May 19, 2021

Interviewer: Perhaps you're a patient that has been suffering in one way or another from atrial fibrillation, otherwise known as a-fib, and you've been working with a specialist and perhaps the medications aren't quite working, or your symptoms don't seem to be getting better. A potential option for treatment is called cardiac ablation, a non-invasive surgical procedure.

We're here with Dr. Jared Bunch, Professor of Medicine and Section Chief for Electrophysiology at University of Utah Health. Now, Dr. Bunch, what does a patient need to know about the cardiac ablation procedure itself? What's going to be happening, and what can they expect?

Dr. Bunch: There's a number of different aspects to consider if you're at the point that you want to pursue a catheter ablation for atrial fibrillation. First, it's that you go to a center that has experience. Centers should at least do 100 atrial fibrillations a year and should do more. Second, the operator that has done it. Have they done over 100 ablations? Have they seen different complications and managed them well? So picking the center and having someone with expertise is critical. It changes the outcomes.

And feel comfortable asking whoever is recommending ablation, how many of these have you done, how many does your center do, have you seen any complications and how did you manage those and did the people do okay? So that's an important foundation in choosing where to go.

The second is understanding what the procedure is. Most centers do ablation under general anesthesia. Some do it under what we call conscious sedation, where you're asleep but you don't need a tube to help you breathe. And the reason mainly this is done is not necessarily because the procedure is overly painful. It's that you'll have to lie flat on a table, what we call a catheterization table, from anywhere from two and a half to four hours, and that's a long time to lay still, and if you shift even a few millimeters, our maps that guide us in the heart have to be redone.

So the way we get to the heart is we put catheters or what we call IVs or intravenous accesses into the big veins, and we thread these long, flexible tools called catheters into the heart. And we go from the vein side to the artery side. The artery side is the oxygenated blood side, the bright red blood side, by making a small hole in the middle of the heart method. That heals up in about two to four weeks. And then fibrillation actually begins in sources outside of the heart, what we call the pulmonary veins, and these are the veins that drain, or bring oxygenated blood from the lungs to the heart. And they can trigger at 300 beats a minute and cause the heart to become unstable and create this rhythm called fibrillation.

So we identify the veins, and then we cauterize around where the veins enter the heart. We can't work in a heart, in the veins directly because they're fragile and they collapse and stenose. So we have to work around them.

Many people ask me, well, how do you choose which vein to treat? And I was part of those studies years ago. We would find the vein that was active and just treat that. And then, we would find that the patients all came back and one vein had replaced the other. So now we find all the veins that you have and treat around all of them. And then, we pull the catheters out and these IV accesses out of the legs, there's not stitches, usually before you wake up, some centers right as you wake up, and then you lie flat from anywhere from two to four hours after. It's a same-day procedure, and if you come off anesthesia well and you're relatively healthy, some centers will send you home that day. Other centers will watch you overnight just to see how you're feeling and how you're doing with the treatment.

Interviewer: Now, when we're talking about a procedure like this, what are some of the potential complications that a patient should keep in mind for a procedure like this?

Dr. Bunch: That's a great question, and it's really important to understand the complications and understand how those are influenced by operator experience and center experience and skill and centers that have dedicated time to be an atrial fibrillation center of excellence. So the most common complication is we access these veins in your leg, and there can be bleeding around them, bruising. Bleeding is what we call a hematoma. We may see that in 1% to 2% of people.

Our tools are designed to work in the heart, move with the heart that's beating, and they're flexible, so they can do that, but occasionally, there can be a small hole in the heart or a tear in the heart that can cause bleeding around the heart. That happens in about 1 in 500 to 1 in 1,000. Typically, we can treat this conservatively, meaning you don't need a surgeon to repair the entry, but about 1 in 10 of the people with these bleeds will need surgical help. There's a risk of stroke or clot formation on our tools. Our tools irrigate themselves. They have fluid bathing around them, so clot is less likely to occur, and that occurs about 1 in 1,000 to 1 in 3,000.

And then, the part that concerns me the most is the, not necessarily the heart at all, it's the structure behind the heart, the esophagus. So we have to identify where the esophagus is and make sure we avoid it, because if you heat two tissues or you freeze two tissues, they can grow together and form a communication. And we perform ablation either with heat injury or with extreme cooling or freezing, and both of those can cause injury to the esophagus. We have to know where that is to avoid.

But those are the most common things that we worry about. There's some other minor things. Major risk RE less than a percent, anywhere from less than a percent to 1 in 1,000. Success rates of the procedures for what we call paroxysmal atrial fibrillation that comes and goes, in most centers is 70% to 80%, and for atrial fibrillation that's persistent, meaning that it lasts longer than a week or we need to shock the heart to restore it, procedures' success rates will fall by about 10% to 20%.

Interviewer: So it sounds like the procedure has a decent success rate, but there are still things that we've got to look out for and what better reason to really be sure that you're going to a good center and have a good surgeon. So, after the procedure, on the same day they're put under general anesthesia, you're saying that some people have to stay overnight?

Dr. Bunch: And it varies a lot from person to person. So, again, once you wake up at our center, all the IVs are out, there's just bandages on the legs. We put little closure devices in the veins so they heal more quickly. So most people are up walking in two to four hours. I would say right now, approximately 50% to 2/3 of our patients go home the same day after being observed in recovery for 3 to 4 hours. We want people up and walking that day, in that evening. We don't want people lifting over anywhere from 10 to 20 pounds for about a week after, not necessarily because of the heart but the veins that we go in through, they have to heal as well. And typically, veins heal a little bit quicker than our skin. So, if there's no evidence that we were in the vein from the skin, you can rest assured that the vein is also healed at that time as well.

But what we have learned after to encourage exercise and activity. A lot of people with fast heart rates worry that they're going to exercise and their heart's going to go fast and it's going to cause fibrillation. But studies have shown that those that engage in exercise, yoga for like 30 to 60 minutes a day, they can influence the risk of recurrence by about 30%. And so we want our patients active right after.

But what I tell most people is follow their body. These procedures, they make people nervous. If it's your first one, you're nervous, you're anxious, you're under anesthesia, and some people just feel tired after it. And so, if you have a few days where you're fatigued, that's your body saying that you need time to recover. But most people can expect to be up and active and walking the day of their procedure with minimal to no pain.

Interviewer: What is recovery like for a procedure like this? It seems like a pretty major procedure to me as a lay person. But how long until a person heals, when can they get back to work, you know? What does the aftercare look like?

Dr. Bunch: That's a great question as well. So we want them up and active, but one of the things our heart doesn't like is to be touched. So our heart's surrounded by sacs. It's surrounded by ribs and muscles, so you can't touch it. And so, when we work in the heart, sometimes it actually gets more irritable for the first few weeks to months. So, if you have abnormal rhythms in the first three months, those really don't mean that this, the procedure has failed. That's part of the heart healing. So about one-third of people will notice some abnormal heart rhythms in that first three months. We want to know about those. We treat them. We'll use medications while the heart's healing. About two-thirds, their heart will be really quiet. And then, anything that happens after three to six months, then there's more significant long term, but it's just important to remember the heart has to heal.

It's easy when we have open heart surgery and there's stitches and our ribs hurt and our sternum hurts to know that the heart was worked on. When there's just some small dots near your veins in your legs, you kind of forget after a week or so that the heart still has to heal. So it is important to realize that our heart is beating 100,000 to 120,000 beats per day. So it's really healing on the run. So it takes time to heal. Even if we don't feel pain or anything, it's still undergoing this reparative or this healing process.

Interviewer: Now, say we're a couple of months after the ablation procedure, and a patient's heart is starting to heal, what are some of the quality of life improvements that we can expect? Keeping in mind that as we've talked about on an earlier interview, this procedure, the cardiac ablation is not a cure for a-fib. After all, there are still medications and other risk factors and other treatments.

Dr. Bunch: Some are intuitive that most people, when we study people and ask them specifically, people have more energy, they don't feel their heart symptoms as much, they want to do more, they're more engaged, they're more active, and those are all what we call physical measures of quality of life improvement. People also tend to have quality of life improvement in mental scores, how often do they feel depressed or a depressed mood. Those tend to improve as well. We can see that as early as three months, and those quality of life scores continue to be higher in patients that have an ablation compared to those that don't upwards to three to five years.

A lot of my research is on the cognitive component of atrial fibrillation and brain health, and we also see that the cognitive scores go up after an ablation as well, particularly in the regions of memory and memory storage. So people do also report a little bit better memory and cognitive function after ablation as well, which I think is exciting, because years ago we found that atrial fibrillation was associated with multiple forms of dementia, and these scores teach us that if we apply aggressive treatment, we improve the rhythm, we lower risk factors, that we can really help the general brain health, and a disease that really is terrifying to all of us or to lose our memory and our brain function and develop severe cognitive impairment or dementia.

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