For people with atrial fibrillation (A-fib), the heart skipping a beat has nothing to with falling in love. Irregular heartbeats are caused by electrical malfunctions in the heart that disturb its rhythm. When undergoing a surgical procedure that requires anesthesia, they benefit from the specialized care of cardiac anesthesiologists.

Patients with atrial fibrillation usually are taking blood thinners prescribed to help prevent stroke, and they may have low blood pressure, which an anesthesiologist needs to monitor carefully during surgery. At Yale Medicine Cardiac Anesthesiology, we work closely with our patients so that we know their medical history and tailor any anesthesia that's administered to their exact needs, keeping patients safe and comfortable during their procedures.

Atrial fibrillation is a complicated disease that cardiologists manage in a variety of ways, depending on the symptoms and wishes of each patient, as well as the patient's medical history.

When surgery is recommended, the anesthesiologist must come up with a plan that will be influenced by how a particular patient's current medications affect body function.

One key consideration for atrial fibrillation patients is that cardiologists almost universally prescribe them blood thinners—a treatment that substantially reduces their risk of stroke. However, during surgery, blood thinners put patients at risk for bleeding.

Patients with atrial fibrillation often have a procedure known as ablation. This is performed by a cardiologist with training in electrophysiology, a procedure that uses either very cold or very hot probes to damage the parts of the muscle that are causing the heart’s arrhythmia.

While the electrophysiologist pokes around for as long as six hours, stimulating the necessary muscles to find the ones causing the atrial fibrillation, the anesthesiologist is responsible for monitoring the patient's vital signs. 

Sometimes the doctor will use general anesthesia, and sometimes monitored anesthesia (anesthesia that leaves the patient conscious but pain-free), all the while closely watching heart and lung functions.

The most important consideration is the patient’s overall medical condition and how frail he or she may be. You have to plan an anesthetic that takes into account many factors and plan accordingly to provide very safe management.

If a patient’s condition is chronic, the patient may have other conditions such as heart failure, difficult breathing and lying flat, kidney dysfunction, and other abnormal findings. Typically, he says, the patient will come through pre-admission testing a few days before surgery.

If a patient’s condition is acute when he or she needs emergent surgery, then the cardiac anesthesiologist must rely on his expertise and experience in handling very sick patients.

When a patient with atrial fibrillation has been prepared for surgery, doctors put in several routine monitors. In addition, they use an arterial line, which is a special catheter that is inserted into an artery in the wrist (radial artery) that allows for continuous blood pressure measurement and for sampling blood for analysis.

Not long after that, doctors give the patient sedation drugs. That’s the last thing a patient should feel until he or she wakes up in the intensive care unit or in a post-anesthesia recovery unit.

In general, the risks associated with anesthesia are very low.

On the other hand, because cardiac surgery is very complex, and the patients who come in are not in peak health, there is some risk. Side effects include a few reactions to narcotics such as nausea and vomiting. Combined with surgery, the drugs can also result in shivering and some mental confusion. All these generally clear up for patients very quickly.

Procedures such as ablation, that are less invasive than surgery, are changing how Yale Medicine’s cardiac anesthesiologists do their work. The biggest challenges for anesthesiologists in cardiac surgery for atrial fibrillation are dealing with a patient’s limited heart functionality, low blood pressure and other conditions such as poor lung function.

When ablation is performed via large veins in the groin as compared to open-chest approach, risks, surgical trauma, and bleeding are minimized and patient recovery is much quicker.

Because Yale Medicine is an innovator and early adopter of new procedures, patients can expect to be treated by cardiologists and surgeons, and anesthesiologists who are experts even in the newest technology and the latest approaches.