹散过程中进行气体交换，血液中形成的气泡用硅类除泡剂消除，根据形态有筒式和袋式，是目前应用最广的，第四军医大学西京医院研制并生产的西京-87型氧合器，其主要部件性能达国际水平，为国内各医院欢迎；③膜式，用高分子渗透膜制成，血液和气体通过半透膜进行气体交换，血、气互相不直接接触，血液有形成分破坏少，其外形有平膜式和中空纤维式。 　　

       变温器：是调节体外循环中血液温度的装置，可作单独部件存在，但多与氧合器组成一体。变温器的水温与血温差应小于10～15℃，水温最高不得超过42℃。 　　

       贮血室：是一容器，内含滤过网和去泡装置，用作贮存预充液，心内回血等。 　　滤过器：滤过体外循环过程中可能产生的气泡、血小板凝块、纤维素，脂肪粒，硅油栓以及病人体内脱落的微小组织块等，不同部位应用滤过器的网眼各异。 　　

       体外循环心内直视手术，一般采用纵劈胸骨入路，纵行切开心包显露心脏，从心内注射肝素2～3mg/kg，经检测血液不凝后，顺序插升主动脉灌注管和下腔静脉，上腔静脉引流管，分别与已预充好的人工心肺机相应管道连接，即可开始外循环转流。体外循环预充，现在常规采用血液稀释法，预充液应考虑渗透压、电解质含量和血液稀释度三方面。血液稀释程度，各家掌握不一，血红蛋白5～10g%之间，血球压积10～30%不等。预充用的晶体液通常有乳酸林格氏液，生理盐水，50%葡萄糖液等，胶体液可选用ACD血、血浆，白蛋白等，还需加入钾、镁、碳酸氢钠以及抗菌素等。 　　

       体外循环方法，根据手术需要，可分为①常温体外循环，用于心内操作简单，时间短者。要求体外循环氧合性能好，能满足高流量灌注需要；②浅低温体外循环：采用体外循环血流降温，心内操作期间鼻咽温维持在28℃左右。心内操作即将结束时开始血液复温，鼻咽温至35～36℃时停止复温；③深低温微流量体外循环：多在心功能差，心内畸形复杂，侧技循环丰富的患者应用。鼻咽温降至20℃左右，心内操作关键步骤可将灌注流量降低，最低可达5～10ml/kg/分。既保持手术野清晰又防止空气进入体循环发生气栓。微量灌注实际上对机体是停止循环，要尽量缩短时间；④深低温停循环，主要用于婴幼儿心内直视手术和成人主动脉瘤手术。术中将体温降至20℃以下，停止血液循环，可提供良好的手术野，但需具备良好条件和熟练的灌注技术。 　　

       心内手术期间，为了便于精细操作，获得无血手术野，必须将升主动脉钳闭，阻断冠状动脉血液循环，这就使心肌处于缺血缺氧状态。早期手术死亡率高的主要原因之一就是心肌缺血坏死。为此，多年来许多学者致力于心肌保护的研究，以期在获得无血手术野的同时，又能使心肌得到妥善保护，术后恢复良好功能，目前应用最广的是全身中度低温，心脏局部深低温，主动脉内灌注冷停跳液法，全身温度维持在28℃左右。心肌温度维持在15～20℃，其方法是升主动脉阻闭后，由主动脉根部灌注配好的4℃冷停跳液，使心肌迅速停止活动，减少能量消耗，并每20分钟灌注一次，同时心包内以冰泥包裹，或4℃生理盐水循环灌注。因心内膜温度偏高，必要时行心腔内降温。 　　

        心内操作结束后，心脏复苏，停止体外循环，待循环稳定后，拔除心内插管，用鱼精蛋白中和肝素。

海军总医院用语音控制智能机器人技术——

成功为一位患者施行冠状动脉搭桥手术

        本网消息：昨天，海军总医院利用世界上最先进的语音控制智能外科机器人技术，成功地为一位59岁的冠心病患者施行了冠状动脉的搭桥手术。手术在医用机器人临床应用专家汤姆博士和田增民教授指导下，由心脏外科主任张载高教授主持，采用微创伤心脏不停跳技术，在胸腔镜帮助下，由机器人操作完成，历经2小时，手术进展十分顺利。现在病人安全返回病房，已清醒，呼吸循环平稳。此例心脏搭桥手术在国内率先开展，标志着机器人技术在中国正式用于心脏外科领域。 北京时间： 2000年11月16日

伊索机器人行肝胆外科高难度的微创手术

      我国著名肝胆外科专家黄志强教授（中国工程学院院士）率先在我国301医院开创了应用医用外科机器人辅助下，成功的进行了肝胆外科高难度的微创手术，使我国微创外科技术提高到一个新的水平，引起世界医学界的关注。黄志强教授认为：伊索机器人这种设备更适合于精细的，时间长的手术，光源更为稳定，手术者可作更准确的操作，不容易疲劳，这是有好处的。随着医疗技术和人们认识的水平提高，微创手术将有更广阔的前景。
     周宁新主任（301医院肝胆外科主任）认为：伊索机器人视野调节的优点非常好，完全按照医生的指令，模拟医生的手势，动作非常准确和安全，排除了误差。最好的功能是具有记忆的功能。按照自己的意思控制镜头的视野，这为医生提供了最大的限度的方便，伊索机器人接管了原来医生的助手的工作，排除了人为的干扰。主刀生有了这样一位稳定准确的助手，手术工作将更为精细，简捷。在新世纪微创外科迅速发展的今天，外科技术的微型化与微创化，即各种类型的腔镜外科技术给现代外科学发展所带来的巨大变革。如今传统的外科手术模式正在向更准确、精细、微创化和多信息导向的智能化转变，医用外科机器人正是在这种新世纪良机中孕育而生的。 
      解放军总医院腔镱中心在黄志强院士的倡导下，近日为一例肝右叶囊肿和一例胰腺体尾部癌患者进行了腹腔镱下肝囊肿开窗术和胰体尾部癌并肝转移灶射频治疗术，与以往的腹腔镱手术不同的是：手术台上只有手术者和一名助手，而原来专门控制光源的另一名助手，却被仅如同人类单臂的声控机器人替代。随着手术者声声的指令，机械手臂顺人准确地将腔镱镱头全方位移动，并可按术者指令记忆定位，使手术视野图像清晰、稳定、手术者对此十分满意，尤其为长时间复杂精细的外科手术提供了保证。
据悉，机器人辅助的腔镱下肝脏与胰腺手术在国内尚属首例。由美国摩星有限公司研制的伊索内窥镱定位器1993年由FDA批准的第一台外科手术机器人，目前已经为第四代产品，其只占了三臂宙斯外科机器人的1╱3，左右两条机器人臂可重复手术者的双臂构成，完成更复杂精细的外科手术。伊索平台在全球已用于130，000例以上的微创手术中，涉及超体重学、心脏外科、普通外科、妇科、神经外科、矫型外科、胸外科、泌尿外科等。

The Adult with Congenital Heart Disease:Frequently Asked Questions

（成人先天性心脏病常问的问题） 

Kevin Mulhern, M.D.

Division of Cardiovascular Diseases University of Iowa Hospitals and Clinics Creation Date: March 2000 Last Revision Date: March 2000 Peer Review Status: Internally Peer Reviewed

What exactly is congenital heart disease? Isn't it a condition you are born with?

That is correct. The word congenital means born with, and this is different than the more common heart diseases that people acquire sometime after birth either from infection, coronary artery disease, trauma, and other problems. Does congenital heart disease last a lifetime? Yes, it does. The congenital heart problem is always there although it can often be made much better as a result of surgery or treatment with a catheter based therapy. Many children born with heart problems live to be active, normally functioning adults, and there are some heart conditions that people are born with that are so well tolerated that sometimes they are not even discovered until the person is a young adult or even elderly. What are the treatment options for congenital heart disease for a child and an adult? That depends on the problem. Sometimes the treatment is nothing. Nothing needs to be done. Sometimes the treatment is surgery. Sometimes this requires more than one operation. Newer treatments have become available in recent years and can be done without surgery. For example, some holes in the heart can be closed with special devices placed under local anesthesia using x-rays to guide the placement. For example, placing a coil to plug the vessel without doing surgery can close some abnormal blood vessels. Is there a cause of congenital heart disease? There is no single cause of congenital heart disease. Some conditions are inherited; others result from a combination of factors probably including inheritance and environment. The Rubella epidemic during the 1960's caused a large number of congenital heart problems. Research is trying to learn the causes and work to prevent the problems. Is it possible for patients born with heart disease who watch their diet and exercise not to develop heart disease that has to be controlled by medication or surgery? A healthy lifestyle is important for everyone. People with congenital heart disease will not prevent problems with their congenital heart disease simply by dieting and exercising. It will preserve their overall health. This is important because people with congenital heart problems are also prone to the same problems as people born without heart defects, such as hypertension and coronary artery disease. You mentioned children born of mothers who had rubella during pregnancy has me wondering what happens to that child if it is female when she herself becomes pregnant and already has stress on her heart from her disease? Pregnancy and congenital heart disease is an important topic. How well a woman and the fetus do during pregnancy depends upon the type of heart problem. Any woman who has a heart problem and is planning pregnancy or has become pregnant should see her doctor. Many women with congenital heart disease are able to become pregnant and carry the pregnancy to term, delivering normal babies. For other women, there are risks involved with pregnancy. I had 5 bypass surgery. How long is it good for? Bypass surgery is done for coronary artery disease, which is not a congenital heart problem. Internal mammary artery grafts tend to stay open for a long time. More than 90 percent are still open 10 years after surgery. Vein grafts from the legs tend to close down as the years pass. It is impossible to predict how long they will stay open. A healthy lifestyle helps keep them open. You should not smoke, and should eat a low fat diet, exercise regularly, and take aspirin if your doctor recommends it. Can pregnancy be life threatening to a woman with congenital heart disease? Yes, it can. There are some conditions that historically carry a higher risk of complications and even death during pregnancy or after delivery. Again, it is very important for any woman with a heart problem to speak to her doctor before pregnancy or when she first learns that she is pregnant. What happens if congenital heart disease goes untreated? Some congenital heart defects cause no problems without treatment. Examples are very small holes in the muscles that divide the two pumping chambers. Other heart defects can cause high pressure in the lung, which cannot be reversed with medication or surgery. Other problems can cause weakening of the pump function of the heart, such as leaky valves. If the congenital heart disease is severe enough, does a patient graduate to the heart failure clinic and possible heart transplant list Some severe congenital heart defects can be repaired with one or more operations. Others cannot. Heart transplantation or heart/lung transplantation are sometimes needed even after a successful repair of the heart performed during childhood. What role does high blood pressure play in congenital heart disease? High blood pressure does not cause congenital heart disease. People are born with congenital heart disease. High blood pressure carries the same risks in these patients that it does in other patients. It increases the thickness of the left ventricle and can cause reduced function. It increases the risk of heart attack and stroke. What has happened to the lungs in congenital heart disease that requires a heart/lung transplant? Some conditions cause high blood pressure in the lungs and permanent changes in the walls of the lung blood vessels. These changes would not improve after heart transplantation. The transplanted heart would fail. The lungs must be transplanted with the heart. Can a child with this disease expect to live a normal healthy life as an adult? That depends on the particular type of heart defect and how fully it can be repaired. It may also depend on how early the problem is repaired. Surgery has been performed on children with congenital heart problems since the 1940's and is improving all the time. Despite all that modern medicine has to offer, many problems cannot be fully corrected. Some adults with congenital heart problems are limited with their heart problem. Can you go into adulthood without realizing that you have a congenital heart disease? Yes. Many problems are discovered in old age or never discovered at all. It is not uncommon for some atrial septal defects, which are holes between the two receiving chambers of the heart, to be detected in young adults. This does not necessarily cause a problem for these people. Sometimes the problem is not easily repaired. Often it can be repaired once discovered. I am 31 years old and have mitral heart value prolapse. I am so tired all the time. Could this be because of the prolapse? How do you know when it is right to request another echocardiogram? Am I in any danger? Mitral valve prolapse is not a congenital heart problem. It is a heritable heart problem. It can cause problems with the heart rhythm. It can also lead to leaky heart valves. This can cause problems with the heart. Many symptoms attributed to mitral valve prolapse in the past have been found to be due to something else. There is no absolute recommendation as to how often to do echocardiograms. This should be decided by you and your doctor based upon your history and physical examination. Can a person who has a heart murmur feel any symptoms? The heart murmur itself is simply a sound that blood flow makes in the heart. Symptoms would depend on the cause of the murmur. Some murmurs are normal innocent murmurs in normal hearts. Others indicate a narrowed valve, a leaky valve or a hole in the heart. I have a child that went thru the Fontan procedure (3yrs ago). He is 7 now. He is doing great. As far as long term problems, are there any resources online where I can investigate? Do adults have success with a Fontan? I am pleased to learn that your child is doing well. The Fontan procedure has been a great operation for children with some complex heart problems. I am unaware of online resources, but I am certain they exist. There are a number of adults who are now living with a Fontan circulation. We are learning more about long-term function and care all the time. The short answer to your question is that there are adults living successfully after the Fontan procedure and living well. If there are no further questions I will ask Dr. Mulhern for a closing statement... Congenital heart disease is not as common as high blood pressure, coronary artery disease, or some of the other problems discussed today. It does affect 1 percent of all newborns, sometimes in a very mild form. Many of these children are surviving to adulthood and living satisfying, productive lives. Regular follow up is necessary for most adults born with heart problems.

Atrial Fibrillation: Frequently Asked Questions

（房颤患者常问的问题）

Brian Olshansky, M.D.,

Professor of Internal Medicine University of Iowa Hospitals and Clinics Creation Date: May 2001 Last Revision Date: May 2001 Peer Review Status: Internally Peer Reviewed

Atrial fibrillation is the most common arrhythmia requiring treatment in the United States. Approximately 2.2 million individuals in this country have atrial fibrillation. What causes atrial fibrillation? Atrial fibrillation is associated with many cardiac conditions, including cardiomyopathy, coronary artery disease, valvular heart disease, ventricular hypertrophy and other associated conditions. Atrial fibrillation has been associated with hyperthyroidism, acute alcohol intoxication, changes in the autonomic nervous system and is common after cardiac surgery. The most common condition associated with atrial fibrillation is high blood pressure. Some people have atrial fibrillation with no obvious source or associated condition. This is more frequent in younger people and it is called "lone" atrial fibrillation. It is likely that people who have this form of atrial fibrillation have had some inflammatory process or trauma to the atrium. Some people have a focal source that originates from the pulmonary veins. Is atrial fibrillation associated with a heart attack or a stroke? Atrial fibrillation is a very rapid irregular rhythm in the top two chambers of the heart. If one were to look at the heart as it were fibrillating, it would look like a bowl of Jell-O quivering. A heart attack is when an artery supplying blood to the heart blocks off causing damage to the heart muscle. A stroke occurs when an area of the brain does not get enough blood supply, in some cases due to a blocked artery supplying blood to the brain. This leads to brain damage and neurologic dysfunction. Atrial fibrillation can be associated with a heart attack or a stroke. Atrial fibrillation is a common cause of stroke in the elderly and up to 30 percent of the strokes in individuals over the age of 75 are due to atrial fibrillation. The reason that atrial fibrillation can be associated with, or cause, a stroke is because blood clots tend to form in the upper chambers, so-called atria, of the heart and these blood clots can break off and travel throughout the body, plugging up blood vessels. 25% of the blood goes to the brain in most cases, it is common that a blood clot, if it travels, will travel to the brain. It can also travel to the heart and clog up a vessel creating a heart attack or it can travel to any other area of the body causing a blocking in an artery--to the leg, for example, in the eye or any other organ. The risk of blood clots caused by atrial fibrillation increases in the following conditions: 1. hypertension, 2. heart failure, 3. diabetes, 4. increasing age. Can a person be cured of this? Can it go away? Yes. One form of atrial fibrillation that is treatable is so-called paroxysmal atrial fibrillation. This form of atrial fibrillation is more common in younger people and in people without serious underlying structural heart disease. In fact, this form of atrial fibrillation often occurs without any other underlying heart disease present. This paroxysmal form occurs when episodes of atrial fibrillation come for a short period of time and go away suddenly, to return later. This form is often associated with frequent extra beats in the atrium. In the electrophysiology laboratory, much the same kind of a place as a cardiac catheterization laboratory, catheters with electrodes on the tips can be placed into the heart to "map" the initiation of atrial fibrillation. The technology in this regard is advancing rapidly. Much of this form of atrial fibrillation originates from the pulmonary veins so the procedure is quite involved. It requires "transeptal puncture" to get the catheters to the left side of the heart. When the source is identified, an application of radiofrequency energy, or more recently, ultrasonic energy, is delivered to eliminate the spot creating the problem. For this form of atrial fibrillation, the success rate has been reported to be as high as 80 percent. There are several important concerns using this number as a benchmark: 1. the procedure is really still new and somewhat experimental. 2. Not all electrophysiologists and not all centers have the expertise to perform this. 3. The long-term success rate is not clear because the follow-up has been in terms of months rather than years. 4. There may be multiple spots that trigger atrial fibrillation and they might not all be obvious at the time of the evaluation. 5. There are some potential risks of this procedure: one risk includes so-called pulmonary vein stenosis. If multiple applications of energy are delivered into the site that triggers atrial fibrillation and if these sites are from the pulmonary vein, then it is possible to cause blockage of the pulmonary vein and this is a very dangerous situation. I would not want to dissuade you from therapy since this therapy can be curative, but there are significant risks such that it would make sense to consider other therapies first to keep the rates low or to supress episodes of atrial fibrillation. Atrial fibrillation also can be cured by a surgical procedure known as a MAZE procedure. Percutaneous approaches in the electrophysiology laboratory have been tried to recreate this MAZE procedure to cure atrial fibrillation in people who have it more chronically, or persistently, than a person who has paroxysmal atrial fibrillation. Atrial fibrillation can also go away on its own in some people. It tends to do this when there is a specific trigger such as coronary artery bypass surgery, hyperthyroidism, pericarditis, alcohol intoxication (or other stimulants such as some of the over-the-counter supplements, and even caffeine), other acute illnesses that cause extreme vomiting, and some conditions that lead to overexertion. Is it safe to work out with this condition? In general, it is not a good idea to workout too vigorously with atrial fibrillation unless you have been carefully evaluated for underlying heart conditions by a doctor. Some people who have atrial fibrillation have significant problems with their heart and with exercise, the heart rate can race tremendously during atrial fibrillation, thereby exacerbating the underlying heart condition and may lead to problems such as very low blood pressure, heart failure or a loss of consciousness. If the problem of atrial fibrillation has been well managed so that the rate is under control, or the rhythm is under control, it is possible to go back to standard physical activity in many cases. In fact, there are several professional athletes, including basketball players, who have atrial fibrillation present at times. Is there a common drug therapy? There are several approaches to atrial fibrillation management with drugs: 1. Drugs to control the heart rate during atrial fibrillation. 2. Drugs to keep someone in sinus rhythm. 3. Drugs to prevent blood clots that can happen from atrial fibrillation. Let's consider the first category of drugs: Drugs to control heart rate include medications known as beta-blockers, calcium channel blockers and digoxin. Sometimes these drugs are given intravenously, but they are also available orally and these drugs are used to prevent the heart rate from speeding up too much during atrial fibrillation with exercise and they need to be adjusted so the rate does not get too slow at rest. The second class of drugs to maintain normal rhythm include so-called antiarrhythmic drugs. Some of these drugs need to be started in the hospital. Some of the older drugs include Quinidine, Procainamide, Disopyramide, Flecainide, Propafenone, Sotalol, Amiodarone and a new drug known as Dofetilide. These drugs are not all approved by the FDA but all have been used for atrial fibrillation by doctors. Each one has its own set of side effects and benefits. Amiodarone is the most potent, but it has a large number of long-term side effects possible. Flecainide and Propafenone are not to be given to anyone who has an underlying heart condition. The third types of drugs are blood thinners to prevent stroke and blood clots. These medications include Heparin and Warfarin. With this large compendium of medications, a doctor may select several, depending on the severity of the symptoms, the age of the patient, the presence of underlying heart conditions and response to other medications, the severity of the episodes and other risk factors for stroke. I read the venom of the tarantula spider is being used to develop a drug to treat this condition, is there anything to it? Yes, there is something to the use of tarantula spider venum. No drug has yet been developed but a report in the journal Nature on January 4, volume 409, page 35, describes the response of atrial fibrillation to this toxin. It works in a different way than the other medications so far developed and it works on stretch channels in the heart. If this proves to be effective, it may provide insight into causes of atrial fibrillation and the development of potentially new useful therapies. Is it true that some people have no symptoms until they have a stroke? Yes, it is true. For some people, atrial fibrillation represents no more than a new, annoying palpitation. For other people, it can be the cause for a stroke but the process might have been unrecognized until that point. The older you are, and the more risk factors you have for stroke, as I mentioned earlier, the greater the chance that without being on a blood thinner, that atrial fibrillation will cause a stroke. With several risk factors present, an older person can have a risk factor for stroke as high as 17 percent each year. One issue about atrial fibrillation is that there are those that have it and do not even recognize that it is present. Stroke can be caused by atrial fibrillation even in younger individuals and it is one of the potential causes for stroke in which no obvious cause can be diagnosed. Is Digitalis still used to treat irregular heartbeat? It's been around forever! Digitalis is one of the treatments used for patients with atrial fibrillation. It comes from the foxglove plant. Digitalis is used mainly to control the rate of the heart during atrial fibrillation. It is not our best drug to control the rate but may be more useful in elderly, less active patients and in patients who cannot take a beta-blocker or a calcium channel blocker. It may also be useful in patients who have atrial fibrillation and congestive heart failure. Digitalis at high doses can be potentially toxic and in anyone who has kidney problems, or is taking Quinidine, or Verapamil (a calcium channel blocker), the levels of Digitalis can increase substantially. Can over-the-counter drugs cause irregular heartbeats? Do symptoms go away when the use of the OTC is discontinued? Or can you cause permanent damage? Regarding the first question, yes, some over-the-counter drugs can cause irregular heartbeat and some OTC drugs can be associated with atrial fibrillation. The ones of concern are the ones that include adrenalin analogs. Adrenalin is made in the body and it increases the heart rate and blood pressure. Pseudoephedrine is one such compound. This is present in many cold and decongestant preparations. It is important to recognize that some weight loss products and some over-the-counter herbal compounds contain an herb known as ma huang. This herb has ephedrine in it. It is important to look at the ingredients in some of these weight loss products or OTC herbal products because this herb can cause irregular heart rhythm and has been associated, in some instances, with sudden death due to cardiac arrest. If an irregular rhythm, or atrial fibrillation, is triggered by an OTC preparation, it may persist for some period of time. But generally, it goes away on its own. However, once atrial fibrillation starts, and if it is not corrected by intervention and does not go away on its own, over time, the presence of atrial fibrillation in which the rate of the heart is not kept under control means there can be permanent damage to the heart. Are women more likely than men to have an irregular heartbeat or vice versa? Actually, with atrial fibrillation, it's men who have more disease. However, women are more likely to feel their irregular heart rhythm and to have irregular heart beats. Younger people with atrial fibrillation tend to be men and tend to be highly symptomatic with their episodes of atrial fibrillation. Younger women tend to feel extra beats both in the upper and lower chambers of the heart. Older women tend to be more likely, than men, to have atrial fibrillation where it is reversed at a younger age. Are there any underlying conditions that make a person more prone to an irregular heartbeat? Yes. While an irregular heart beat can occur independent of any other heart condition, it is worth having the problem checked out because an irregular heart rhythm may be a sign of a concerning underlying heart condition such as cardiomyopathy, heart failure, coronary artery disease, valvular heart disease and other conditions like that. Do things like caffeine or intensive exercise enhance a heart arrhythmia? Caffeine and intense exercise are some of the triggers for irregular heart beats and in particular, atrial fibrillation. It is important to try to relate any irregular heart beat and the presence of atrial fibrillation to what is going on at the time. Because some people will go to a doctor and mention that they drink, for example, a large amount of caffeinated beverages, and have atrial fibrillation. The doctor may restrict them unnecessarily from drinking caffeinated beverages, and there may be no benefit in doing so. On the other hand, if the individual recognizes a relationship between drinking caffeinated beverages and irregular heart rhythms, then it would make perfect sense to abstain from this. Similarly, with exercise and alcohol ingestion. Is tachycardia the same thing? Atrial fibrillation is a form of tachycardia. Tachycardia really means a fast heart rhythm. There are many forms of tachycardia. Most people think of tachycardia as a supraventricular tachycardia. But, there are many other forms of tachycardia. Supraventricular tachycardia is a specific rapid rhythm often due to a spot in the top chamber of the heart that is beating rapidly, or it is due to an abnormal electrical pathway that allows for a kind of "short circuiting" of the heart. These pathways can be eliminated by ablation techniques in the electrophysiology laboratory. Tachycardia can be a normal response to exercise, this is known as sinus tachycardia. The heart rate will race simply because of the exercise. Another form of tachycardia, a potentially life-threatening form, is known as ventricular tachycardia. It is when the lower chambers of the heart are racing rapidly. If you are diagnosed and treated for atrial fibrillation, and experience fast heart rhythm, could you take additional meds? Yes, you can take additional medication but is very important to realize that the medicines that are available for atrial fibrillation can interact with each other in a bad way. One reason to take additional medicines would be to try to stop the rhythm. Fleconaide and Propafenone, two antiarrhythmic medications are sometimes prescribed to be taken only when the rhythm occurs. This would be safe as long as these medications are indicated for that specific individual (they would not be for an underlying heart condition) and you should never mix two antiarrhythmic medications. Sometimes medications, which are given, are given specifically to keep the heart rate under control. If the heart rate gets faster, it would be appropriate to take a little extra of these medications. It is unlikely that taking a blood thinner, specifically at the time of the onset of atrial fibrillation, would be of any use. What we have discussed today is the problem of a serious condition known as atrial fibrillation. This common medical problem has many different presentations and associations with other conditions. There are new advances in therapies, some of which can cure atrial fibrillation, which are being investigated further. Medical therapy often requires multiple adjustments until the proper prescription is achieved for any given individual. Any therapy that is used for atrial fibrillation has potential risks and must be prescribed on an individualized basis. A "one-size-fits-all" for atrial fibrillation simply does not work. Newer therapies are being developed at a rapid rate and it is likely that in the next five to ten years, cures for atrial fibrillation will be common and perhaps of lower risk than they are now.