Ablation for atrial fibrillation

Another one from the catch-up pile: this BMJ article.

Catheter ablation is an alternative to pharmacotherapy for atrial fibrillation. The info is as follows:

  • It’s no better than pharmacotherapy for reducing mortality or disabling stroke.
  • It also, for reasons that are not fully understood, doesn’t reduce stroke risk. Even if the procedure is successful in keeping the person in SR, they should still continue on anticoagulation according to whatever their pre-ablation risk was (which I assume would have to be adjusted for age as they get older and risk goes up anyway?)
  • It does, however, improve quality of life to a clinically significant degree, and reduces hospitalisations (both pieces of info from the CABANA trial, which now has that damn Barry Manilow song running in my head). It’s also better than pharmacotherapy at keeping the person in SR.
  • It’s an ‘if at first you don’t succeed…’; in up to a third of people the procedure has to be repeated, and repeating it can work.
  • Assessment as to whether it’s succeeded or not should only be made three months down the line, as prior to that it’s common to get episodes of AF, flutter or atrial tachycardia due to irritability from the ablation procedure, which often resolve spontaneously.
  • The overall success rate, including those needing repeat procedures, is around 80% at 3 years post-procedure.
  • Success is less likely with older age, persistence of AF, and co-morbidities (obesity, hypertension, DM, heart failure, and, interestingly, sleep apnoea). Conversely, optimising co-morbidities can increase the likelihood of success.
  • Morbidity and mortality are higher in the presence of heart failure.
  • Intermittent chest pain is a common side-effect
  • Stroke is a complication in around 1% of people undergoing this.
  • So is cardiac tamponade.
  • Nerve damage and pulmonary vein stenosis are also SEs, listed simply as occurring <1% of the time.
  • Atrio-oesophageal fistula and death are complications in <0.1% of cases. (The former presents with fevers, collapse, and vomiting blood; symptoms can be insidious at first.)

Practicalities

It takes between one and four hours, and can be done under local or general anaesthetic.

Pre-procedure:

  • Anticoagulate for at least four weeks
  • As above, aim to optimise co-morbidities
  • Remember not to book any flights for the week afterwards (see below).

Recovery:

  • Most often an overnight stay, though patients sometimes discharged same day if all goes well.
  • Don’t drive or have sex for two days afterwards.
  • Don’t fly or have baths for one week afterwards (showers are OK). Keep the wound site clean during this time.
  • Don’t lift anything heavy for 2 – 3 weeks afterwards.
  • Groin bruising is a normal side-effect, but if the groin becomes painful, swollen, or red or develops a palpable lump then contact the centre that performed the procedure.
  • PPIs are often advised for a month afterwards to reduce the risk of fistula, although this is based only on case reports and expert opinion.
  • Antiarrhythmics and nodal blocking drugs are recommended for six weeks afterwards to reduce the risk of post-procedure arrhythmias requiring hospitalisation.
  • Take anticoagulation for at least two months afterwards. Men with a pre-ablation CHA2DS2-VASC score of 1 or more or women with a pre-ablation score of 2 or more should continue anticoagulation lifelong.
  • FU appt is normally at three months (which makes sense, since that’s when you can tell whether it’s worked or not, as per above).

About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in Cardiovascular, Credits 2020. Bookmark the permalink.

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