There are three primary goals in the treatment of atrial fibrillation: alleviate symptoms, decrease the risk of heart failure, and reduce stroke risk. These treatment goals can be achieved with medications or procedures.
Atrial fibrillation ablation, most commonly via catheter ablation, is a procedure for atrial fibrillation which aims to eliminate abnormal electrical signals in the heart and restore normal rhythm.
During an atrial fibrillation catheter ablation procedure, abnormal heart tissue is burned (radiofrequency) or frozen (cryoablation) to create small areas of scar tissue. This scar tissue prevents abnormal electrical signals from initiating atrial fibrillation.
The left upper chamber (left atrium), specifically the pulmonary veins, are the most common site of catheter ablation for atrial fibrillation because most of the abnormal electrical signals which cause atrial fibrillation start within the pulmonary veins.
AFib catheter ablation surgery is minimally invasive which decreases recovery time and the risk of complications like bleeding and infection. During an atrial fibrillation catheter ablation, small flexible tubes called catheters are inserted into the veins in the groin.
When the ablation is performed, catheters are guided up into the right upper chamber of the heart (right atrium). Atrial fibrillation originates in the left atrium. Therefore a small puncture is made in the wall separating the right and left upper heart chambers to allow access to the left atrium.
Once the catheters are in the left atrium, an electrical map is made and the pulmonary veins are isolated using either radiofrequency energy (burn) or cryoablation (freeze). Sometimes additional areas of the left atrium are also ablated.
Ablation is the most successful for people with paroxysmal (intermittent) atrial fibrillation and can effectively decrease atrial fibrillation symptoms and frequency and recurrence of AFib. Seventy to 75% of patients with paroxysmal atrial fibrillation who undergo catheter ablation are symptom-free at 1 year.
There is an increased incidence of AFib recurrence after ablation in people with underlying cardiovascular disease (i.e. hypertension, valvular heart disease), older age, obesity and untreated sleep apnea. There is also a higher rate of recurrence of AFib after catheter ablation in patients with persistent atrial fibrillation, heart failure and enlargement of the left atrium.
Previously, it had been thought that rate control was more important than rhythm control to prevent long term atrial fibrillation complications. Rhythm control was a secondary goal and catheter ablation was only indicated if patients had tried and failed at least one antiarrhythmic medication. However, newer research supports the use of catheter ablation as a first line option for rhythm control in patients with recent onset paroxysmal atrial fibrillation.
Cryoablation and radiofrequency ablation have similar overall safety and efficacy. Research shows that patients with AFib who were treated with catheter ablation reported improved quality of life, had fewer recurrences of atrial fibrillation and decreased rates of hospitalization compared to patients treated with antiarrhythmic medications. A recent study of patients with AFib and cardiac conditions (i.e. hypertension or prior stroke) showed that an early rhythm control strategy with AFib ablation was associated with a lower risk of stroke, lower risk of death from cardiovascular causes and fewer hospitalizations for heart failure or heart attack compared to patients treated with usual care over a 5 year period.
Catheter ablations are significantly less effective for persistent atrial fibrillation. In paroxysmal AFib, most of the abnormal electrical impulses come from the pulmonary veins. But in persistent atrial fibrillation, other areas may be involved in propagating the abnormal rhythm. A hybrid approach can be a good option for these patients.
The hybrid approach combines catheter ablation (ablation of the inside of the heart) with heart ablation surgery (ablation of the outside of the heart). This approach is more effective at eliminating atrial fibrillation but is associated with more risks and longer recovery time because it is a more involved surgery.
An atrial fibrillation catheter ablation is a minimally invasive procedure and therefore recovery time is considerably less than with an open heart surgery. Most people can return to normal activities within a week or so.
Ablations are usually done under general anesthesia. Some of the recovery from ablation is secondary to recovering from anesthesia rather than the procedure itself. Patients frequently report fatigue and lower than normal energy for the first week after atrial fibrillation catheter ablation.
Typically, the patient stays overnight in the hospital although opportunities for same day discharge are being researched and are discussed below. After the procedure, the patient will lie still (bed rest) for 4-6 hours to minimize risk of bleeding at the catheter insertion sites in the groin.
There are lifting restrictions for the first 5-10 days after ablation to allow time for the groin to heal. Chest pain and shortness of breath are common after ablation and typically resolve in the first few weeks. Many people report elevated resting heart rate, which is actually normal after an ablation and has been associated with lower rates of AFib recurrence.
The first 2-3 months after ablation is called the blanking period. Recurrences of atrial fibrillation during this time do not necessarily indicate that the ablation ‘did not work.’ Radiofrequency or cryoablation creates a lot of inflammation within and around the heart which can be irritating and help create a milieu which lends itself to atrial fibrillation. When patients develop atrial fibrillation during the blanking period, they may be started on an antiarrhythmic medication and/or undergo cardioversion to restore a normal rhythm.
There are risks inherent in any invasive procedure. The overall risk for complications with Afib catheter ablation is 4%. The most common complication is an injury at the vascular access site.
Other complications include bleeding, pericarditis (inflammation around the heart), pericardial effusion (fluid around the heart), cardiac tamponade (decreased heart function as a result of a fluid collection around the heart), phrenic nerve injury and atrioesophageal fistula (very rare). As with any invasive procedure, there is a risk of infection.
Catheter ablation for atrial fibrillation does not inherently shorten life span. A recent study published in the New England Journal of Medicine actually showed a lower risk of death from cardiovascular causes in patients with paroxysmal atrial fibrillation who underwent catheter ablation compared to those receiving antiarrhythmic medication therapy.
Early studies showed patients with atrial fibrillation undergoing catheter ablation have a 1 in 1000, or 0.001%, risk of death in the first 30 days after catheter ablation. More recent studies show the 30 day risk as closer to 4-5 out of 1000. There is a greater risk of complications in patients who are older and have other health problems such as heart disease, heart failure, COPD, diabetes, kidney failure and sleep apnea.
It is typical for a patient to stay overnight in the hospital after a catheter ablation for atrial fibrillation.This is to observe the patient for post-operative complications. In 2020, studies were released which reported successful same day discharge. Each of these studies found that safe same day discharge after atrial fibrillation catheter ablation required the use of standardized protocols, appropriate patient selection, and early follow up in the clinic.
There is not necessarily an age limit for cardiac ablation for atrial fibrillation. However, the risk of anesthesia and procedure related complications does increase with age. There are a number of effective antiarrhythmic medications. Attempting to control atrial fibrillation with medications may be preferred if a person is of very advanced age or has a number of other health problems which would increase the risk of anesthesia and decrease the probability of ablation success.
There are often tests completed prior to cardiac ablation. These include blood tests and a chest x-ray. In addition, we complete a specialized computed tomography (CT) scan of the heart. This is done to make a 3D image of the left upper heart chamber (left atrium) and pulmonary veins which is used during ablation.
Testing for sleep apnea should be completed prior to an atrial fibrillation ablation. If sleep apnea is found, adequate treatment is important. People with untreated sleep apnea have an increased risk of AFib recurrence after ablation.
The first step in preparing for an atrial fibrillation ablation is to have an in-depth discussion with your healthcare provider(s) to determine if an ablation is right for you. The decision to have an ablation should be made through a shared decision-making process during which you and your doctor can review treatment options and discuss your priorities and goals. Ask your doctor about the risks and benefits associated with the various medications vs. ablation.
Some people decide to get an ablation because antiarrhythmic medications have been ineffective or because of medication side effects. Some people want an ablation because they want to minimize the need to take medications long term.
If you are having an ablation, it is important for your healthcare providers to assess if you have any modifiable risk factors for atrial fibrillation like hypertension, sleep apnea, obesity, or excessive alcohol intake. Addressing these issues prior to an ablation will improve its success.
Once the decision has been made to proceed with ablation, it is very important to take all your medications as instructed. It is common that some medications may be stopped for a few days prior to the procedure. This is done to reduce the risk of complications during and after the procedure.
