Isolated Atrial Fibrillation Episodes: Is Ablation a Good Fit?

You have to be careful. We had two cardiologists in Maryland get caught over-diagnosing coronary artery disease so they could do unnecessary stents. I lost two teeth from a Maryland dentist who pretended to provide the necessary dental care so he could offer more expensive procedures. I would not be surprised if there were Cardiologists who under-treat patients so they can do more procedures. It may be worth getting a second opinion if it takes more than one ablation. What are they going to do, burn/scar your entire atria?

I do not need a second opinion thankyou, my cardiologist is the head of the hospital.
Your not a Doctor so please don't diagnose me.
The tissue actually heals over time and repairs itself, that's why the AF comes back, that's why it's not a permanent fix, only temporary.
I will be having the new procedure called Pulsed field ablation, no burning involved.
Also I have not paid for any of my procedures or appointments with my cardiologist at all, its bulk billed, so your wrong that he is after more money.

I have been diagnosed with AF Rapid and Persistent 5 years ago with Stroke and 4th day during a scan Papillary Thyroid Cancer.
I stay out of the actual debate on which ablation is best because of heart structural damage I can't consider one or cardioversion or anti-arrhymic med like Flec..
But I do read the overall debate on those debating to have an ablation vs meds. I have earlier nursing and read medical information by joining research papers. Radcliffe Research is very good.
My own information
Ablation procedures causes scarring - unable for the areas to be returned. Some say the scarring is success because it stops the rogue electrical way.
There is radiation used during the procedure which is not explained. The surgeons who do the procedure wear heavy aprons and some hide behind glass.
The balloon procedure is very successful.. But at one stage the balloon were collapsing.
% of success vary.
A cardiologist who has done ablations and stopped are very knowledgeable.
Its like me being under an Endocrinologist for my papillary cancer. She wanted to wait 6 months after stroke whereas surgeon and anaesthetist said asap. She wanted me to have RAI post op and TSH suppression when I said no and no. My surgeon said to her "we should respect Joy's decision'. No respect was taken over Joy's age 70 nor my heart condition and with AF.
Overall I saw a friend have an ablation - catheter where he discovered that he had two rogue electrcal responses doing on. These two were stopped, my friend relieved at last and tells no AF in 3 years. He was a success story.
Meds vs waiting for a better way to eleviate symptoms.
Always your decision to proceed or not. Ablation is a money making procedure overall and it is important that some push it when the med pathway is another.
cherio jOY. (Tuckie)

I'm 72, retired ICU nurse. For decades, I took atenolol for high blood pressure. Of course, ACE inhibitors became first-line therapy, and last year I weaned off the atenolol, following consultation with my physician. My blood pressure stayed until control with the ACE inhibitor, but about a month later, I had my first episode of AF.

My rate was 150 but well tolerated, went immediately to the ER, and cardioverted within a few hours with a Cardizem (diltiazem) drip. I have a history of WPW (Wolfe-Parkinson-White) syndrome, which can seriously complicate AF, but didn't in my case, other than to make doctors nervous. Skipping many details, normal echocardiogram ("like a baby"), saw a cardiologist (an old-school "my way or the highway" guy), then an electrophysiologist (a good collaborator), and am back on the atenolol. My EP and I agreed on a wait-and-see approach --- no loop recorder, no anti-coagulants. I sailed along for 8 months with no problem.

This past week I got the flu. I was careful about over-the-counter meds but perhaps not careful enough. Yesterday, I went into AF, rate about 120. Called my EP doc's office, got a week's worth of Eliquis samples, went home and converted on my own after about 6 hours but started on the Eliquis anyway. I'll continue to take the Eliquis until I can talk to my EP next week.

I tend to be conservative in matters of health care. I realize my episodes are likely to become more frequent, eventually, but for now, I still feel like further intervention is not necessary. I feel like it's still not time for a loop recorder, and I also feel like the risk/benefit ratio of taking Eliquis continuously is questionable.

Am I in denial? I've been reading some patient teaching information online, but it's not exactly what I'm looking for. I'm thinking of calling a medical librarian friend of mine for articles from the latest issues of Heart Rhythm (the official journal of the Electrophysiology Society), as this is the way I'm accustomed to receiving and digesting medical information, and it will prepare me to meet my EP halfway, if he presses convincingly for a more aggressive plan of care.

Any thoughts would be appreciated.

As a general rule, treat AF early. However, too early may mean that your re-entrant foci will be difficult to locate, and an EP doing ablation might just default to a simple PVI (pulmonary vein isolation) because that is where the re-entrant for the AF-inducing signal is found in the heavy majority of patients...at first.

As you know, an ICU nurse (bless you!), symptomology, the worst of it, drives a LOT OF medicine. You say you tolerate AF reasonably well. I didn't, and won't if I have any say in the decision-making that follows. But you do okay, and there's no harm, in my thinking, to staying calm, minimizing medicines (except apixaban or rivaroxaban...those you should take if you ask me for my opinion). It is when your AF begins to be intrusive, to come maybe two/three times each week...that is when you might want to enlist the help of a really top-notch EP who can offer you relief, but also help to stem the onset of heart insufficiency or mitral valve prolapse...IF...IF... those lie ahead of you (we're all on our own journeys with our aging hearts, so our stories will differ).

You are your own best coach. I think you are dealing with this sensibly. Just, please, don't err on the side of caution and let your heart get too far into AF before you recognize that it's time for an ablation, or some other remedial measure, including anti-arrhythmic drugs. Spend as little time in arrhythmia as you can so that you don't speed or encourage the remodeling that is sure to take place with collagen deposition interstitially and with fibrosis.

Yes. The physician will find it difficult to identify where, exactly, the node cells have implanted themselves in places near and around the left atrium, but also other places in the heart. Near and around the atrium means the left atrial appendage, the coronary sinus, and in the septum between the two upper chambers, the atria. These are all places where the extra signals that cause chaotic beating may be, and they would have to be ablated where they lie. Most early cases of AF originate in what is called the pulmonary vein ostia....literally the mouths of each of the four pulmonary veins where they empty oxygenated blood returning from the lungs into the left atrium. They are located on the rear wall of the left atrium. So, most EPs expect to have to do an initial, or index, ablation to isolate the pulmonary veins from the tissue around their mouths. In case you're curious and would rather know, the only nerves that carry Sino-Atrial electric current to the left atrium are called the Bachmann's Bundle. These enter the pulmonary veins in some cases, or rather they 'invade' those places....but....so does endothelial tissue that comprises the inner lining of the atrial surfaces. IOW, both the Bachmann's Bundle AND the atrium's endothelial lining find their way into the Pulmonary veins...in some people. The atrium does not contract due to the nerve impulses running into the muscle from tiny nerves issuing from the Bachmann's Bundle. Instead, the electrical impulse runs on the surface of the endothelium and spreads like a rapidly expanding wave. This is what causes the atrial myocytes to contract sequentially, in a wave, and this is what forces the atrium's contents, freshly oxygenated blood, through the mitral valve and into the larger ventricle. So, chances are good, but not 100% that an index ablation will be best done as a PVI to isolate the inner ostia from the atriums endothelium, just cutting off the signal, the unwanted one. This leaves the SA node to continue to determine the contraction rhythm for the atrium. But, maybe it is the left atrial appendage that starts first. Remember 25% of all index ablations fail. Do they fail because the EP didn't completely close off the pulmonary veins? Probably, yes. But it could also be that the newly self-activated nodelette, if I can call it that, is somewhere else. A PVI might be a waste of time.

But also, some people can get by with a single cardioversion and not present at their local ER or doctor's offices for another six years. There is some risk to every invasive procedure, which an ablation surely is. So, if the heart is maintaining itself in NSR (Normal Sinus Rhythm), when go in and zap what it's causing any problems currently? Instead, wait until there's more activity consistently, but get that zapped early after it begins to take place.

The EP performs a 'mapping' procedure to identify where the new electrical signal is entering the atrial endothelium. She can't just being heating and scarring wherever the wand happens to touch your atrial wall. That would be irresponsible, and it's risky for the phrenic, andVagus nerves and for the esophagus. So they use a special wand first to pinpoint the 're-entrant' or focus of the unwanted new signal. THAT is where she needs to apply the thermal heat generated by the RF wand.

I guess my question is can the EP identify the entry points only if they see you while in afib? Or do they have a way to identify them when you’re not currently in afib?

Great question. They do have a couple of ways to 'challenge' the heart, and they would if there was no alternative and your heart is quiescent at the time of the operation. It's just better if the heart does its own talking. So, if the heart is currently cranky and showing ectopy, all they have to do is locate the general area and begin to circle that area with lesions created by RF energy. They touch the wand to the endothelium and apply energy for between 15 and 30 seconds.
Move it slightly, and repeat, and repeat until he/she feels they have made enough lesions that, when they scar over during healing in the next ten days to two weeks, it will provide a complete blockage.

The EP can use any of the following (that I am aware of): adenosine, isoproterenol, and good old caffeine. Adenosine is an inhibitory chemical that slows the heart, while the other two stimulate the heart. One, or all three, applied sequentially in whatever order is suggested, will hopefully cause ectopy.