Atrial Fibrillation Ablation
What is an Atrial Fibrillation Ablation?
Atrial Fibrillation is the most common arrhythmia. Over two million Americans are living with atrial fibrillation. Although it is not life-threatening, it can cause uncomfortable symptoms. It can also cause other problems such as congestive heart failure and stroke. To fully understand atrial fibrillation, you need to know how the normal heart works.
There are four chambers in the heart, two atria, which are the upper chambers of the heart, and two ventricles, which are the lower chambers of the heart. There is a right and left atrium and a right and left ventricle. Native electrical impulses stimulate the heart muscle to contract. The normal electrical conduction starts in the sino-atrial (SA) node sending an impulse through the atria to the atrioventricular (AV) node, which is the relay station of the heart. It sends the electrical impulses to the ventricles. They are the major pumping structures of the heart.
With atrial fibrillation, there is an abnormal focus of electrical impulses that cause the atria to fibrillate or quiver rather than contract in a regular pattern. The storm of impulses is sent to the AV node, which conducts some of the impulses through to the ventricle. If the impulses are rapidly conducted the ventricular rate can be very fast. Some people experience atrial fibrillation on and off, which is classified as “paroxysmal.” Some people experience atrial fibrillation that needs to be terminated with some type of treatment to revert to normal sinus rhythm and that is classified as “persistent.” Some people are always in atrial fibrillation and even with treatment they stay in atrial fibrillation and that is classified as “permanent.”
Since the atria are not emptying properly when in fibrillation, blood clots can develop and travel to vessels in the head causing a stroke. It is important for people experiencing atrial fibrillation to be treated with an anticoagulant (i.e. blood thinner) such as Warfarin (Coumadin), Pradaxa, Eliquis, Xarelto or aspirin.
Some people are not symptomatic with atrial fibrillation. Other people can feel one or more of the following symptoms: palpitations, fluttering, shortness of breath, particularly with exertion such as climbing a flight of stairs or walking up an incline, chest pressure or discomfort and lightheadedness.
Atrial fibrillation, if it is persistent or permanent, can be diagnosed with a 12 lead electrocardiogram (EKG). 1f it comes and goes then it may not be seen on a routine EKG. Then a prolonged cardiac monitor can be used to make the diagnosis.
Cardioversion: This is a sameday procedure where a patient comes to a designated monitored area such as the emergency room, electrophysiology laboratory or same day procedure unit and receives an intravenous medication that will acutely convert the atrial fibrillation to sinus rhythm. Alternatively, some people would come to the same area, receive a sedating medication through an intravenous line and have electrical energy applied to the chest using paddles or specialized pads that connect to an external defibrillator. The whole procedure takes about 5-10 minutes. Generally, one has to remain at the hospital for approximately 2 hours after cardioversion to recover from the anesthesia. Someone must accompany you home. Most patients need a transesophageal echocardiogram (TEE) prior to cardioversion to make sure a clot is not already present in the heart.
A TEE is done by a specially trained cardiologist with ultrasound imaging equipment. A special probe for visualizing the structures of the heart is placed into the esophagus after receiving IV sedation and spraying the back of the throat with a local anesthetic. The probe pictures the inside of the atria while the doctor studies and records it for further analysis. He is determining if there is a thrombus (blood clot) in the atria and for other abnormalities such as a patent foramen ovale (a benign, congenital heart condition that you may not be aware you have). It takes approximately 30 minutes to accomplish a TEE. You must remain in the hospital for 2 hours after the procedure.
If a person experiences frequent episodes of paroxysmal or persistent atrial fibrillation despite medication therapy, ablation therapy may be an option to prevent further episodes. Ablation therapy is when an energy source, currently radiofrequency energy, is applied to an area of the heart that is a focus for an arrhythmia. In the case of atrial fibrillation, research shows that the source of electrical irritability is surrounding the os ( opening) of each of the pulmonary veins.
There are typically four pulmonary veins that drain blood from the lungs into the left atrium.
Once Dr. Ahuja has decided that pulmonary vein ablation may help you he will plan to do an electrophysiology test and ablation procedure. This procedure is performed in a special electrophysiology laboratory under sterile technique and using general anesthesia. You will be asked to prepare for this procedure by having blood work done and a special chest scan called a CT (computerized tomography) scan.
The CT scan is done in the radiology department. It involves having an iodine-based contrast injected intravenously. Please be sure to tell the staff if you are allergic to contrast or shellfish. After a brief interval, the patient is placed under a specialized scanning machine that moves slowly over the chest as it revolves from one side of the stretcher to the other. The patient is not in a tube or tunnel. It does not require sedation and takes approximately 1 hour to complete.
The heart’s image is later downloaded into the navigating equipment in the electrophysiology laboratory. This allows Dr. Ahuja to visualize the specific anatomy as a guide to the area he needs to ablate in the heart.
You will be expected to fast (nothing by mouth) from midnight the night prior to the ablation.
Please remove nail polish and do not use body lotion the day of the procedure. The laboratory has a lot of equipment including monitors and big X-ray machines. The room is sterile so the doctors and nurses are wearing specialized clothing called scrubs. You will be covered with special drapes; an intravenous (small tube in the vein for administering fluid) will be placed as well as a clip on your finger to monitor the level of oxygen in your bloodstream. Your chest and groin area is shaved. Special electrodes are placed on your chest and back for monitoring throughout the procedure.
There will be other people in the room with Dr. Ahuja, including 2 nurses and other doctors, who will assist him with your procedure. There will be an anesthesiologist for general anesthesia.
After injecting a local anesthetic, Dr. Ahuja will insert catheters into the veins in your groins and advance them, under fluoroscopic (X-ray) guidance into your heart and through the septum (the wall between the right and left atria) to the left atrium to access the area surrounding the pulmonary veins. After positioning the catheter and mapping (locating the area to ablate electrical triggers), he wi 11 pass radio frequency energy through the special catheter. This allows the tip of the catheter to beat up and destroy a small amount of tissue. Ablation cauterizes abnormal arrhythmia-causing tissue, making it incapable of transmitting electrical impulses.
Radiofrequency energy is applied in a circular pattern around the tissue of each the pulmonary veins and possibly other areas of the heart if needed at the discretion of the physicians. He will also apply radiofrequency energy to another area in the right atrium to remove the foci of another common atrial arrhythmia called atrial flutter, which coincides with atrial fibrillation. The whole procedure can take up to 4-6 or more hours to perfom1. You are sedated and kept comfortable throughout the process.
After the Procedure
The patient is brought to the cardiac care unit (CCU) and monitored overnight. It is not unusual to feel some discomfort in the chest and groin areas where the catheters were inserted. You may feel some skipped beats. When you are ready to go home the next day you will be given special instructions about how to take care of your groin, what medications to take and what symptoms you may expect to feel. Some patients feel chest discomfort, especially with a deep breath, for several days to a week after the procedure. We suggest taking Extra-Strength Tylenol for this discomfort; it is caused by inflammation. You should avoid the non-steroidal anti-inflammatory drugs like Ibuprofen because they can promote bleeding.
It is not unusual for your arrhythmia to recur in the first three months after the ablation. It can take up to 3 months for the ablation scars around the pulmonary veins to totally heal and for Dr. Ahuja to know if the procedure is successful. If your atrial fibrillation recurs, don’t be alanned; it is part of the process for healing after the ablation. If it is persistent, that is 24 hours in duration without significant symptoms, you should call Dr. Ahuja. If you are uncomfortable with serious symptoms, call him immediately.
Another similar arrhythmia, called an atrial tachycardia, may develop after your ablation.
Generally you may be aware of a fast heartbeat, but because it is regular, it will feel different from your atrial fibrillation. They usually resolve spontaneously but occasionally need to be treated with medications or in rare circumstances, another ablation procedure. You will probably go home on an antiarrhythmic medication to allow the healing process to take place while maintaining regular sinus rhythm. Depending on your post procedure course, you may be on this medication for 3 months. Some patients retain a little fluid for several days after the procedure and we may prescribe a diuretic for 3 days.
To prevent any emboli from developing after the procedure you will be placed on a blood thinner for at least 3 months. You will be asked to come to the office in about 2 weeks after the procedure so we can see how you are doing. You will have an EKG done at that time and you wi 11 be asked if you have had any symptoms, specifically how often and for how long. Two weeks later, we will want to obtain a 24-hour Holter monitor recording of you rhythm. You will be seen again in our office two weeks after that as we monitor how you are doing.
Schedule a Consultation
If you have any questions in the post procedure period you can always contact us. Our emergency number, 24 hours a day is 516-437-5600. The office is open Monday-Friday, 9 AM-5 PM, but after normal business hours you will be directed to our answering service where Dr. Ahuja can be paged.