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"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

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"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

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"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

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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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risks

FAQs A-Fib Ablations: Risks of Pulmonary Vein Procedure

 FAQs A-Fib Ablations: Risks

Catheter Ablation

Catheter Ablation

5. “How dangerous is a Pulmonary Vein Ablation procedure? What are my risks?”

As a point of reference, the complication rate for the common Appendectomy is about 18%.4 Catheter ablation has a complication rate of 1%–3% which is comparable to other routine, low-risk procedures such as Tubal Ligation (1%–2%).

A small percentage of PVI patients develop minor complications such as bleeding and bruising at the groin (where the catheters are inserted). This is usually a temporary complication that resolves in two–three weeks.

About 2% of patients develop more serious or major complications such as:

•  Stenosis (constriction or narrowing of the Pulmonary Vein openings reducing blood flow from the lungs to the heart.)
•  Stroke
•  Tamponade (blood leaking into the sac around the heart from a catheter puncture.)
•  Atrial-Esophageal Fistula. (very rare complication) that is often fatal

Doctors are aware of these dangers and use many techniques to prevent or address complications.

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. Be assured that doctors and staff monitor you very closely and are prepared to deal with emergencies and complications.

Bottom-line: for most A‑Fib patients, it’s probably safer getting a PVI than not getting one. The long-term risks of living a lifetime in A‑Fib and/or on antiarrhythmic drugs is potentially more damaging than the generally short-term risks of a Pulmonary Vein Isolation. For more detailed information, see Risks Associated with Pulmonary Vein Procedure.

References
¤  Katkhouda, N., Mason, R. J., Towfigh, S., et al. (2005). Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Annals of surgery , 242 (3). Retrieved Nov 30, 2011. URL http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357752
¤  Radiofrequency catheter ablation is considered safe. (2010). AFIB Alliance: Atrial Fibrillation Resource. Retrieved August 01, 2011, from https://www.afiballiance.com/patient-edu.php
¤  Professional answers to your atrial fibrillation questions: what are the risks of AF ablation?  Atrial Fibrillation Institute/St. Vincent’s HealthCare. Retrieved August 01, 2011, from http://www.jaxhealth.com/services/afib/faq/
¤  Atrial Fibrillation Educational Material,” University of Pennsylvania, 2001, p.7 “Catheter ablation is a low-risk procedure.”

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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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 

 

 

The 2014 CHA2DS2-VASC Guidelines and the Risks of Life-Long Anticoagulation Therapy

Risks of Life-Long Anticoagulation Therapy

Risks of Life-Long Anticoagulation Therapy

A-Fib-Free After Catheter Ablation, Patient on Anticoagulation Therapy for 10 years Develops Cerebral Microbleeds and Associated Early Dementia.

By Steve S. Ryan, Updated March 2016

Dr. John Day, in an editorial in The Journal of Innovations in Cardiac Rhythm Management, described his patient, Bob, who had been on anticoagulation therapy for 10 years, even though he had had a successful catheter ablation and was A-Fib free.

Of concern, these new guidelines call for many more people to be on anticoagulant therapy, particularly women.

Bob was suffering from early dementia. A cranial MRI revealed many cerebral microbleeds, probably caused by taking anticoagulants for years. Both antiplatelet and anticoagulant therapy significantly increase the risk of cerebral microbleeds which are associated with dementia. These microbleeds are usually permanent and irreversible.

Dr. Day asked, “Could it be that this was an iatrogenic (caused by a doctor’s activity or therapy) case of dementia? Was his 10 years of anticoagulant use for atrial fibrillation the cause of his dementia?”

The New CHA2DS2-VASc Guidelines for Anticoagulation Therapy

Dr. Day discusses the new CHA2DS2-VASc guidelines for anticoagulation therapy. He points out that none of the major studies supporting the CHA2DS2-VASc guidelines have reported the accompanying cerebral microbleed risk. He also calls our attention to the reports from many centers that long-term stroke risk following catheter ablation is very low. Ablation may reduce the total arrhythmia burden or convert recurrences to more organized rhythms, such as an atrial tachycardia, with a lower stroke risk.

This effect of A-Fib ablation isn’t recognized in the latest guidelines.

So, the question is, ‘Why the risks of life-long anticoagulation therapy if the patient has had a successful ablation procedure?’

Also, these new guidelines call for many more people to be on anticoagulant therapy, particularly women. Dr. Day does not go so far as to say the new guidelines are in error (as I do), but he does ask,” What about the 35 year old woman with borderline hypertension and only one A-Fib recurrence each year? Should she now take anticoagulants for the rest of her life even if she has had a successful ablation?”

(See more research contradicting the 2014 Guides: A study using the Taiwan Research Database of 186,570 A-Fib patients, they discounted female gender and only looked at females with a CHA2DS2-VASc score of 2 (one additional risk factor besides being female).1,2,3

Warning: The Risks of Life-long Anticoagulation Therapy

Dr. Day concludes, “Somehow I think we have lost sight of the total picture with the new A-Fib management guidelines. In my mind, I am not convinced that the long-term stroke risk of a CHA2DS2-VASc score of 1 or 2 (depending on which risk factors are present) justifies all of the risks of life-long anticoagulation therapy, particularly if the patient has had a successful ablation procedure.”4 Dr. John Mandrola echoes Dr. Day, “And if there is no A-Fib, there is no benefit from anticoagulation.”5

Editorial comments:
“But CHA2D2-VASc are just guidelines, aren’t they? Doctors don’t have to follow them, do they?”
Unfortunately once guidelines like these become official, they in effect become the law of the land. If a doctor doesn’t follow them and a patient has a stroke, the doctor is almost guaranteed a losing malpractice law suit. The first thing a trial lawyer will point out to an arbitrator or jury is that the doctor didn’t follow current guidelines.
This puts doctors in a very difficult position. Even though Dr. Day knows all too well and agonizes over the fact that his anticoagulant therapy probably caused his patient Bob’s dementia, he can’t change the guidelines.

See also my articles: Women in A-Fib Not at Greater Risk of Stroke! and Israeli Study-Being Female Not a Risk Factor for Stroke.)

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Last updated: Tuesday, March 29, 2016

References for this article
References    (↵ returns to text)

  1. Chao TF, et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (beyond sex) receive oral anticoagulation? J Am Coll Cardiol. 2015 Feb 24;65(7):635-42. doi: 10.1016/j.jacc.2014.11.046. PubMed PMID: 25677422. http://www.ncbi.nlm.nih.gov/pubmed/25677422
  2. Amson, Yoav et al.  Are There Gender-Related Differences In Management, And Outcome Of Patients With Atrial Fibrillation? A Prospective National Study. Arrhythmias and Clinical EP. Acc.15. JACC. March 17, 2015, Volume 65, Issue 10S.  doi: 10.1016/S0735-1097(15)60469-7 http://content.onlinejacc.org/article.aspx?articleid=2198096&resultClick=3
  3. Friberg et al. Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1. J AM Coll Cardiol. 2015; 65(3):a-232. URL: http://www.sciencedirect.com/science/article/pii/S0735109714070119. doi:10.1016/j.jacc.2014.10.052
  4. Day, John. Letter from the Editor in Chief. The Journal of Innovations in Cardiac Rhythm Management, 5 (2014), A6-A7. Last accessed May 15, 2014, URL: http://www.innovationsincrm.com/cardiac-rhythm-management/2014/may/586-letter-from-the-editor-in-chief
  5. Mandrola, John. Atrial Flutter–15 facts you may want to know. In AF Ablation, Atrial fibrillation. August 5, 2013. http://www.drjohnm.org/2013/08/atrial-flutter-15-facts-you-may-want-to-know

Obesity in Young Women Doubles Chance of A-Fib

Obesity in Young Women Doubles Chances of Developing A-Fib

Report by Lynn Haye, March 3, 2013

A-Fib.com is happy to introduce a new volunteer writer, Dr. Lynn Perryman Haye, Ph.D. from Huntington Beach, CA. She recently had a successful catheter ablation at Hoag Memorial Hospital Presbyterian Heart and Vascular Institute by Dr. Michael Panutich. Lynn is a retired licensed clinical Psychologist. Thanks, Lynn, for this excellent report and for adding a much-needed woman’s touch to our A-Fib.com reports.

Image courtesy of imagerymajestic at FreeDigitalPhotos.net

A 2012 Danish study found that obese, fertile younger women had a 2 to 3-fold higher risk of developing A-Fib than their normal weight counterparts. Previously it was unknown whether obesity increased the risk of A-Fib in young people without other risk factors.  This study adjusted for other risk factors while analyzing the effect of weight on the development of new-onset A-Fib. These findings suggest that strategies to promote weight loss may also decrease the burden of A-Fib.

The study employed the use of the Body Mass Index*(BMI) to categorize the women according to weight. For example, a 5’4” woman would have the following BMI calculations:

BMI Weight
Normal 18.5-24.9 108-145 lbs.
Overweight  25-29.9 146-174 lbs.
Obese 30-35 175-204 lbs.
Very obese >35 >204 lbs.

Statistical analysis revealed a hazard ratio of 2.04 in the obese women or a 2-fold greater risk than normal weight women of developing A-Fib.  A hazard ratio 3.50 in the very obese women showed an even greater 3-fold risk of developing A-Fib compared to normal weight women.  These findings were significant and add another potential risk factor for ‘Lone A-Fib’.

This was a unique study that analyzed the data from a national Danish Registry.  The research identified 271,203 women (aged 20-50, mean age of 30.6 years) from a nationwide register of childbirths and hospitalizations in Denmark. The women had all given birth between 2004 – 2009 and did not have prior histories of A-Fib. The women were followed for an average of 4.6 years during which time 110 were hospitalized for first-time A-Fib.  Due to the nature of the data base, the investigators were able to adjust for age, comorbidities, hyperthyroidism, smoking status, pharmacotherapy and previous use of beta-blockers during pregnancy.  However, they were unable to adjust for either alcohol use or diagnoses of sleep apnea either at baseline or during follow-up.

The primary researcher, Dr. Deniz Karasoy, concluded that; “….obesity increases the risk of new-onset atrial fibrillation in seemingly healthy fertile women.”  He states that; “Dietary modifications combined with physical exercise are warranted in obese fertile women to decrease their risk of atrial fibrillation.”

BMI Formula*
English  BMI = Weight in Pounds / ( Height in inches x Height in inches )  x 703
Metric BMI = Weight in Kilograms / ( Height in Meters x Height in Meters )

References for this Article

(A special thanks to David Holzman for calling our attention to this article and its importance.)

Photo of Lynn Haye, PhD

Lynn Haye, PhD

LYNN HAYE, PhD, is a clinical psychologist and former A-Fib patient. She studies and writes about current trends in the treatment and diagnosis of atrial fibrillation and has a special interest in women’s health issues. Dr. Haye and her family live in Orange County, CA.

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Last updated: Sunday, February 15, 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.

Cardioversion to Restore Normal Sinus Rhythm

VIDEO: EKG display of heart in Atrial Fibrillation, A-Fib

EKG display of heart in A-Fib

Cardioversion for Atrial Fibrillation

Your doctor may recommend a cardioversion to restore your heart to normal sinus rhythm (NSR). There are two types of cardioversion: chemical and electrical. Cardioversion through the use of drugs is called chemical cardioversion. Electrical cardioversion uses a low-voltage, timed electrical shock to restore normal rhythm.

Most cardioversions are planned and scheduled several weeks in advance.

On the other hand, if your A-Fib is so irregular and rapid that it is life threatening, you may be sent to the emergency room, given the intravenous anticoagulant Heparin, and an electrical cardioversion performed.

CHEMICAL CARDIOVERSION

The goal of chemical cardioversion is to make your heart beat regularly (in normal sinus rhythm). It is usually done in a hospital. Some combination of medications (see Treatment/Drug Therapies) is administered intravenously, such as Cardizem, verapamil, ibutilide, or adenosine (a class V antiarrhythmic agent). Doctors monitor you closely for adverse side effects.

Chemical cardioversion is often done in combination with Electrical Cardioversion described below.

Electrical Cardioversion

Electrical Cardioversion is a medical term for giving your heart a low-voltage electrical shock to synchronize it, that is, to make it beat regularly (in normal sinus rhythm). It is often used in combination with Chemical Cardioversion.

Note: Electrical cardioversion is not the same as Defibrillation. In defibrillation, doctors use high-voltage shocks to treat life-threatening arrhythmias or a heart that has stopped.

During Electrical Cardioversion you are anesthetized and are unconscious when you receive the shock. The shock causes the signal producing areas of your heart to discharge all at once. This stops all electrical activity in your heart momentarily, hopefully allowing your normal heart rhythm to take over. Usually only one shock is required to restore NSR.

VIDEO 1: Patient video, short animation (:60) explaining the steps in performing an electrical cardioversion for patients in Atrial Fibrillation; By eMedTV 1

Low Risk Treatment But High Risk of Clots Forming

Electrical Cardioversion is considered a low risk procedure. But it is a ‘shock’ to the body and requires general anesthesia. (It’s like a mini electrocution. The metal paddles or patches, for example, can potentially leave burn marks on the chest.)

Cardioversion does carry a high risk of forming clots and causing stroke.2

Why? An Electrical cardioversion “stuns” your heart along with your Left Arial Appendage (LAA). Clots may form in the LAA while your heart is stunned and not beating. The clot can break away and enter the blood stream with the potential of causing a stroke. (The LAA is where most A-Fib clots originate.)

To dissolve potential clots, your doctor will have you take an anticoagulant like warfarin (Coumadin) before the treatment and in the three to four weeks following treatment.

While on warfarin (Coumadin), your blood will be tested for how long it takes to clot (a prothrombin time test, PT). The goal is to keep your INR (International Normalized Ratio) score between 2.0 and 3.0. Your dosage will be adjusted if necessary. You may have to have your blood tested weekly until your doctor determines you are in the proper INR range.

Success Rate of Cardioversion

Electrical Cardioversion (often combined with Chemical Cardioversion) is considered a standard, routine, low risk treatment option, particularly for recent onset A-Fib patients. If your A-Fib has just started, it may be a momentary aberration; and an Electrical Cardioversion may correct it.

Cardioversion has a very high initial success rate, returning up to 95% of A-Fib patients to NSR.

While the conversion rate is high, recurrence of A-Fib is high too. As few as 23% of patients remain in normal sinus rhythm for more than one year post-procedure. For most, their A-Fib returns within the first five days.4

Are Repeated Electrical Conversions Dangerous?

People with A-Fib often ask, “How often can I be Electrical Cardioverted? Does it ever become counterproductive or dangerous?” Right now we just don’t know the answer to this question.

Former Senator and NBA basketball player Bill Bradley had three successful Electrical Cardioversions from 1996-1998 without any apparent ill effects.5 I’ve heard of an A-Fib patient who received an Electrical Cardioversion once a month for a year without any apparent problems.

VIDEO 2: Watch an actual Electrical Cardioversion recorded at the patient’s request: “Me Being Cardioverted” posted by reddy321.6But be advised: the patient in this video is partially awake (this is not the norm). This video is a bit unsettling to watch (but not dangerous or painful for the patient).

Don’t Be Frightened

Don’t let this type of video frighten you. It may look and sound traumatic, but Electrical Cardioversion is in fact non-invasive and is one of the easiest and safest short term treatments available for A-Fib.

And don’t let TV shows with emergency room scenes frighten you either. In fact, those scenes are usually depicting defibrillation, not cardioversion (defibrillators use high-voltage shocks to treat a heart that has stopped beating).

In her Personal Experiences story, Kris tells of accidentally being awake during an electrical cardioversion (see Personal Experiences story #37). According to Kris, the shock is relatively mild compared to what you often see portrayed in medical dramas on TV.

Last updated: Wednesday, April 6, 2016

Back to the Top
Return to Treatments for Atrial Fibrillation

 

 

References    (↵ returns to text)

  1. VIDEO 1: Short animation explaining electrical cardioversion when in Atrial Fibrillation. YouTube video posted by eMedTV; Last accessed Oct 12, 2014; URL: http://www.youtube.com/watch?v=-jkhQ5Tl2fs
  2. Haines, D. “Atrial Fibrillation: New Approaches in Management.” Un. of Virginia multi-media presentation, 1999, p.2. http://www.a-fib.com/HainesUnOfVirginiaAtrialFibrillation.htm
  3. Boos C , More RS, Carlsson J. Persistent atrial fibrillation: rate control or rhythm control. BMJ 2003;326:1411–2.
  4. Gorman, Christine, “A Candidate’s Racing Heart,” TIME, Sunday, Dec. 12, 1999. http://www.time.com/time/printout/0,8816,35831,99.html
  5. VIDEO 2: Me Being Cardioverted YouTube video; Last accessed February 22, 2013; URL: http://www.youtube.com/watch?v=2nsN0vdXZuY&feature=fvw.

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