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 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 is a procedure which aims to restore normal heart rhythm (sinus rhythm). There are two main types: chemical and electrical.
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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’.
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.
Yet while cardioversion can have a good success rate in restoring normal heart rhythm, it does not always work.
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People we spoke to were not always convinced about the value of having a cardioversion, or were disappointed in the results. Janet, 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.
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 explains, 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.
Bob reported that AF symptoms can take a few months to ‘settle down’ after a catheter ablation. He now takes a small dose of flecainide and has 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, found that his specialist and nurse were happy to discuss it in detail and then allow him to decide in his own time.
Jenny, James’ wife, recalled how she found it ‘absolutely petrifying’ when her husband had the ablations but after the third ablation proved successful 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 in having four 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, had an ablation conducted ‘while the surgeon had me open’. Six clots were found during the procedure, so he reported feeling very lucky that his surgeon had been able to remove these.
Catheter ablations are not always successful. Elisabeth X, who turned down an ablation over ten years ago when she was in her sixties and ‘didn’t think the odds of success were too good’, now believes she is ‘past the age’ to have the operation. Martin has been told that if his symptoms worsen, he can 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 has decided to take medication while it continues to work rather than ‘risk having an ablation’. Glyn believes 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 seven 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 his heart had been ‘horribly abused’, and decided to wait and see if his AF would settle down. He continues 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 six weeks later.
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.
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 six 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.
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.
(For more see ‘Heart rate and rhythm medication for atrial fibrillation’)


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