The normal heartbeat is regular and is controlled by a natural, internal pacemaker (the sinus node) in the heart’s right upper chamber (atrium).
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The normal heartbeat is regular and is controlled by a natural, internal pacemaker (the sinus node) in the heart’s right upper chamber (atrium). The electrical impulse which passes through the heart muscle causes it to beat in a controlled and regular way. This creates the normal regular pulse. In atrial fibrillation (AF), the normal regular heartbeat is replaced by a disorganised, irregular rhythm which gives rise to an irregular and often fast heartbeat.
Surgical or Catheter Ablation of atrial tissue are the only curative treatments for atrial fibrillation (AF). The major goal of Catheter Ablation is restoration of normal rhythm to relieve symptoms associated with AF and minimisation or suppression of the associated risks of blood clot formation, cardiac failure and increased mortality.
In about 90% of patients AF originates from one or more of the four pulmonary veins that carry blood from the lungs to the left atrium. Radiofrequency energy is delivered via an intracardiac catheter (plastic coated wire) to disrupt or eliminate the electrical connections between the pulmonary veins and the left atrium that trigger or maintain episodes of AF. This is called Pulmonary Vein Isolation (PVI).
How long will the procedure take?
PVI is performed in a specially equipped room. The procedure can take 2–4 hours to perform. From time to time, the Cardiology Department can experience delays due to the nature of illnesses we deal with and cases which need urgent attention. We do our best to minimise delays and to keep you informed.
Preparation for the procedure
Because the upper chambers of the heart are quivering and do not contract vigorously, there is a possbility that blood clots can form in the heart. With Catheter Ablation a clot could become dislodged during the procedure and cause a stroke
For safety reasons, patients may be treated with blood thinners, Aspirin and Plavix or Warfarin for at least 1 week before the procedure or as directed by your doctor.
In addition a Transoesophageal Echocardiogram (TOE) may be performed to confirm the absence of a clot. Your doctor will tell you which blood thinners you should be on and any other medication changes required for the procedure. A CT scan of your heart may be performed before your ablation to create a 3-D image of the heart which we use during the procedure.
How the procedure works
The procedure may be done under general anaesthesia or alternatively some light sedation will be given through a drip in your arm to help you relax.
Two or three catheters are typically introduced to the heart through a vein in one or both groins for identification of the Pulmonary veins. This is usually done by a process called 3-D ‘mapping’ of the left atrium. Electrical energy or other energy sources may then be used to destroy the connections between the veins and atrium until Pulmonary Vein Isolation is achieved. The likelihood of further AF after PVI is about 35%in patients with paroxysmal fibrillation and about 50% in patients with persistent fibrillation.
A second procedure may be needed if the AF is not cured by the initial ablation.
Typically, patients have very little or no recall of the procedure and experience little or no discomfort.
Following the procedure
Bed rest is required usually for 4-6 hours after completion of the procedure with limited movement of both legs. Patients usually recover quickly. You may feel stiff from lying in the same position for hours. Your heart rhythm is usually monitored overnight.
Patients usually stay in hospital for 2 days after the procedure to receive blood thinner injections. Anticoagulation medication is usually recommended for 1- 3 months after ablation. Additional medication to prevent the AF recurring may also be recommended.
Before leaving the hospital you should receive a 6 week follow-up appointment with your doctor.
Potential risks, complications and discomforts
The procedure is usually relatively painless though minor discomfort such as the following may occur:
- Possible reaction to medications administered.
- Bruising, mild soreness or mild oozing from the puncture site(s) and mild chest soreness can be quite common following the procedure.
- Occasionally the bruising can be very extensive and cause considerable discomfort.
- Very rarely the bruising can be so extensive that a corrective procedure is required which involves either the application of an external clamp/pressure device or some form of surgery. Internal bleeding around the heart (cardiac tamponade) has occurred in 1.5% of patients in our experience. This is treated with emergency drainage.
- Blood clot formation which could lead to stroke (<1%).
- Infection of blood, heart valve or puncture site.
- Damage to blood vessels including narrowing of veins that carry blood from the lungs to the heart (pulmonary vein stenosis).
- Damage to the oesophagus which can be fatal (less than 1-in-10,000).
- Death (less than 1-in-5,000 cases).
- Possible reaction to medications administered.