Atrial fibrillation
Medical procedures and interventions for atrial fibrillation
In cases where heart rate and rhythm medication cannot be tolerated or fail to restore the heart to normal rhythm (sinus rhythm), a number of medical procedures and interventions carried out in hospital are available for people with atrial fibrillation (AF).
These include chemical and electrical cardioversion, catheter ablation, pulmonary vein isolation ablation, and, more infrequently, AV node ablation and the insertion of a pacemaker.
Cardioversion
Cardioversion is a procedure which aims to restore normal heart rhythm (sinus rhythm). There are two main types: chemical and electrical.
Dr Tim Holt explains what cardioversion is and when it is used.
Dr Tim Holt explains what cardioversion is and when it is used.
In what sort of circumstances would cardioversion be used?
Well, it’s used for people who’ve got persistent atrial fibrillation. It can’t be used in somebody who’s got intermittent atrial fibrillation that’s coming and going. You know, it’s, there’s no point in giving it to somebody who is currently in the normal rhythm. So it’s usually given to people who’ve got persistent atrial fibrillation.
Chemical (or pharmacological) cardioversion
This procedure uses drugs such as adenosine and flecainide, injected intravenously (through the vein), in the hope of returning the heart to normal sinus rhythm.
David X, who had intravenous flecainide, said that he preferred chemical to electrical cardioversion, after experiencing both procedures. For him, electrical cardioversion was ‘a bit traumatic’, whereas chemical cardioversion was ‘a gentle way of getting back into sinus rhythm’.
After the first attempt at chemical cardioversion failed, Eileen was reluctant to try it again. The procedure was again unsuccessful.
After the first attempt at chemical cardioversion failed, Eileen was reluctant to try it again. The procedure was again unsuccessful.
So you’re awake when they’re doing that?
With the chemical one, yes.
Yeah and you’re on a monitor and there’s everybody standing by, you know but even then it’s quite frightening. In fact, the last time I went in and the little casualty officer, my sister, my daughter took me in, this is just anecdotal, and we went into A and E about eleven o’clock at night and they’re very good. You walk in and you say, “I’m in AF.” Get seen by the triage and then you’re walked straight through. I think they were having a bad night because I was walked into resus and the staff nurse had a go at the other staff nurse, saying, “We’re not doing your ECGs in here blah blah blah.” So I said to my daughter, “If they feel like that, let’s go home.” You know, “Oh no.” So they wired me up in AF, picture’s changed and then they came along, they actually spoke to the cardiology team and they said, “Oh, we’re going to do this IV drug.” And I said to the chap, “Have you ever had it done?” “No.” “Well, it won’t work. I don’t want it done.” I was feeling quite stroppy. Anyway, so we did it. For some reason, my daughter was allowed to stay, probably because she was a nurse and I was grip gripping hold of her hand. She found it the most terrifying experience and it didn’t work and they did it twice. And when I said, and then they said, “Oh we’re admitting you.” So I said, “I told you it wouldn’t work. You could have bypassed all this.”
Electrical cardioversion
This procedure, which is usually carried out as a day patient in hospital, uses an electric shock to activate the heart and return it to normal sinus rhythm.
For some, electrical cardioversion successfully stops further AF episodes, possibly for weeks or even years, and so no further symptom control treatment is needed.
Eileen described what happens in cardioversion.
Eileen described what happens in cardioversion.
Cardioversion successfully restored Pauline’s heart rhythm.
Cardioversion successfully restored Pauline’s heart rhythm.
However, while cardioversion can have a good success rate in restoring normal heart rhythm, it does not always work.
Dr Tim Holt explains why cardioversion is not always successful.
Dr Tim Holt explains why cardioversion is not always successful.
And can people have multiple cardioversions then?
They can. Some people have many attempts but the more attempts that fail, the more likely, it seems, that this is the wrong treatment for this person. And then there are other ways of restoring the rhythm or controlling the rate.
People we spoke to were not always convinced about the value of having a cardioversion, or were disappointed in the results.
Janet, who was recently diagnosed with AF, was unsure whether to go ahead after finding out the procedure had only been successful in 1 of 3 friends with AF.
Mary decided against it when told cardioversion would involve ‘stopping the heart and then restarting it artificially’.
For others who underwent the procedure, the results were disappointing. Dot said she had ‘got away’ with not having cardioversion after her heart reverted to normal sinus rhythm of its own accord.
Dave explained why he refused cardioversion.
Dave explained why he refused cardioversion.
Nuala had over 20 unsuccessful cardioversions before reaching a decision with her cardiologist to remain in AF and regulate her heart rate rather than rhythm.
Nuala had over 20 unsuccessful cardioversions before reaching a decision with her cardiologist to remain in AF and regulate her heart rate rather than rhythm.
Did they discuss it with you much in previous times and so on?
They would have done I, you know, and talked about long term and said to me that I probably will go into AF and I suppose again I was in denial and didn’t want to hear it and I really pushed for it not to happen. And, at the same time, was thinking, if you keep doing the same thing, “If you if you keep doing what you’re doing, you’re going to keep getting what you get.” And all that was in my head but there was still this drive in me to keep in sinus rhythm.
Eileen underwent a number of cardioversions over the years, none of which worked for more than six weeks. She described the worst of these.
Eileen underwent a number of cardioversions over the years, none of which worked for more than six weeks. She described the worst of these.
Coming to and thinking I’d had a stroke, because my mother had had a big stroke, although she’d died by then but she’d still had the stroke, because I couldn’t move my arms and I hurt. Oh, I did hurt all over. And it turned out they’d given me whatever the maximum number of shocks were and then I think one extra for luck, if they were allowed to. And to wake up for that and then find that it hadn’t worked and it never occurred to me that a cardioversion wouldn’t work.
Ablation
Ablation is a way of controlling AF symptoms and heart rate. Ablation procedures include catheter ablation, pulmonary vein isolation ablation, and AV node ablation and the insertion of a pacemaker.
Catheter ablation
With the exception of athletes, catheter ablation is not usually a first line treatment for people with AF. It may be offered, however, when a person experiences side effects or does not respond to medication, or when cardioversion has been unsuccessful.
As Dr Tim Holt explained, although the aim of catheter ablation is to ‘control symptoms and heart rate, it is not yet clear whether these procedures will reduce the lifetime risk of having a stroke in the future’.
Usually performed in hospital by an electrophysiologist, catheter ablation involves destroying (ablating) faulty electrical pathways from the heart by freezing or burning the heart tissue.
As Jeni described it, ablation involves ‘getting rid of the damaged or problematic tissue in your heart that sends the electrical current the wrong way’. This is done using a long wire (catheter) threaded into the heart. Once the tissue is treated in this way it forms a scar which can no longer conduct the abnormal impulses.
Glyn, who has had two unsuccessful ablations after medication failed to control his AF, described his experience.
Glyn, who has had two unsuccessful ablations after medication failed to control his AF, described his experience.
[*Note: Glyn’s experience is unusual as this procedure does not usually take this long].
Ginny, whose passion is mountaineering, explained her decision to have a catheter ablation. Although successful so far, she is unsure how long it will last.
Ginny, whose passion is mountaineering, explained her decision to have a catheter ablation. Although successful so far, she is unsure how long it will last.
I mean my cardiologist said to me, the guy who did the, the specialist said to me, “Some people have one ablation and then that’s it for the rest of their life. No more AF ever.” I suppose for them, the jury is probably out on that because if I’m right, I think this is still considered to be in its infancy because it’s fifteen years research or something into it and there are a number of things they need to research as it like after the ablation on the left hand side of the heart for fibrillation, you do get headaches for two up to two weeks afterwards and they can be really quite, quite debilitating and quite, for me, they were and that that that I did not know before I went in for the ablation and that that was a bit of a surprise. But the arrhythmia nurse told me that that was the case, that the jury is out on that one. They really don’t know exactly why that happens. They think it might be alteration in blood pressure in the heart because of the hole they’ve made in your heart or it could be anything. They’re not really sure. So I I’m not worried that it’s going to necessarily come back but there is a possibility that it could come back within seven years.
Well, I am aware that ablations might not last forever and that AF can come back. I am also aware that, you know, that that, as I say, that that it possibly, that it can it can come back, anybody can get AF at any time. So I’m not I’m not going to worry about it. Once I am, you know, fairly sure, and I am more or less fairly sure now that it that it’s gone, I, you know, I, you know, I want to just get on with the rest of my life and move on and I think yeah, there is that that in the back of your mind that maybe when you get to fifty five or sixty, you could be looking at this problem again. And then you’ll just have to assess where you are, whether you’re fit enough to go through another ablation, whether you actually want to go through another ablation or whether you just want to stay on tablets, you know. Life is a lottery.
Bob, who had two unsuccessful ablations, was delighted when the third attempt proved successful.
Bob, who had two unsuccessful ablations, was delighted when the third attempt proved successful.
We did a second ablation in, just after Easter in 2007 and that was very good. It was very positive. I came out of hospital thinking, “That’s it. I’m cured.” And for about eight or nine months, I had virtually no AF at all, a few little bumps and grinds occasionally, little bit of flutter but no debilitating atrial fibrillation. And then, towards the end of 2007 I started to get occasional times when I have a little bit of an attack and, I was still under the [general hospital]. So we talked about it and, in fact, I had a third ablation, I think it must now have been early 2009 and, since then, I’m delighted to say I’ve not had atrial fibrillation at all.
So it is quite common that it sometimes takes two or three ablations to actually get on top of it. But it’s a very effective for those people that can have it.
But we did discuss it with the medical profession. I discussed it with my GP, and my wife and I discussed it at home and, as I said, there comes a point when you think, okay, there is a risk, but as much risk feeling ill like this all the time and having had one ablation, I never thought twice about having a second or third, and if I’d have needed it, I’d have gone for a fourth as well.
Bob reported that AF symptoms can take a few months to ‘settle down’ after a catheter ablation. He took a small dose of flecainide and had not had AF for 18 months. He asked the surgeons not to ablate to such an extent that he might need a pacemaker, as he said that, being an engineer, he did not trust technology to keep him alive.
Chris X initially rejected having an ablation procedure, but when he later changed his mind, he found that his specialist and nurse were happy to discuss it in detail and then allow him to decide in his own time.
James, who had a stroke due to AF, had three ablations and said he felt a little better after each one.
James, who had a stroke due to AF, had three ablations and said he felt a little better after each one.
Jenny, James’ wife, recalled how she found it ‘absolutely petrifying’ when her husband had ablation, but after the third ablation proved successful, she acknowledged that ‘He was right that his quality of life was non-existent really. And if that is the case, you just do whatever it takes to get you back on track’.
Geoff spoke of breaking a record in his hospital by having 4 ablations, where the final one was successful. He planned to start reducing his medication soon. He noted that the need to come off his medication prior to each procedure sent his AF ‘haywire’.
David Y, who had a triple heart bypass, also had an ablation conducted ‘while the surgeon had me open’. 6 clots were found during the procedure, so he reported feeling very lucky that his surgeon had been able to remove these.
Gail was pleased that her second ablation appeared to be working. The procedure left her feeling traumatised.
Gail was pleased that her second ablation appeared to be working. The procedure left her feeling traumatised.
I was very sick afterwards and the, because of the sedatives, and the, I had a bit of a bleed from the where they’d put the catheter in. Presumably when I was being sick something kind of popped and that was, you know, mildly alarming and, but the nurse was so kind of, it’s very routine for them probably people bleeding a bit afterwards, so, and that was good in one way, but in another way, it was not so good because you thought, “[aaagh] Just acknowledge that this is a little bit scary would you please?” [Laughs].
So that might have added to my sense of having been a bit traumatised after that, after that second ablation, and I feel I just don’t want to go through that again. I mean that’s why I’m so pleased that it might be getting better.
Catheter ablations are not always successful. Elisabeth X, who turned down an ablation over 10 years before when she was in her 60s and ‘didn’t think the odds of success were too good’, now believed she was ‘past the age’ to have the operation.
Martin had been told that if his symptoms worsened, he could increase his dose of sotalol or consider an ablation. Aware that ‘the longer you leave it before having an ablation, the less successful it is deemed to be’, he decided to take medication while it continied to work rather than ‘risk having an ablation’.
Glyn believed that his ablations may have failed because his medical team ‘left it too late’ to decide ‘on some really serious action’. They carried out the first ablation 7 years after his diagnosis, which he felt made it harder to treat.
David X had a haematoma in his leg after both of his ablations which he found ‘alarming’. He said he was reluctant to have a third ablation as he felt that his heart had been ‘horribly abused’, and decided to wait and see if his AF would settle down. He continued to take medication for his AF.
Pulmonary vein isolation ablation
Pulmonary vein isolation is another form of ablation used when medication fails to eliminate symptoms of AF caused by an irregular heartbeat, or in cases where people cannot tolerate medications.
Performed under local anaesthetic with sedation, the procedure uses radiofrequency energy (heat energy) to destroy tissue around the four pulmonary veins. The resulting scar tissue, which takes from 2 to 3 months to form, blocks abnormal signals reaching the rest of the atrium (one of the two blood collection chambers of the heart).
The procedure is not always successful and may need to be repeated.
Eileen had the procedure carried out privately. Despite its initial success, she went back into AF 6 weeks later.
After many failed cardioversion procedures, Nuala went on to have a pulmonary vein isolation ablation. She was disappointed when she went back into AF a few weeks later.
After many failed cardioversion procedures, Nuala went on to have a pulmonary vein isolation ablation. She was disappointed when she went back into AF a few weeks later.
And they talked away, the people in the, the doctor and the nurses and the other staff that were there, the ECG technicians all talked away to me and probably that it was because I had been given valium, I felt settled. So it was about, I think it was about four, maybe four hours to six hours. Of course it didn’t seem like that length of time when it was being done and that was okay.
Just immediately after the pulmonary vein isolation, [doctor] had said to me that he felt my left atrium was badly scarred and he didn’t think it would work, which was very disappointing. However, I left with hope that it would and within a few weeks, it went back into AF again.
AV node ablation and pacemakers
In some cases medication or an ablation procedure are either not appropriate or are unsuccessful in restoring regular heart rhythms and people continue to experience AF symptoms.
A third alternative is either to have a pacemaker fitted, or to have an irreversible AV node ablation and a pacemaker implant to prevent the heart rate falling too low. In this procedure the AV node is destroyed, leaving the person dependent on a pacemaker to take over their heart rhythm for the rest of their lives.
Some of the people we spoke to had had a permanent pacemaker fitted. This is a small metal box weighing 20-50g attached to one or more wires that run to your heart. The device uses electrical impulses to regulate the heartbeat.
Fitting a pacemaker is a day surgery procedure and takes about an hour under local anaesthetic. It can have a positive effect in reducing the symptoms of AF and improving quality of life. After having a pacemaker implanted, people need to attend regular check-ups to make sure it is working properly.
Glyn, who had a pacemaker fitted after two failed ablations, described his recovery from the operation.
Glyn, who had a pacemaker fitted after two failed ablations, described his recovery from the operation.
So I didn’t… I sort of very, you know, if someone had bumped into your shoulder or something like that because it was very sore and still a bit sore now actually. They said it could take another three months because they’ve cut into a lot of muscle on your chest wall and, therefore, your muscle takes a while to mend, if you like, to get back into normal.
Raymond, who had a pacemaker fitted after collapsing several times, was delighted with the result.
Raymond, who had a pacemaker fitted after collapsing several times, was delighted with the result.
Eileen had a pacemaker fitted after her pulse rate dropped below 30 and doctors advised her that ‘atrial fibrillation will never kill you but a very slow pulse will’. Despite having to restrict her arm movement so as not to ‘dislodge the wires’ for 6 weeks after the operation, she described how her life had improved: ‘I can certainly walk upstairs, I can even make a bed without getting out of breath’.
However, although she felt better, she still experienced palpitations, and after consultation, decided to have an AV-node ablation.
Eileen spoke about the psychological impact of having a pacemaker, but admitted that her quality of life had improved since having an AV-node ablation.
Eileen spoke about the psychological impact of having a pacemaker, but admitted that her quality of life had improved since having an AV-node ablation.
And if ever the pacemaker should stop, I haven’t got very long to get to a, well, no, they try and leave, they don’t totally take out the AV node. They try and leave a little bit, so that should anything happen and the pacemaker stops, you’ve got a heartbeat of about thirty beats a minute. You can’t do very much on thirty beats a minute but you can you can call an ambulance.
I still am aware of going into either AF or it fluttering but I can feel it in my chest but it doesn’t get through to my pulse, if you see what I mean, because the AV node ablation stops it doing that. So, although I can feel it in my chest, I don’t have to sit down and I did get breathless. I do get breathless, walking up hill I get breathless. Whether that’s the AF or something else I don’t know. But no, having had the AV node ablation, life is pretty good. To what it was, it’s brilliant because you’re not frightened and although they say, you do get, you know, you’re waiting for the next attack, whereas I’m not because even when it comes on, it doesn’t actually affect me, you know.
Although having an AV node ablation and pacemaker fitted can improve the quality of life for people with AF, they are irreversible procedures. This can have an effect on whether people decide to go ahead with the operation, and how they feel about the procedure afterwards.
Despite having had 3 unsuccessful ablations, Roger is not keen on having an AV-node ablation.
Despite having had 3 unsuccessful ablations, Roger is not keen on having an AV-node ablation.
The sense of finality of having an AV-node ablation and pacemaker fitted was a factor in discouraging Nuala from having the procedure.
The sense of finality of having an AV-node ablation and pacemaker fitted was a factor in discouraging Nuala from having the procedure.
Despite having no regrets about having an AV node ablation and pacemaker, Eileen wonders whether she might have ‘jumped the gun’.
Despite having no regrets about having an AV node ablation and pacemaker, Eileen wonders whether she might have ‘jumped the gun’.
See also ‘Heart rate and rhythm medication for atrial fibrillation’.
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