Atrial Fibrillation/Pulmonary Vein Ablation Procedure

Overview

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. An electrical impulse stimulates the heart muscle to contract. The normal electrical conduction starts in the sino-atrial (SA) node sending an impulse through the atria to the atrio-ventricular (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, terminating without treatment and 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 (or embolize) to small vessels in the head and cause a stroke. It is important for people experiencing atrial fibrillation to be treated with an anticoagulant (drug that reduces the blood’s ability to clot) such as Warfarin (Coumadin) or aspirin.

Symptoms

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.

Diagnosis of Atrial Fibrillation

Atrial fibrillation if it is persistent or permanent can be diagnosed with a 12 lead electrocardiogram (ECG). If it comes and goes and is paroxysmal then it may not be seen on a routine ECG. A Holter monitor is a 24-hour recording of the heart rhythm. If within a 24-hour window, while being monitored the person experiences atrial fibrillation, it will be diagnosed. If the patient is symptomatic with atrial fibrillation and it has not been documented with either an ECG or Holter monitor than an event recorder can be used. This is a monitor that can either be worn or carried in a pocket to be applied to the chest when experiencing symptoms. With either model, the monitor is activated when symptoms are felt. The symptomatic recording can then be transmitted through the telephone to a technician who will print out a rhythm strip that may demonstrate atrial fibrillation.

Treatment of atrial fibrillation

Some people can be controlled with medications to prevent atrial fibrillation.
If atrial fibrillation is diagnosed within 24-48 hours of symptoms, the person can be electrically cardioverted to normal sinus rhythm.

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.

If it cannot be determined how long a patient has been in atrial fibrillation or if it is greater than 48 hours, a person would need to be on warfarin for anticoagulation for 3-4 weeks prior to conversion to sinus rhythm or undergo a transesophageal echocardiogram (TEE).

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.

Illustration of small transducer
passed down the throat, lying
close to heart

Pulmonary Vein Isolation Ablation Procedure

If a person experiences frequent episodes of paroxysmal or persistent atrial fibrillation despite medication therapy, ablative therapy may be an option to prevent further episodes. Ablation therapy is when an energy source, currently radio frequency energy, is applied to an area in 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 come off the left atria leading to the lungs.

Pulmonary Veins

Once the doctor 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 laboratory under sterile technique and using conscious sedation (light 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

CT scan of the heart: This 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 and ½ hours to complete. The heart’s image is later downloaded into the navigating equipment in the electrophysiology laboratory. This allows the physicians who are completing the ablation to visualize the specific anatomy as a guide to the area they need to ablate in the heart.

CT Scan

The ablation procedure

The patient is told when to report to the hospital the day of the ablation procedure. You will be expected to fast (nothing by mouth) from midnight on the morning of the procedure and instructions in reference to medications will be given in advance. We do not necessarily discontinue coumadin/warfarin before the procedure. You will be instructed in this regard. 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 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 may be other people in the room with your doctor, including 2 nurses and other doctors, who will assist him with your procedure. There may be an anesthesiologist or a nurse who is assessing your level of comfort and will give you small doses of continuous anesthesia. You should always let them know how you feel, especially if you are uncomfortable.

After injecting a local anesthetic, the doctor 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 will pass radiofrequency energy through the special catheter. This allows the tip of the catheter to heat up and destroy a small amount of tissue. Ablation cauterizes abnormal arrhythmia- causing tissue, making it incapable of transmitting electrical impulses.

Electrophysiology Lab

Electrophysiology Lab

Radiofrequency energy is applied in a circular pattern around the tissue of each the pulmonary veins and across the roof of the atria. Other applications of radiofrequency energy may be applied in other areas of the left atrium at the discretion of the physicians.

Radiofrequency Energy

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 perform. You are sedated and kept comfortable throughout the process.

After the Procedure

The patient is brought to a recovery area, adjacent to the EP lab, and monitored while the sedating medications wear off before being sent to the 13th floor of Schwartz Health Care Center, (HCC) where you will stay and be 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.

HCC-13 where you
will stay overnight

It is not unusual for your arrhythmia to recur in the first two to six weeks after the ablation. It can take up to-3 months for the ablation scars around the pulmonary veins to totally heal and for us to know if the procedure is successful. If your atrial fibrillation recurs, don’t be alarmed; 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 us. If you are uncomfortable with serious symptoms, call us 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.

Other medications

To prevent any emboli from developing after the procedure you will be placed on Warfarin (Coumadin) for two to three months. It takes 3-4 days for the effects of Warfarin to be therapeutic. If you were not on Warfarin (Coumadin) before the procedure we will bridge the therapeutic gap with a fast acting anticoagulant called Lovenox. This involves giving yourself a small injection twice a day for up to 5 days after the procedure. You will be fully instructed on how to do this prior to discharge by the nurse practitioner. It is always important to have your blood work checked after the procedure, as instructed at discharge, for us to properly instruct you on how much Warfarin (Coumadin) to take.

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 ECG done at that time and you will 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.

If you have any questions in the post procedure period you can always contact us. Our emergency number, 24 hours a day is 212-263-5555. The NYU Heart Rhythm Center number is 212-263-7149 and can be called Monday-Friday, 9 AM-5 PM.

Cardiac Electrophysiology / NYU Heart Rhythm Center

NYU Langone Medical Center
Cardiac Electrophysiology Lab

560 First Ave TH576
New York, NY 10016
Phone: 212-263-5555

NYU Heart Rhythm Center
403 East 34th Street, RIV-4th Floor
New York, NY 10016
Phone: 212-263-7149

Larry A. Chinitz, MD
Director, The NYU Heart Rhythm Center

Anthony Aizer, MD
Associate Director, The NYU Heart Rhythm Center

Neil E. Bernstein, MD
Associate Director, The NYU Heart Rhythm Center

Douglas Holmes, MD
Associate Director, The NYU Heart Rhythm Center

Scott Bernstein, MD
Assistant Professor of Medicine

Steven Fowler, MD
Assistant Professor of Medicine

Mark Mascarenhas, MD
Instructor of Medicine

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