Atlanta Heart Associates
Atrial Fibrillation Ablation Atrial fibrillation (AF) is the most common heart rhythm disorder. It is unknown why patients develop this condition although increasing age, genetics, and many medical conditions (heart failure, high blood pressure, sleep apnea, obesity, etc) have been associated with it. Once present, there is no true cure for AF, but it can be treated with medications or procedures. Medications can have varying effectiveness in different people, and each medication has its own set of potential side effects.What is catheter ablation?At times, additional strategies are needed to help treat AF in patients who continue to have symptoms despite medications. Catheter ablation is a commonly used strategy which can help; however, it is important to note that AF ablation is not for everyone. Your doctor will carefully consider your case and discuss whether you would benefit from such a treatment. AF ablation is performed by a minimally invasive, non-surgical approach by electrophysiologists (i.e., electricians for your heart). The foundation for AF ablation was built on research which identified the pulmonary veins as the source for AF. Normally, there are 4 small pulmonary veins which connect the lungs to the left atrium (top left chamber of your heart). When someone has AF, abnormal electrical activity from these pulmonary veins enters the heart and causes AF. In AF ablation, the main goal is to perform pulmonary vein “isolation,” which blocks the abnormal electrical signal from entering the heart and causing AF. Studies have shown that pulmonary vein isolation can reduce the time in AF (thereby increasing the time patients stay in normal rhythm), improve the effectiveness of medications, and improve quality of life.35756016330011353091738847CryoablationCryoablation30719811566674615079156494637818721738847Radiofrequency ablationRadiofrequency ablationTwo commonly used techniques to perform pulmonary vein isolation include cryoablation (freezing to create lesions) and radiofrequency ablation (heating to create lesions). Studies have shown that both strategies are equally effective for pulmonary vein isolation. Your doctor will typically decide on a case by case basis which strategy would be most effective for you. In some cases, a doctor may use both techniques to perform the ablation.How is the procedure done?On the day of the procedure, you will meet with an anesthesiologist. This doctor may place a breathing tube and will administer medications to make you go to sleep for the procedure. Your vital signs will be closely monitored by the anesthesia doctor during the procedure. The AF ablation is a minimally invasive procedure which is performed with catheters (long, thin tubes inserted in pelvic blood vessels on both sides and sometimes in the neck). The catheters enter the top right chamber of the heart, and we must cross a “wall” to enter the top left chamber (where pulmonary veins connect to the heart). This step is performed with a special needle and with ultrasound. Through this hole, different catheters are used to perform the ablation. Your doctor is able to see each step of the procedure, which makes the procedure safer and more effective. A mapping system may be used to create a detailed map of the heart, which allows the doctor to clearly see the heart and the catheters within it. The map also provides doctors with data, which helps identify problem spots that may need to be treated with ablation. Additionally, mapping systems reduce use of X-rays and harmful radiation exposure.Ablation is performed around the pulmonary veins, and depending on the patient, the doctor may also perform ablation at other spots. After ablation, the heart is stimulated in an attempt to re-start (induce) abnormal rhythms. Your doctor will decide whether or not to target these additional rhythm problems by considering multiple factors, including your history and whether this is a first or repeat ablation. Thus, it is difficult to determine the time frame of your procedure as we cannot predict how much ablation will need to be done at the start.What are the risks of AF ablation?AF ablation is a widely used procedure which has been shown to be safe, but there are important risks which must be considered. Certain strategies are commonly used during the procedure to minimize these risks. Bleeding/infection at catheter insertion site - risk is minimized by sterile techniquesHeart injury - risk reduced by seeing catheters and their movement inside the heartStroke or mini stroke - blood thinner is given during procedure to reduce risk Pulmonary vein narrowing - lower risk with modern ablation techniques which is done outside the veins(not inside pulmonary vein as was done previously)Injury to phrenic nerve (which controls lung movement during breathing) - risk is minimized by locating the nerve and ablating far from itEsophagus (food pipe) injury - risk is minimized by monitoring esophagus temperature during ablation and ablating far from itThe risks listed above are specifically associated with AF ablation, but it is important to note that certain risks, such as heart attack, heart block requiring a pacemaker, cardiac arrest, and even death, exist with all heart procedures even though this risk may be very low. What are the outcomes and how to improve chances of success?The success after AF ablation depends on several factors:How long a person has been diagnosed with AFDoes abnormal rhythm come and go, or is it always presentHas the heart undergone “remodeling” in which the chambers of the heart get larger and develop scarWhat other health problems, including other heart conditions, are presentThere is no cure for AF. AF ablation helps primarily by improving symptoms, by reducing the amount of time a person is in abnormal rhythm, and by making medications more effective. It will typically not allow you to stop blood thinners. In the early stages of AF, response to ablation is very good (possibly greater than 80%). In later stages of the disease, the success rate may be less (50-60%). It is, thus, better to perform AF ablation early in the disease process although patients who have later stages of the disease may still benefit. Patients with more advanced disease sometimes will need a second ablation procedure to feel better after ablation. In addition, since AF generally progresses with age, patients may have recurrence of abnormal rhythm after a long period of having normal rhythm. Success of AF ablation can be improved by controlling other medical conditions, such as high blood pressure, heart disease, diabetes, and sleep apnea. We recommend following up with your primary care doctor, heart doctor, and other specialists so that these conditions can be properly treated. Additionally, lifestyle changes are important to improve success of AF ablation. Studies have shown that 10% weight loss can greatly improve ablation results. Regular physical activity is key, and a good goal is to perform 30 mins/day for at least 5 days/week. Avoidance of alcohol is very helpful as alcohol can trigger more AF.What to expect after the procedure?After ablation, anesthesia will be discontinued, and your breathing tube will be removed. It is common to have a sore throat from the breathing tube. You will have dressings at catheter insertion sites. You will be on bed rest for several hours, and it is important to remain still and to not move/bend your legs to prevent bleeding. You will be monitored overnight before discharge the following morning. You need to take certain medications after the procedure.Blood thinner (anticoagulation) - It is essential to continue a blood thinner after ablation procedure since you remain at risk for blood clots and stroke after the procedure. Please do not stop this medication without checking with your EP doctor.Colchicine - After ablation, you may have some chest discomfort / aching which worsens with deep breathing. These symptoms are related to pericarditis, an irritation of the lining around the heart from the ablation procedure. Colchicine is a medication that helps prevent these symptoms and promotes healing after ablation. You may be prescribed a 2 week course of this medication. Common side effects are an upset stomach and diarrhea.Pantoprazole (protonix) and/or sucralfate (carafate) - These medications help protect the stomach and esophagus (food pipe). If prescribed after ablation, protonix is taken once daily for 1 month and carafate is taken three times per day for 2 weeks.Please keep in mind the following activity restrictions after your procedure.No driving for 48 hours.No strenuous exercise for about 7 days. Avoid activities such as yoga, running, weights, lunges, sexual activity, or any exercise that causes pressure on groin sites. No lifting greater than 10 pounds for 7 days. You may shower on the day after the procedure. You may return to work in 2 days but do not perform heavy lifting or strenuous activity.After leaving the hospital, it is important to monitor for any symptoms of fever, chest / upper abdominal pain, shortness of breath, bloody vomiting, or stroke like symptoms (facial droop, slurred speech, inability to move an arm or leg). Some complications of AF ablation can occur even weeks after the procedure. Please seek medical attention immediately if you develop any of these symptoms or any other concerning symptoms, either right after or several weeks after your procedure. After AF ablation procedure, you may have fatigue, skipped beats, and even episodes of palpitations. Many of these symptoms will resolve in the first few weeks after ablation and may be related to anesthesia effect and also to the healing process that occurs after ablation. However, sometimes these symptoms can last longer. This does not mean that ablation did not work, and you may still have a good result long term. Therefore, we typically determine a patient’s response to ablation after 90 days. At that point, your doctor will discuss with you treatment options, including medications (that typically work better after ablation) or a repeat ablation procedure.This document intends to provide supplemental information to what was discussed at your clinic visit. If you have any additional questions/concerns, please contact our office (770-692-4000).
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