Isolated Atrial Fibrillation Episodes: Is Ablation a Good Fit?

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'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.

I’m a healthy 78 year old female who has had AFib since 2016. I’m finally booked for a catheter ablation in March. I’m to be put to sleep during the procedure - four catheters - two on either side of the groin will be inserted around my heart. I’m starting to worry - wondering if I will survive it and not pass away. I know it’s silly to worry but this is part of the stress I keep putting myself through. Then there’s the worry it might not take and I don’t want to go through it a second time.The part I don’t like is it will take place in a hospital in another city an hour away - I’ve booked a patient transfer ambulance since I have to be there for 6:15 a.m. and my family can’t drive me. Bottom line - I’ll be relieved when it is over. Any encouraging thoughts? Thanks!

You could also die in your sleep tonight. Or, have done so last night. You didn't worry because it was out of your control and unpredictable. And being unconscious, you'd not have known anyway. Same, same. Stop worrying. Instead, spend some energy on gratitude that you have an EP working for you and you're in line for relief. That was my orientation. Or, worry if your affairs are not in order. Do you have a will? An executor? Those would be a far more productive spend of your time than worrying about eventualities with an exceedingly low probability...like 0.5%!! I was only worried about long-term effects, and in order to delay them or to stave them off entirely, I needed a heart spending as little time in AF as humanly possible. I am that human, and by God, I was going to have someone try to stem the tide of ectopy.

My wife and I have had to travel three times to Victoria, southern tip of Vancouver Island, to where the cath lab is at Royal Jubilee. Once for an angiogram in workups for the ablation, and then for two ablations (first one wiggled its way into the 25% failure-for-first-ablations category). We also travel every three months to see her oncologist and her rheumatologist, same area around Royal Jubilee Hospital. Now in normal sinus rhythm (NSR) for coming up to two years already, I can't begin to describe the relief and gratitude I have for the facilities and the wonderful medical staff and surgeons, and for the reduction in anxiety I now have. Also, I was highly symptomatic and felt awful in the last year that included both ablations. Truly awful. Now....amazing. I urge you to look forward to that orientation to your own eventual success.

You could also die in your sleep tonight. Or, have done so last night. You didn't worry because it was out of your control and unpredictable. And being unconscious, you'd not have known anyway. Same, same. Stop worrying. Instead, spend some energy on gratitude that you have an EP working for you and you're in line for relief. That was my orientation. Or, worry if your affairs are not in order. Do you have a will? An executor? Those would be a far more productive spend of your time than worrying about eventualities with an exceedingly low probability...like 0.5%!! I was only worried about long-term effects, and in order to delay them or to stave them off entirely, I needed a heart spending as little time in AF as humanly possible. I am that human, and by God, I was going to have someone try to stem the tide of ectopy.

My wife and I have had to travel three times to Victoria, southern tip of Vancouver Island, to where the cath lab is at Royal Jubilee. Once for an angiogram in workups for the ablation, and then for two ablations (first one wiggled its way into the 25% failure-for-first-ablations category). We also travel every three months to see her oncologist and her rheumatologist, same area around Royal Jubilee Hospital. Now in normal sinus rhythm (NSR) for coming up to two years already, I can't begin to describe the relief and gratitude I have for the facilities and the wonderful medical staff and surgeons, and for the reduction in anxiety I now have. Also, I was highly symptomatic and felt awful in the last year that included both ablations. Truly awful. Now....amazing. I urge you to look forward to that orientation to your own eventual success.

When you say you "felt awful" what exactly do you mean? What were your symptoms? Did you feel bad even when you were not having an episode or were you in persistent Afib? Thanks for explaining more.

The sensation signaling an oncoming AF episode was unmistakable, like a heart pause or a swelling around the heart. It was very transitory, maybe a full second or two, and then my heart would begin to beat erratically, and I felt the thumping through my chest wall. The sound of it kept me awake if it didn't stop by bedtime. This interferes with sleep, and the ensuing fallout is probably well understood by you. This can go on for days.

There is shortness of breath, a sense of unease, a sense of foreboding and dread because the beast has a mind of its own. Being paroxysmal, an early stage, it comes and goes seemingly for no apparent reason, and it stays for as long as it thinks it is welcome. But, it isn't a sensitive or well-bred disorder, so it ALWAYS overstays its welcome...period.

In the latter days just before my first and second ablations, still well-ensconced in the paroxysmal stage, people told me I looked grey. Nobody looks like that, and sufficiently so that others are concerned and let you know of your appearance, unless there is a distinct malady that is sapping strength and well-being.

And yes, the dread lingers and leaps into prominence at the first signals that an AF episode is just a few minutes or hours away. The feeling of tightness or swelling in the tissues surrounding the heart, maybe some belching, a bit of reflux, and then.....chaos. So, more directly, the malaise is constant, even when not in AF. It is an irregularly irregular beat that comes and goes, persists for hours, may or may not respond to medication or to a cardioversion (only my second cardioversion lasted as long as 16 hours; the others less than four hours), and that makes its presence, at least in my chest, a chaotic and lumpy sensation, almost like I have bowel gas moving right to left along the transverse colon. I could even feel it in my carotid arteries without touching those places.

I have an enlarged heart, a very fit heart, due to living at altitude in the Andes Mt. in Peru during my youth, and then for being fit while in the military, and for having been a competitive runner all my adult life. My heart, at least, is a powerful muscle that can make my whole body shake when it is beating. At full rest, when in my 30's, it beat at only 24 BPM, and that made my whole body move in rhythm to it. This doesn't happen during AF, but the sensation of its chaotic beats can be felt easily in the thorax and up into my neck. Trying to sleep like that is almost impossible.

Well said.