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recurrence

Recurrence: Odds of Staying A-Fib Free After Ablation

I’ve updated and expanded the answer to a Frequently Asked Question about recurrence of your A-Fib after a successful ablation:

Illustration of catheter ablation

Illustration of catheter ablation

“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?”

I think your chances of staying A-Fib free are pretty good.

A PVI is Like a Kind of Immunization Against A-Fib

If your Pulmonary Veins (PV) are well isolated and stay that way, you can’t get A-Fib there again. When the PVs are isolated and disconnected and haven’t reconnected, it seems to be permanent. But it’s too early in the history of PVA(I)s to say this definitively.

NOTE: PVA(I) is a relatively new procedure. I had my catheter ablation in 1998 and I’m still A-Fib free today. However, at that time of my ablation, only one of my Pulmonary Veins was isolated, so in theory, the other veins could start producing A-Fib signals—but that hasn’t happened.

Regrowth/Reconnection of Ablated Heart Tissue

There is a tendency for ablated heart tissue to heal itself, regrow the ablated area, reconnect, and start producing A-Fib signals again. But if this happens, it usually occurs within the first three to six months of the initial PVA(I).

Recent research indicates that for a small number of people, a successful Pulmonary Vein Ablation (Isolation) procedure may not be a permanent “cure.” Dr. Francis Marchlinski of the University of Pennsylvania…read the rest of Steve answer.

FAQs A-Fib Ablations: Recurrence or Reconnection Explained

 FAQs A-Fib Ablations: Recurrence 

Catheter Ablation

Recurrence after Catheter Ablation

26. “What is ‘recurrence’ or ‘reconnection’? Could you explain it in layman’s terms? (I worry after my ablation, my A-Fib will return.)”

“Recurrence” or “Reconnection” is a general term EPs use to describe any A-Fib that re-occurs after a catheter ablation. In practice, there are four basic types of recurrence or reconnection found primarily when using RF point-by-point ablation:

1. Self-Healing Recurrence/Reconnection. Heart tissue is very tough and resilient. There is a tendency for ablated heart tissue to heal itself, regrow the ablated area, reconnect, and start producing A-Fib signals again. But if this happens, it usually occurs within approximately the first three to six months of the initial PVA(I).

This type of recurrence may happen because the heart tissue was not originally ablated properly, the burn lesion may not have been deep enough (transmural). The EP may not have applied sufficient contact catheter pressure to achieve transmurality and permanent blocking. But with the new Contact Force Sensing catheters, top tier EPs tell me “the use of contact force has definitely reduced the reconnection rates.  It is very unusual to see reconnection these days.”

2. Gap Reconnection. RF point-by-point ablation is not easy to do. It requires manual dexterity, feel and intense concentration to make sure there are no gaps between the RF point-by-point ablations in order to, for example, make a circular lesion line around the opening of a Pulmonary Vein. If a significant gap is left, this can result in recurrence. The A-Fib signal escapes from the Pulmonary Vein through this gap into the rest of the left atrium, thereby producing A-Fib again.

EPs have strategies to find any gaps during and after an ablating an area of tissue. They use a drug like adenosine to try to stimulate A-Fib. They may instead or in addition wait 30 minutes or an hour after the ablation is complete to see if there is any reconnection.

It’s also possible that, after the blanking period when the swelling from point-by-point RF ablations goes down, gaps may appear which were hidden by the swelling of the RF burns—though this is increasingly rare with the use of Contact Force sensing catheters and proper ablation techniques. In this case you will probably need a short touch-up ablation to fix this gap.

(CryoBalloon ablation usually doesn’t produce these types of gaps, because it produces a continuous freezing ablation line around a PV.)

3. Recurrences/Reconnections Due to Pre-Existing Conditions. There are health conditions which tend to cause A-Fib to recur, such as hypertension, obesity, sleep apnea, diabetes, smoking and binge drinking. Controlling these conditions will reduce the risk of recurrence.

For example, let’s say patient “Joe” has A-Fib and sleep apnea, then has a successful A-Fib ablation and is A-Fib free. Because of his sleep apnea, Joe’s A-Fib is more likely to recur than someone without sleep apnea. So much so, that Electrophysiologists (EPs) today are insisting that A-Fib patients with sleep apnea be treated and use devices like a CPAP breathing machine before they can get a catheter ablation. In one study sleep apnea was an independent predictor for catheter ablation failure after a single procedure.

Also, those with long-standing persistent A-Fib, or those with vascular heart disease, or cardiomyopathy are more likely to have a recurrence.

4. “Lone” Recurrence. Around 50% of A-Fib patients have no apparent cause for their A-Fib—called “lone A-Fib” because there’s no other contributing health condition. After a successful catheter ablation, those with lone A-Fib are less likely to have a recurrence. But some lone A-Fib patients do have recurrences.

Your EP may not use the word ‘cure’, but the dictionary defines ‘cure’ as “restoration of health; recovery from disease.

What This Means to Patients

Catheter ablation today is the best hope of a “cure” for A-Fib (Your doctors may not use the word ‘cure’, but the dictionary defines ‘cure’ as “restoration of health; recovery from disease.”) That should be your goal!

Let’s take a worst case scenario after your ablation:

You’re in good health and have no pre-existing medical conditions. Seven years after your ablation you have a “recurrence” of A-Fib.

Think about that for a moment.

You’ve had seven years of a normal heart beat and a normal life! (Only those of us who’ve had symptomatic A-Fib know how wonderful it is to be A-Fib free―even if it’s just for three, five or whatever length of time.)

So what if you have a recurrence. You know what to do. Your EP does a touch-up ablation (which is much easier and faster than your original ablation). That reassuring, isn’t it!

Don’t waste your life worrying about recurrence/reconnection. Live your life as though you are cured for the long term. You probably are.

Last updated: Sunday, October 4, 2015

Return to FAQ Catheter Ablation Catheter Ablation, Pulmonary Vein Isolation/Ablation, CyroBalloon Ablation

FAQs A-Fib Ablations: Success Rate for Chronic

 FAQs A-Fib Ablations: Success for Chronic

Catheter Ablation

Catheter Ablation

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?”

This is a question that is currently in dispute among researchers in A-Fib. However, most clinical studies suggest that Paroxysmal is more frequently curable by PVA(PVI) than Chronic.

In fact, the French Bordeaux medical group, considered among the world’s leaders in A-Fib research, now uses a combination PVI and linear catheter ablation procedure for Chronic A-Fib as compared to a PVI ablation procedure for Paroxysmal A-Fib. They only consider patients with chronic A-Fib if they have “symptomatic and complicated AF” because of the following reasons: patients with Chronic A-Fib often have “poor hemodynamic tolerance” (their blood isn’t being pumped out properly), “suspicion of tachycardiomyopathy” (the heart tissue may have been damaged by the rapid, irregular heart beats or fibrillation), and “suspicion of thromboembolic events” (a greater risk of stroke).

Linear ablation techniques, though more difficult to perform effectively, may work better for people with chronic A-Fib and/or structural heart disease. In a Boston A-Fib Symposium 2006 presentation Dr. Jaïs from the French Bordeaux group reported a study in which 95% of Chronic A-Fib patients were restored to normal sinus rhythm.

For someone with Chronic A-Fib, you have a better chance of being cured of your A-Fib if you’ve been Chronic for a short period of time rather than for a number of years. Does that mean that people with Chronic A-Fib have little hope of being permanently cured by a catheter ablation? No. It’s just that right now most major heart centers have a long waiting list and have better success rates with Paroxysmal A-Fib.

References:
•  Adams Jr. H. “How To Avoid Stroke,” The Good Life. Boardroom Inc., 2001, p. 31.
•  Jais, P. “Ablation Therapy for Atrial Fibrillation: Past, Present and Future,” Cardiovascular Research, Vol. 54, Issue 2, May 2002, P. 343.

Return to FAQ Catheter Ablations

FAQs A-Fib Ablations: Will My A-Fib Eventually Return?

 FAQs A-Fib Ablations: Will My A-Fib Return? 

Catheter Ablation

Catheter Ablation

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?”

I think your chances of staying A-Fib free are pretty good. A Pulmonary Vein Isolation (Ablation) is like a kind of immunization against A-Fib. If your Pulmonary Veins (PV) are well isolated and stay that way, you can’t get A-Fib there again.

When the PVs are isolated and disconnected and haven’t reconnected, it seems to be permanent. Intuitively it makes sense that A-Fib wouldn’t reoccur in areas that were successfully ablated and that haven’t reconnected. But it’s too early in the history of PVA(I)s to say this definitively.

NOTE: PVA(I) is a relatively new procedure. I had my catheter ablation in 1998 when I was 57 years old and I’m still A-Fib free today at age 74. However, at that time of my ablation, only one of my Pulmonary Veins was isolated. In theory the other veins could start producing A-Fib signals. But that hasn’t happened. My catheter ablation procedure back in 1998 was primitive compared to what is done today.

Regrowth/Reconnection of Ablated Heart Tissue: There is a tendency for ablated heart tissue to heal itself, regrow the ablated area, reconnect, and start producing A-Fib signals again. But if this happens, it usually occurs within the first three to six months of the initial PVA(I).

Recent research indicates that for a small number of people, a successful Pulmonary Vein Ablation (Isolation) procedure may not be a permanent “cure.” Dr. Francis Marchlinski of the University of Pennsylvania persuaded patients who had experienced successful PV ablations and who were A-Fib symptom free, to be re-examined in the EP lab. He found that some had regrowth/reconnection in their ablated vein openings even though they were A-Fib symptom free. He also examined patients who had regrowth/reconnection and reoccurrence of A-Fib after a successful PV ablation.

He estimated that there is a 5-6% chance of regrowth/reconnection each year (though not necessarily of A-Fib recurrence), out to five years. He doesn’t have data for beyond five years.

Who Is Most Likely to Have Recurrences? The people most likely to get recurrences often have pre-existing conditions or risk factors like obesity, diabetes, high blood pressure, sleep apnea, smoking, binge drinking, etc. Even though their PVs may remain well isolated, these risk factors could stimulate A-Fib in some other part of their heart or perhaps cause regrowth/reconnection in the PVs.

Don’t Fear Recurrence. But let’s say you do have a recurrence, for example, after seven years. It’s nothing to worry about and it can be fixed. You go in for a touch-up ablation which may take a whole 20 minutes to do.

Marilyn Shook

Marilyn Shook

The EP usually only needs to fix a gap or a new spot that has appeared, rather than do a whole ablation and isolation of your PVs and heart. (And remember, you have been A-Fib free for all those years!)

This is exactly what happened to Marilyn. Read Marilyn Shook Updates Her 2008 Personal A-Fib Story. She had a ‘touchup’ ablation September 2014 and wrote us in July 2015 that she’s had no A-Fib since.

Live Life Like You Are Cured! It’s a waste of time to be concerned about something that may never happen (A-Fib recurrence). It’s like worrying about getting struck by lightning.

Thanks to Rob Muscolino for this question and to A-Fib Support Volunteer Jerry for helping write this answer.

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Last updated: Friday, October 9, 2015

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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A-Fib Producing Spots Outside the Pulmonary Veins – 2014 Boston AF Symposium

Vivek Reddy Mt Sinai Hospital

Dr Vivek Reddy Mt Sinai Hospital

2014 Boston AF Symposium

A-Fib Producing Spots Outside the Pulmonary Veins

Report by Dr. Steve S. Ryan, PhD

Dr. Vivek Reddy of Mount Sinai Hospital in New York gave a presentation entitled “What is the true rate of Non-PV triggers?”

Why do ablations fail?

Dr. Reddy posed the question, ‘Why do ablations fail?’ The most common reason is a gap in an ablation lesion. Dr. Reddy showed slides of a typical wide area antrum isolation ablation with remarkably precise point-by-point burns. But there was a slight gap which let A-Fib signals escape from the pulmonary veins into the rest of the heart. But Non-PV triggers can also cause ablation failure.

Dr. Reddy asked the BAFS attendees:

“What is the rate of non-PV triggers after an extra-ostial PV isolation procedure?”

The choices ranged from 5% to over 25%.

The actual rate of non-PV triggers is approximately 23%.

Carina important origin of A-Fib triggers

Dr. Reddy showed how the ‘carina’ (the area in the heart between the left and right pulmonary vein openings) is often a source of A-Fib triggers and of recurrence after an ablation. According to the study cited, “the carina region (has an) apparently unique electrical behavior.” To effectively isolate PVs, it is frequently necessary to target within the circumferentially ablated veins in the carina region, even though there is a risk of stenosis.

Where are the non-PV triggers usually from?

In an older study of 248 Paroxysmal A-Fib patients, 28% had non-PV triggers. (These earlier studies often used segmental or ostial isolation and weren’t as durable as later procedures.) The most common locations were:

▪  LA Posterior Free Wall: 38% ▪  Superior Vena Cava: 37% ▪  Crista Terminalis: 13.7% ▪  Ligament of Marshall: 8.2%

(In this study, the Carina area and newer areas of interest such as the Left Atrial Appendage were not mentioned)

Left Atrial Appendage (LAA)

In a study of nearly 4,000 A-Fib patients that looked at redo procedures for paroxysmal, persistent and long-term persistent A-Fib, 27% had LAA firing (the LAA is the source of arrhythmia), much more in the long-term persistent (58%) compared to paroxysmal (18%). Most wound up having a LAA isolation procedure. (Many centers, as part of their protocol, now routinely first look at the LAA after isolating the PVs. See Bordeaux Five-Step Ablation Protocol for Chronic A-Fib.)

Age Dependent

Paroxysmal patients over 80 years old had many more non-PV triggers than other patients.

Recurrence Associated with Predominately Non-PV Triggers

In a study of 197 paroxysmal A-Fib patients from 2009 to 2012 using irrigated tip RF catheters and extraostial PV isolation, there were non-PV triggers in 23.7% of patients. In patients who had recurrence, 70.8% had non-PV triggers.

 In patients who had recurrence, 70.8% had non-PV triggers.

Editor’s Comments:
Dr. Reddy’s research is important for EPs who will now look more closely at areas like the Carina and the Left Atrial Appendage to find and ablate/isolate non-PV triggers.
What does Dr. Reddy’s research mean for patients? Since 23% of A-Fib ablation triggers are found in other areas of the heart than the pulmonary veins, a simple Pulmonary Vein Isolation (PVI) or Maze surgery may not be enough to cure your A-Fib.
One of the most important findings of Dr. Reddy’s research is that recurrence (a failed ablation) is most often associated with non-PV triggers (70.8%). When searching for the right Electrophysiologist (EP) to do your ablation, they have to have experience in tracking down these non-PV triggers. When interviewing EPs, maybe one of the questions needs to be “How often do you find non-PV triggers? How do you track them down and ablate them?”
You should probably avoid any EP who only isolates the PVs. [I’ve read Operating Room reports from EPs who only do a PVI, never look for non-PV triggers, and don’t terminate the A-Fib by ablation. Instead they shock the patients back into sinus rhythm, then load them up with powerful but toxic antiarrhythmic meds like amiodarone. This usually doesn’t work.)
If you are considering (Wolf) Mini-Maze surgery, be aware that most Mini-Maze surgeries only isolate the PVs. Your chances of having non-PV triggers which a Mini-Maze surgery will not ablate/isolate are approximately 23%. That translates to at least a 23% chance of failure.
If you have non-PV triggers or A-Fib/Flutter coming from the right atrium, most Maze surgeries won’t make you A-Fib free. Surgeons currently do not access the right atrium during most Maze surgeries. To take care of these other A-Fib spots, you will have to schedule a catheter ablation.
References for this article

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Last updated: Friday, August 28, 2015 

About Recurrence of A-Fib After Successful Catheter Ablation

by Steve S. Ryan, PhD, June 2014

Ed Grossman recently wrote and asked me about recurrence of A-Fib after a successful catheter ablation:

Recurrence of A-Fib After Catheter Ablation“I’ve read studies from the French Bordeaux group that talk about A-Fib recurring after a catheter ablation, that A-Fib tends to come back. Can A-Fib be cured permanently by a catheter ablation? After a successful catheter ablation, what are my chances of A-Fib recurring?”

The French Bordeaux group pioneered the original Pulmonary Vein Isolation procedure.

The studies you refer to were done in 2001-2002 with 100 patients. There’s been a great deal of improvement in the procedure since then, such as the use of irrigated tip catheters and the increased use of circumferential pulmonary vein isolation (PVI). (For example, when I had my procedure done in Bordeaux in 1998, they did what was then called a focal ablation in only one of my pulmonary vein openings. I’ve been A-Fib free “cured” for 16 years. Today though, they routinely isolate all four pulmonary veins.)

Don’t let the threat of recurrence put you off of having a catheter ablation. Recurrence is often influenced by several factors unrelated to the actual catheter ablation procedure, some of which you can control.

Certain Health Conditions Cause Recurrence of A-Fib

There are health conditions which tend to cause A-Fib to recur including hypertension, obesity, sleep apnea, diabetes, smoking and binge drinking. Controlling these conditions will reduce the risk of recurrence.

For example, let’s say patient “Joe” has A-Fib and sleep apnea, then has a successful A-Fib ablation and is A-Fib free. Because of his sleep apnea, Joe’s A-Fib is more likely to recur than someone without sleep apnea. So much so, that Electrophysiologists (EPs) today are insisting that A-Fib patients with sleep apnea be treated and use devices like a CPAP breathing machine before they can get a catheter ablation. In one study sleep apnea was an independent predictor for catheter ablation failure after a single procedure.

Also, those with long-standing persistent A-Fib, or those with vascular heart disease, or cardiomyopathy are more likely to have a recurrence.

Less recurrence for those with Lone A-Fib

Around 50% of A-Fib patients have no apparent pre-existing medical condition—called “lone A-Fib” because there’s no other contributing health condition. After a successful catheter ablation, those with lone a-fib are less likely to have a recurrence. But some lone A-Fib patients do have recurrences. (Some studies estimate a 7% chance of recurrence out to five years, though most recurrences occur in the first six to 12 months.)

So why the recurrence for lone a-fib patients? Heart tissue is very tough and tends to heal itself after an ablation. Or, there may be gaps in the ablation lines and the spots may require a touch-up ablation (usually with a much shorter procedure time and easier to perform than the first ablation).

The joy of Years of living in ‘Normal Sinus Rhythm’

Let’s discuss a worst-case scenario. You have a catheter ablation that makes you A-Fib free. Then three years later you develop A-Fib again. But the bottom line is you’ve been “cured” for three years. (The dictionary defines “cure” as “restoration of health; recovery from disease”.)

Most people with symptomatic A-Fib are overjoyed to have a normal heart beat and a normal life for three years, to be freed from both A-Fib symptoms and from the anxiety, fear and depression that often accompany A-Fib.

(See the personal experience stories by patients who had recurrence and a successful second ablation: Jay Teresi, “In A-Fib at Age 25 and Robert Dell’s A-Fib Experience: “Daddy is always tired”.)

Only people with A-Fib appreciate how wonderful it is to be in ‘Normal Sinus Rhythm’ (NSR). For most of us, catheter ablation provides “acceptable” long-term relief from A-Fib. And it’s comforting to know, you can go back for another ablation, if you need it.

Catheter Ablation is the Best Hope for a “Cure”

Today, catheter ablation is the best A-Fib treatment offering hope for a “cure”—for making you A-Fib free. Current medications, for the most part, don’t work or have bad side effects or lose their effectiveness over time. Electrocardioversions usually don’t last. Surgical approaches work, but are generally more invasive, traumatic, and risky, and not recommended as first-line therapy for A-Fib.

Yes, A-Fib can return after a catheter ablation; the benefit may not be permanent. But, as a point of reference, consider heart by-pass operations or heart stents—are they always permanent? (Often they aren’t.)  Do patients need additional surgeries? (Often they do.) With the option to return for an additional or “touch-up” procedure, catheter ablation is still today’s best hope for a life free from the burden of Atrial Fibrillation.

References for this Article

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Last updated: Monday, August 17, 2015

Obesity Strong Predictor of A-Fib Risk and Recurrence – 2014 Boston AF Symposium

Boston AF Symposium 2014

Obesity Strong Predictor of A-Fib Risk and Recurrence

Report by Steve S. Ryan, PhD

Dr David Wilber Loyola University Medical Center

Dr. David Wilber Loyola University Medical Center

Dr. David Wilber of Loyola University Medical Center in Chicago, IL gave a presentation entitled “Obesity, Inflammation and Atrial Fibrillation.”

Dr. Wilber described the findings of several studies on obesity and A-Fib:

1. Obese Patients Are at Greater Risk of Developing A-Fib.

In the Framingham Heart Study of 5,282 patients followed for 13.7 years, obese patients had a 1.5 greater risk of developing A-Fib. (Wang et al. JAMA 2004; 2022:2474)

In studies involving 68,000 people, obese patients had a 49% increased risk of new onset A-Fib (Wanahita et al. AHJ 2008; 155:310-315)

Increase In BMI (Body Mass Index) Is associated with a risk of developing A-Fib

♦  16% for a BMI increase of 5-15%
♦  46% for a BMI increase of 16-35%
♦  90% for a BMI increase of over 35%

2. Obesity Produces Left Atrium Volume Changes and Overload

In the MONICA study of 1212 patients followed for ten years, 36% had hypertension, 34% were obese. Only obesity predicted Left Atrium volume changes and produced volume overload. (Hypertension produced pressure overload.) (Stritzke et al. JACC 2009; 54:1982-9)

3. Predictably Progress to Permanent A-Fib

In the Olmstead County study of 3,248 patients with Paroxysmal A-Fib (1980-2000), BMI greater than 35 (obese) predicted progression to permanent A-Fib independent of age, gender and clinical variables.

Obesity Factors Influencing or Responsible for A-Fib

Dr. Wilber then examined what factors or elements of obesity were responsible for affecting A-Fib.

1.  Epicardial fat had more local chemokines, cytokines, and cellular infiltrates (fibrosis) than subcutaneous fat. He described an experimental study where epicardial and subcutaneous fat were added to atrial rat tissue. (Epicardial fat had higher levels of activin A and other biomarkers of fibrosis.)

2.  In the Framingham Offspring study, only pericardial fat volume was significantly associated with A-Fib risk. 13% increased risk of A-Fib per 10 ml volume of pericardial fat.

3.  In sheep experiments, obesity was profibrotic (increase in interstitial and cytoplasmic TGF-B1, PDGF-BB, and CTGF levels). Increasing weight produced significant increase in A-Fib burden (more and longer A-Fib episodes)

4.  Risk of recurrence increases with obesity (Guijian et al, PACE 2013; 36:748-756). Left Atrium fat volume was the only significant predictor of recurrence (Tsao et al 2011)

5.  A 19% decrease in weight significantly decreases A-Fib burden.

Dr. Wilber’s Conclusions

•  Obesity is a strong independent predictor of A-Fib risk

•  Obesity produces cardiac structural remodeling, notably LA volume and diastolic dysfunction

•  Local direct effects which promote Left Atrium fibrosis through inflammatory and profibrotic cytokines

•  Epicardial fat volume may be a useful way to measure or be a marker for local direct effects like fibrosis. Epicardial fat is independently associated with A-Fib risk relative to BMI, Left Atrial Volume, and other risk factors

•  Obesity significantly impacts A-Fib recurrence after ablation

•  Weight lost reduces the risk of new onset A-Fib, and subsequent progression/recurrence after A-Fib onset

Editor’s Comments:
Obesity is a major problem particularly in the US, so we can expect to see an increased number of the obese developing A-Fib (along with a host of other problems like hypertension, diabetes, coronary disease and sleep apnea).
The most startling statistic Dr. Wilber cited was that a BMI increase of 35% in men from age 25 to 50 increased the risk of developing A-Fib by 90%. Practically speaking, almost everyone who becomes obese in their lifetime will develop A-Fib. That’s a really scary statistic with enormous public health consequences.
And paroxysmal A-Fib patients who are obese will predictably progress to persistent (chronic) A-Fib.
“Is it a waste of time to perform a catheter ablation on someone who is obese? Aren’t they more at risk of recurrence?” They certainly are more at risk of recurrence. But a successful catheter ablation will change their lives and improve their quality of life. However, EPs should insist that obese patients who have a successful ablation must lose weight. But that should be easier to do if the obese person is in normal sinus rhythm and isn’t plagued by A-Fib symptoms like being unable to exercise because of a racing heart.
As Dr. Wilber suggests, measurement of epicardial fat volume should become a routine part of a yearly physical.  For example, if a patient has a certain amount of epicardial fat volume, they should be told they are at a greater risk of developing A-Fib (and other health problems).
The good news is that weight loss both reduces the risk of developing A-Fib and reduces A-Fib burden (how badly A-Fib affects us). And it lowers the risk of recurrence after a successful catheter ablation.

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Last updated: Tuesday, February 9, 2016 

 

 

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