"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"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."

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"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."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"


"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…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"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."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013

The Bordeaux Group

Updated FAQ about ‘The Bordeaux Group’ & Dr. Häissaguerre

We’ve updated the contact information in the FAQ asking about Dr. Michel Häissaguerre and the University Hospital of Bordeaux (Hôpital Cardiologique du Haut Lévêque-de Bordeaux) often referred to as ‘The Bordeaux Group’.

“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?”

Prof. Häissaguerre and his colleagues invented catheter ablation for A-Fib (Pulmonary Vein Isolation) in the late 1990s. (They cured my A-Fib back in 1998. I was their first U.S. patient. Read my story.) The Cardiologic Hospital of Haut-Lévêque is still considered one of the top A-Fib centers in the world.

How to Contact The Bordeaux Group

Online links to the University Hospital of Bordeaux, Cardiology and Electrophysiology services (Hôpital Cardiologique du Haut Lévêque-de Bordeaux):

• Cardiology and Electrophysiology and Pacing ServicesHead of department: Pr Jean-Michel Haïssaguerre
• Electrophysiology and Ablation, Head of Unit: Prof. Pierre Jais
• Patient Care: Services and Appointment Request – online form

Continue… to read my full answer.

Note: While the website is written in French, my search engine/browser (Google/Google Chrome) offered to translate to English and did a great job! (Learn more at: https://translate.google.com)

FAQs A-Fib Ablations: The Bordeaux Group

FAQs A-Fib Ablations: The Bordeaux Group 

CHU Hopitaux de Bordeaux logo

“The French Bordeaux Group”

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?”

Prof. Häissaguerre and his colleagues invented catheter ablation for A-Fib (Pulmonary Vein Isolation). The Bordeaux group at the Cardiologic Hospital of Haut-Lévêque is still considered one of the top A-Fib centers in the world. (They cured my A-Fib back in 1998. I was their first U.S. patient. Read my story.)

In particular, they are doing cutting edge research using ECGI (CardioInsight) to map and ablate persistent A-Fib. ECGI will probably revolutionize how ablations are mapped and performed.

For the 2016 costs, see my post about David Neth.

How to Contact the Hôpital Cardiologique du Haut Lévêque-(CHU) de Bordeaux 

Online links to University Hospital of Bordeaux, Cardiology and Electrophysiology services (June 2016):


Cardiology and Electrophysiology and Pacing ServicesHead of department: Pr Jean-Michel Haïssaguerre
• Electrophysiology and Ablation, Head of Unit: Prof. Pierre Jais
• Patient Care: Services and Appointment Request – online form (in English)

2010 Article by The Bordeaux Group

Here is something they published in 2010 which explains their methodology and the costs of being treated at Bordeaux. Published as: Are you a good candidate? http://Are you a good candidate?


Currently the only treatments that cure atrial fibrillation (AF) are:

a) Surgery (such as the Cox Maze operation and its variations)
b) Catheter Ablation

The main goals of catheter ablation of AF are to:

1) restore the heart to normal sinus rhythm, thereby eliminating the symptoms of AF.
2) relieve the patient from the associated risks of AF, such as blood clot formation, stroke, cardiac failure, and increased mortality. (It has not been proven that a successful Catheter Ablation will achieve these goals in all A-Fib patients.)

In the catheter ablation procedure a catheter, a soft, thin, flexible tube with an electrode at the tip, is inserted through a large vein in the groin and moved into the heart. This catheter delivers Radiofrequency (RF) energy to cauterize and eliminate the sources or spots in the heart (ectopic foci or wavelet circuits) that are triggering or maintaining the episodes of AF. These sources or spots in the heart are usually found in the pulmonary vein openings. The catheter also makes linear lines or lesions to segment the atrial tissue, thereby interrupting the errant electrical waves responsible for maintaining AF.

This isolation of the pulmonary veins cures the intermittent (paroxysmal) form of AF in 80% of patients (without having to take any medications). An additional 10% of patients are improved—an antiarrhythmic drug keeps them is sinus rhythm without the need for blood thinners.

For patients with permanent or persistent AF (lasting more than 48 hours or who have had Electrocardioversion), isolation of the pulmonary veins is less effective and should be combined with linear lines or lesions. This is because the longer one has episodes of AF, the more the sources or spots in the heart which produce AF signals tend to spread outside the pulmonary veins.

Ablated heart tissue has a tendency to heal itself and recover. For this reason and to increase the success rate to 90%, more than one procedure is required after 1-3 months of follow-up.


For safety reasons (to avoid clot formation during the catheter ablation procedure) the patient should take oral anticoagulation (coumadin, not aspirin) at an optimal therapeutic range (INR 2-3) for at least 1-2 months before the procedure. In addition, a transesophageal echocardiogram should be performed a few days before hospitalization to make sure there are no clots in the heart, particularly in the left atrial appendage. If clots are found, the procedure must be postponed a few days until these clots can be dissolved by blood thinners.

Anticoagulants should be interrupted 48 hours before the day of the procedure. If the patient is taking antiarrhythmic drugs, they should be stopped on admission.


General anesthesia is rarely performed on adult patients, in order to minimize the associated risks of anesthetic drugs. The patient is slightly sedated and a local anesthetic is applied to the groin area. Usually three catheters for mapping and ablation are inserted through one or two femoral veins in the groin and moved up into the heart.

The mapping catheters have multiple electrodes mounted in a longitudinal or circumferential shaft. (Other configurations including investigational designs may be used for individual situations.) The ablation catheter has an irrigated tip to prevent local clot formation and to allow greater energy delivery if needed (at thick parts of the cardiac tissue). To insert these catheters into the left atrium, it is usually required to make a puncture of the transseptal wall between the two upper chambers (atria) at what is called the foramen ovale. After the ablation procedure, this foramen ovale closes back up and heals over. (In 20% of patients this foramen ovale hole never closes up completely and remains open, creating a pathway between the two atria chambers.)

Two or three physicians usually perform the catheter ablation procedure. They are involved in positioning the catheter, and in the collection, analysis and interpretation of heart signals obtained during conventional or computerized mapping.

RF ablation is performed around the openings of the pulmonary veins, one by one or two by two, using a limited level of energy to avoid swelling of the pulmonary vein openings or atrial perforation. Isolation of the pulmonary vein openings is successfully performed in 100% of cases.

In paroxysmal (occasional) AF, PV isolation cures AF in 60-70% of cases. Ablation of the appropriate site in the right atrium (Cavotricuspid Isthmus) is also performed to prevent right atrial flutter. Linear block here is successfully achieved in 99% of cases.

In persistent AF (lasting more than 48 hours or with a history of electrical cardioversion), PV isolation is rarely sufficient. Additional RF applications are required to eliminate spots of AF activity outside the pulmonary veins. In the most resistant cases (usually long lasting AF), linear ablation similar to surgical incision is performed in the left atrium between the two superior PV and/or from the vein to the mitral annulus (mitral “isthmus”). This achieves linear block in 90% of cases. The success depends on achieving continuous and coalescent cauterizing lesions to create a complete barrier. Any gap in the lesion line, even of a millimeter size, allows AF signals to cross thereby keeping the heart in AF. A gap in the lesion line is due either to a too thick atrial wall or recovery of atrial tissue during the 1-4 week healing process following ablation.

Pain and discomfort associated with ablation are controlled by Midazolam and Morphine. Because there are no nerve endings in the smooth tissue of the heart and veins, the pain and discomfort are minimal and usually well tolerated.


The duration of the procedure varies from one to five hours depending on individual conditions:

• the number of ectopic sources in the atrial tissue (outside the pulmonary veins) may require more mapping time.
• successful lineal ablation lines depend on the thickness of the heart wall which varies from one patient to another and can not be precisely determined by pre-ablation imaging.

The end point or goal of the procedure is the achievement of local block in all targeted structures (veins and isthmuses) so that no AF signals travel through the heart. In addition, after the ablation multiple pacing maneuvers are used to try to induce sustained AF. In paroxysmal AF, multiple pacing maneuvers do not induce AF in 90% of cases.

A second procedure may be needed within 3-5 days in 25% of AF patients due to partial recovery of ablated tissue and/or secondary AF sources not ablated in the original procedure. In difficult cases of multiple or unmapable ectopic foci (heart tissue generating AF signals), a second linear ablation may be required in the left atrium.

Patients are hospitalized 4 to 6 days depending on the number of procedures required. Typically they return to the normal care

unit after ablation and are ambulatory 12 to 24 hours later. They are monitored by telemetry during the next 3 days when any recurrence of arrhythmia is most likely to occur. The likelihood of recurrence decreases over the next month.

Patients are usually admitted on Monday and can leave the hospital for the week-end, if there are no complications. They must stay in the region during the week-end and must return the following Monday for outpatient evaluation, which could result in re-hospitalization if needed.

The occurrence of complications may increase the duration of the hospitalization and therefore the cost. In our experience, this happens to 2.5% of patients.

If AF symptoms do not reoccur, patients can return home and resume normal activities. Anticoagulants are recommended for at least 1-3 months after ablation, and can then be stopped if there is no AF or other risk factors. In persistent AF, antiarrhythmic medications are recommended for 1-3 months after ablation to enable the atria to return to normal (this process is called “remodeling.”)


Catheter ablation of AF has been performed since 1994 in Bordeaux. As of October 2009, over 6,000 patients have been treated. At least 15 cases of atrial fibrillation or flutter are treated every week. The clinical characteristics of patients cover a wide spectrum of age (15-84 years old, average 52 years old). 78% of patients are male, while 22% are female. 80% have paroxysmal (occasional) AF, 20% have persistent AF. All patients were resistant to or intolerant of an average of 4 antiarrhythmic drugs and experienced at least weekly episodes of AF at their referral.

Some patients had documented pauses in their sinus heart beat after an attack of AF. They were cured by AF ablation, and thus avoided pacemaker implantation. 12% reported a previous embolic event (stroke), most in the circulation of the brain.

In patients with heart failure and permanent AF, the restoration of sinus rhythm (normal heart beat) is associated with a significant improvement of ventricular function in 80% of the patients.


Currently no one has died of a catheter ablation procedure in our department. Compared to other catheter procedures a 0.1% risk of death is a reasonable estimation.

The other risks of catheter ablation of AF are:

• bleeding in the pericardial sac surrounding the heart and requiring drainage (0.5-1%)
• embolic event (stroke) (0.2%)
• groin access hematoma (bruising) (4%)

There is no risk of sinus node or AV node damage by ablation which would require implanting a pacemaker.
World-wide there have been deaths reported by the use of high wattage catheters (50 watts or higher) creating a fistula (burn through) to the esophagus, usually 2 days after the procedure. We have not observed this complication.
Pulmonary vein narrowing (stenosis), if it did occur, would not usually cause symptoms. Out of 6,000 patients treated in our institution, 7 developed symptoms due to PV narrowing (>70% of lumen [opening] diameter) and required angioplasty and stenting.

The above risks compare very favorably with the risks involved in living with untreated AF. The risks of catheter ablation also compare very favorably with the risks involved in taking antiarrhythmic drugs and anticoagulants.


This cost is fixed by the public health administration.  The cost for a private service (operators: Drs. M. Haissaguerre/P. Jais/ M. Hocini) is 5000 euros (around $6,000) (hospital and physician charges). The total cost of AF catheter ablation depends on the duration of one’s stay in the hospital, which depends on the difficulty of individual ablation cases.

The typical hospital stay of 5 days with an ablation including pulmonary vein isolation and ablation of the right and left atria would cost about 10,328 euros (around $12,600). One day more or less would be 2044 Euros (around $2,500).

The total costs of a 5 day stay and ablation would be 17,600 euros (around $21,500).
For patients accompanied by a family member and without local accommodations, a meal, bed and breakfast is provided in the same room 27,10 euros/day (around $33.00).

The current waiting time for a procedure is 2 months.

Patients should come with personal clothes, since it is possible to walk outside. Patients are generally expected to wear their own clothes, including pajamas. Since the hospital only provides small towels, you may wish to bring your own towels.


Cardiologic Hospital of Haut-Lévêque is a 300 bed hospital entirely dedicated to medical and surgical cardiology. It is located in Pessac and is a 20 minute drive from the airport, and a 20-30 minute drive from the center of Bordeaux and the TGV station.

Languages spoken: English and Spanish

The web site is: http://www.chu-bordeaux.fr/LES-HOPITAUX-ET-SITES-DU-CHU/Groupe-hospitalier-Sud/Hôpital-Haut-Lévêque/.

If you find any errors on this page, email us. Y Last updated: Saturday, October 1, 2016

Return to FAQ Catheter Ablation and Maze Surgeries

Dr. Carlo Romero A-Fib Patient Story

Dr Carlo Romero from The Philippines

Dr Carlo Romero
from The Philippines

A-Fib Patient Story #79

Philippino Dr. with A-Fib Has Amiodarone Problems—Then ECGI & Ablation at Bordeaux

By Dr. Carlo Romero, The Philippines, February 2015

I am a 49-year-old male from the Philippines. I was diagnosed with A-Fib in 2007 at age 42. It happened after I was dehydrated playing golf. The A-Fib resolved by itself after a few hours. But after a few months, I had another attack. When I went to the ER, an ECG documented the AFIB. I was not given any medication but was advised to stay away from triggers which I did. I even stayed away from cigarettes, drinking, chocolates, food with monosodium glutamate.

After Three Years, Severe Pain Triggers A-Fib—Amiodarone Works, But Thyroid Problems

 I did not have any attacks for a year, but my thyroid hormones were becoming abnormal due to the amiodarone.

I had no known A-Fib attacks for three years until I was operated on for a herniated disc in 2010. The severe pain and the medications probably triggered the A-Fib again as I had several attacks. I was referred to an electrophysiologist in Manila which is an hour and half plane ride from our province. This time I was given amiodarone and Coumadin. I did not have any attacks for a year, but my thyroid hormones were becoming abnormal due to the amiodarone. I was shifted to 100mg flecainide bid which again limited my A-Fib to probably one attack per year.

A-Fib Attacks Become More Frequent—Decides To Go To Bordeaux

At this time I was already doing research about what other options were available, because I know that in time, the medications will stop working. In 2010, I was already in touch with Steve Ryan and had already heard of ablation. I had written several big centers and inquired about ablation procedures and cost. I wrote emails to Bordeaux and to the secretary of Dr. Natale. But since the attacks were few and far between, I decided to stick to medication which controlled the symptoms.

 It was a choice between having the ablation in San Francisco or the Bordeaux group…The cost made me decide on Bordeaux, because it cost half that of San Francisco.

However mid-2014, after a bout of flu, the A-Fib symptoms recurred and the attacks became more frequent. I learned that at this time that there was an ablation center here in Manila, but it is still in the infancy stage. So, I decided to go abroad. It was a choice between having the ablation in San Francisco or the Bordeaux group since they have been the most talked about ablationists in the forums. The cost made me decide on Bordeaux, because it cost half that of San Francisco.

Arriving at Bordeaux Hospital

Carlo Romero in Bordeaux hospital room 500 pix at 96 res

Carlo Romero in Bordeaux, France, hospital room

In August 2014, I wrote Bordeaux emails, and they made me answer a questionnaire to determine my status. I sent my reply and was told I would be a good candidate. I was given an ablation date Nov 3, 2014, more than 2 mos. from the time I inquired. I was instructed to do some blood tests and a TEE 2-3 weeks prior to my ablation and to settle the payment for the procedure 1 month before the ablation date. I complied with all of these requirements, got a medical visa from the French Embassy, plane ticket, hotel booking and was all set. I arrived in Bordeaux on Oct 29, 2014. Since we still had time, we first went to Lourdes, France and then back to Bordeaux the next day.

Nov 3, 2014, Monday, I was told to be at the Hospital at 8am. To be sure that we didn’t get lost, we took a cab which cost around 45 euros coming from the center of Bordeaux near the opera house. Admission was a breeze, and I made sure we had internet which you can get in the Admitting section (ask them about it because the nurses are not familiar with it). I made sure of the internet connection to be able to use the app I downloaded which helps me to communicate in French. (Translate App) When you type in English, the app will translate it to French.

I was attached to a holter monitor whose signals were transmitted to the nurse’s station. The first day was spent getting X-rays, lab exams, preparation and shaving of the groin area. They also started injecting heparin. I was told to stop amiodarone 5 days prior to ablation. But since I learned from Steve Ryan that amiodarone has a long half-life, we asked Dr. Jais thru email if the instruction was right. He was able to correct it to 10 days prior to ablation and pradaxa 48 hours prior to ablation.

Ablation with ECGI

Carlo Romero with nurse preparing the ECGI before ablation

Carlo Romero with nurse preparing the ECGI before ablation

The next day, I received IV fluids and was brought down to the CT scan area. I laid down on a bed and was given a vest which I learned later was an ECGI. It’s the new procedure which, according to Dr Haissaguerre, is not yet in use in the US. But they have found it very useful and promising.

His explanation is that it is like an ECG. But instead of 12 leads, it has 252 leads (attached in the vest) The ECGI vest represents the future of the mapping procedure, and according to him will shorten the OR time since they can map out the heart prior to the procedure. (For a further explanation of how the ECGI mapping system works, see “How ECGI [Non-Invasive Electrocardiographic Imaging] Works.”)

I think I was the 2nd case that day since I was brought down at the theatre at 1 pm. I did not see Dr Haissaguerre at that time nor prior to the procedure which made me a little bit anxious. But I was assured by his assistant that He will be doing the ablation. The assistant doctor asked me if it was ok that he start with the insertion of the catheter and that Dr Haissaguerre will be the one doing the ablation later, to which I agreed.

I must have dozed off. Because when I became aware again, I heard that we were about to be finished. Although during the ablation there were instances where I felt my heart going very fast, then they would later massage my neck area. And then after a while, there were two more cycles like that. I was told later that, since I was not in A-Fib, they had to induce me several times. My procedure took almost 4 hours.

After the Ablation—Time With Dr. Haissagguerre

Wednesday, when I woke up, I had a fever of about 39 degrees and had a difficult time breathing. The nurses upon instruction from the doctor gave me paracetamol which lowered the fever, but I was still in pain if I breathed. I was really worried at that time and kept on reminding the nurses to ask the doctor when will they see me so I can talk with them about these symptoms.

That night, a young doctor came to my room with a portable 2d echo and, after examination, concluded I had fluid around my heart and that the fever and the difficulty of breathing were related to that. I was given an anti-inflammatory which relieved the symptoms in 2 days. At this time my abdomen was black and blue due to the round-the-clock injection of heparin. Towards the evening , I was allowed to start with soup and yogurt and later solid foods if I could tolerate them.

Thursday, the fever and the difficulty of breathing diminished. The nurses also advised me to start pradaxa after my last dose of heparin. I was allowed to sit up already and go to the bathroom. In the afternoon, Dr Haissaguerre was able to visit me which was the first time I met him face-to-face. My wife told me that he visited a few hours after my procedure, but I was mostly asleep at that time. He had an aura of confidence in him that made me feel that I was talking to a very knowledgeable person. He explained that I had 3 problematic areas. 1 in the atrial septum and 2 near the pulmonary veins. He added that since I was not in A-Fib, they had to induce it with isoproterenol.

Dr Haissaguerre stayed in the room for almost an hour explaining to us what was done and what to expect in the future. I asked him how many international patients they have. He informed that they accept only 2 international patients per week.

They started with the atrial septum focus which made the A-Fib stop after they had ablated it. But since they knew that I had 3 problematic areas even before the procedure, they induced me again and ablated the 2 remaining areas near the pulmonary veins. After that I was told they could no longer induce my A-Fib.

Dr Haissaguerre stayed in the room for almost an hour explaining to us what was done and what to expect in the future. I asked him how many international patients they have. He informed that they accept only 2 international patients per week. And I was told that I was the first Filipino patient he had. I was also able to meet for the first time Laurence Bayle, the secretary of the doctors with whom I was in contact most of the time. Sometimes it would take a day or two for my emails to be answered, sometimes a week. But despite that, I was able to arrange and carry out my ablation. Probably the volume of the inquiries made it impossible for them to answer immediately.

Dr. Michele Haissagguerre with Dr. Carlo Romero

Dr. Michele Haissagguerre with Dr. Carlo Romero

Discharge—Questions For Dr. Haissaguerre

The next day, Friday, I was told that I would be discharged. I was given all the instructions. While waiting for our Dr Haissaguerre to meet us prior to discharge, we were able to go around the hospital and outside it. From what I understand, it’s a big hospital building which caters solely for heart patients. We were sent to the admitting section to settle our accounts, but we were told that we would have no additional payments, as everything is included in the package.

When Dr. Haissaguerre arrived to see us in the afternoon, I informed him about skipped beats which bothered me post op. He told me that it was normal for an ablated heart to skip beats especially since I had a pericardial effusion, but that they will go away in time. (the skipped beats slowly went away in a month’s time).

I went back to the hospital in November 10, 2014 for my final check-up prior to being allowed to go home. The next few days, we opted to go to Paris and spent some vacation time just in case there was still a need to see Dr. Haissaguerre prior to our flight back home to the Philippines.

Lessons Learned

The whole “healing journey” was very memorable. I cannot believe that I really went out of country just to have the procedure, but everything went as planned. A lot of anxious moments and hesitancy, but I made it through. A few hitches here and there, but nothing that couldn’t be handled.

In this age of the Internet, we as patients have the power to learn more about our disease and act accordingly. We can opt to just live with it which is not really a bad choice as a lot of A-Fib patients have done successfully. Or we can be proactive about it. Of course the ablation procedure is not 100% curative nor 100% safe, But I made my decision based on my goal that I still wanted to practice my profession as a doctor. I owe it to my patients to try to heal myself by the best possible means so that I can render the best medical service to them.

I am now exactly 100 days post ablation. I’m still on anticoagulants, but am A-Fib free. In the last conversation I had with Dr Haissaguerre, I asked him if there are things that I am prohibited to do or food that I am not allowed to eat, and he told me no prohibitions.

“Live a Normal life” and that’s what I plan to do.

Carlo Romero
Email: cadromero1170@yahoo.com

Editor’s Comments:
Because Dr. Carlo had been in A-Fib for some time, his ablation probably was more challenging. It took four hours which was longer than usual considering that the mapping had been done already by the ECGI system. He had a minor pericardial effusion which is often unavoidable in more extensive ablations.
The ablation Dr. Carlo had represents a radical, transformative change in ablation therapy and may alter the way ablations are done. Normal catheter ablation for A-Fib usually starts with isolating the pulmonary vein openings. But Dr. Haissaguerre instead started with the atrial septum area as indicated by the ECGI system. Only later did he go to the pulmonary vein areas. ECGI will certainly change the way catheter ablations are performed.
Dr. Carlo Romero is a great example of a proactive A-Fib patient who educated himself about A-Fib, researched all his options, found the right doctor for him, and wouldn’t settle for less than the opportunity for a complete cure of his A-Fib.

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If you find any errors on this page, email us. Y Last updated: Sunday, July 17, 2016

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.

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Last updated: Monday, August 17, 2015

Bordeaux Five-Step Ablation Protocol for Chronic A-Fib

Catheter inserted into the heart and through septum wall into Left Atrium

Catheter inserted into Left Atrium

By Steve S. Ryan, PhD, July 18, 2007, Updated October 2014

The French Bordeaux group uses a five-step process to treat Chronic A-Fib.

1. They start by isolating the Pulmonary Vein openings. They also eliminate potentials at the base of the Left Atrial Appendage, but do not isolate or electrically disconnect the whole of the LAA which could possibly lead to clots forming in the LAA and A-Fib stroke. (Ablating at the base of the LAA as part of the first step in treating A-Fib is a new approach and may become a very important first step in the ablation treatment of A-Fib.)

2. Next they make a roof line linear ablation linking the Right Superior Pulmonary Vein with the Left Superior Pulmonary vein opening to create complete electrical block

3. They then work in the Inferior Left Atrium and the Coronary Sinus. They make an incomplete blocking line between the Right Inferior and Left Inferior PVs in order to slow down the rapid atrial electrical activity.

They treat the Coronary Sinus as though it were another heart structure or Left Atrium, rather than just another vein opening. They disconnect the CS from the Left Atrium and ablate potentials along the Mitral Annulus. They also slow down Coronary Sinus electrical activity by ablating both inside and outside the CS with a lower wattage power, usually 25 Watts.

Dr. Jais, The Bordeaux Group

Bordeaux Five-Step Ablation Protocol for Chronic A-Fib

Editor’s comment: Treating the Coronary Sinus as another Left Atrium is a new approach. Most current A-Fib ablation procedures tend to stay away from the Coronary Sinus because of the risk of Stenosis (swelling). The French Bordeaux group, by using a low wattage, irrigated tip catheter, ablates within the Coronary Sinus without damaging it.

4. The fourth step is eliminating organized atrial activity in areas such as:

• Anterior Left Atrium & Left Atrial Appendage
• Septum
• Posterior Left Atrium
• Superior Vena Cava
• Right Atrial Septum

5. The fifth step is to create a Mitral Isthmus blocking linear ablation line from the Mitral Annulus to the Left Inferior PV. The goal is to eliminate all potentials along this line.

In practice, even after these five steps, rapid atrial activity often remains. It has to be mapped, traced to its source and ablated. Often the top of the Left Atrial Appendage has to be ablated.

This whole procedure requires a great deal more time, effort, persistence, skill and experience than normal left ablation procedures.

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Last updated: Sunday, February 15, 2015

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