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Persistent A-Fib

In Persistent A-Fib? Time Matters: Ablate Sooner for Better Outcomes

Note: This research study is important if you have Persistent A-Fib or your Paroxysmal A-Fib has progressed to Persistent A-Fib.

The Cost of Waiting to Ablate

In patients with persistent atrial fibrillation undergoing ablation, the time interval between the first diagnosis of persistent A-Fib and the catheter ablation procedure had a strong association with the ablation outcomes.

Cleveland Clinic researchers found that shorter diagnosis-to-ablation time spans were associated with better outcomes. Longer diagnosis-to-ablation times was associated with a greater degree of atrial remodeling.

When A-Fib becomes persistent A-Fib, the ‘first diagnosis-to-ablation time span’ had a stronger impact on outcomes than the time spent in paroxysmal A-Fib.

According to electrophysiologist Dr. Oussama Wazni, “once the diagnosis of atrial fibrillation is made, it’s important not to spend too much time trying to keep a patient in normal rhythm with medical [drug] therapy” before referring for radio-frequency ablation.” Dr. Wazni is Co-Director of the Center for Atrial Fibrillation at the Cleveland Clinic.

His comments are based on the published analysis of two-year outcomes among 1,241 consecutive patients undergoing first-time ablation of persistent atrial fibrillation over an eight-year period at Cleveland Clinic. All patients had successful isolation of all 4 PVs (pulmonary veins), and the superior vena cava was isolated in 69.6%. In addition, Left Atrium ablations (including complex fractionated electrograms) were performed in 65.6% of patients.

First Diagnosis-to-Ablation Time Span: The Shorter the Better

Importantly, the first diagnosis-to-ablation time interval (of persistent A-Fib) had a stronger impact on outcomes than the time spent with a paroxysmal A-Fib diagnosis or the duration of continuous A-Fib before the ablation procedure.

These findings suggest that A-Fib is a disease with a continuous spectrum…
The findings suggest that A-Fib is a disease with a continuous spectrum, with patients at the extreme end of that spectrum having higher arrhythmia recurrence rates after catheter ablation, whereas patients with shorter diagnosis-to-ablation times having lower recurrence rates.

The analysis was published in the Jan. 2016 issue of Circulation: Arrhythmia and Electrophysiology. (Read online or download as a PDF.)

Reference for this Article

FAQs Coping with A-Fib: Living in A-Fib vs. Ablation

 FAQs Coping with A-Fib: Living in A-Fib

FAQs A-Fib afib“In one of your articles it said that having an ablation was better than living in A-Fib.  If your article means all types of A-Fib including Paroxysmal, then I will consider an ablation.

I’m 73 years old and have Paroxysmal A-Fib. I’ve been taking 75 mg of propafenone 3X/day for seven years and have only had 5 A-Fib attacks in 7 years.

You really aren’t living in A-Fib. You’re taking an antiarrhythmic treatment meant to stop or limit your A-Fib. (Unlike rate-control drugs which only try to limit or control heart rate while leaving you in A-Fib.) For now it’s working fairly well for you.

Drug therapy tends to become ineffective or stop working over time.

Five A-Fib attacks in seven years is very few. With paroxysmal A-Fib like yours, most doctors would say to continue on propafenone till you start having more or longer A-Fib attacks.

(As a point of reference, about 54% of those in paroxysmal A-Fib will go into permanent A-Fib within one year. You’ve made it 7 years!)

A-Fib is a progressive disease that tends to get worse over time.

Consider this. By the time propafenone loses its effectiveness (which is probably inevitable), how permanently damaged will your heart be? How much will your A-Fib have progressed? Will your A-Fib be harder to cure than if you had had a catheter ablation earlier? 

For future reference, you need to know the physical diameter or stretching of your left atrium.

What to Do Now

You need to know the physical diameter or stretching of your left atrium. Electrophysiologists normally perform this measurement when giving patients a stress and Echo test.

For your own records, you should get the actual physical diameter measurement in mm or cm and/or the volume of your left atrium. Don’t settle for words like “mildly dilated” or “normal.” You want a benchmark measurement to compare to in the future.

Check for “silent” no-symptom A-Fib which you aren’t aware of. ‘Silent A-Fib’ is common. Up to 30%−50% of A-Fib patients are unaware they have A-Fib, often only learning about their Atrial Fibrillation during a routine EKG in their doctor’s office. 

Ask your doctor to check for ‘Silent A-Fib’ because it puts you at risk for blood clots and stroke.

Any type of longer-term monitoring (such as a Zio patch which you wear like a Band-Aid for 1-2 weeks or the Reveal Insertable Cardiac Monitor which is inserted just under your skin) could give you this info.

It’s important to know if you have ‘Silent A-Fib,’ because it puts you at risk for blood clots and stroke.

The Bottom Line. Propafenone may be just prolonging the inevitable. Since you now have very few A-Fib attacks, you would probably be a relatively easy fix with a catheter ablation.

On the other hand, you may be one of the fortunate few who will never progress into more serious A-Fib. Everybody’s A-Fib is unique.

See 2015 AF Symposium: Living in A-Fib More Dangerous Than Having an Ablation. Thanks to Thomas Scheben for this question.

If you find any errors on this page, email us. Y Last updated: Monday, February 13, 2017
Back to FAQs: Coping with Your A-Fib

AF Symposium 2015: Clues to Finding Drivers When Ablating for Persistent A-Fib

Pierre Jais MD

Pierre Jais MD

In my new report, Dr. Pierre Jais of the French Bordeaux/LIRYC group describes a research study of ablations performed on 50 patients with persistent A-Fib. He shares the insights he learned using the CardioInsight mapping system (ECGI) to map and ablate A-Fib signal drivers.

First, a little background. During an ablation procedure, A-Fib signals are mapped and lesions made to eliminate the signal drivers. After this initial effort, it is not uncommon for some arrhythmias signals to continue. So, another round of time-consuming mapping, analysis and diagnosis is needed.

Dr. Jais describes how he used the research data from the ECGI and learned how to anticipate the probable location of these additional A-Fib signals.

This is a very important clue for doctors and patients. It helps doctors spend less time mapping and ablating these additional sources of A-Fib signals. The benefit to the patient is a shorter ablation procedure time and fewer lesions (burns) to eliminate the A-Fib signals.

To learn more, see my 2015 AF Symposium report, see Persistent A-Fib: Insights into Finding Additional Drivers May Shorten Ablation Procedures with Fewer Lesions.

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