Written by Dimitrios Vrachatis, Specialist Cardiologist, PhD, National and Kapodistrian University of Athens.
What is atrial fibrillation ablation?
Atrial fibrillation ablation is often called pulmonary vein isolation (PVI). It is an invasive procedure for patients with atrial fibrillation when the treating cardiologist, after assessing individual characteristics, chooses a rhythm-control strategy.
How is it performed?
A peripheral vein, usually the femoral vein, is punctured. The electrophysiologist advances catheters into the right atrium, then makes a small opening in the interatrial septum to access the left atrium.
The pulmonary veins return oxygenated blood from the lungs to the left atrium; most people have four. Special catheters are positioned at their antra and treatment is applied. The aim is to disrupt the tissue connections between the atrial myocardium and the pulmonary veins.
Are different ablation techniques available?
Several techniques can achieve pulmonary vein isolation.
Historically, the first approach used catheters delivering radiofrequency energy at their tips. Balloon cryoablation is also used. These techniques are generally equivalent.
The operator’s experience and the patient’s characteristics guide the choice. Other approaches, including laser ablation, are being developed around the same therapeutic principle.
What is the success rate?
Success in maintaining sinus rhythm, strictly defined as no episode of atrial fibrillation after the first 2–3 months following ablation, is approximately 60–70%.
Could a repeat procedure be needed?
Sometimes a repeat intervention is required. Additional treatment sites beyond the pulmonary veins may be sought. Your cardiologist will discuss this according to your characteristics and medical history.
When is success more likely?
The chance of maintaining sinus rhythm is greater when ablation is performed earlier in the disease course. A longer atrial fibrillation burden causes more electrical and anatomical changes in the myocardium.
If atrial fibrillation returns, was ablation pointless?
No. Evidence shows benefits even without complete elimination of atrial fibrillation, including:
- Fewer symptoms, such as palpitations, breathlessness, chest pain, dizziness or feeling faint
- A lower atrial fibrillation burden, meaning less time in AF rather than normal sinus rhythm
- A lower average heart rate
- Fewer emergency hospital admissions
Who should have atrial fibrillation ablation?
Until recently, ablation was indicated after medication failed to maintain rhythm. Newer safety and efficacy evidence supports its use even as a first-line treatment.
Decisions always follow an individual assessment of symptoms, anatomy and medical history.
Who should not have the procedure?
It is not recommended when atrial fibrillation is chronic and satisfactory control of heart rate and symptoms has been achieved.
Is preparation needed?
No special preparation is needed. Do not eat on the morning of the procedure. Medication is usually unchanged except for anticoagulants, for which your cardiologist will provide instructions. A younger patient not already taking long-term anticoagulation should have received it for at least three weeks.
What anaesthesia is used?
In most centres, local anaesthesia is used. Mild sedation may be given, rather than general anaesthesia.
What are the complications?
Ablation is generally safe, but risks include:
- Periprocedural stroke: less than 1%
- Various minor complications: approximately 1–2%
- Death: less than 0.2%
Benefits and risks are always weighed before a final decision.
What happens to anticoagulation afterwards?
Anticoagulation continues according to the estimated stroke or thromboembolic risk score, regardless of the success of ablation.
What happens to antiarrhythmic medication?
It is usually given for 2–3 months, the blanking period, then stopped. Decisions are individualised.
What else should I do after ablation?
For better long-term results, alongside medication and ablation, follow healthy lifestyle habits: physical activity, avoiding alcohol and smoking, and controlling blood pressure, cholesterol and blood glucose.