Questions about Ablation

It turns out the EP has set my ablation date for May 6th. I was surprised to learn that I'll be under general anesthesia, as I've read and heard that many people are under conscious sedation. A few questions for you experts:

1. If they get in and can't provoke a-fib, is it still expected that they will ablate the pulmonary veins?

2. If you've had an ablation, has yours been under general anesthesia?

It also never occurred t me that they'd have to puncture the atrial septum until I thought about the anatomy, and, of course, how else do they get to the pulmonary veins.

Not sure I have a ton of questions...just seeking support and reassurance from those who have had it, as I suppose it is normal to be somewhat apprehensive, right?

Cheers to All!
Doug

My husband has had two ablations in London, both under a general anaesthesia. I, too, thought this was quite unusual. Also unusual was the fact that he wasn't put on Warfarin either before or after the procedure. He is scheduled for a third (and hopefully final) ablation in Bordeaux on June 8th.

regards
Valda

My ablation was general anesthetic. In hospital overnight after procedure. No warfarin before, only after procedure.
Cyndie

Doug - Good luck with your procedure. Be sure to remind us so we can send in the angels!

As reported recently by several, general anesthesia is what most are currently using. The stability of the patient is important and a steady breathing pattern is essential. With the IV sedation such as I had, they were yelling at me not to take deep breaths (which I was doing because of the pain I felt as the sedation wore off) so it makes sense to have the best possible environment while the EP works. In the long run, it probably speeds up the procedure time. The good news is you won't feel any pain.

It won't be long now and we'll be anxious to see your report.

Best to you, Jackie

Thanks for the information. The nurse had said that the EP used to do conscious sedation, but for a few years has been doing general. It makes sense to me, just curious to see what other people have experienced.

I'm ready to get the ablation underway and [crosses fingers] with avoidance of triggers, etc. this will actually work. The doctor's office has several EPs, but only two who do work with a-fib. The other EP had a skiing accident and was to be out for 12 weeks, so my date was pushed back to late June.

Earlier this week I was leaving work because I was having a bad run of a-fib and felt like crap, and the nurse called to move me up to May 6th. That call came at the perfect time.

Again, many thanks. Valda, I hope that this is your last one!

Cheers,
Doug

Doug:

Have you had an attempt at cardio-version? It's much less invasive and has about an 85% success rate.

Marv

With the exception of the first attack which required cardioversion at 50, 100, and 200 joules (the last attempt finally converted me into NSR), I have been able to self-convert during subsequent attacks. However, quality of life is an issue and I get quite symptomatic with a rapid ventricular response leaving me SOB and miserable.

While they were tinkering with my meds, I had a seizure in the shower due to vasodilation and a brief lack of oxygen to the brain. I was relieved that neuro and cardio agreed the seizure was not neuro related, rather cardiac induced, but still, it left me with lacerations and apparently I was hitting my head on the shower walls when my wife found me.

So, I would be all about cardioversion as opposed to ablation if I thought it was the best option. However, after having failed flec and sotalol, I'm not interested in more meds for a lifetime, and given my age, the three cardiologists I've seen, all agree an ablation is in order.

Congratulations on making a difficult decision. I felt such relief when I had a plan. I had general anesthesia. Felt nothing. I was full of fears real and imaginary. I was in hosptial one night. Try to relax. Keep us posted and we will be thinking of you on your big day!
Claudia

Marv,

Unfortunately electrical cardioversion is not that effective in the long term. See following excerpt from Volume 6 of Lone Atrial Fibrillation: Toward a Cure:

"Metoprolol improves cardioversion results
STOCKHOLM, SWEDEN. Electrical cardioversion is often used in an attempt to convert persistent afibbers to normal sinus rhythm (NSR). Unfortunately, the relapse rate is high and even with the use of class I or class III antiarrhythmic drugs, only about 50% of electro-cardioverted patients remain in NSR for 6 months or longer.

Researchers at the Karolinska Institute now report that pretreatment with the beta-blocker metoprolol (time-release version, Toprol XL) significantly improves the success rate for cardioversion. Their study involved 168 persistent afibbers who were randomized to receive metoprolol or a placebo starting at least a week prior to cardioversion (NOTE: only about 15% of the study participants were lone afibbers). On average, the participants were on metoprolol or placebo for 28 days prior to cardioversion and they were also prescribed warfarin (INR 2.1 – 3.0) for at least 3 weeks before and 6 weeks after cardioversion. The starting dose of metoprolol was 50 mg/day with a 50 mg stepwise increase to a target dose of 200 mg once a day.

The participants were checked with an ECG 2 hours after cardioversion and then every week for 6 weeks, and then 3 and 6 months after cardioversion. During the first 6 weeks, 49% in the metoprolol group and 47% in the placebo group developed afib again and were given a second cardioversion. At the 6-month checkup, 46% of patients in the metoprolol group were still in NSR as compared to only 26% in the placebo group. It is also of interest to note that while 8% of placebo group members relapsed into afib within 2 hours of their first cardioversion, none of the patients in the metoprolol group did.

Nergardh, AK, et al. Maintenance of sinus rhythm with metoprolol CR initiated before cardioversion and repeated cardioversion of atrial fibrillation. European Heart Journal, Vol. 28, 2007, pp. 1351-57

Editor’s comment: It is likely that the metoprolol pretreatment would be beneficial for adrenergic and perhaps mixed afibbers, but it is not at all clear that it would benefit vagal, persistent afibbers. Researchers at the Mayo Clinic have reported that a high blood level of C-reactive protein (CRP), a marker of systemic inflammation, prior to cardioversion is associated with a greater probability of afib recurrence within one month. There is also evidence that a low level of potassium is associated with poorer outcome of cardioversion. Thus, combating inflammation with Moducare or beta-sitosterol, and supplementing with potassium and magnesium prior to cardioversion may improve both the short- and long-term outcome of the procedure."

Hans

Two ablations with Dr. Pinksi, Cleveland Clinic (Florida) and under general anesthesia both times. Your best friend will be the anesthesiologist and when you get that tap on the shoulder just before the procedure and after the usual 'do you have any questions?'...good night Irene.

I never had a cardioversion and always converted spontaneously. When the PAF bouts became more frequent and more often, I went the ablation route. I was never a good candidate for the antiarrhythmics since I have asymptomatic bradycardia and it was decided on all fronts to skip the med route and go directly to the ablation.

Good luck....things will be great!!

Thanks to all who have answered. My question (and perhaps it stems from ignorance of the procedure), is what happens if they can't induce a-fib during the EP study? Do they even have to induce a-fib to ablate? If they try and try, but I stay in NSR, will they just close up shop and say all's fine? Or will they still perform the ablation? This is wherein a lot of my confusion/anxiety lies.

I asked the nurse, who said she'd ask the doctor...but I was curious if anyone here had any insight.

Cheers to All,
Doug

Doug,

It is not necessary for the doctor to induce afib in order for him to do the ablation. In fact it is better if the patient is not in afib during the ablation because the heart is quieter and easier to work with. The monitoring equipment enables him to identify 'potentials' or hot spots which are know to trigger the afib. He then ablates those areas as well as isolating the pulmonary veins.

At the end of the procedure it is common for the doctor to attempt to induce afib by means of a drug such as atropine. If the atropine induces the afib, then he has to do more work in there. Otherwise the ablation is all done.

My first ablation was with conscious sedation and the pain was just awful. For the second ablation (Dr. Pinski) I had general anesthesia and it proved to be much, much better.

Marian

Marian,

Thank you for sharing your story!

I guess I was just concerned about the proverbial "car acts fine when at the mechanic's shop" situation. They have ECG tracings of my a-fib, so I am comforted to know I won't wake up and have someone say, "ah, we couldn't find anything to ablate, but thanks for coming in!"

Cheers!
Doug

Hi Doug,
No worries. I too failed drug therapy and had RF ab last Monday, 13 April under general anesthesia (8 hrs) The worst for me was the foley 'ouch'

I started Coumadin 2 wks prior to the procedure. Lovenox 3 days prior and 8 days post procedure, stopping today the 22d because my INR is 2.4. I'm still on Coumadin (low dose) and Sotolol. Have been in and out of sinus since the procedure. Today, after a 48 hour run of Afib I've converted to normal sinus. No worries, the doc says it's normal up to 3 months post. (Please read report below)

The report reads: After initialisolation, after which all 4 pulmonary veins appeared electrically silent, the patient was given isoproterenol and AF was induced. Rapid pulmonary vein potentials were seen to arrise from the left superior pulmonary vein. Additional lesions were given to ensure complete electrical isolation and the AF terminated, with restoration of sinus rhythm.

There was AF recurrence in the morning post precedure, acceptable in the first 3 months post ablation.

Some folks come out completely free of Afib, not me but it's OK, I would still to it again. Good luck to you......Pat