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"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."

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pulmonary veins

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

Return to FAQs

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

2. Is my Atrial Fibrillation genetic? Will my children get A-Fib too? Updated!

3. Why do older people get Atrial Fibrillation more than younger people?

4. Is Atrial Fibrillation (A-Fib) different from what doctors call Paroxysmal Supraventricular Tachycardia?

5. 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?

6. What causes Paroxysmal (occasional) A-Fib to turn into Persistent (Chronic) A-Fib?

7. 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?

8. A-Fib and Flutter—I have both. Does one cause the other?” 

9. “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?” 

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

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

12. “I read that the local anesthesia my dentist uses may trigger my A-Fib. Why is that?”

13. “How can I determine or measure how much fibrosis I have? Can something non-invasive like a CT scan measure fibrosis?

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

15. I have paroxysmal A-Fib and would like to know your opinion on which procedure has the best cure rate. NEW!

Last updated: Monday, August 8, 2016

Return to Frequently Asked Questions: Coping with A-Fib

FAQs Understanding A-Fib: Pulmonary Vein Openings

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

1. “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

Renal Sympathetic Denervation (RSDN) for A-Fib? – 2014 Boston AF Symposium

Vivek Reddy Mt Siani Hospital

Dr Vivek Reddy Mt Sinai Hospital

Boston AF Symposium 2014

Renal Sympathetic Denervation (RSDN) for A-Fib?

Report by Steve S. Ryan, PhD Dr. Vivek Reddy of Mount Sinai School of Medicine, NY gave a presentation entitled “Renal Denervation for AF—Physiology, Mechanisms of Action and Rational in AF.”

RSDN Found Ineffective, Symplicity HTN-3 Trial

Background: (Before reading this report, it is recommended to first look at the our 2014 BAFS satellite presentation “Renal Denervation and Pulmonary Vein Isolation for PAF.)
Earlier in the Symposium, the results of the Medtronic Symplicity HTN-3 trial were announced and discussed. Medtronic’s renal denervation system was found to be basically no better than a sham procedure for reducing systolic blood pressure through six months.
Dr. Reddy described how previous surgical interventions (Thoracolumbar Surgical Sympathectomy—destroying some of the sympathetic nerve trunk) did reduce blood pressure by affecting the Sympathetic Nerves (Smithwick et al. JAMA 1953;152(16);1501-4). And the clinical trial Symplicity HTN-2 did work—84% of patients had a 10 mmHg or greater decrease in Systolic Blood Pressure (Esler et al. Lancet 2010;376(9756): 1903-9)
Then why was Symplicity HTN-3 a negative study? Was the catheter not properly employed? (Dr. Reddy described a new method of performing RSDN by using External Ultrasound Energy which has a minimal effect on the arterial wall.) Is refractory hypertension not primarily “sympathetically-driven?”

Does RSDN do anything?—Mechanistic Data

•  In a small study of patients with refractory high blood pressure (HBN) that couldn’t be lowered by drugs and other methods, RSDN did significantly lower high blood pressure (Brandt et al. JACC 59:901 [2012]).

•  In another study RSDN lowered blood pressure and Muscle Sympathetic Nerve Activity (MSNA) (Achlaich et al. NEJM 36:932-934 [2009])

•  In another study RSDN lowered renal hormones like Aldosterone, Metanephrine and Normetanephrine (Ahmed H/Neuzil P/Reddy VY: JACC-CV Interv 5:758-65 [2012])

•  RSDN improved heart rate variability (F. Himmel et al. J.Clin.HTN 14:654 [2012]}

Supporting Evidence for RSDN Helping A-Fib

•  Experimental studies of sheep show that high blood pressure (hypertension) produces fibrosis (interstitial collagen) and remodeling of the atria. (Heart Rhythm 2010;7:1282-1290)

•  In the ARIC study of nearly 15,000 people followed for 17 years, high blood pressure accounted for 20%-25% of all A-Fib cases (other factors were Obesity, Diabetes, Smoking and Prior Cardiac Disease). (Huxley et al Circulation 123:1501-1508 [2011])

•  Hypertension was the most significant predictor of recurrence after A-Fib ablation (Takigawa et al. JRAS, DOI: 10.1177/1470320312446212 [2012])

•  Sympathetic Nervous System overactivity predicted A-Fib recurrence (Arimoto et al. JCE [2011])

•  In Dr. Pokushalov’s work described under 2014 BAFS Satellite Presentations-Siberia, PVI with RSDN had much less recurrence than just a PVI (Pokushalov et al. JACC [2012])

But What About A-Fib Patients without High Blood Pressure—Would RSDN Help Them?

•  In a small experimental study using dogs, RSDN kept the dogs from going into A-Fib and reduced renal hormones (Q.Zhao et al. JICE [2012; DOI 10.1007/s10840-012-9717-y).

•  In another dog study, RSDN ameliorated pacing-induced changes in hormones and tissue structure (X.Wang et al. PloS ONE 8(5): e64611 [2013])

•  In a study of Obstructive Sleep Apnea in pigs, RSDN helped blood pressure and reduced A-Fib when the pigs had induced sleep apnea.(Linz et al. Hypertension 62:767 [2103])

Renal Sympathetic Denervation as Upstream Therapy in A-Fib?

Dr. Reddy described a multi-center randomized study of A-Fib and Hypertension. Patients with A-Fib and hypertension will have a catheter ablation procedure (PVI). Then some will be in the placebo group and others will have a RSDN procedure. Follow-up will measure A-Fib recurrence. (H Ahmed/MA Miller/VY Reddy, JCE 25:503-9 [2013]). The rational for this study is that Renal Denervation can dramatically affect sympathetic tone, is technically simple to do, and has minimal safety issues. In an earlier study, Renal Denervation significantly reduced blood pressure after three months (Ahmed H / Neuzil P / Reddy VY: JACC-CV Interv 5:758-65 [2012])

Dr. Reddy’s Final Thoughts

•  RSDN is a novel approach to modulate the sympathetic nervous system (one of several)

•  Many animal studies demonstrate the electrophysiological effects of RSDN

•  Potential Role for RSDN in A-Fib—Reduce A-Fib recurrence

Editor’s Comments:
In spite of the preliminary results of Symplicity HTN-3, Renal Denervation is not dead in the water. The full results of Symplicity HTN-3 haven’t been released and examined yet. And the new multi-center randomized study Dr. Reddy described may yet prove the effectiveness of RSDN.
Renal Denervation, in addition to helping people with high blood pressure and A-Fib, may benefit anybody with A-Fib. Because Renal Denervation is easy to do and relatively safe, RSDN may become another treatment option for A-Fib.

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Last updated: Wednesday, September 2, 2015 

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.1 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.

Risk Step By Step

1. When the catheters are inserted, there is a “small risk”2 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 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. 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%.”3

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 risks 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”4 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.”5 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.6 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.

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 injury7

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 does 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).8

Boston AF Symposium: In-depth Review of Ablation Complications

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

Updated March 2013

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Return to Index of Articles: Catheter Ablation

Last updated: Monday, February 1, 2016

[[7]]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. http://www.annalsthoracicsurgery.org/article/S0003-4975(03)01928-3/abstract

References    (↵ returns to text)
  1. Atrial Fibrillation Educational Material. University of Pennsylvania. 2002, p.7.
  2. Ibid
  3. Jais, P. “Ablation Therapy for Atrial Fibrillation: Past, Present and Future,” Cardiovascular Research, Vol. 54, Issue 2, May 2002, P. 343.
  4. Atrial Fibrillation Educational Material. University of Pennsylvania. 2002, p.7.
  5. Jais, P. “Ablation Therapy for Atrial Fibrillation: Past, Present and Future,” Cardiovascular Research, Vol. 54, Issue 2, May 2002, P. 343.
  6. Catheter Ablation for AF. The London AF Centre. Last accessed November 5, 2012 http://www.londonafcentre.co.uk/catheter_ablation/
  7. 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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