Cardiac ablation side effects

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More than half of atrial fibrillation patients become asymptomatic after catheter ablation

After the procedure, patients with two or more stroke risk factors should be prescribed oral anticoagulants, while those with no risk factors should not receive them. But the study found that 27% of patients with two or more risk factors were not anticoagulated, while one-third of low risk patients were receiving the drugs.

“This is a serious issue,” said Dr Arbelo. “High risk patients who do not receive oral anticoagulation have a greater chance of a stroke. Patients receiving unnecessary treatment are in danger of intracranial and other types of bleeding.”

Catheter ablation was successful in 74% of patients, meaning that they had no atrial arrhythmias between three and 12 months after the procedure. Atrial arrhythmias in the first three months were classified as early recurrences and not considered as failure. Some 45% of patients who had a successful procedure were still on antiarrhythmic drugs at 12 months.

Regarding monitoring after the procedure, 83% of patients had at least one cardiology evaluation and 86% had at least one electrocardiogram (ECG). However, just 60% of patients had the recommended serial ECGs and multiday ECG recordings to check for recurrent AF.

“Catheter ablation is not open heart surgery but it is still an invasive procedure that has risks,” said Dr Arbelo. “It is disappointing that 40% of patients are not being comprehensively monitored afterwards.”

Complication rates were 8% in-hospital and 11% during the one-year follow up. “Patients and referring doctors should be aware that complications can occur,” said Dr Arbelo. “Catheter ablation should be done in centres and by electrophysiologists with sufficient experience to minimise the risk.”

Explore further

Catheter ablations reduce risks of stroke in heart patients with stroke history, study finds More information: Contemporary management of patients undergoing atrial fibrillation ablation: in-hospital and 1-year follow-up findings from the ESC-EHRA atrial fibrillation ablation long-term registry, European Heart Journal (2016). DOI: 10.1093/eurheartj/ehw564

Paulus Kirchhof et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016). DOI: 10.1093/eurheartj/ehw210

P. Kirchhof et al. Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events—European Registry in Atrial Fibrillation (PREFER in AF), Europace (2013). DOI: 10.1093/europace/eut263

G. Y. H. Lip et al. A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry, Europace (2013). DOI: 10.1093/europace/eut373

G. Y. H. Lip et al. Prognosis and treatment of atrial fibrillation patients by European cardiologists: One Year Follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot registry), European Heart Journal (2014). DOI: 10.1093/eurheartj/ehu374

Journal information: European Heart Journal Provided by European Society of Cardiology Citation: More than half of atrial fibrillation patients become asymptomatic after catheter ablation (2017, January 19) retrieved 2 February 2020 from https://medicalxpress.com/news/2017-01-atrial-fibrillation-patients-asymptomatic-catheter.html This document is subject to copyright. Apart from any fair dealing for the purpose of private study or research, no part may be reproduced without the written permission. The content is provided for information purposes only.

Catheter Ablation

Electrophysiology (or EP) is the name of the branch of cardiology that deals with heart rhythm disorders. Catheter ablations are performed by an electrophysiologist (also sometimes called an EP). The University of Michigan electrophysiology program has been a national and international leader in catheter ablation of arrhythmias (irregular heart rhythms) over the last three decades. We’ve been at the forefront of catheter ablation of atrial fibrillation during the last eight years and played a key role in understanding the mechanisms of atrial fibrillation and developing new treatment strategies.
Doctors at the University of Michigan have performed crucial studies that have helped to perfect the tools used in ablation. We handle large volumes of patients and have conducted extensive studies to prove that ablation is effective long term.

What is Catheter Ablation?

Catheter ablation is a minimally invasive technique intended to treat atrial fibrillation (Afib) without major surgery. Using a specially designed catheter that is positioned in the left atrium, radiofrequency energy is applied to the heart muscle to cauterize the “short circuits” that are triggering atrial fibrillation.

For the ablation procedure, catheters are inserted with a needle into a vein that runs up to the heart from the groin. The procedure requires the insertion of a catheter into the left atrium. This is accomplished by “transeptal catheterization,” in which a small hole is purposely made with a needle that is pushed through a thin membrane that separates the two top chambers of the heart.
With a computerized, three-dimensional mapping system to guide the procedure, the doctor can see the catheter and the left atrium on the computer screen, which makes it possible to guide the catheter very precisely and cuts down on the amount of X-ray needed during the procedure.
By recording the electrical activity inside the heart, we can identify the short circuits that are generating the atrial fibrillation. These spots are cauterized with the radiofrequency energy. To eliminate the atrial fibrillation, a typical patient requires between 150 and 250 different spots to be ablated.
The entire procedure usually takes 2 to 4 hours and the patient spends one night in the hospital. Patients are put on blood thinners for at least three months before and after the procedure, until the inner lining of the heart has healed from the effects of the radiofrequency energy.

Cryoballoon Ablation

Another type of ablation, known as cryoballoon ablation, uses liquid nitrogen instead of radiofrequency energy. Cryoballoon ablation precisely targets the multiple nerve connections around the opening of the pulmonary veins, which deliver oxygenated blood back to the left side of the heart. Pulmonary vein connections contribute to all types of atrial fibrillation — including paroxysmal and persistent — so it is important to target them during any ablation procedure.

A cryoballoon ablation procedure can be shorter than radiofrequency ablation, although both approaches are equally effective. With cryoballoon ablation, however, only pulmonary vein connections can be targeted. Radiofrequency ablation enables all types of arrhythmias (other than atrial fibrillation), which can coexist in up to 30 percent of patients, to be targeted.
During cryoballoon ablation, a catheter is threaded from the femoral vein in the groin to the pulmonary veins of the heart’s left atrium, followed by insertion of the cryoballoon catheter. The balloon, filled with liquid nitrogen, is positioned against the opening of the pulmonary veins and inflated. This causes the tissue touched by liquid nitrogen to become frozen, or scarred. This ablated tissue then can no longer trigger the electrical currents responsible for atrial fibrillation.

Success Rates for Catheter Ablation at the University of Michigan

We have performed thousands of ablation procedures aimed at curing atrial fibrillation over the past few years. Success rates of left atrial ablation in patients with atrial fibrillation depend on whether the atrial fibrillation is paroxysmal (the kind that comes and goes on its own) or persistent (the kind that has been present consistently for several months to years).

Paroxysmal atrial fibrillation can be eliminated in 70-75 percent of patients with a single procedure. When the procedure is repeated in patients who still have atrial fibrillation after the first procedure, the overall success rate is approximately 85-90 percent.

Persistent atrial fibrillation can be eliminated in approximately 50 percent of patients with a single procedure. In about 30 percent of patients who undergo ablation of chronic atrial fibrillation, the atrial fibrillation is replaced by a different kind of short circuit referred to as “left atrial flutter.” These patients are treated temporarily with medications and the left atrial flutter sometimes goes away on its own within a few months. If it does not, you may need a second catheter ablation procedure to eliminate the flutter. In these cases, the overall success rate is approximately 75-85 percent. If the atrial fibrillation has been persistent for more than 1-2 years, almost all patients will require more than one ablation procedure before a normal heart rhythm is restored.

Patient Resources

Make an Appointment

The Arrhythmia Program at the University of Michigan has been a national and international leader in the treatment of arrhythmias for more than 30 years. To schedule an appointment to discuss catheter ablation or any other cardiovascular condition or treatment, call us at 888-287-1082 or visit our Make a Cardiovascular Appointment page, where you may fill out a Patient Appointment Request Form and view other details about scheduling an appointment.

Sustained High Quality of Life in a 5-Year Long Term Follow-up after Successful Ablation for Supra-Ventricular Tachycardia. Results from a large Retrospective Patient Cohort

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Int J Med Sci 2009; 6(1):28-36. doi:10.7150/ijms.6.28

Research Paper

Axel Meissner1 , Irini Stifoudi1, Peter Weismüller2, Max-Olav Schrage1, Petra Maagh1, Martin Christ1, Thomas Butz1, Hans-Joachim Trappe1, Gunnar Plehn1

1. Department of Cardiology and Angiology, Ruhr-University Bochum, Germany
2. Department of Cardiology and Angiology, General Hospital Hagen, Germany

This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY-NC) License. See http://ivyspring.com/terms for full terms and conditions. Citation:
Meissner A, Stifoudi I, Weismüller P, Schrage MO, Maagh P, Christ M, Butz T, Trappe HJ, Plehn G. Sustained High Quality of Life in a 5-Year Long Term Follow-up after Successful Ablation for Supra-Ventricular Tachycardia. Results from a large Retrospective Patient Cohort. Int J Med Sci 2009; 6(1):28-36. doi:10.7150/ijms.6.28. Available from http://www.medsci.org/v06p0028.htm

Abstract

Introduction: The ablation of supraventricular tachycardias (SVT) using radiofrequency energy (RF) is a procedure with a high primary success rate. However, there is a scarcity of data regarding the long term outcome, particularly with respect to quality of life (QoL).

Methods and Results: In this retrospective single-center study, 454 patients who underwent ablation of SVT between 2002 and 2007 received a detailed questionnaire addressing matters of QoL. The questionnaire was a modified version of the SF-36 Health Survey questionnaire and the Symptom Checklist – Frequency and Severity Scale.

Conclusion: The high acute ablation success of SVT persists for years in long term follow up and translates into a significant improvement of QoL in most patients.

Keywords: Quality of Life, Ablation, SVT, Atrium, Radio Frequency

Introduction

RF catheter ablation of SVT is a well-established treatment in invasive electrophysiology with a primary success rate of more than 90% in all substrates. SVT ablation specifically targets the electroanatomical substrate, such as the slow pathway in AVNRT, the accessory pathway in AVRT or an ectopic focus in EAT.

Oftentimes, these specific SVT are difficult to treat medically due to therapy refractoriness. Therefore, RF ablation has become the treatment of choice due to its high primary success rate and low complication rate (1-6).

Patients with paroxysmal SVT often present with symptoms like palpitations, dyspnea, fatigue, chest pain or worsening of heart failure under physical or emotional stress. Heart rates of 200 beats per minute and more are not uncommon, especially in young patients or in patients with AVRT and associated atrial fibrillation (AF). Recurrent syncope or other life-threatening complications like ventricular tachycardia and/or ventricular fibrillation may occur.

Due to the paroxysmal character of the tachycardia, with sudden unexpected onset of symptoms, patients are limited in their daily life concerning work, social events and sports. Due to this nature of the disease QoL is increasingly impaired over time. Despite of the high immediate success rate of SVT catheter ablation, very little data is available concerning the development of QoL in the long-term. The published literature mainly deals with the electrophysiological long term results of RF ablation. So far, QoL before and after ablation has not been systematically investigated in these patients (7-13). In contrast, other SVT like atrial flutter and AF have been intensively investigated under this aspect (14-23).

Study population

All patients included either had a typical history of a paroxysmal on-off tachycardia or documented narrow complex SVT pattern in a twelve lead ECG. They consecutively underwent an electrophysiological study. If an AVNRT, AVRT or EAT could be induced and ablated with primary success, patients were later selected for participation in this retrospective single-center study.

All 454 patients, (59.2% female, 40.8% male, mean age 58 (+/- 16.5) years) who had undergone RF catheter ablation for AVNRT, AVRT or EAT at our institution between 2002 and 2007 were mailed a detailed questionnaire. This questionnaire was a version of the SF-36 Health Survey questionnaire and the Symptom Checklist-Frequency and Severity Scale, modified to specifically reflect questions of QoL in SVT, enabling the authors to translate the various domains and components of well being into a quantitative value.

For reasons of structure and to simplify answering for the patients we divided the questionnaire in three different blocks: the first block was related to the situation for the patients before ablation, questions in the second block dealt with the situation during ablation and the third block exclusively applied to the post ablation period.

The modified version of the SF-36 consists of a 36 item questionnaire that assesses eight health concepts: general health perception, physical functioning, social functioning, role limitations due to physical problems, bodily pain, mental health, role limitations due to emotional problems, and vitality. In addition the SF-36 also generates physical and mental component summery scores.

Irrespective of the well known shortcomings of the Symptom checklist because of the nonspecific nature of a number of the symptoms asked for and the lack of assessment of functional status the Symptom checklist is straightforward to use, sensitive to change, and has been utilized in a growing number of studies concerning arrhythmias. We asked for specific symptoms e.g. as tachycardia, palpitations, dyspnea, anxiety and angina pectoris.

If no response had been received after 4 weeks, the patients were contacted by telephone and asked to participate. 309 (68.1%) of the contacted 454 patients fully completed the questionnaire. 145 (31.9%) patients had to be excluded due to incomplete or incoherent answers or because they completely failed to participate. Patients suffering from new palpitations and SVT were contacted for a second time and were asked to additionally submit a recent 12 lead ECG for analysis.

Electrophysiological study and radiofrequency catheter ablation

In all patients, a standard setting with four diagnostic catheters was used (high right atrium, HIS bundle region, right ventricular apex and coronary sinus). Before ablation, the underlying clinical tachycardia had to be able to be repeatedly induced before detailed mapping and the ablation maneuvers were performed. The ablation itself was performed in sinus rhythm in most cases or under continuing tachycardia, if so required for mapping.

The ablation itself was performed using either an irrigated tip or a conventional tip ablation catheter. Successful ablation was defined as the non-reinducibility of the native tachycardia or the loss of the delta wave in AVRT. Subsequently, further electrophysiological testing for additional tachycardias, which could potentially have been masked by the now ablated primary tachycardia, was performed. The aforementioned endpoints were re-evaluated after a waiting period of at least 20 minutes.

Statistical Analysis

For the description of the metric variables the results are expressed as number, mean, standard deviation (SDA) and extreme (minimum and maximum), quartile (25. and 75. percentile) and median. The distribution of categorical data is expressed by absolute and relative frequency.

The comparison of the distribution of the categorical variables before and after ablation concerning two variables was expressed by the McNemar Test. More than two variables were compared using the Chi-square-distribution. For the comparison of the distribution of categorical and ordinal variables of independent random samplings we used Fisher’s exact test. If the Gaussian distribution acceptation was declined, we used a non-parametric test for differences in groups the Mann Whitney U Test or the Kruskal-Wallis-Test, otherwise the t- or F-test.

Time to diagnosis, time to ablation, baseline data of ablation

Regarding the time interval between the first occurrence of the tachycardia, its diagnosis and the year of ablation, we found significant differences. Regarding the whole study cohort, the underlying SVT was diagnosed 9.1±11.2 years (25%/75% percentile – 1.0/15.0) and ablated 14.4±12.7 years (25%/75% percentile – 3.0/24.0) after the first episode of tachycardia. These time intervals (time to diagnosis/time to ablation) differed between the specific SVT (Table 1). The time interval between the first occurrence of the tachycardia and the diagnosis in AVRT was therefore significantly shorter compared to the AVNRT patients (p<0.05); however, the earlier diagnosis of AVRT did not lead to earlier ablation as well.

Baseline data of the ablation procedure comparing the number of RF burns, the total examination time and the fluoroscopy duration are summarized in Table 1. There were no significant differences between the different types of SVT.

Table 1

Baseline demographic characteristics and procedural findings in 309 patients with completed questionnaire.

Quality of life and specific symptoms due to tachycardia prior to ablation

In the questionnaire, all patients were asked to state their symptoms and grade them on a severity scale. We inquired about the nature and quantity of tachycardia and the associated symptoms. Furthermore, the effect of symptoms on the patients` daily and social life, especially with respect to abstinence from work, sports and hobbies was surveyed.

Patients were asked to assess the changes in daily and social life prior to the ablation procedure itself using a 5-level ranking scale (extreme, very strong, strong, moderate, low). In total, more than 60% of the patients (178, 60.7%) stated a strong to extreme impairment in daily life, whereas the rest of the patients (94, 29.3%) indicated only moderate or little changes due to the tachycardia. The detailed results are listed in Table 2.

Table 2

Distribution of symptoms prior to ablation for AVNRT-, AVRT-and EAT patients. Panel A: Quantity and duration of episodes and the associated symptoms. Panel B: Detraction in daily life generally and in parts of daily life.

Figure 1 (Click on the image to enlarge.)

Ablation success rate

Independent of symptoms, the patients had to rate the perceived success of the ablation procedure in general (very successful, successful, moderately successful or not successful). The majority of patients rated the ablation procedure “very successful” or “successful”. This is true for the whole study population as well as for each SVT subgroup. Details are given in Figure 2.

Figure 2 (Click on the image to enlarge.)

Comparison of quality of life before and after ablation

The general QoL and QoL with respect to the above mentioned symptoms were retrospectively evaluated before and after ablation. The aforementioned questionnaires included a section asking participants to grade their well-being using a six-level ranking scale (very good (1), good (2), satisfactory (3), sufficient (4), defective (5) and insufficient (6)).

Patients with AVNRT, AVRT and EAT rated their state of health before and after ablation. The changes within the ranking scale before and after ablation is demonstrated in Figure 3.

Figure 3 (Click on the image to enlarge.)

Comparing the categorical variables before and after ablation in AVNRT patients, applying the McNemar-Test we found a highly significant improvement with respect to state of health (p<0.0005) in this large patient group (Figure 3, Panel A). Regarding the single aspects of well-being, we found highly significant improvements in daily (hobbies and work at home, p<0.0005) and social life (p<0.039). Professional life and participation in sports as well showed a trend towards improvement; however, this difference was not significant (p>0.05).

Comparing the categorical variables in patients with AVRT before and after ablation applying the McNemar-Test, we found a significant improvement with respect to state of health (p<0.044) in this patient cohort (Figure 3, Panel B). Regarding the individual data, we found a highly significant improvement for all variables concerning daily and social life (p<0.0005).

In patients with EAT a remarkable improvement in state of health was found. This difference was not significant (p<0.505). Analysis of data concerning individual symptoms were not accomplished because of the small patient cohort.

Recurrent arrhythmias

Recurrent arrhythmias were defined as relapse of the ablated tachycardia (true relapses), or the crossover to a new SVT like atrial flutter or AF. Figure 4 demonstrates the relationship between true relapses and the crossover to a new SVT. In long term follow up, 219 patients (73%) of the whole study population deemed themselves completely free of SVT, whereas 27% (81 pts.) stated to be suffering from recurrent tachycardia (AVNRT: 155 (69.8%) patients free of SVT, 67 (30.2%) patients with relapse; AVRT: 56 (86.2%) versus 9 (13.8%) patients and EAT 8 (61.5%) versus 5 (38.5%) patients).

Bivariate analysis was performed to calculate if relapses were influenced by different types of variables, such as gender or age. Gender was found to not have a significant influence, this was true for the whole population and as well for patients with AVNRT or AVRT (Fischer`s exact test: All patients p=0.430, AVNRT p=0.552, AVRT p=0.149, EAT with too small a sample size). Age was as well found to not have a significant influence, this was true for the whole population and as well for patients with AVNRT or AVRT (Shapiro-Wilk-Test, Mann-Whitney-U-Test: All patients p=0.540, AVNRT p=0.179, AVRT p=0.352, EAT with too small a sample size).

Multivariate analysis was performed applying a logistic regression analysis. None of the abovementioned factors was shown to have an influence on the frequency of relapses, neither for the whole study cohort nor for patients with AVNRT or AVRT.

Concerning the patients with recurrent tachycardias, there still was a non-significant trend towards better QoL. We detected significant improvement in the symptoms tachycardia and anxiety as well as an increase in work capacity (McNemar Test: p<0.0005, p=0.007 and p=0.004 respectively).

Figure 4

Recurrent arrhythmias dependent on true relapses of the pre-existing native tachycardia ablated (dark pillar), or the crossover to a new SVT (bright pillar). X-axis: Relapses in all patients, patients with AVNRT, AVRT and EAT. Y-axis: Percentage of patients

(Click on the image to enlarge.)

Discussion

Background: The ablation of AVNRT, AVRT and EAT using RF energy has become the first line therapy for patients with recurrent episodes of these arrhythmias. Acute and long term success with respect to the primary electrophysiological outcome has been very well documented (6, 9, 10, 20, 24).

However, there are indications that, despite of successful primary ablation, new arrhythmias can arise in the long term (1, 2, 7). Data on QoL in short term follow-up after RF ablation of SVT is available from a few studies of smaller patient groups, but despite of the large number of patients ablated worldwide, there is a scarcity of data regarding the long term outcome, particularly with respect to QoL (8, 9, 25). This is somewhat surprising, as atrial flutter and AF have been intensively investigated under this aspect (14-23). This is the first study on long term electrophysiological outcome and its impact on the QoL in a large patient group.

Study cohort: The number of patients lost in long term follow up is consistent with long-term surveys using written questionnaires (14, 19). A significant number of submitted questionnaires had to be excluded because they were not fully completed. This is most likely due to patients not being able to remember the initial symptoms after the relatively long follow-up interval. We observed a linear increase in the proportions of sufficiently completed questionnaires over the time during which the ablations were performed.

Regarding the patients reporting tachycardic palpitations during follow-up, we found only a low rate of recurrences of the original tachycardia and mainly a shift to new SVT. This corresponds with the findings of other series in which catheter ablation was performed with a high primary success rate (1, 7, 14,). The technical data of the ablation procedure as well as the primary and long-term electrophysiological success rates are in line with the literature (1-6, 9, 10).

Quality of life in long term follow-up: Prior to interventional therapy, patients mainly suffered from symptoms like tachycardia, increasing incidence of episodes over time, reduction in physical work capacity, dyspnea and angina pectoris. These symptoms were the main reasons why patients seeked treatment.

More than 90% of the patients in each arrhythmia subgroup described the procedure as successful in the long-term follow up. A highly significant improvement in QoL could be demonstrated in the majority of patients. More detailed analysis as well revealed highly significant and sustained improvement in fundamental daily and social life, both for the whole study cohort and for the different types of SVT.

In contrast, patients without ablation therapy and longstanding medical therapy suffer from side effects of medication as well as from recurrent episodes of SVT leading to reduced QoL (12).

Recurrent arrhythmias: 27% of all patients suffered from recurrent arrhythmias which, apart from AVRT patients, to the largest part were not relapses of the primary SVT, (Figure 4). This phenomenon has as well been observed by other groups (26, 27). Bi- and multivariate analysis of the data collected in this study did not identify independent predictive factors of arrhythmia recurrence. The data does not comprise information on total RF energy used; therefore, no statement with regards to its effect on arrhythmia recurrence can be made based on this study.

Even if the patients developed a recurrent arrhythmia, their QoL still measurably improved. Although the total QoL-score only showed a non-significant trend towards improvement, various symptoms, such as tachycardia, anxiety and performance capacity were significantly improved. Previous studies have suggested a causal relationship between different types of right inferior atrial SVT, such as common type atrial flutter and AVNRT, because of a possible shared pathway in the low right atrium, leading to an electrical modulation of atrial tissue substrate (28, 29, 30). A placebo effect as well might be responsible for the improvement in QoL in patients with recurrent arrhythmias.

Study limitations

There are some limitations to this study: First, the subjective benefit of an ablation procedure is complex. Various tools have been developed trying to translate the various domains and components of well-being into a quantitative value. We assessed the subjective benefit with a modified version of the SF-36 Health Survey questionnaire and the Symptom Checklist – Frequency and Severity Scale. Although conclusions are clinically relevant, it still remains difficult to provide quantitative assessment of QoL.

Second, since all patients had been willing to undergo an invasive procedure with potentially significant adverse effects, this study group was highly motivated and highly selected. The perspective of a definitive treatment and ongoing medical surveillance after the procedure may have induced a perception bias in patients and have lead to overstatement of the perceived ablation success.

Third, the potential negative impact of anti-arrhythmic drug therapy on QoL may have significantly contributed to the low baseline scores, further motivating patients to seek non-pharmacological therapy. The marked improvement in measurement of QoL may have been related to reduced symptoms from side effects after the discontinuation of anti-arrhythmic medication. Pharmacological treatment was not studied in detail. Finally, the study was retrospective and the time interval between the ablation procedure and the questionnaire was not uniform. Patients who had more recently undergone the procedure may therefore have had a different recollection of symptoms than those having undergone the procedure at an earlier point of time. Therefore, placebo effects as well may have affected the perception of the patients of the success of the procedure and improvement in their QoL.

Conclusions

Patients with symptomatic arrhythmias treated with RF catheter ablation show significant reductions in arrhythmia-related symptoms and improvement in physical, emotional and social indexes of their health-related QoL. Self-imposed restrictions on physical and social activities are markedly reduced after catheter ablation. These improvements persist during long term follow up. Efforts should be made to increase awareness of symptoms and treatment options of SVT among patients and physicians, aiming at the elimination of delays in the process of symptom onset, first diagnosis and ablation therapy.

Abbreviations

AVNRT: Atrio-Ventricular Nodal Reentry Tachycardia; AVRT: Atrio-Ventricular Reentry Tachycardia; AF: Atrial Fibrillation; EAT: Ectopic Atrial Tachycardia; F: French; INR: International Normalized Ratio; QoL: Quality of Life; RF: Radio Frequency; SDA: Standard Deviation; SVT: Supraventricular Tachycardia.

Conflict of Interest

The authors have declared that no conflict of interest exists.

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22. Erdogan A, Carlsson J, Neumann T, Berkowitsch A, Neuzner J, Hamm CW, Pitschner HF. Quality-of-life in patients with paroxysmal atrial fibrillation after catheter ablation: results of long-term follow-up. Pace. 2003;26:678-684

23. Lee Sh, Chen SA, Tai CT, Chiang CE, Wen ZC, Cheng JJ, Ding YA, Chang MS. Comparisons of quality of life and cardiac performance after complete atrioventricular junction ablation and atrioventricular junction modofication in patients with medically refractory atrial fibrillation. J Am Coll Cardiol. 1998;31:637-644

24. Delise P, Sitta N, Bonso A, Coro L, Fantinel M, Mantovan R, Sciarra L, Zoppo F, Marras E, Verlato R, D’Este D. Pace mapping of Koch’s triangle reduces risk of atrioventricular block during ablation of atrioventricular nodal reentrant tachycardia. J Cardiovasc Eelectrophysiol. 2005;16:30-35

25. Hamer ME, Blumenthal JA, McCarthy EA, Phillips BG, Pritchett EL. Quality of life assessment in patients with paroxysmal atrial fibrillation or paroxysmal supraventricular tachycardia. Am J Cardiol. 1994;74:826-829

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28. Kimman GP, van Hemel NM, Jessurun ER, van Dessel PF, Kelder J, Defauw JJ, Guiraudon GM. Comparison of late results of surgical or radiofrequency catheter modification of the atrioventricular node for atrioventricular nodal re-entrant tachycardia. Eur Heart J. 1999;20:527-534

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30. Interian A, Cox MM, Jimenez RA, Duran A, Levin E, Garcia O, Cooper DK, Castellanos A, Myerburg RJ. A shared pathway in atrio-ventricular nodal reentrant tachycardia and atrial flutter: Implications for pathophysiology and therapy. Am J Cardiol. 1993;71:297-303

Author contact

Received 2008-12-9
Accepted 2009-1-9
Published 2009-1-11

If you have been diagnosed with a heart arrhythmia — a problem with the rate or rhythm of your heartbeat — your doctor may recommend a procedure called catheter ablation to improve your condition.

Facts About Catheter Ablation

Also known as a cardiac ablation or radiofrequency ablation, this procedure guides a tube into your heart to destroy small areas of tissue that may be causing your abnormal heartbeat.

Not everyone with a heart arrhythmia needs a catheter ablation. It’s usually recommended for people with arrhythmias that can’t be controlled by medication or with certain types of arrhythmia from the heart’s upper chambers, called the atria. Catheter ablation is also sometimes recommended for people with arrhythmia that begins in the lower chambers of the heart, known as the ventricles.

The Procedure

Catheter ablation can take between two and four hours to complete. The procedure is done in an electrophysiology lab where you will be monitored closely.

Before the procedure begins, you will be given intravenous medications to help you relax and even fall asleep. In some cases, you may be put to sleep by an anesthesiologist.

After the medication has taken effect, your doctor will numb an area in your groin and make a small hole in your skin. Then, the doctor will place three or four catheters through blood vessels to your heart to help guide the procedure.

After the catheters have been placed, electrodes at the ends of the catheters are used to stimulate your heart and locate the area that is causing the abnormal heart rhythm. Then, the doctor will use mild radiofrequency heat energy to destroy or “ablate” the problem area, which is usually quite small — about one-fifth of an inch in size. Other types of ablation techniques may be used, such as cryoablation, in which very cold temperatures destroy the problem area. Your doctor will decide which type of ablation therapy is most appropriate for you. Once the tissue is destroyed, the abnormal electrical signals that created the arrhythmia can no longer be sent to the rest of the heart.

Most people do not feel pain during the procedure. You may sense mild discomfort in your chest. After the ablation is over, your doctor will remove the guide wire and catheters from your chest.

After the Procedure

After the catheter ablation, you will probably need to lie still for two to six hours to decrease the risk of bleeding. Medical staff members may apply pressure to the site where the catheter was inserted. Special machines will monitor your heart as you recover. Some people can go home the same day as the ablation, but others will stay in the hospital for one or more nights.

Managing After a Catheter Ablation

Recovery from catheter ablation is usually fairly straightforward. In the days after the procedure, you may experience mild symptoms such as an achy chest and discomfort, or bruising in the area where the catheter was inserted. You might also notice skipped heartbeats or irregular heart rhythms. Most people can return to their normal activities within a few days.

Contact your doctor immediately if you have unusual pain or swelling, excessive bleeding or consistent irregularities in your heartbeat.

Depending on the type of arrhythmia being treated, catheter ablation can have a success rate of more than 90 percent, but some people may need to have the procedure again or other treatments for heart arrhythmias. Your doctor may want you to remain on medications to help control your heartbeat.

After the catheter ablation, be sure to follow all instructions from your doctor, especially regarding follow-up visits, medication schedules and safe levels of physical activity.

Testing

You may need some tests before your ablation procedure. Your doctor will let you know which tests you will need, if any. Testing requirements will vary for each patient.

Tests that you may need include:

  • Cardiac stress test,
  • Cardiac MRI or CT,
  • Transesophageal echocardiogram (TEE), and
  • Blood work.

Cardiac MRI: What Is Cardiac Magnetic Resonance Imaging?

Magnetic resonance imaging (MRI) is a safe, non-invasive test that creates detailed images of your organs and tissues by using radio waves and magnets. Cardiac MRIs give doctors valuable information about your heart.

Cardiac MRIs give doctors baseline images of your heart before a procedure. Doctors also use cardiac MRIs to rule out post-procedure complications. With cardiac MRI, we evaluate your anatomy and see how much scarring you have in areas we might target for ablation. We can also use the MRI images to integrate into our computer mapping system, a tool that helps doctors see your heart more clearly. Doctors also use cardiac MRIs to rule out post-procedure complications.

Before Your MRI

Before your MRI we will draw blood. This blood helps us see if your kidneys are healthy and working the way they should. (Your will need your blood drawn one month before your MRI).

  • Do not drink any caffeine 24 hours before the scan.
  • You must remove all metal objects (such as glasses, jewelry, belts, or clothing with zippers.) Remember to dress comfortably.
  • You must fill out a pre-screening form.
  • You will change into a hospital gown.

After those things are done, an MRI tech will place an IV in your arm (possibly two). Please tell your doctor if you have contrast allergies (allergies to iodine or shellfish). You will need a 13-hour medication treatment before the MRI. Also tell your doctor if you are claustrophobic or if you get anxious in tight spaces.

During MRI

During the MRI, you will be lying on your back. We will try to make you as comfortable as possible by putting a cushion under your knees and giving you a ball that you can squeeze in your hand, which will alert the tech if you are feeling too uncomfortable or having any problems.

The MRI machine itself is loud. You will be given head phones so you can hear the technician who runs the machine and so that they can give you instructions on how to breathe during certain parts of the scan (breath in, breath out, hold).

If you are cold, we can get you a blanket.

If your physician decides you are unable to have a cardiac MRI, they will schedule you for a cardiac computed tomography (CT). This is also a non-invasive, painless test.

It’s important to note that even if you have an implantable pacemaker or defibrillator, we can often still safely perform an MRI at University of Utah Health. However, the quality of the imaging may be lower than usual. We evaluate this on a case-by-case basis.

Transesophageal Echocardiogram (TEE): What is TEE?

A transesophageal echocardiogram is a sonogram that allows your doctor to record images of your heart from inside your esophagus, or food pipe. This test looks for blood clots in your heart and needs to be done 24-48 hours before your ablation procedure.

If there is a clot found in your heart, we will reschedule your ablation procedure. Plan for the procedure to take one to two hours.

Before Your TEE

  • Make a list of all your medications and check with your doctor to see if you can take them before the test.
  • Don’t eat or drink for six hours before the test (this includes drinking water).
  • Tell your doctor if you have ulcers, a hiatal hernia, or problems swallowing. Also, let him or her know of any allergies to any medications or sedatives.
  • Plan for someone to drive you home after the exam.

During Your TEE

When you arrive for you TEE, you will change into a hospital gown and then be taken to the testing room. Once in the room, we will spray your throat with an anesthetic to numb it. We may also give you a mild sedative through an IV in your arm to help you relax. (You could also be given oxygen.). Then we will ask you to lay on your side.

The doctor will gently insert a probe into your mouth. As you swallow, your doctor will slowly guide the tube into your esophagus. The tube is lubricated so that it will slide easily. You may feel the doctor moving the probe, but it shouldn’t hurt or interfere with your breathing.

A nurse will monitor your heart rate, blood pressure, and breathing. The test usually takes 20-40 minutes.

After the Test

If your TEE is the day before your ablation procedure, you can eat and drink again as soon as your throat isn’t numb. You will need someone available to drive you home after the test.

Pros and Cons of Medication vs. Ablation for Atrial Fibrillation

If you’re one of the 2.7 million Americans who live with atrial fibrillation — a tricky-to-treat condition that causes your heart to beat irregularly — you may be unsure how to treat it.

Symptoms of atrial fibrillation, also called afib, can be debilitating. They may include palpitations, shortness of breath, fatigue, and weakness.

But trying to reduce these symptoms through drugs that control the abnormal heart beat, called anti-arrhythmic drugs, can come with serious side effects.

Another treatment option is catheter ablation. During ablation, the abnormal heart tissue is destroyed by burning or freezing it. Ablation has a greater chance of reducing and even eliminating your symptoms and making you feel better. But the procedure is invasive, expensive, and not right for everybody.

How do you choose between the two? Having a clear sense of the risks and benefits for both can help.

Neither anti-arrhythmic drugs nor catheter ablation decrease the risk of stroke — these treatments are designed to control symptoms caused by the abnormal heart rhythm.

Walid Saliba, MD, a cardiologist who treats atrial fibrillation at the Cleveland Clinic in Ohio, says, “The aim of any treatment for atrial fibrillation is to reduce the burden of the arrhythmia — the frequency, impact, and symptoms — and improve quality of life.”

Treatments are more effective and better understood than ever, say experts. Guidelines issued in March 2014 by the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society recommend ablation as a first-line therapy for atrial fibrillation.

And research continues. A large trial called Cabana is underway, sponsored by the National Institutes of Health, to provide even more answers regarding the use anti-arrhythmic medication versus ablation.

Medications can stabilize the heart muscle tissue and help return the heart to its normal rhythm, notes the American Heart Association. Some people take the meds every day, while others take them just when they feel palpitations. These drugs work well for some people, but not all. How do the pros and cons compare for now? Here’s a look.

Pros of Anti-Arrhythmic Drugs for Atrial Fibrillation

  • Many options Your doctor will recommend certain drugs based on your age, your health, and the severity of your symptoms. “If there’s underlying heart disease, you may be restricted in what medication you can take,” says Dr. Saliba.
  • Cost effective Medication is typically less expensive than procedures like ablation, in the short term. But if your atrial fibrillation results in repeated hospital visits and changes in your meds to better manage your symptoms, the cumulative costs may even out over time.
  • Noninvasive It’s easier to take a pill than to undergo surgery. Patients who are squeamish about surgical procedures and more comfortable taking a less aggressive approach to controlling their symptoms typically start with medication.
  • Moderate success rate Success rates average around 50 percent overall. “Research shows that with medication there’s a good 40 to 60 percent maintenance of normal rhythm at one year,” says Saliba. “And that’s acceptable to some patients.”

Cons of Anti-Arrhythmic Medication

  • Dangerous side effects and interactions Nausea, dizziness, diarrhea, breathing problems, and swelling are some of the side effects associated with anti-arrhythmic drugs. Other side effects are more serious. The drug amiodarone (Cordarone, Pacerone, Nexterone), for instance, can cause scarring of the lungs, a condition called pulmonary fibrosis. It can also interact with blood thinners, which you may be taking to reduce your risk of stroke. Tikosyn (dofetilide) can cause dizziness and can interact with antibiotics. All anti-arrhythmic drugs can cause life-threatening heart rhythm disturbances, such as ventricular tachycardia or ventricular fibrillation. This is why some heart patients are hospitalized for observation for three to four days when they first start taking them.
  • Less effective over time The benefits of these drugs diminish with time, says Gopi Dandamudi, MD, cardiologist and assistant professor of clinical medicine at Indiana University School of Medicine’s Krannert Institute of Cardiology in Indianapolis. “Less than 20 percent of patients truly maintain sinus rhythm on anti-arrhythmic medication,” he adds.
  • Blood thinners If you are in afib at the time that the anti-arrhythmic medications are started, then you will need to be on blood thinners for at least a few weeks (and weren’t previously on blood thinners). This will help to decrease the risk of having a stroke, but blood-thinning medication also comes with an added risk of causing problems with bleeding.

Catheter ablation has evolved over the last decade into a routine procedure, and compelling evidence supports its effectiveness. During the procedure, which is conducted by an electrophysiologist under local anesthesia, the tip of a catheter is guided to the area of heart tissue that is producing abnormal electrical signals. The catheter emits a pulse of painless radio-frequency energy that destroys the abnormal tissue, correcting the irregular heartbeat.

Research into the long-term effects of catheter ablation is promising. “If you look at the studies over the last 10 years,” says Saliba, “there’s no doubt that ablation results in more freedom from atrial fibrillation at one-year and three-year follow-ups compared to anti-arrhythmic medication.”

RELATED: New Guidelines for Afib Patients: Better Blood Thinners, Less Aspirin

Pros of Ablation

  • Higher success rate On average, ablation has a 70 to 80 percent success rate. Those who are young, whose afib is intermittent, and who have no underlying heart disease, can have success rates as high as 95 percent. Those with persistent afib who are older and have underlying heart disease have a lower success rate — around 40 to 60 percent. The skill of the operator is also a factor, with highly experienced practitioners at high volume medical centers having higher success rates.
  • Low risk of complications Fewer than 5 percent of patients develop any problems. Rarely, the use of the catheters can damage your blood vessel, or cause bleeding, or infection. The risk of more serious complications, like stroke and heart failure, is less than 1 percent. Dr. Dandamudi says, “Most of the risks of catheter ablation are avoidable and not life-threatening.”
  • Quick recovery The procedure takes about two to four hours, and patients can be discharged the same day or after an overnight stay. It causes little or no discomfort and is done under mild sedation with local anesthesia. “The vast majority of patients sail through the procedures and go home the next day,” says Dandamudi.

Cons of Catheter Ablation

  • Repeat procedures For 20 to 30 percent of patients, the first ablation doesn’t work and they have to go back for another. That’s because some abnormal tissue might have been missed, or burned tissue healed and recovered function. “You can increase the success rates by another 10 percent with a repeat ablation,” says Dandamudi.
  • Ablation doesn’t work for everybody. Ablation works best on patients who have the kind of atrial fibrillation that comes and goes (called paroxysmal) and are otherwise healthy. People who aren’t well suited for it are those with long-standing afib who have underlying heart disease. Another factor is how long the afib has been going on. “Someone who has had it for just one year has a much better chance of having a positive outcome than someone who has had it continuously for five or ten,” says Saliba.
  • Sometimes medication is still needed. It can take one to three months for scars to fully form on the sites that were ablated and to know if the procedure worked. During that time, a patient may still experience palpitations and may even be prescribed antiarrhythmic medication. “Sometimes you need both ablation and medication for things to work and result in significant oppression of atrial fibrillation,” says Saliba.
  • New arrhythmias Ablations can sometimes even cause new arrhythmias. When an area of scar is created in a chamber of the heart, that scar can be the site of a new abnormal rhythm, though this is rare.
  • Blood thinners You will need to be on blood thinners for a few weeks after the ablation to decrease the risk of stroke, even if you weren’t on blood thinners before.

Catheter ablation is a procedure that uses radiofrequency energy (similar to microwave heat) to destroy a small area of heart tissue that is causing rapid and irregular heartbeats. Destroying this tissue helps restore your heart’s regular rhythm. The procedure is also called radiofrequency ablation.

Quick facts

  • Catheter ablation is used to treat abnormal heart rhythms (arrhythmias) when medicines are not tolerated or effective.
  • Medicines help to control the abnormal heart tissue that causes arrhythmias. Catheter ablation destroys the tissue.
  • Catheter ablation is a low-risk procedure that is successful in most people who have it.
  • This procedure takes place in a special hospital room called an electrophysiology (EP) lab or a cardiac catheterization (cath) lab. It takes 2 to 4 hours.

Why do people have catheter ablation?

Special cells in your heart create electrical signals that travel along pathways to the chambers of your heart. These signals make the heart’s upper and lower chambers beat in the proper sequence. Abnormal cells may create disorganized electrical signals that cause irregular or rapid heartbeats called arrhythmias. When this happens, your heart may not pump blood effectively and you may feel faint, short of breath and weak. You may also feel your heart pounding.

Medicines to treat rapid and irregular heartbeats work very well for most people. But they don’t work for everyone, and they may cause side effects in some people. In these cases, doctors may suggest catheter ablation. The procedure is used most often to treat a condition called supraventricular tachycardia, or SVT, which occurs because of abnormal conduction fibers in the heart. Catheter ablation is also used to help control other heart rhythm problems such as atrial flutter and atrial fibrillation. Catheter ablation destroys the abnormal tissue without damaging the rest of the heart.

What are the risks of catheter ablation?

There are few risks. The most common problems result from the use of the catheters – long, thin tubes doctors insert into your arteries or veins. Inserting the tubes can occasionally damage your blood vessel or cause bleeding or infection. These problems are rare.

“I was in the emergency department every few days with SVT. I felt awful and the medicines just weren’t working. After catheter ablation I can go to work and exercise without SVT.” Bill, age 61.

How should I prepare for catheter ablation?

  • Your doctor will tell you what to eat and drink during the 24 hours before the test.
  • Usually, you’ll be asked not to eat or drink anything for at least 6 to 8 hours before the procedure.
  • Tell your doctor about any medicines you take. He or she may ask you not to take them before your test. Don’t stop taking your medicines until your doctor tells you to.
  • Leave all your jewelry at home.
  • Arrange for someone to drive you home after your procedure.

What happens during catheter ablation?

A doctor with special training performs the procedure along with a team of nurses and technicians. The procedure is done in a hospital EP or cath lab.

  • A nurse will put an IV (intravenous line) into a vein in your arm so you can get medicine (anesthesia) to prevent pain. You may also get a medicine (sedative) to help you relax but you will be awake throughout the procedure.
  • The nurse will clean and shave the area where the doctor will be working. This is usually in your groin.
  • The nurse will give you a shot — a local anesthetic — to numb the needle puncture site.
  • The doctor will make a needle puncture through your skin and into the blood vessel (typically a vein, but sometimes an artery) in your groin. A small straw-sized tube (called a sheath) will be inserted into the blood vessel. The doctor will gently guide a catheter (a long, thin tube) into your vessel through the sheath. A video screen will show the position of the catheter. You may feel some pressure in your groin, but you shouldn’t feel any pain.
  • The doctor inserts several long, thin tubes with wires, called electrode catheters, through the sheath and feeds these tubes into your heart.
  • To locate the abnormal tissue causing arrhythmia, the doctor sends a small electrical impulse through the electrode catheter. This activates the abnormal tissue that is causing your arrhythmia. Other catheters record the heart’s electrical signals to locate the abnormal sites.
  • The doctor places the catheter at the exact site inside your heart where the abnormal cells are. Then, a mild, painless, radiofrequency energy (similar to microwave heat) is sent to the tissue. This destroys heart muscle cells in a very small area (about 1/5 of an inch) that are responsible for the extra impulses that caused your rapid heartbeats.
  • Catheter ablation usually takes 2 to 4 hours. If you have more than one area of abnormal tissue, the procedure will take longer. You can usually go home the same day, or you may have to stay overnight.

NOTE: During this procedure, the tip of a catheter is guided to the area of heart tissue that is producing abnormal electrical signals. Then the catheter emits a pulse of painless radiofrequency energy that destroys the abnormal tissue and corrects the irregular heartbeat.

What happens after catheter ablation?

You’ll be moved to a recovery room. The sheath usually stays in your leg for several hours after catheter ablation. During this time, you have to lie flat.

After the doctor or nurse removes the sheath:

  • A nurse will put pressure on the puncture site to stop the bleeding.
  • You should keep your leg straight for 6 to 8 hours after the doctor or nurse removes the sheath. The nurse will tell you when you can get out of bed.
  • The nurse will watch you carefully and check your heartbeat and vital signs (pulse and blood pressure).
  • Tell your doctor or nurse right away if you notice any swelling, pain or bleeding at the puncture site, or if you have chest pain.
  • Before you leave the hospital, the nurse will give you written instructions about what to do at home.
  • Aspirin is often prescribed for 2 to 4 weeks to minimize risk of clot formation at ablation sites.

What happens after I get home?

Follow the instructions your nurse or doctor gave you. Most people can return to their normal activities on the day after they leave the hospital.

  • Don’t drive for 24 hours after you leave the hospital.
  • Don’t drink alcohol for 24 hours after you leave the hospital.
  • Avoid heavy physical activity for three days. Ask your doctor when you can return to strenuous exercise.
  • A small bruise at the puncture site is normal. If the site starts to bleed, lie flat and press firmly on top of it. Have someone call the doctor or hospital.

Call 911 if you notice:

  • The puncture site swells up very fast.
  • Bleeding from the puncture site does not slow down when you press on it firmly.

Call your doctor if:

  • Your leg with the puncture becomes numb or tingles, or your foot feels cold or turns blue.
  • The area around a puncture site looks more bruised.
  • The spot begins to swell, or fluids drain from it.
  • You feel pain or discomfort in your chest that moves into your neck, jaw or arm.
  • You feel sick to your stomach or sweat a lot.
  • You have a fast or irregular heartbeat.
  • You feel short of breath.
  • You feel dizzy or lightheaded enough to have to lie down.

How can I learn more about catheter ablation?

Talk with your doctor. Here are some good questions to ask:

  • Why do you think catheter ablation will help me?
  • Are there other treatments we should consider?
  • How did I get this arrhythmia?
  • Will I need to take medicine or have another procedure after I have catheter ablation?

Learn more:

  • Cardiac Catheterization
  • Implantable Cardioverter Defibrillator (ICD)
  • Pacemakers

Treating AFib with Catheter Ablation

Quick facts about catheter ablation:

  • Catheter ablation is used to treat abnormal heart rhythms (arrhythmias) when medicines are not effective or compatible with a person’s lifestyle.
  • Medicines help to control the abnormal heart tissue and pulmonary vein tissue that causes arrhythmias. Catheter ablation blocks the pathway so the erratic contraction signals cannot control the heart and cause the arrhythmias.
  • Catheter ablation is a procedure that is successful for many people with AFib, although the success rates can vary widely.
  • This procedure takes place in a special hospital room called an electrophysiology (EP) lab or a cardiac catheterization (cath) lab.

What is a catheter ablation and why is it used to treat atrial fibrillation?

Medicines to treat rapid and irregular heartbeats work well for many people. But they don’t work for everyone, and they may cause side effects in some people. In these cases, doctors may suggest catheter ablation. Catheter ablation is also used to help control other heart rhythm problems such as atrial flutter. Catheter ablation aims to block the signals that trigger the erratic activity controlling the heart without damaging the rest of the heart.

It may be helpful to know that although many AFib patients are understandably reluctant to undergo invasive procedures, recent studies indicate an encouraging number of people are able to achieve long-term symptom relief from catheter ablation, but many only after having the procedure more than once. If you’re considering this route, it is important to realize that a follow-up ablation may be necessary to achieve the desired results.

How does a catheter ablation work?

Special cells in your heart create electrical signals that travel along pathways to the chambers of your heart. These signals make the heart’s upper and lower chambers beat in the proper rhythm and sequence or keep your heart in “normal sinus rhythm.” Abnormal cells in the heart or pulmonary veins may create disorganized electrical signals that cause irregular or rapid heartbeats called arrhythmias. When this happens, your heart may not pump blood effectively and you may feel faint, short of breath and weak. You may also feel your heart pounding.

Before an ablation procedure, electrical mapping of the heart is performed. An electrically sensitive catheter is used to map the heart muscle and the origins of the “extra” electrical activity throughout the heart. The map tells the physician which areas of the heart are creating problematic electric signals that interfere with the proper rhythm.

How is an ablation performed?

Summary of the Procedure: A catheter (thin, flexible tube) is inserted into the patient’s blood vessels and is gently guided to the heart. The physician carefully creates a conduction block (an interruption in the electrical signals) using the catheter to deliver energy (such as radiofrequency, cryo or laser) to scar the problematic areas. The goal is to eliminate the abnormal signals reaching the heart. If successful, the heart will return to a normal rhythm. This minimally invasive procedure usually has a short recovery period. Patients may be placed on a short course of anti-arrhythmic drugs while the procedure takes full effect.

Are there different types of ablation for AFib?

Yes, the more common AFib ablation procedure is called a pulmonary vein isolation ablation, but sometimes an AV node ablation is still performed today.

  • Pulmonary vein isolation ablation (PVI ablation or PVA).
    • In some AFib patients, fibrillation is triggered by extra electrical currents in the pulmonary veins. During this procedure, the catheter tip is used to block the erratic signals to the tissue and, in most cases, normal heart rhythm returns.
  • To learn more about varying types of ablation techniques and procedures, visit the StopAfib.org Catheter Ablation pages.

There are few risks. Fewer than 5 percent of people who have the procedure develop complications. The most common problems result from the use of the catheters, the long, thin tubes doctors insert into your arteries or veins. Inserting the tubes can occasionally damage your blood vessel or cause bleeding or infection. There are a few other risks to consider, but these problems are rare. (Further reading available on StopAfib.org.)

Before Checking In: How should I prepare for catheter ablation?

  • Your doctor will tell you what you can eat and drink during the 24 hours before the procedure.
  • Usually, you’ll be asked not to eat or drink anything for at least 6 to 8 hours before the procedure.
  • Tell your doctor about any medicines you take. He or she may ask you not to take them before your catheter ablation. Don’t stop taking your medicines until your doctor tells you to.
  • Leave all your jewelry at home.
  • Arrange for someone to drive you home after your procedure.

A doctor with special training performs the procedure along with a team of nurses and technicians. The procedure is done in a hospital EP or cath lab.

  • Clot Prevention and Visual Inspection: The hospital staff will likely perform some diagnostic imaging before prepping you for the procedure to verify the plan and safety of the procedure for you. (More about diagnostics and prepping here.)
  • Sedation for The Procedure: A nurse will put an IV (intravenous line) into a vein in your arm so you can get medicine (anesthesia) to prevent pain. In most cases, general anesthesia is recommended although a few doctors use a milder form of sedation.
  • Infection Prevention: The nurse will clean and shave the area where the doctor will be working. This is usually in your groin.
  • Accessing Your Heart Tissue for Treatment: The nurse will give you a shot — a local anesthetic — to numb the needle puncture site.
  • The doctor will make a needle puncture through your skin and into the blood vessel (typically a vein, but sometimes an artery) in your groin. A small straw-sized tube (called a sheath) will be inserted into the blood vessel. The doctor will gently guide a catheter (a long, thin tube) into your vessel through the sheath. A needle carries the catheter through the septum, the wall between the left and right atrium, and into the left atrium.
  • A video screen will show the position of the catheter. You may feel some pressure in your groin, but you shouldn’t feel any pain.
  • Locating Cells and Performing Ablation: To locate the abnormal tissue causing arrhythmia, the doctor sends a small electrical impulse through the catheter. When the source of your irregular heartbeat is located, the doctor will use the catheter to apply a mild, painless, energy-–radiofrequency (similar to microwave heat), cryo (freezing), or laser-–to produce a scar that blocks electrical impulses from the pulmonary veins and other areas of the left atrium, shutting down the abnormal rhythms and preventing afib.
  • Recovering and Going Home: Catheter ablation usually takes three to six hours, but occasionally more time is needed. If you have more than one area of abnormal tissue, the procedure will take longer. In general, you can expect an overnight stay.

You’ll be moved to a recovery room. The sheath usually stays in your leg for several hours after catheter ablation. During this time, you have to lie flat.

After the doctor or nurse removes the sheath:

  • A nurse will put pressure on the puncture site to stop the bleeding.
  • You should keep your leg straight for 6 to 8 hours after the doctor or nurse removes the sheath. The nurse will tell you when you can get out of bed.
  • The nurse will watch you carefully and check your heartbeat and vital signs (pulse and blood pressure).
  • Tell your doctor or nurse right away if you notice any swelling, pain or bleeding at the puncture site, or if you have chest pain.
  • Before you leave the hospital, the nurse will give you written instructions about what to do at home.

Follow the instructions your nurse or doctor gave you. Most people can return to their normal activities within a few days after they leave the hospital.

  • Make sure you understand how long you should wait before you drive. You will be instructed not to drive for at least 24 hours after you leave the hospital.
  • Ask your doctor how long you should expect to be off work. Typical time frames may be up to a week.
  • You will need to avoid strenuous physical activity for a while following the procedure. Ask you doctor when you can return to strenuous exercise.
  • A small bruise at the puncture site is normal. If the site starts to bleed, lie flat and press firmly on top of it. Have someone call the doctor or hospital.

Call 9-1-1 if you notice:

  • The puncture site swells up very fast.
  • Bleeding from the puncture site does not slow down when you press on it firmly.
  • Your leg with the puncture becomes numb or tingles, or your foot feels cold or turns blue.
  • The area around a puncture site looks more bruised.
  • The spot begins to swell, or fluids drain from it.
  • You feel pain or discomfort in your chest that moves into your neck, jaw or arm.
  • You feel sick to your stomach or sweat a lot.
  • You have a fast or irregular heartbeat.
  • You feel short of breath.
  • You feel dizzy or lightheaded enough to have to lie down.

Talk with your doctor. Here are some good questions to ask:

  • Why do you think catheter ablation will help me?
  • Are there other treatments we should consider?
  • How did I get this arrhythmia?
  • Will I need to take medicine or have another procedure after I have catheter ablation?

Here is a list of ten things to say about the experience of having an AF ablation.

(Note: This list concerns standard radio frequency catheter ablation for AF.)

1. AF ablation is a big deal:

The first thing to say about AF ablation is that it is a big procedure. I tell patients to expect AF ablation to be hard on them. How could it be easy to undergo hours of general anesthesia, insertion of big tubes in the leg veins, 50-75 burns in the atrium and hours of bed rest? Although a minority sail through the recovery without complaints, most patients tell me they were surprised at how hard it was on them. I recommend taking a few weeks off after the procedure. Specifically, I say…read books, watch movies, write a blog, take short walks. but don’t go back to full-gas exercise or work for a couple of weeks.

2. Chest pain is common:

A majority of patients have chest pain for a few days after the procedure. The severity of the pain varies a lot. Most often, it hurts to take a deep breath or cough. Some patients say their chest feels tight. These symptoms are likely due to irritation of the lining of the heart, called the pericardium. It’s hard to predict who will get post-procedural chest pain. Sometimes you do extensive ablation and there is no pain, while other times you have an easy ablation and there is severe pain. It resolves over days.

3. Pain at the insertion site in the groin:

It’s common to have soreness at the insertion site in the groins. We access the heart by inserting multiple sheaths (essentially big IVs) in the leg veins at the groin. To prevent clots from forming in the heart, we perform AF ablation without interrupting anticoagulation. This means firm pressure will be required when the sheaths are removed. And that causes varying degrees of soreness in the groin region over the following days. Bruising is common. And bruising will follow gravity, so it’s common for black-and-blue marks to move down the leg. Sheath placement or removal may also irritate the nerve bundle that runs adjacent to the leg (femoral) vein.

Although most patients have discomfort at the insertion site, persistent pain (for more than a few days) or swelling are causes for concern. One of the most common complications of AF ablation is injury to the vein or artery in this region. In these cases, a caregiver will likely want to take a look at the site. Occasionally, we might order an ultrasound.

4. General anesthesia effects:

Most electrophysiologists use general anesthesia for AF ablation. Some patients chew up (metabolize) the gas and drugs easily; others do not. Many patients feel nausea and groggy for hours. Some patients experience these symptoms for days. It’s also common to have a sore throat or cough from the (endotracheal) tube. There is a great deal of variation in how people tolerate anesthesia.

5. Arrhythmia:

Do not expect to have a flawless rhythm after AF ablation. Remember that this was a big procedure. The many burns it takes to isolate pulmonary veins can irritate the heart, which in turn may cause arrhythmia. Other possible disruptions to the rhythm include prolonged bed rest, effects of anesthesia, and pain.

Premature beats in the hours to days after the procedure are common. Atrial fibrillation can occur. Although having AF after an ablation is a risk factor for a future recurrence, it doesn’t mean the procedure did not work. The burns irritate the heart, and as they heal (expand), over days to weeks, the irregular rhythm can resolve. This is why we have what’s called a waiting period (6-8 weeks) after the procedure before we declare success–or not. AF that occurs in the post-procedure period is rarely dangerous because all patients are kept on anticoagulation and most patients remain on rate-slowing meds. Persistent high heart rates (which sometimes indicates left atrial flutter) can be more difficult to control, sometimes requiring cardioversion.

6. Resting heart rate changes:

The resting heart rate can increase in the weeks or months after ablation. The increase is usually 10-20 beats per minute more than pre-procedure levels. This phenomenon usually resolves.

We do not fully understand the way in which AF ablation works. It’s not as simple as just building an electrical fence around pulmonary veins. One effect of ablation in the region of pulmonary veins is changing neural input to the heart. Bundles of nerves, called ganglia, reside close to the origin of the veins. Ablation at these sites can alter neural control of the heart. Some experts believe this is a positive effect in that it may predict ablation success.

8. Exercise Tolerance:

The ability to sustain exercise can be decreased for weeks to months after the procedure. It will likely come back. The reasons AF ablation transiently decreases exercise tolerance are numerous: it is a big procedure, the burns can cause stunning of the atria, there is deconditioning that occurs before and after the procedure, and many patients remain on AF drugs for a month or two after the procedure. The main message here is be patient. Give yourself weeks to months to recover.

9. Fluid overload/Edema:

It is not uncommon to develop volume excess. This can manifest as swelling of the hands, feet, or face. It may also cause transient shortness of breath, cough or high blood pressure. Reasons: ablation catheters deliver saline (salt water) with each burn; anesthesia often requires saline infusions to maintain blood pressure, and the heart can be stunned after ablation. Swelling and volume excess is not heart failure per se, but it usually responds to a few days or weeks of taking a diuretic medication.

10. Digestive problems:

I have seen, in a handful of cases, patients have trouble moving food through their GI tract after ablation. Symptoms include reflux, feeling bloated, and intolerance of big meals, while signs may include distention of the abdomen.

Ablation in the left atrium may transiently damage nerves that control motility of the GI tract. The good news is that these effects resolve with time. I usually treat this problem by recommending small meals, and an acid blocker.

***

Note that this is not a complete list of complications, but a compilation of common issues I’ve come across in the last ten years and 800 left atrial ablations. It should be self-evident that if you experience severe new symptoms or signs, such as stroke, esophageal swallowing pain, fever, unremitting chest pain, breathing problems, or expansion of swelling in the leg veins you should contact your doctor or seek medical attention.

JMM

I closed the comment section on this post in an effort to avoid patient-specific experiences. Posts such as these are meant as informational and do not constitute specific medical advice.

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