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pulmonary vein openings

Multielectrode RF Ablation Catheters

Technology & Innovations

Medtronic multielectrode ablation catheter

Medtronic multielectrode ablation catheter

Multielectrode RF Ablation Catheters

These circular and mesh array shaped catheters are also probably years away from FDA approval. Like balloon catheters they can fit into a pulmonary vein opening and isolate the opening in two or more passes.

These catheters also offer ablation at specific poles to produce pin-point ablation of A-Fib spots in the heart. Currently none of the versions offer internal or external irrigation. (Most RF catheter ablation today uses open irrigation to cool the catheter tip, which allows more energy to be delivered without the limitation of overheating the catheter tip.) (posted 2011)

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Return to Index of Articles: Research and Innovations

Last updated: Sunday, February 15, 2015

FAQs Understanding A-Fib: Questions from Patients

FAQs Understanding Your A-Fib A-Fib.comFAQs: Understanding Atrial Fibrillation

Atrial Fibrillation patients often have loads of “Why?” and “How?” questions. Here are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)

1.  Causes: Why does so much Atrial Fibrillation come from the Pulmonary Vein openings?”

Related Question: Why do older people get Atrial Fibrillation more than younger people?”

Related Question: “What causes Paroxysmal A-Fib to turn into Persistent (Chronic) A-Fib?”

Related Question: “A-Fib and Flutter—I have both. Does one cause the other?”

2.  Hereditary: Is my Atrial Fibrillation genetic? Will my children get A-Fib too?”

3.  PSVT: Is Atrial Fibrillation (A-Fib) different from what doctors call Paroxysmal Supraventricular Tachycardia?”

4.  Adrenergic/Vagal: What is the difference between “Adrenergic” and “Vagal” Atrial Fibrillation? How can I tell if I have one or the other? Does it really matter? Does Pulmonary Vein Ablation (Isolation) work for Adrenergic and/or Vagal A-Fib?”

5.  Heart Condition: “How do I know if I have an enlarged left atrium and what does it mean, if it is? What is the size of a normal left atrium? 

Related Question: Fibrosis:How can I determine or measure how much fibrosis I have? Can something non-invasive like a CT scan measure fibrosis?”

Related Question: Stiff Heart: I’ve heard about ‘stiff heart’ or diastolic dysfunction. When you have A-Fib, do you automatically have diastolic heart failure? What exactly is diastolic dysfunction?”

6.  Stem Cells:I’ve read about stem cells research to regenerate damaged heart tissue. Could this help cure A-Fib patients?”

7.  EF: What is the heart’s ejection fraction? As an A-Fib patient, is it important to know my EF?”

8.  Anesthesia:I read that the local anesthesia my dentist uses may trigger my A-FibWhy is that?”

9.  Treatment Options:My surgeon wants to close off my LAA during my Mini-Maze surgery. Should I agree? What’s the role of the Left Atrial Appendage?”

Related Question: “My cardiologist recommends a pacemaker. I have paroxysmal A-Fib with “pauses” at the end of an event. Will they stop if my A-Fib is cured? I am willing, but want to learn more about these pauses first.”

Related Question: My EP won’t even try a catheter ablation. My left atrium is over 55mm and several cardioversions have failed. I am 69 years old, in permanent A-Fib for 15 years, but non-symptomatic. I exercise regularly and have met some self-imposed extreme goals. What more can I do?

10.  Cure Rate: I have paroxysmal A-Fib and would like to know your opinion on which procedure has the best cure rate.”

If you find any errors on this page, email us. Y Last updated: Saturday, June 16, 2018

Return to Frequently Asked Questions

FAQs Understanding A-Fib: Pulmonary Vein Openings

FAQs Understanding Your A-Fib FAQs Understanding A-Fib: Pulmonary Veins

“Why does so much Atrial Fibrillation come from the Pulmonary Vein openings?”

Perhaps A-Fib signals come from the PV openings because the embryonic origin of the Pulmonary Vein openings (Ostia) is the same as that of the Sinus and AV Nodes. They are similar in structure and have similar smooth muscle tissue.

The Pulmonary Vein openings are electrically active in the heart like the Sinus and AV Nodes but usually beat in sync with them. Disease, viral infections, stretching, fibrosis, or other factors may cause the Pulmonary Vein openings to start beating out of sync with the Sinus and AV Nodes thereby producing A-Fib signals.

Please be advised that the above statement is an observation, an attempt to explain, rather than a medical fact. Further research is necessary to confirm this observation.

Go back to FAQ Understanding A-Fib
Last updated: June 18, 2018

What are the Risks Associated with a Pulmonary Vein Ablation Procedure?

Floroscopy image of catheter placement

Floroscopy image of catheter placement

By Steve S. Ryan, PhD

Pulmonary Vein Catheter Ablation is considered a “low-risk procedure.” In practice, for most A-Fib patients, the actual risks are so small that it’s safer getting a PVA than not getting one. In fact, the catheter-related complication rate fell to less than 2% in 2010. (As a point of reference, the complication rate of the common appendectomy is 18%.)

A PVA is safer and certainly feels a lot better than a life in A-Fib and/or a life on antiarrhythmic drugs and anticoagulants. One reason people get a PVA is so that they don’t have to live the rest of their lives on these drugs.

Risks Step By Step

1. When the catheters are inserted, there is a “small risk” of damaging the veins and/or arteries which could cause bleeding. This can be repaired surgically. It’s similar to, though obviously not the same as, the risk you take when you donate blood.

Your groin will generally have two access site points, one on each side. After a Pulmonary Vein Ablation, some minor bruising is common at each site with minor soreness as if you had banged the area. Bruising may occasionally be seen to extend down the leg. This is normal as is an occasional small quarter sized bump in the area. (If larger swelling or more significant pain occurs at the area, please contact the electrophysiologist who did the procedure.)

2. To get to the left atrium which is usually the source of most A-Fib signals, the doctor must pass the catheter through the transseptal wall between the left and right atria. This puncture technique and the catheter manipulation involved in the actual ablation increase the chance of heart puncture and bleeding through the heart walls (tamponade). If this happens, blood may fill the sac surrounding the heart (the pericardium) and may have to be drawn off with a needle and catheter. Very rarely, surgery may be required. The more experienced and skillful your doctor is, the less this catheter manipulation is a risk.

Note: The doctors don’t just punch through the transseptal wall. The catheter is often inserted through a membrane formed when your heart developed as a fetus. In early fetal development your two atria weren’t completely separate. As the transseptal wall formed, this opening between the two atria (the foramen ovale) closed up to form what is called the fossa ovalis. The catheter is inserted through this former opening or membrane. After the ablation procedure, this membrane closes back up and heals over.
[In some adults like Tedy Bruschi, linebacker of the New England Patriots, this foramen ovale opening between the two atria doesn’t grow closed. This allows small blood clots that otherwise would be absorbed in the lungs to pass from one atrium to the other, and then travel to the brain. It’s estimated that nearly 20% of adults have a foramen ovale opening between the two atria that never closes up completely.]

For most A-Fib patients, the actual risks are so small that it’s safer getting a PVA than not getting one.

3. As in A-Fib, there is a risk of blood clotting and stroke, which is why most medical centers use a blood thinner like Heparin during the procedure to prevent clotting during the application of RF energy to heart tissue. Also, before an ablation procedure a patient is often checked to see if there is any pooling or clotting of blood in the atria. If any clots are found, medications can be used to dissolve them. According to figures from the French Bordeaux group, “the risk for thromboembolic (stroke) events is lower than 0.5%.”

4. When the pulmonary vein openings are ablated or isolated, there is a risk of damaging and narrowing these vein openings. If a significant amount of this swelling (Stenosis) occurs, the doctors may have to stretch the narrowed area or insert a stent to keep the veins open. This ability to correct Stenosis correspondingly lessens your risk.

[Note: In the early days of Pulmonary Vein Ablations, Stenosis (defined as over 50% narrowing of the vein opening) was a major problem. But with more experience, the use of irrigated-tip low wattage catheters, and ablating in the antrum area outside of the Pulmonary Vein openings, it is less of a problem. Ask the doctor or medical center you are working with how often Stenosis occurs due to their ablation procedures and how severe it generally is. If they can’t provide those figures, think about going somewhere else. You will find that most major medical centers now have fairly low rates of Stenosis.]

5. A possible risk to consider is the amount of X-ray exposure during an ablation procedure. Most catheter ablation procedures use fluroscopy, a type of X-ray with a fluorescent screen, to see inside the heart and to position the catheter(s). Many medical centers have limits to how much fluroscopy you can be exposed to and will stop a procedure if you exceed it.

[Since this article was written in 2010: Many centers are now using non-fluroscopy type imaging such as MRI which greatly reduces the amount of X-ray exposure.]

6. Then there is the unforeseen, the strange things that happen sometimes in operations―allergic reactions to medications, anesthesia problems (some centers put you under completely, others don’t, “extremely small risk of infection, valve damage, or heart attack” during the procedure. But the doctors and staff are prepared to deal with emergencies and complications and they monitor you very closely.

What’s the Risk of Dying?

There is very little risk of dying from a Pulmonary Vein Ablation (Isolation) procedure. “To the best of our knowledge, no deaths have been reported in the literature in more than 2000 PV isolation procedures.” Recently, however, there have been 20+ deaths reported due to a very rare complication called “atrial-esophageal fistula” where a hole forms between the atrium and the esophagus within 2-3 weeks after the ablation. Heat from the ablation catheter may irritate the esophagus where it rests next to the heart. Over time acid reflex may eat through this weakened area of the esophagus. This may be due to using high wattage catheters in the back of the atrium near the esophagus. If you develop unexplained fevers exceeding 100 degrees anytime within the first 3 weeks post-ablation, you need to contact the electrophysiologist who performed your procedure. Low grade fevers of around 99 degrees are common in the first day or so post-ablation.

After an ablation, many centers give patients a Proton Pump Inhibitor (PPI) (such as Nexium) to prevent stomach acids from affecting the esophagus. If your center doesn’t do that, you can take a Proton Pump Inhibitor yourself for 2-3 weeks after your ablation. In the U.S. one doesn’t need a doctor’s prescription to buy a PPI. Added 9/11/17: Cecelia writes that taking the Proton Pump Inhibitor omeprozole (Prilosec) caused her muscle weakness, weak legs and arms (and anxiety). She took it for six weeks during her blanking period after her ablation to protect the esophagus. Pantoprozole (Protonix) seemed to have the same effect on her. Muscle weakness is listed as a possible side effect of reflux meds.

Rare Complications

Another rare complication is damage to the Phrenic nerve in the Pericardium around the heart due to heat from the ablation catheter. This may result in breathing difficulties. Many centers now pace the diaphragm during the ablation to prevent phrenic nerve injury.

An even more rare complication is getting the loop/mapping catheter caught in the mitral valve. In some cases it may require open heart surgery to remove it. The more experienced and skillful your doctor is, the less likely this is to happen. (When talking with a potential ablation doctor, you may want to ask how often do the doctor’s patients have to be taken for open heart surgery.)

After a Pulmonary Vein Ablation you may have some minor chest pain for the next week or so. The pain will often worsen with a deep breath or when leaning forward. This is pericardial chest pain from the ablation and is generally not of concern. It should resolve within a week although it might increase for a day or so after the ablation.

Since Pulmonary Vein Ablation is a relatively new procedure, we don’t have much data yet on long term risks. One long term study of Pulmonary Vein Ablations (Isolations) has indicated that many of the bad remodeling effects of A-Fib such as enlargement of the left atria and the ability of the atria to contract can be reversed after a successful PVA(I).

AF Symposium: In-depth Review of Ablation Complications

For a more extensive catalog of every conceivable complication, even the most rare, see Catheter Ablation Complications: A 2014 In-depth Review and Comparison with Anticoagulation Drug Therapy 

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Return to Index of Articles: Catheter Ablation

Last updated: Monday, September 11, 2017

References for this Article
Updated March 2013

• Atrial Fibrillation Educational Material. University of Pennsylvania. 2002, p.7.

• ]Jais, P. “Ablation Therapy for Atrial Fibrillation: Past, Present and Future,” Cardiovascular Research, Vol. 54, Issue 2, May 2002, P. 343.

• Atrial Fibrillation Educational Material. University of Pennsylvania. 2002, p.7.

• Jais, P. “Ablation Therapy for Atrial Fibrillation: Past, Present and Future,” Cardiovascular Research, Vol. 54, Issue 2, May 2002, P. 343.

• Catheter Ablation for AF. The London AF Centre. Last accessed November 5, 2012

• Romano, M. A. et al.Atrial reduction plasty Cox maze procedure: extended indications for atrial fibrillation surgery. Ann Thorac Surg 2004;77:1282-1287. Accessed Nov 4, 2014.

• Pappone, C. et al. “Circumferential Pulmonary Vein Ablation for Atrial Fibrillation: the Milan Experience,” Cardiac Electrophysiology and Pacing Unit of the Department of Cardiology, San Raffaele University Hospital, Milan, Italy. 2003. p. 7.

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