What is the recovery time from the ablation procedure?
This depends on the type of ablation and anesthesia used. Patients who undergo atrial flutter or other right sided atrial ablations such as SVT usually go home the same day. These are done under conscious sedation anesthesia
Atrial fibrillation ablation patients have an overnight stay. This procedure is done under general anesthesia. Patients have to lie flat for a few hours before the sheaths (big IVs) are pulled from the groin. They can walk around 6 hours after the procedure. The recovery usually depends on how patients recover from general anesthesia. It is advised not to undergo anything more than mild physical exertion for one week after the procedure. Many patients feel shortness of breath and cough for a week or two after the procedure.
For patients with persistent atrial fibrillation what is the risk of staying in atrial fibrillation versus restoring a normal rhythm with catheter ablation?
Unfortunately it is currently unknown whether patients who have atrial fibrillation have a shorter life expectancy than those with a normal sinus rhythm. The landmark Atrial Fibrillation Investigation of Rhythm Management (AFFIRM) study of 2005 studied patients from two investigational arms. One was a rate control strategy where patients were kept in atrial fibrillation and the rate was controlled with medications and the other arm was a rhythm control strategy where patients were attempted to be maintained in normal sinus rhythm with ant arrhythmic medications. This study proved no difference in mortality between the two groups. Unfortunately the antiarrhythmic medications had an only 30% efficacy in maintaining a normal rhythm. If specifically patients who were in normal rhythm were compared to those in atrial fibrillation at the end of the study, those in atrial fibrillation had a 50% higher mortality.
What are the success rates for ablation procedures?
This depends highly on the specific arrhythmia being treated-
Right sided atrial flutter– 98% with first attempt at ablation
SVTs– typically around the normal conduction system of the heart- 90-95%
Paroxysmal Atrial Fibrillation– about 85% at 3 months when the scars are fully formed. About 15% of patients need a second touch up ablation after this period. After 2 ablations the success rate is about 95%
Persistent atrial fibrillation– The success rates for catheter ablation for persistent atrial fibrillation depend mostly on the length of time spent in atrial fibrillation and control of triggers such as hypertension and sleep apnea. Patients who have had atrial fibrillation continuously for less than a year have the best outcomes. After five years the success rate drops off significantly. Overall the success rate is about 70% with the first ablation procedure utilizing the Bordeaux step wise technique. After three months, about 30% of patients need a second procedure. Typically the second ablation procedure is directed at a more organized rhythm that is either coming from a specific point in the upper chambers (atrial tachycardia) or a circuit that goes round and round (atrial flutter). The second procedure is usually not as extensive as the first. After two ablations the overall success rate is about 90%.
Ventricular tachycardias related to scars from coronary artery disease and previous heart attacks- about 80% Ventricular tachycardias in patients with a structurally normal heart – about 95% when enough arrhythmia is induced during the procedure allowing it to be mapped and ablated.
What is the difference between a surgical MAZE and the step wise technique for persistent atrial fibrillation?
The Ex-MAZE or minimally invasive MAZE procedure is a surgical not catheter based procedure. Trochars are placed in the thorax and the heart is ablated from the outside. This technique is intended to isolate the pulmonary veins and then cut up the upper chambers (atria) like a tic tac toe. This is intended to keep atrial fibrillation from perpetuating by breaking up the areas the impulses can travel. It can be successful but mostly depends on the surgeons accumen of electrophysiology to determine actual isolation of pulmonary veins. The lines that are created during this procedure can set up a milieu for atrial flutter- or circuits – patients can feel worse in these flutter rhythms than in atrial fibrillation. It is vastly different than a catheter based approach that targets the areas that need to be ablated based on local electrical activity rather than a gun shot approach
If the data for the step wise technique is convincing why don’t more electrophysiologists utilize it?
There are mainly two reasons
A. Time- the majority of EPs that perform AF ablation can take 3-6 hours to perform a pulmonary vein isolation. This severely limits the time for additional ablation. Few have the experience or dexterity to perform the procedure adequately in an acceptable time frame of under 5 hours
B. Training- the US centers vary considerably in training for cure of atrial fibrillation and many electrophysiology fellowships have limited experience with AF ablation. Only a select few centers currently in the United States train EPs on the step wise technique, as such most who perform it (limited number) have usually sought additional training at Bordeaux on their own accord.