Atrial Fibrillation Ablation

What is ablation for atrial fibrillation?

Ablation is a procedure to treat atrial fibrillation. It uses small burns or freezes heart cells to cause some scarring on the inside of the heart. This helps break up or insulate the electrical signals that cause irregular heartbeats. This can help the heart maintain a normal heart rhythm.

The heart has 4 chambers. There are 2 upper chambers called atria and 2 lower chambers called ventricles. Normally a special group of cells begin the signal to start your heartbeat. These cells are in the sinoatrial (SA) node in the upper right atrium of the heart. During atrial fibrillation (AFib), the signal to start the heartbeat doesn’t begin in the sinoatrial node the way it should. Instead, the signal begins somewhere else within the tissue of the atria. This abnormal signaling most commonly occurs near the connection between the pulmonary veins and the left atrium. These veins are what bring blood back from the lungs to the left atrium. When in AFib, the atria can’t contract normally to move blood to the ventricles. This causes the atria to quiver or fibrillate. The disorganized signal spreads to the ventricles, causing them to contract irregularly and sometimes more quickly than they normally would. The contraction of the atria and the ventricles is no longer coordinated, and ventricles may not be able to pump blood as effectively to the body.

For ablation, a healthcare provider puts a thin wire (catheter) into a blood vessel in the groin and threads it up to the heart. This may be done in one or both groins. Once the catheter is inside the heart, software mapping systems are used to allow the provider to study the electrical signals as they occur in the heart, as well as navigate where to position the catheter. The provider then uses the catheter to burn or freeze an organized scar in a small area of the heart where the abnormal signal starts. In the burning process, the provider uses radiofrequency energy to heat and scar the tissue. The freezing process uses a method called cryoablation. Oftentimes, a freezing balloon is used to create scar. Scar tissue doesn't conduct electrical signals inside the heart. So creating a scar with the ablation helps to prevent the heart from conducting the abnormal electrical signals that cause AFib.

Sometimes healthcare providers use a surgical method instead. This is most common when you're already having heart surgery for another reason.

Why might I need ablation?

Some people have unpleasant symptoms from AFib, such as shortness of breath and palpitations. AFib also greatly increases the risk for stroke. Blood-thinning (anticoagulant) medicines used for preventing stroke have their own risks. People on certain blood thinners need to have extra blood draws and tracking. The main reason for ablation is to control symptoms. Another reason is to maintain normal rhythm. This reduces the risk of heart failure and stroke. However, it may not eliminate the need for blood thinners to prevent stroke.

Many people with AFib take medicines to help control their heart rate or heart rhythm. The medicines don't work well for some people. In such cases, your provider may suggest ablation to correct the problem. In general, ablation also works better to keep your heart at a normal heart rhythm when compared with medicines.

Ablation may be more likely to work long term if you have AFib that has lasted for no more than 7 days at a time. It may be less likely to work long term if you have AFib that lasts longer and if you've had it for years. Ablation might be a good option for you if:

• You don't have other structural problems with your heart

• You have symptoms from your AFib and don't want to take medicine for the rest of your life

Currently, healthcare providers treat most people with medicine before considering ablation. But ablation can be considered a first-line alternative to heart rhythm medicine. Ask your provider about the pros and cons of the procedure in your particular situation.

What are the risks of ablation?

You may have certain risks based on your health conditions. Discuss all your concerns with your healthcare provider before your ablation. Most people who have AFib ablation have a successful outcome. But there are some risks linked to the procedure. Although rare, there is the risk of death. Other risks include:

• Bleeding, infection, and pain from the catheter insertion

• Damage to blood vessels from the catheter

• Hole (puncture) to the heart

• Damage to the heart. This damage might need a permanent pacemaker.

• Blood clots, which might lead to a stroke

• Narrowing of the pulmonary veins. These are the veins that carry blood from the lungs to the heart.

• Radiation exposure

• Damage to the esophagus

• Damage to the nerves of the diaphragm or gut

You are more likely to have complications if you're older, smaller in size, or if you have certain other health and heart conditions.

It's important to understand that the procedure won't permanently stop AFib for some people. Sometimes AFib or other abnormal heart rhythms can develop months to years after an ablation. You might be more likely to have this problem if you're older, have other heart problems, or have had AFib for a long time. Having the ablation again can often improve the results of the first ablation procedure. You may also find that medicines work more effectively after an ablation.

How do I get ready for an ablation?

Talk with your provider about what you should do to prepare for your AFib ablation. Follow any directions you're given for not eating or drinking before your procedure. Follow your provider’s instructions about what medicines to take before the procedure. Don’t stop taking any medicine unless your provider tells you to do so.

Your provider might order some tests before your procedure. These might include:

• Electrocardiogram (ECG) to analyze the heart rhythm

• Echocardiogram (echo) to assess heart structure and function

• Stress testing to see how your heart responds to exercise

• Blood tests like those to check thyroid levels

• Cardiac computed tomography (CT) scan or MRI to further look at your heart's anatomy

Let your provider know if you're pregnant before having the procedure. Ablation often uses radiation, which may be a risk to the unborn baby. If you're of childbearing age, your provider may want to do a pregnancy test to make sure you aren’t pregnant.

Someone will shave your skin above the area of operation (usually in your groin). About 1 hour before the operation, you'll be given medicine to help you relax.

What happens during ablation?

Talk with your healthcare provider about what to expect during your ablation. The procedure usually takes 2 to 4 hours. A cardiac electrophysiologist and a special team of nurses and technicians will do the ablation. During the procedure:

• You may have numbing medicine (local anesthetic) put on your skin where the team will insert several IV (intravenous) lines called sheaths. This is usually in your groin.

• You'll likely get medicine (general anesthesia) so that you'll sleep through the surgery.

• Your provider will put a series of electrode catheters through the sheaths and into your vein most often located in the groin. Electrode catheters are long, thin, flexible wires with electrodes at the tip. The team will then move the catheters through the vein to the correct place in your heart.

• Next, the provider will locate the abnormal tissue using special technology. This technology involves a mapping system. It may also have a GPS- like feature to let the provider see where the catheter is inside the heart. They'll send small electrical impulses through the catheter. Other catheters will record the heart’s signals to find the abnormal sites.

• The provider will place the catheter at the site where the abnormal cells are. They will then scar the abnormal area by freezing or burning it. This might cause slight discomfort if you're awake.

• You will get blood-thinning medicine through an IV line to help prevent clots from forming on the catheters while they're inside your heart. This helps lower the risk for stroke.

• Once the ablation is completed, the team will remove the catheters. They'll close your vessel with firm pressure or internal stitches or other closure devices.

• The team will close and bandage the site where the provider inserted the catheters.

What happens after ablation?

Talk with your healthcare provider about what to expect after your ablation. In the hospital after the procedure:

• You'll spend several hours in a recovery room.

• The team will watch your vital signs, such as your heart rate and breathing.

• You'll need to lie flat for several hours after the procedure. You shouldn't bend your legs. This will help prevent bleeding.

• Some people spend the night in the hospital.

• You may feel some chest tightness after the procedure.

• Your provider will review which medicines you need to take, including blood thinners.

At home after the procedure:

• Most people can return to normal activities within a few days after leaving the hospital.

• Don't do heavy physical activity for a few days.

• Don't drive for 48 hours after the procedure.

• You may have a small bruise from the catheter insertion. If the insertion site starts to bleed, press down on it and call your provider.

Call your provider if you have an irregular heartbeat, your leg is numb, or if your puncture site swells. Also call your provider if you have a fever, or signs of infection around the catheter site. This includes redness or drainage.

After you leave the hospital, it's important to follow all the instructions your provider gives you for medicines, exercise, diet, and wound care. Be sure to keep all your follow-up appointments.

Call 911

Call 911, or get immediate medical care at the nearest emergency department if you have:

• Chest pain

• Shortness of breath

• Lightheadedness

• Fainting

• Confusion

• Trouble speaking or using your arms or legs

• Vision changes

• Bleeding that can't be controlled with pressure

• Rapid swelling at the puncture site

Next steps

Before you agree to the test or procedure make sure you know:

• The name of the test or procedure

• The reason you're having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you're to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you didn't have the test or procedure

• Any alternative tests or procedures to think about

• When and how you'll get the results

• Who to call after the test or procedure if you have questions or problems

• How much you'll have to pay for the test or procedure