Atrial fibrillation ablation

The idea of having a heart-related procedure can be a daunting prospect for a patient. A detailed understanding of what the procedure involves is critical for making an informed decision about the best treatment option for you. The aim of this article is to provide more information on what is involved during the procedure, success rates and potential complication rates.

WHERE DOES ATRIAL FIBRILLATION COME FROM?

Atrial fibrillation originates from the left upper chamber of the heart, referred to as the left atrium. Atrial fibrillation is commonly triggered by abnormal electrical impulses that originate from four veins that drain blood into the left top chamber of the heart, called the pulmonary veins. The pulmonary veins can be thought of as four large ‘pipes’ that drain blood into a ‘tank’ (the left atrium).

WHAT DOES AN ABLATION PROCEDURE FOR ATRIAL FIBRILLATION INVOLVE?

Catheter ablation is an established procedure for the treatment of atrial fibrillation. Since the first procedure was performed by the pioneering team led by Prof. Haissaguerre and Prof Jais in Bordeaux in the late 90s, millions of procedures have been performed worldwide. Atrial fibrillation ablation is by far the most common ablation procedure performed in the field of heart rhythm management.

During a catheter ablation procedure, known as a pulmonary vein isolation procedure, the tissue in the region where the pulmonary veins join the heart is modified in order to block the abnormal impulses that trigger atrial fibrillation. In certain circumstances, the heart rhythm doctor may decide to modify other areas of the upper chambers of the heart in order to treat other irritable areas that have the potential to cause atrial fibrillation.

IS AN ATRIAL FIBRILLATION ABLATION A BIG ‘HEART OPERATION’?

With increasing experience, and in parallel with technological advances, atrial fibrillation ablation has evolved from a procedure that took many hours to one that can be completed in just over an hour. Conceptually, atrial fibrillation ablation can be thought of as a key hole procedure, with the point of access being the vein at the top of the leg (the femoral vein). Plastic ports are inserted into the vein through incisions of less than a centimetre. An example of a port being introduced into a vein is included below.

Long thin tubes, called catheters are then introduced through the ports and advanced via the vein to the heart, as demonstrated in the video clip below. Once catheters are introduced into the heart, the ablation procedure involves cauterizing regions of the left upper chamber to electrically isolate the pulmonary veins from the chamber. As discussed above, the pulmonary veins drain blood into the left upper chamber.


The ablation procedure commonly involves either using heat (radiofrequency energy) or freezing (cryoballoon) to create the scar (examples are included in the videos below). There are also new technologies that have been developed to perform atrial fibrillation ablation (discussed here).


In certain circumstances, after an atrial fibrillation ablation, patients can be discharged on the same day. Therefore, in the case of atrial fibrillation ablation, the concept of a ‘heart operation/procedure’ is a far cry from the traditional heart operation.

WHAT ARE THE SUCCESS RATES AND POTENTIAL RISKS?

Catheter ablation is an effective procedure for treatment of atrial fibrillation, particularly amongst patients with the paroxysmal (intermittent) type of atrial fibrillation.

  • The success rates of a single procedure for paroxysmal atrial fibrillation are between 70-75% and approach 85-90% after more than one procedure.
  • Amongst patients with continuous atrial fibrillation, the success rates after one procedure are 50%-60%. The success rates approach 70%-80% after more than one procedure. Because the success rates are lower in patients with continuous atrial fibrillation, there is an argument for early treatment, before atrial fibrillation progresses from the intermittent (paroxysmal) to continuous (persistent) type. A more detailed discussion on the importance of early treatment is included here.

WHAT ARE THE POTENTIAL COMPLICATIONS ASSOCIATED WITH ATRIAL FIBRILLATION ABLATION?

While complications associated with catheter ablation rarely seen, they can be significant. The risk associated with the majority of serious complications is 1 in 100 (1%)  or less (specific numbers are included below). Your physician will have a detailed discussion with you about the procedure in order to allow you to make an informed decision. You will subsequently be asked to sign a consent form.

Potential complications include:

  • Damage to blood vessels (1-2 in 100 risk)
  • Buildup of fluid in the sac around the heart needing a drain to remove the fluid (1 in 100 risk)
  • Blood clots resulting in heart attack or stroke (1 in 200 risk)
  • Damage to nerves around heart (1 in 200 risk)
  • Narrowing of the pulmonary veins (1 in 200 risk)
  • Significant damage to the gullet (1 in 1000 risk)

WHAT IS THE PROCEDURE LIKE FROM A PATIENT’S PERSPECTIVE?

A catheter ablation procedure is performed in a specific environment within a hospital referred to as a cardiac catheterization laboratory. During the procedure, multiple members of a team will be involved, including the heart rhythm specialist doctor (who will perform the procedure), cardiac physiologists and cardiac nurses. The cardiac nurses assist with ensuring that the patient is comfortable and monitor vital signs while the physiologists monitor various technical parameters associated with the procedure.

The ablation procedure is commonly performed under general anaesthesia (in which case an anaesthetist will also be present). The procedure can also be performed with a patient under conscious sedation (awake with medications administered though the vein to help the patient to relax). Patients who have the procedure under conscious sedation may experience mild discomfort during the ablation procedure. In certain circumstances, artificial hiccups maybe induced for a few minutes to monitor function of nerves around the heart.

After the procedure, the catheters and ports will be removed, and manual pressure will be applied over the puncture site to stop bleeding. Patients are subsequently required to lie flat for a period of four hours to ensure that the bleeding remains controlled. During this period, nursing staff will monitor the puncture site and also vital signs. Anticoagulant (blood thinning medication) and other medications will be prescribed by your physician.

WHAT HAPPENS AFTER HOSPITAL DISCHARGE?

An important consideration for patients is the recovery phase post-ablation. Specifically, when they can get back of their feet and when they get back to normal activities, including work. While post-procedure management may vary from one hospital to the next, the general principles are the same. The majority of patients are discharged after an overnight stay, although some patients can be discharged on the same day.

In the first few days after the procedure, patients are advised to undertake light exercise (walking). Exercise maybe increased gradually with the eventual aim of returning to normal activities (including intense exercise) after two weeks. For patients who do not have physically demanding jobs, after three to four days, patients can return to work. However, if a patient’s occupation involves heavy lifting, the physician may recommend increasing the time off work to two weeks.

Detailed guidance for UK patients in terms driving following a catheter ablation is included here . Based on these guidelines, if patients hold a car or motorcycle license, they can return to driving after two days following your catheter ablation.

Dr Mahida’s publications on atrial fibrillation

  • Yamashita S, Tokuda M, Matsuo S, Mahida S, Sato H, Oseto H, Yokoyama M, Isogai R, Tokutake K, Yokoyama K, Narui R, Kato M, Tanigawa S, Miyanaga S, Sugimoto K, Yoshimura M, Yamane. Risk of Coronary Sinus Stenosis After Epicardial Radiofrequency Ablation for Mitral Isthmus Linear Ablation. Circ Arrhythm Electrophysiol 2020 Jul 27. doi: 10.1161/CIRCEP.120.008388. Online ahead of print.
  • Derval N, Takigawa M, Frontera A, Mahida S, Konstantinos V, Denis A, Duchateau J, Pillois X, Yamashita S, Berte B, Thompson N, Hooks D, Pambrun T, Sacher F, Hocini M, Bordachar P, Jaïs P, Haïssaguerre M. Characterization of Complex Atrial Tachycardia in Patients With Previous Atrial Interventions Using High-Resolution Mapping. JACC Clin Electrophysiol. 2020 Jul;6(7):815-826. doi: 10.1016/j.jacep.2020.03.004. Epub 2020 May 27.
  • Ding WY, Williams E, Das M, Tovmassian L, Tayebjee M, Haywood G, Martin C, Rajappan K, Bates M, Temple IP, Reichlin T, Chen Z, Balasubramaniam R, Ronayne C, Clarkson N, Mahida S, Sticherling C, Gupta D. Cryoballoon pulmonary vein isolation as first line treatment for typical atrial flutter (CRAFT): study protocol for a randomised controlled trial. J Interv Card Electrophysiol. 2020 May 8. doi: 10.1007/s10840-020-00746-6. Online ahead of print.PMID: 32385774
  • Bartoletti S, Mann M, Gupta A, Khan AM, Sahni A, El-Kadri M, Modi S, Waktare J, Mahida S, Hall M, Snowdon R, Todd D, Gupta D. Same-day discharge in selected patients undergoing atrial fibrillation ablation. Pacing Clin Electrophysiol. 2019 Nov;42(11):1448-1455. doi: 10.1111/pace.13807. Epub 2019 Oct 13.
  • Yamashita S, Tokuda M, Matsuo S, Mahida S, Hachisuka EO, Sato H, Ikewaki H, Oseto H, Yokoyama M, Isogai R, Tokutake K, Yokoyama K, Narui R, Kato M, Tanigawa S, Sugimoto K, Yoshimura M, Yamane T. Comparison of atrial arrhythmia recurrence after persistent atrial fibrillation ablation between patients with or without tachycardia-induced cardiomyopathy. J Cardiovasc Electrophysiol. 2019 Nov;30(11):2310-2318. doi: 10.1111/jce.14144.
  • Pearman CM, Redfern J, Williams EA, Snowdon RL, Modi P, Hall MCS, Modi S, Waktare JEP, Mahida S, Todd DM, Mediratta N, Gupta D. Early experience of thoracoscopic vs. catheter ablation for atrial fibrillation. Europace. 2019 Feb 6. doi: 10.1093/europace/euy303.
  • Wynn G, Gupta D, Maille B, Snowdon R, Waktare J, Todd D, Hall M, Mahida S, Modi S. Demonstration of pulmonary vein exit block following pulmonary vein isolation: A novel use for adenosine. J Cardiovasc Electrophysiol. 2018 Sep 19. doi: 10.1111/jce.13744.
  • Yamashita S, Hooks DA, Shah A, Relan J, Cheniti G, Kitamura T, Berte B, Mahida S, Sellal JM, Jefairi NA, Frontera A, Amraoui S, Collotand F, Denis A, Derval N, Sacher F, Cochet H, Dubois R, Hocini M, Haïssaguerre M, Klein G, Jaïs P. Atrial tachycardias: Cause or effect with ablation of persistent atrial fibrillation?. J Cardiovasc Electrophysiol. 2018 Feb;29(2):274-283.
  • Lim HS, Hocini M, Dubois R, Denis A, Derval N, Zellerhoff S, Yamashita S, Berte B, Mahida S, Komatsu Y, Daly M, Jesel L, Pomier C, Meillet V, Amraoui S, Shah AJ, Cochet H, Sacher F, Jaïs P, Haïssaguerre M. Complexity and Distribution of Drivers in Relation to Duration of Persistent Atrial Fibrillation J Am Coll Cardiol. 2017 Mar 14;69(10):1257-1269
  • Tucker NR, Mahida S, Ye J, Abraham EJ, Mina JA, Parsons VA, McLellan MA, Shea MA, Hanley A, Benjamin EJ, Milan DJ, Lin H, Ellinor PT. Gain-of-function mutations in GATA6 lead to atrial fibrillation. Heart Rhythm. 2017 Feb;14(2):284-291. doi: 10.1016/j.hrthm.2016.10.014.
  • Yamashita S, Shah AJ, Mahida S, Sellal JM, Berte B, Hooks D, Frontera A, Jefairi NA, Wielandts JY, Lim HS, Amraoui S, Denis A, Derval N, Sacher F, Cochet H, Hocini M, Jaïs P, Haïssaguerre M. Body Surface Mapping to Guide Atrial Fibrillation Ablation Arrhythm Electrophysiol Rev. 2015 Dec;4(3):172-6.
  • Mahida S, Sacher F, Derval N, Berte B, Yamashita S, Hooks D, Denis A, Amraoui S, Hocini M, Haissaguerre M, Jais P. Science Linking Pulmonary Veins and Atrial Fibrillation. Arrhythm Electrophysiol Rev. 2015 May;4(1):40-3.
  • Ma JF, Yang F, Mahida S, Zhao L, Chen X, Zhang ML, Sun Z, Yao Y, Zhang YX, Zheng GY, Dong J, Feng MJ, Zhang R, Sun J, Li S, Wang QS, Cao H, Benjamin EJ, Ellinor PT, Li YG, Tian XL TBX5 mutations contribute to early-onset atrial fibrillation in Chinese and Caucasians. Cardiovascular Research. 2016 Jan 13. pii: cvw003
  • Lim, H Denis A, Middeldorp M, Lau D, Mahajan R, Derval N, Albenque JP, Boveda S, Zellerhoff S, Yamashita S, Mahida S, Berte B, Komatsu Y, Daly M  Jesel L,, Pomier C, Meillet V, Dubois R, Amraoui S , Shah A, Sacher F, Cochet H, Hocini M, Jais  P, Sanders P, Haissaguerre M. Persistent Atrial Fibrillation from the Onset: a Specific Subgroup of Patients with Biatrial Substrate Involvement and Worse Clinical Outcome. JACC Clin Electrophysiol. 2016 Apr;2(2):129-139.
  • Mahida S, Hooks DA, Nentwich K, Ng GA, Grimaldi M, Shin DI, Derval N, Sacher F, Berte, B, Yamashita S, Denis A, Hocini M, Deneke T, Haissaguerre M, Jais, P. nMARQ Ablation for Atrial Fibrillation; Results from a Multicentre Study. J Cardiovasc Electrophysiol. 2015 Jul;26(7):724-9.
  • Lim HS, Zellerhoff S, Derval N, Denis A, Yamashita S, Berte B, Mahida S, Hooks D, Aljefairi N, Shah AJ, Sacher F, Hocini M, Jais P, Haissaguerre M. Noninvasive mapping for atrial fibrillation ablation. Card Electrophysiol Clin. 2015 Mar;7(1):89-98.
  • Mahida S, Berte B, Yamashita S, Derval N, Denis A, Shah A, Amraoui S, Hocini M, Haissaguerre M, Jais P, Sacher F. New Ablation Technologies and Techniques. Arrhythm Electrophysiol Rev. 2014 Aug;3(2):107-12.
  • Mahida S. Genetic Discoveries in Atrial Fibrillation and Implications for Clinical Practice. Arrhythm Electrophysiol Rev. 2014 Aug;3(2):69-75.
  • Mahida S. Expanding Role of SK Channels in Cardiac Electrophysiology. Heart Rhythm. 2014 Mar 25. pii: S1547-5271(14)00337-3.
  • Macri V*, Mahida S*, Zhang ML, Sinner MF, Dolmatova EV, Tucker NR, McLellan M, Shea MA, Milan DJ, Lunetta KL, Benjamin EJ, Ellinor PT. A novel trafficking-defective HCN4 mutation is associated with early-onset atrial fibrillation. Heart Rhythm. 2014 Mar 4. pii: S1547-5271(14)00235-5
  • Lubitz SA, Lunetta KL, Lin H, Arking DE, … Mahida S, …Alonso A, Benjamin EJ, Ellinor PT. Novel genetic markers associate with atrial fibrillation risk in Europeans and Japanese. J Am Coll Cardiol. 2014 Jan 17. pii: S0735-1097(14)00171-5
  • Mahida S Transcription factors and atrial fibrillation. Cardiovasc Res. 2014 Feb 1;101(2):194-202.
  • Mahida S, Ellinor PT. New advances in the genetic basis of atrial fibrillation. J Cardiovasc Electrophysiol. 2012 Dec;23(12):1400-6.
  • Rienstra M, Lubitz SA, Mahida S, Magnani JW, Fontes JD, Sinner MF, Van Gelder IC, Ellinor PT, Benjamin EJ. Symptoms and functional status of patients with atrial fibrillation: state of the art and future research opportunities. Circulation. 2012 Jun 12;125(23):2933-43.
  • Ellinor PT, Lunetta KL, Albert CM, … Mahida S,…, Heckbert SR, Benjamin EJ, Gudnason V, Kääb S. Meta-analysis identifies six new susceptibility loci for atrial fibrillation. Nat Genet. 2012 Apr 29;44(6):670-5.
  • Mahida S, Lubitz SA, Rienstra M, Milan DJ, Ellinor PT. Monogenic atrial fibrillation as pathophysiological paradigms. Cardiovasc Res. 2011 Mar 1;89(4):692-700.

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