"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

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Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"


"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013

hot spots

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

FAQs A-Fib Treatments: Catheter Ablation Procedures

Catheter ablation illustration at A-Fib.com

Catheter ablation

Atrial Fibrillation patients seeking a cure and relief from their symptoms often have many questions about catheter ablation procedures. Here are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer)

1. “I have a defective Mitral Valve? Is it causing my A-Fib? Should I have my Mitral Valve fixed first before I have a PVA?

2. “With the recent improvements in Pulmonary Vein ablation techniques, should I wait for a better technique? I’m getting by with my Atrial Fibrillation.”

3. “Are there different types of “Pulmonary Vein Ablation”? Are they different from “Pulmonary Vein Isolation?

4. I’’ve heard of Cryo (freezing) catheters for PVA(I) ablations. Are they good or better than the RF (Radio Frequency) catheters for ablations?

5. “How dangerous is a Pulmonary Vein Ablation procedure? What are my risks?

6. “During the ablation procedure A-Fib doctors actually burn within the heart with RF energy. How does this burning and scarring affect how the heart functions? Should athletes, for example, be concerned that their heart won’t function as well after an ablation?

7. “How dangerous is the fluoroscopy radiation during an ablation? I know I need a Pulmonary Vein Ablation (Isolation) procedure to stop my A-Fib—A-Fib destroys my life. I can’t work or exercise, and live in fear of the next attack. Antiarrhythmic meds cause me bad side effects. But I’m worried about being exposed to radiation during the ablation.

8. “I have serious heart problems and chronic heart disease along with Atrial Fibrillation. Would a Pulmonary Vein Ablation help me? Should I get one?

9. “What is an enlarged heart? Does it cause A-Fib?. I was told I can’t have a Pulmonary Vein Ablation (Isolation) procedure because I have an enlarged heart. Why is that?”

10. “I am 82 years old. Am I too old to have a successful Pulmonary Vein Ablation? What doctors or medical centers perform PVAs on patients my age?

11. “Since my PVI, I have been A-Fib free with no symptoms for 32 months. What do you think my chances of staying A-Fib free are?”

12. “How long before you know a Pulmonary Vein Ablation procedure is a success? I just had a PVA(I). I’ve got bruising on my leg, my chest hurts, and I have a fever at night. I still don’t feel quite right. Is this normal?”

13. I want to read exactly what was done during my Pulmonary Vein Ablation. Where can I get the specifics? What records are kept?

14. “What is the typical length of a catheter ablation today versus when you had your catheter ablation in 1998 in Bordeaux, France? What makes it possible?

15. “After my successful Pulmonary Vein Ablation, do I still need to be on blood thinners like Coumadin or aspirin?

16. “I’ve had a successful ablation. For protection against potential stroke risk if my A-Fib re-occurs, which if better—81 mg baby aspirin or 325 mg?

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?

18. “I love to exercise and I’m having a PVA. Everything I read says ‘You can resume normal activity in a few days.’ Can I return to what’s ‘normal’ exercise for me?

19. I have Chronic Atrial Fibrillation (the heart remains in A-Fib all the time). Am I a candidate for a Pulmonary Vein Ablation? Will it cure me? What are my chances of being cured compared to someone with Paroxysmal (occasional) A-Fib?

20. “I’m 80 and have been in Chronic (persistent/permanent) A-Fib for 3 years. I actually feel somewhat better now than when I had occasional (Paroxysmal) A-Fib. Is it worth trying to get an ablation?

21.“Will an ablation take care of both A-Fib and Flutter? Does one cause the other? Which comes first A-Fib or Flutter?

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

23. “During an ablation, how much danger is there of developing a clot? What are the odds? How can these clots be prevented?

24. “I was told that I will have to take an anticoagulant for about 2-3 months after my ablation. After all, if fibrillation episodes are reduced or eliminated after an ablation, shouldn’t there be even less need for a prescription anticoagulant rather than more?

25. “I’m six months post CryoBalloon ablation and very pleased. But my resting heart rate remains higher in the low 80s. Why? I’ve been told it’s not a problem. I’m 64 and exercise okay, but I’ve had to drop interval training.”

26. “I’ve heard good things about the French Bordeaux group. Didn’t Prof. Michel Häissaguerre invent catheter ablation for A-Fib? Where can I get more info about them? How much does it cost to go there?

27. “I’m a life-long runner. I recently got intermittent A-Fib. Does ablation (whether RF or Cryo) affect the heart’s blood pumping output potential because of the destruction of cardiac tissue? And if so, how much? One doc said it does.

Last updated: Thursday, September 8, 2016

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