Ablation therapy for Atrial Fibrillation

  1. Q.What is AF ablation?

In this procedure the cardiologist uses Radiofrequency energy to get rid of the actual triggers that cause AF. These triggers reside in the pulmonary veins in most cases but occasionally may lie in other parts of the heart. This limited ablation strategy is often sufficient to cure the early Paroxysmal stage of AF. In the more advanced cases of persistent AF, a more extensive lesion may be needed in which not only are the AF triggers targeted but also the underlying atrial substrate is modified. This involves creating ‘road-blocks’ in the atrial muscle which prevent AF circuits from developing (‘catheter maze operation’, see Images here). For a detailed idea of Dr Gupta’s technique and approach to AF ablation, please download AF ablation Northern AF meeting.ppt.

  1. Q.This sounds quite complicated. Does it involve open heart surgery?

No, it doesn’t. Current technology allows this treatment to be delivered simply via tubes placed into veins at the top of the leg. In most cases, the procedure is performed under local anaesthesia and sedation. See photos here. Patients are on their feet after a few hours, and go home the following day. An increasing number of patients are now able to go home the same evening.

Q. How effective is this procedure in treating AF?

The quoted success rates in literature vary from 70-90%. Dr Gupta’s results are very much at the higher end of this range. (See ‘Our results page’, and download Gupta AF ablation results 2007-9.ppt ). About 1 in 3 patients may need more than one ablation procedure to get cured of their AF. This is especially the case in those patients who are at a more advanced stage of the disease, i.e., persistent rather than paroxysmal AF.

Q. What are the risks involved?

To prevent a clot from forming in the heart during ablation, we use strong blood-thinning drugs. This increases the risk of bleeding in the leg and around the heart and these are the commonest complications of the procedure, occurring in 1-2% of patients. These are seldom life threatening and can be treated in the catheter lab itself. The most serious complication is that of intra-procedural stroke, but this is thankfully very uncommon, occurring in 0.3% of cases. NO patient of Dr Gupta’s  has experienced this complication till date. Other rarer complications include narrowing of the pulmonary veins and formation of a fistula between the heart and the gullet. There is a procedural mortality of about 1 in 1000.

  1. Q.Am I too old for AF ablation?

While in the past, AF ablation was generally reserved for younger patients, more recent experience with this treatment has shown that older patients too have a very good chance to benefit from it.  Dr Gupta has performed AF ablation in patients older than 80 years of age with good results. (see Case Histories and patient accounts). More than your age, what is more important is that AF be your main  health problem and that there are no other long term illnesses. You should ask yourself: ‘If my AF is treated successfully, would my health be restored to a normal/ near-normal state?’ If your answer to this question is yes, then AF ablation may be for you.

  1. Q.Do I need to have ‘failed’ treatment with medicines before being considered for ablation?

This used to be the practice till a few years ago. However as AF ablation becomes a more routine and safer procedure, physicians have been considering it earlier and earlier in the treatment cycle. In fact, current scientific guidelines from the European Society of Cardiology endorse the use of catheter ablation as first line treatment for those patients with paroxysmal AF who do not have significant structural heart disease. Many patients may prefer the option of a ‘fix’ with catheter ablation to lifelong treatment with medications, and the latest guidelines support this choice.

  1. Q.Which patients may not be suitable for AF ablation?

Recent advances in this field have allowed ablation therapy to be used for a wide range of AF patients. However, there are still some characteristics that would act as relative contraindications for ablation therapy. These include severe obesity (Body mass index >40), very long duration of persistent AF (longer than 2-3 years) or very large size of the left atrium (>5.0-5.5 cm). If more than one of these adverse factors are present, that would constitute an absolute contraindication.

  1. Q.I have had AF for several years. Am I now past the stage where ablation is likely to be successful?

If your AF is still in the intermittent/ paroxysmal stage, then the duration of AF has very little bearing on the outcomes of AF ablation. However, if your AF is already at the more advanced stage of continuous/persistent AF, the results of AF ablation will be less good if you’ve been in this stage for more  than 2-3 years. There are other factors too that determine the chances of success in these cases of ‘long standing persistent AF’ ; Dr Gupta would be able to advise you upon assessing your case in detail.

Q. How do I decide that my specialist is the right one for me?

As AF ablation is a technically challenging procedure, the success rates vary from doctor to doctor to a greater extent than they do in less complex procedures. Even among cardiologists, those that have a special interest in AF and perform a large number of these ablation procedures can be expected to have better results than those who do less.

It’s a good idea to ask your doctor pointedly the following two questions

  1. 1.How many AF ablations have you done personally in the last year? Ideally, this number should be greater than 50 (or average of one a week).

  2. 2.What percentage of your AF patients have needed repeat ablation procedures to get cured of AF? Ideally, this figure should be less than 1 in 3 for Paroxysmal AF cases.

Don’t be embarrassed to ask these questions. After all, it is your own heart and you have the total right to decide who operates upon it!

For reference, Dr Gupta performed over 150 AF ablations in each of the past 3 years (2009, 2010, 2011) and his ‘redo rate’ for paroxysmal AF is around 1 in 4.

  1. Q.What is Dr Gupta’s technique for AF ablation?

Dr Gupta uses a technique of AF ablation known as WACA (Wide Area Circumferential Ablation) using Radiofrequency ablation. He often uses 3D Image Integration;  the patients undergo a CT  or MRI scan of the heart prior to their ablation and the images of the heart are imported into the advanced 3D mapping system at the time of ablation. This allows for precise delivery of Radiofrequency energy in a tailored fashion specific to the individual patient’s anatomy. See images on the Gallery page and the video link below. For an in-depth description of our technique, please click AF ablation Northern AF meeting.ppt.

Q. What should I expect coming in for the ablation?

If patients are on Warfarin, this is usually continued during the procedure.   Dr Gupta performs a TOE (Transesophageal Echocardiogram) before the ablation to rule out a pre-existing heart clot in some patients. The ablation procedure takes around 2 to 3 hours and is usually done under sedation. It may also be performed under general anaesthesia if patients so prefer. Most patients stay in hospital the night of the procedure and go home the following morning. Increasingly, patients are being able to go home the same day itself (see ‘Patient Accounts’)

  1. Q.What can I expect following the ablation?

Patients are advised to ‘take it easy’ for a week after the procedure. This involves not returning to active full time work. This is mainly to allow the groin site to heal properly.  It is not unusual for AF to occur during the first few weeks post-ablation and this does not necessarily indicate a procedure failure. Most patients find that these AF episodes subside with time as the lesion set matures, and the full benefit of the ablation procedure may not be realised till about 3 months afterwards. For this reason, most patients need to be on Warfarin for this 3 month period.

Some patients may experience a different kind of palpitations after ablation when they feel that their heart beat is racing in a regular fashion. This indicates regularizing of the electric circuits in the heart, from AF to atrial flutter. These flutter episodes often also subside with time, but sometimes repeat ablation may be needed to treat them.

A patient with persistent AF treated by Dr Gupta

The 2 atria are shown on which the red and blue orbs indicate RF application sites