#AF-004 When Should I Consider an Ablation for A-Fib?

January 4th, 2014 by

When Should I Consider an Ablation for A-Fib?

John had been struggling with atrial fibrillation (A-Fib) for years.  He had tried the medications but they all made him feel tired.  He just did not like the way he felt when his heart was out of rhythm.  Should he consider a catheter ablation procedure to manage his A-Fib?

In this article we will discuss when an ablation procedure should be considered for the treatment of A-Fib.

What is a catheter ablation procedure?

A catheter ablation procedure is a minimally invasive procedure where a cardiologist inserts thin catheters through your veins and advances them to the heart.  Once these catheters are in your heart, a 3D map is often created to see where these abnormal heart rhythms are originating from.  Once the rogue spots that are causing A-Fib are identified, these areas are then cauterized or frozen to keep the heart beating normally.

Patients may go home the same day or they may be observed overnight.  Typically just a band-aid is used for the puncture sites as stitches are not even required for this procedure.  To see video footage of an ablation you can watch this TV segment.

Do I have to take a medicine first?

Many patients who come to see me are disheartened to learn that I generally encourage them to try an antiarrhythmic medication first.  The reason is that this is the approach recommended by the A-Fib Treatment Guidelines and the fact that many insurance companies will not pay for the procedure unless an antiarrhythmic has been tried first.

On average, I find these anti-arrhythmic medications generally only work for a year or two.  For some patients they do not work at all.  For other patients I have found that they may effectively control A-Fib for more than 20 years!

One potential advantage to trying a medication first is that our technology for catheter ablation procedures just gets better with time.  Thus, if you can control your A-Fib for 3-5 years, we may have an even better treatment option for A-Fib at that time.

One thing to remember is that antiarrhythmics are not without risk.  Most of the antiarrhythmics studied have been shown to increase the risk of premature death.

Should I wait to have my ablation procedure?

Patients often ask me, “can I wait to have my ablation?”  My answer generally is that as long as you can maintain normal rhythm it is a reasonable option to wait for an ablation procedure.

There is a common saying that “A-Fib begets A-Fib.”  The reason is that episodes of A-Fib may lead to scarring of the heart.  This heart scarring then leads to even more episodes of A-Fib.

For patients who have been continuously out of rhythm for more than 1 year, the chances of a successful ablation procedure decrease significantly.  Indeed, we have published a study which showed that the longer an ablation is delayed the lower the chances of success.

What are the benefits of a catheter ablation?

In countless studies, the two clearly proven benefits of catheter ablation for A-Fib include the following:

1. To control A-Fib symptoms

2. To increase your chances of holding normal rhythm

While no one questions the role of a catheter ablation to control symptoms and increase your chances of holding normal rhythm, the question many have sought to know is will it prolong life, prevent strokes, and prevent dementia.

In our study of 37,908 patients at Intermountain Healthcare we asked this very question.  Our study showed that those patients who elected to have a catheter ablation procedure lived much longer and were much less likely to suffer from a stroke or dementia.

It should be pointed out that our study did not randomize patients to the two different treatments strategies, namely ablation versus drugs.  As it was not a randomized study, catheter ablation cannot yet be considered as a proven way to prevent premature death, strokes, and dementia.

To fully answer this question, there is an ongoing large multi-center study, called the CABANA Study, which will answer this question.  This study is funded, in part, by the National Institutes of Health.

Who is the ideal ablation candidate?

Another question I am frequently asked is “am I a good candidate for an ablation?”  After personally performing more than 4,000 catheter ablation procedures for A-Fib, these are the patients that I have found who are most likely to be “cured” from A-Fib.

1. They have paroxysmal A-Fib (A-Fib stops on its own)

2. Their left atrium is normal in size

3. They don’t have any other cardiac or medical problems

4. They have an ideal body weight

5. They are young

What are the risks of a catheter ablation procedure?

Unfortunately, catheter ablation procedures are not risk free.  Many complications can occur.  For example, patients could suffer the following complications: bleeding, infection, heart attack, stroke, tear in the heart, damage to the pulmonary veins, esophageal perforation, nerve damage, emergent open-heart cardiac surgery, or even death.

When it comes to the risk of a complication, experience does matter.  Like everything in life, the more you do something the better you get at doing it.

When it comes to catheter ablation, studies show that if your procedure is done by an inexperienced physician or hospital, you have a 1 in 200 chance of never leaving the hospital alive.  In this study, an inexperienced physician was defined as a cardiologist (an electrophysiologist or cardiologist specializing in heart rhythm disorders) who did less than 25 of these procedures each year.  An inexperienced hospital was defined as a hospital that did less than 50 of these procedures each year.

If your electrophysiologist has recommended a catheter ablation procedure for A-Fib, find out how experienced they are, how experienced the hospital is, and ask them to show you their complication rate data.  If they cannot show you these numbers you may want to consider looking elsewhere for a procedure which could have significant complications.

Should I have a radiofrequency or cryoballoon ablation procedure?

There are two general ablation approaches for atrial fibrillation, radiofrequency (heat energy) or cryo (cold energy).  Either approach can effectively eliminate the areas of the heart which are misfiring.  As there are no data showing which approach is best, the best approach for you is the technique your electrophysiologist is most comfortable with.

Is a surgical ablation procedure better?

In addition to the catheter approaches, there is also a surgical approach to treating atrial fibrillation.  If you need open-heart surgery bypass surgery or valve surgery, your surgeon could easily perform a MAZE surgery for atrial fibrillation while your chest is open.

Surgeons have now started doing less invasive surgeries for atrial fibrillation which involve much smaller incisions in your chest.  For many patients, these “Mini-MAZE” surgeries can be very effective in controlling A-Fib.

Certainly, the more invasive the procedure is the higher the risks.  Studies have not shown whether the surgical approach is more effective than catheter approaches in treating A-Fib.

The surgical approach for A-Fib could be a good option if you live in a region where you have an experienced surgeon and your electrophysiologist is inexperienced in performing catheter ablation procedures.

Should John consider an ablation procedure?

In John’s case, his atrial fibrillation has caused him significant symptoms.  When he is out of rhythm he feels very tired and short of breath with any activity.

John had also tried an antiarrhythmic medication to control his A-Fib.  Initially he tried flecainide.  When flecainide was no longer effective he tried sotalol.  Both of these medicines not only failed to control his symptoms but also caused him to feel very tired.  To be honest, John also did not like having to take medications for the rest of his life.

As he had symptoms from A-Fib and medications were ineffective, he clearly met the established criteria for a catheter ablation procedure.  Fortunately, his procedure went well and he is now drug-free and doesn’t have any more A-Fib.

Should I consider an ablation procedure?

At the end of the day, should you consider a catheter ablation procedure?  Regardless of whether you are an ideal candidate or not, the following are the people who should at least consider this procedure:

1. Your A-Fib causes you symptoms

2. Antiarrhythmics either don’t work or cause significant side effects

3. You have been in normal rhythm within the last year

Has your doctor recommended a catheter ablation procedure?