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electrical signals

FAQs A-Fib Ablations: Hot Spots Beyond the Pulmonary Veins?

 FAQs A-Fib Ablations: Hot Spots 

Catheter Ablation

Catheter Ablation

22. “Are there other areas besides the pulmonary veins with the potential to turn into A-Fib hot spots? I had a successful catheter ablation and feel great. Could they eventually be turned on and put me back into A-Fib?

My answer is going to be somewhat speculative, because right now we don’t have the research necessary to give a definitive answer.

After a successful PVI, your Pulmonary Vein Openings have probably been well isolated. Most A-Fib comes from the PVs, some say as much as 95% in cases of paroxysmal A-Fib such as yours. Unless some gap develops in the ablation burns or freezing around your PVs, you probably won’t develop A-Fib coming from your PVs again. As far as we know today, your PVs have been “immunized” against A-Fib by the PVI. Though nothing is guaranteed.

PVs Structurally Similar to Sinus Node

The probable reason most A-Fib comes from the Pulmonary Vein openings is they are related embryonically to the Sinus Node and usually beat in sync with it. But something goes wrong, and they start beating on their own. If your PVs are well isolated, someone in good heart health like you is probably protected for life, barring unforeseen deterioration of your health.

Pre-Existing Health Problems

On the other hand, people not in good health, who have pre-existing medical conditions like uncontrolled hypertension, obesity, sleep apnea, diabetes or who are heavy drinkers or who smoke, are more likely to have a recurrence of A-Fib after a catheter ablation. Though they have been made A-Fib free, the pre-existing conditions that caused or triggered their A-Fib are still there and may develop A-Fib spots in other parts of their heart.

Three Tiers of Propensity

The PVs are the most likely area or the areas in the heart with the most propensity to develop A-Fib, what I call ‘the first tier of propensity’ (or tendency or predisposition). A ‘second tier’ closely related to the PVs are other thoracic veins such as the Superior Vena Cava (SVC) and the Coronary Sinus (CS). (When EPs are inside your heart ablating your PVs, they usually also look at areas like the SVC and CS to see if there is anything amiss.) The ‘third tier of propensity’ is almost any other area of your heart.

[This is a “Ryan” hypothesis yet to be proven by scientific studies.You will not read in medical journals anything about “tiers of propensity.”]

Third Tier A-Fib Hot Spots Can Appear Almost Anywhere

In the case of someone in A-Fib for a long time, their atria are no longer normal. Their heart has been modified (remodeled) by A-Fib or by some other disease. Electrically and structurally their heart has changed (e.g., fibrosis and left atrial enlargement). Other A-Fib hot spots or potentials, besides in the PVs, can develop. But these ‘third tier propensity’ hot spots can appear almost anywhere.

We don’t yet know why these third-tier triggers develop in one spot compared to another. It may relate to specific genes which control the electrical properties of the atrial cells. If you look closely at these trigger spots, they are relatively small groups of atrial cells that are mysteriously capable of generating burst of electrical waves at an excessively high rate. They frequently generate waveforms like rotors. Some researchers describe these areas of electrical activity as Complex Fractionated Atrial Electrograms (CFAEs). Advanced ablation strategies have been developed to identify and ablate these trigger areas, but we still have a lot to learn about them.

In your case, the chances of developing “third tier propensity” hot spots is remote. You had Lone paroxysmal A-Fib with no pre-existing health problems and are in good health and heart health. It would probably take something major to push you into developing “third tier propensity” A-Fib hot spots. If you stay that way, you have a good chance of staying A-Fib free. But as we age or develop health problems, things obviously can change.

Thanks to Barry Schwartz for this excellent question.

 

Return to FAQ Catheter Ablations

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