In his 2015 AF Symposium presentation, Dr. Pierre Jais makes reference to the typical progression of a catheter ablation procedure. You may ask, what does he mean? What is the typical progression of an ablation?
Goals of Catheter Ablation for A-Fib
Just a reminder: the main goals of catheter ablation of A-Fib are to restore the heart to normal sinus rhythm and eliminate the symptoms of A-Fib. This also relieves the patient from the associated risks such as blood clot formation, stroke and increased risks of dementia and mortality.
The main goals of catheter ablation of A-Fib are to restore the heart to normal sinus rhythm and eliminate the symptoms of A-Fib.
Progression of a typical ablation for Persistent A-Fib:
• First, the sources of the rogue A-Fib electrical signals are mapped using a computerized system.
• The tip of the catheter is then maneuvered to the various sources of the A-Fib signals (usually starting with the openings to the pulmonary veins). Using RF energy (or Cryo) a tiny burn or lesion is made at each location to disrupt (or ablate) the electrical pathway.
• As the series of lesions progress, more and more of the A-Fib signals stop. OR, A-Fib signals may transition into Atrial Flutter which is a more stable and less erratic heart rhythm.
• At this point it is not uncommon for some A-Fib signals to continue. So, one or more rounds of mapping and ablation may be required to stop any remaining sources of arrhythmic signals.
• Finally, the heart typically transitions to either a stable atrial tachycardia (a fast, but regular heartbeat) OR transitions into normal sinus rhythm (NSR).
After the Ablation
While many patients will be in normal sinus rhythm (hurray!), some patients will be in stable atrial tachycardia (a fast and regular heartbeat)—but here’s the important part— they are NOT in A-Fib. This is still a good result!
Why? If you’re in stable atrial tachycardia, with rhythm or rate control medication your heart will typically heal itself over the following three months—called the ‘blanking period’ (or up to a year) and on its own return to normal sinus rhythm (NSR). (That’s why you shouldn’t rush to decide if your ablation is a success until several months post-ablation.)
For more about catheter ablation see, The Evolving Terminology of Catheter Ablation
See also, Dr. Pierre Jais’ 2015 AF Symposium presentation “The Spectrum of Atrial Tachycardias Following Ablation of Drivers in Persistent AF.”
17. “Since my ablation, my A-Fib feels worse and is more frequent than before, though I do seem to be improving each week. My doctor said I shouldn’t worry, that this is normal. Is my ablation a failure?”
It takes about three months to know if your ablation is a success. It takes that long for your heart to heal. For a period of time (which varies from patient to patient) your A-Fib may seem to get worse. Why?
Inflammation: This happens in some people because of the inflammation and trauma to the heart and body tissues caused by the catheter ablation burns and the poking around in your heart during the procedure. These can seem to exacerbate your A-Fib. (An ablation procedure doesn’t create new A-Fib producing areas in your heart, though it may stir up existing A-Fib areas temporarily.)
There is a tendency for ablated heart tissue to heal itself, re-grow the ablated area, reconnect, and start producing A-Fib signals again.
Gaps and Scar Tissue: Another reason you may still have A-Fib is because of gaps in the ablation lines. In the most common A-Fib ablation procedures used today, doctors try to create ablation lines around your pulmonary vein openings to isolate them from the rest of your heart. (A-Fib producing areas are usually found inside your pulmonary vein openings.) But it’s difficult making continuous, perfect ablation lines. Sometimes there are gaps in those lines which let A-Fib signals through. But as your heart heals, these gaps usually fill in gradually with scar tissue that reaches its thickest size at the end of three months.
Milestones: In general, if you’re in sinus rhythm after the third month, the chances are good you’ll stay in sinus rhythm. If you’re in sinus rhythm after the sixth month, the chances of a reoccurrence of A-Fib are even less.
Remember—it isn’t the end of the world if your ablation isn’t a total success. There is a tendency for ablated heart tissue to heal itself, re-grow the ablated area, reconnect, and start producing A-Fib signals again.
Second Ablation: Many people (as many as 15%-25%) have to go in for a ‘touch up’ ablation procedure (including myself). This second ablation is usually, though not always, easier than the first. Often all the doctor has to do is ablate any gaps that haven’t filled in or ablate where there has been re-growth/re-connection. This usually isn’t the doctor’s fault. Heart tissue is very tough and has a tendency to heal itself.
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