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radiation risk

FAQs A-Fib Ablations: Radiation Risks

 FAQs A-Fib Ablations: Radiation Risks 

Catheter Ablation

Catheter 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.”

Back in 2003, exposure to radioactivity during an ablation was a legitimate concern; a typical A-Fib ablation resulted in around 50 minutes of fluoroscopy time.

Today, many centers use much less or no fluoroscopy at all. Instead many use 3D non-fluoroscopy (no radiation) imaging techniques such as Intracardiac Echocardiography (ICE) and/or Magnetic Resonant Imaging (MRI). Check with your A-Fib center as to how much radiation their typical A-Fib ablation patient is exposed to, then compare it to the following points of reference to determine if you should be concerned.

TYPE OF RADIATION EXPOSURE AMOUNT (mSv units)
Average Background Radiation/year 2.4 mSv
Chest X-Ray Radiation 0.02-0.2 mSv
Full-mouth Dental X-Ray 0.03-0.2 mSv
Mammogram 0.7 mSv
Spinal X-Ray Radiation 1.5 mSv
Heart CT Scan Radiation (100-600 Chest X-rays) 12.0 mSv
25.5 min. fluoroscopy during an A-Fib Ablation 15.2 mSv

But bear in mind, even a one hour-long exposure to fluoroscopy is a relatively small risk compared to the risks of being in A-Fib, taking anti-arrhythmic meds, and/or Maze surgery.

Protecting Yourself from Radiation Damage

You can take safeguards before and after your ablation to help protect yourself from radiation damage. Since much of the cancer-causing damage from ionizing radiation is from hydroxyl free radicals, it’s recommended to take antioxidant supplements to neutralize them. A typical plan is to take the following natural supplements every six hours for at least 24 hours before and after your radiation exposure. These are available without a prescription from health food stores. But check with your doctor before taking any supplements.

1.  Vitamin C 1000 mg
2.  Lipoic Acid 400 mg
3.  N-Acetyl Cysteine 200 mg
4.  Melatonin 3 mg

Dr. Leo Galland, MD of the Foundation for Integrated Medicine suggests two additional supplements to reduce the risks of radiation exposure:

• Egb 761 (Tebonin), a Ginkgo extract to be taken a week after being exposed to imaging radiation, 120 mg daily. “Reduced the damaging effects of radiation on chromosomes—and the benefits persisted for several months after workers stopped taking it.”

• The flavonoid Hesperidin, a type of antioxidant, 250 mg about one hour before testing. “In human tests…it reduced radiation-induced damage by about one third.”

Editor’s comment: The nuclear theory that any level of radiation is cumulatively damaging may not be valid (the “Linear No Threshold” theory). The levels of radiation received during a typical catheter ablation may not be dangerous, but may even be healthful. See
Thanks to Stephanie Fagan for this question.

References
¤  Macle, L et al. “Radiation Exposure During Radiofrequency Catheter Ablation for Atrial Fibrillation.” Pacing and Clinical Electrophysiology, March 28, 2003. Volume 26, Issue 1p2, Pages 288-291.
¤  Efstathopoulos et al. “Patient and staff radiation dosimetry during cardiac electrophysiology studies and catheter ablation procedures: a comprehensive analysis.” Europace (The European Society of Cardiology), 2006 8(6): 443-448; doi:10.1093/europace/eul041
¤ Galland, Leo. Guard Against Radiation Danger. Bottom Line/Health, May 2015, p. 9.

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

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

Back to top

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.

Radiation Exposure During Ablation: How to Protect Yourself from Damage

Floroscopy image of catheter placement

Floroscopy image of catheter placement

By Steve S. Ryan, PhD, January 2012

Exposure to radioactivity during an ablation used to be a legitimate concern. (Doctors and nurses wore lead aprons during an ablation.) Back in 2003, a typical A-Fib ablation resulted in around 50 minutes of fluoroscopy time.1 One hour of fluoroscopy imaging is associated with a lifetime three-in-ten thousand chance (0.03%) of developing a fatal malignancy, and a risk of passing on a genetic defect of 20 per 1 million births,2These risks were considered relatively small compared to the risks of being in A-Fib, antiarrhythmic drug therapy, and/or surgery.3

Doctors follow directives which limit the amount of radiation you can be exposed to during an ablation. If you get close to exceeding these limits, they will stop the ablation (though this rarely happens).

Today Less or No Fluoroscopy

But many centers today use much less or no fluoroscopy at all. Instead many use 3D non-fluoroscopy (no radiation) imaging techniques such as Intracardiac Echocardiography (ICE), and Magnetic Resonant Imaging (MRI). You need to check with your A-Fib center as to how much radiation their typical A-Fib ablation patient is exposed to. The radiation dose for a typical A-Fib ablation is estimated to be 18.4 mSv.4 However, the radiation amount at your A-Fib center will vary depending on what type of imaging equipment they use.

Once you learn what amount of ablation radiation you might be exposed to at your A-Fib center, then you can compare it to the following to determine if you should be concerned:

TYPE OF RADIATION EXPOSURE AMOUNT (mSv units)
Average Background Radiation/year 2.4 mSv
Chest X-Ray Radiation 0.02-0.2 mSv
Full-mouth Dental X-Ray 0.03-0.2 mSv
Mammogram 0.7 mSv
Spinal X-Ray Radiation 1.5 mSv
Heart CT Scan Radiation (100-600 Chest X-rays) 12.0 mSv
25.5 min. fluoroscopy during an A-Fib Ablation 15.2 mSv

[The author did a very unscientific survey of the A-Fib medical centers in his area. The average seemed to be 10-20 minutes of fluoroscopy time [for those who used fluoroscopy] for an A-Fib ablation, but more complicated cases could expose patients to 60(+) minutes of fluoroscopy time.]

Before and After:  Protecting Yourself from Radiation Damage

You can take measures before and after your ablation to help protect yourself from radiation damage. Since much of the cancer-causing damage from ionizing radiation is from hydroxyl free radicals, it’s recommended to take antioxidant supplements to neutralize them.

Before and after your ablation, it’s recommended to take antioxidant supplements to neutralize hydroxyl free radicals.

A typical plan is to take the following natural supplements every six hours for at least 24 hours before and after your radiation exposure. These are available without a prescription from health food stores. Check with your doctor before taking any supplements.

  1. Vitamin C 1000 mg
  2. Lipoic Acid 400 mg
  3. N-Acetyl Cysteine 200 mg
  4. Melatonin 3 mg

Do Low Doses of Radioactivity Combat Cancer?

In 2004, the Journal of American Physicians and Surgeons published an amazing study of radiation exposure that calls into question the prevailing “linear no-threshold” (LNT) theory of radiation.5

But bear in mind that, even a one hour-long exposure to fluoroscopy, is a relatively small risk compared to the risks of being in A-Fib, antiarrhythmic meds, and/or surgery.

The story starts 20 years earlier in 1983 when 180 apartment building were built in Taiwan. But somehow highly radioactive Cobalt-60 was mixed into the concrete. The 10,000 people who lived in these apartments for 9-20 years received an average of 74 millesieverts (mSv) of radiation a year (a typical catheter ablation using fluoroscopy produces around 15 mSv6 but much less for non-x-ray imaging systems).

Amazingly, the cancer rates of people living in these highly radioactive buildings were 3.6% of prevailing Taiwanese rates. This is a reduction in cancer rates of 96.4%. This phenomenon is perhaps explained by the theory of hormesis which holds that intermediate levels of radioactivity actually stimulate life and improve health.

Editor’s Note: The nuclear theory that any level of radiation is cumulatively damaging may not be valid (the Linear No Threshold theory). The levels of radiation received during a typical catheter ablation may not be dangerous, but may even be healthful.

The levels of radiation received during a typical catheter ablation may not be dangerous, but may even be healthful.

Back to top

Return to Index of Articles: Catheter Ablation

Last updated: Tuesday, August 23, 2016

 

References    (↵ returns to text)

  1. Macle, L et al. “Radiation Exposure During Radiofrequency Catheter Ablation for Atrial Fibrillation.” Pacing and Clinical Electrophysiology, March 28, 2003. Volume 26, Issue 1p2, Pages 288-291.
  2. Shapira, AR. “Catheter Ablation of Supraventricular Arrhythmias and Atrial Fibrillation.” American Family Physician, November 15, 2009, p. 1089. http://www.aafp.org/afp/2009/1115/p1089.html
  3. Calkins, H. et al. “Radiation exposure during radiofrequency catheter ablation of accessory atrioventricular connections.” Circulation, Vol. 84, 2376-2382, 1991.
  4. Shapira, A R. Catheter Ablation of Supraventricular Arrhythmias and Atrial Fibrillation. American Family Physician, November 15, 2009, p. 1089. http://www.aafp.org/afp/2009/1115/p1089.html.
  5. Chen, W. et al. Is Chronic Radiation an Effective Prophylaxis Against Cancer? Journal of American Physicians and Surgeons, Spring 2004 Vol 9, Issue 1, p6. Last accessed Sept. 13, 2012 http://www.jpands.org/jpands0901.htm
  6. Efstathopoulos, EP, et al. “Patient and staff radiation dosimetry during cardiac electrophysiology studies and catheter ablation procedures: a comprehensive analysis.” Europace (The European Society of Cardiology), 2006 8(6): 443-448; doi:10.1093/europace/eul041

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