The goals of treatment for atrial fibrillation include (1) regaining a normal heart rhythm (called "normal sinus rhythm"); (2) controlling the heart rate; and (3) preventing blood clots and strokes. Initially medications are used to treat atrial fibrillation. The medications may include:

• Rhythm control medications (antiarrhythmic drugs) to try to maintain normal sinus rhythm
• Rate control medications (to slow the heart rate)
• Coumadin (warfarin – an anticoagulant or blood thinner) and/or aspirin to prevent blood clots and stroke

Other treatments for atrial fibrillation, such as catheter ablation or pulmonary vein isolation, are appropriate for patients who:

• Have a history of chronic or paroxysmal atrial fibrillation
• Have continued symptoms of atrial fibrillation, despite treatment with medications
• Can not tolerate antiarrhythmic drugs, or have had complications from these drugs
• Wish to discontinue medications altogether used for the treatment of atrial fibrillation and are considered a good candidate for ablation after an evaluation by a physician

What is an atrial fibrillation ablation or a pulmonary vein isolation (PVI) procedure?

Research has shown that almost all atrial fibrillation signals come from the four pulmonary veins (the veins that connect the lungs to the upper left chamber of the heart called the left atrium) (figure 2). Pulmonary Vein Isolation (PVI) ablation is a procedure whose goal is to alter the pulmonary vein areas of the heart such that atrial fibrillation will not occur. During pulmonary vein isolation, the physician inserts catheters from both groin veins into the upper left atrium chamber of the heart. The patient is asleep under conscious sedation.

A special machine delivers radiofrequency energy through the catheters to the area where the pulmonary veins enter the left atrium. This energy delivered by the tip of the ablation catheter produces a circular scar that blocks any impulses firing from within the pulmonary veins, thereby "disconnecting" the pathway of the abnormal rhythm and preventing atrial fibrillation (figure 3). In some cases, pulmonary vein isolation also may be performed in other parts of the heart such as the superior vena cava.

How can I be evaluated for catheter ablation of atrial fibrillation or for a pulmonary vein isolation (PVI) procedure?

All you need is an appointment with a cardiologist at Capital Cardiology Associates, or you can ask to make an appointment with Ian Santoro, MD or Jim O'Brien, MD, the cardiac electrophysiologists who perform the procedure.

Evaluation:

Before pulmonary vein isolation, what tests may be performed?

In all patients, spiral computed tomography (CT) test will be performed before the procedure; in some patients, a transesophageal echocardiogram (TEE) may be performed before the procedure. If you take coumadin, the results of your INR test (a blood test to evaluate blood clotting) must be within a suitable range before the procedure can be performed. You will be given instructions regarding all of this.

Should I take my medications before the procedure?

Your physician may ask you to stop taking certain medications. Do not discontinue any of your medications without first talking to your physician. Bring your prescription medications with you to the hospital, but follow the directions about taking them as given to you by your physician. If you have diabetes, ask the nurse how you should adjust your diabetes medications and/or insulin.

Can I eat before the procedure?

Eat a normal meal the evening before your procedure. However, DO NOT eat, drink, or chew anything after 12 midnight before your procedure. This includes gum, mints, water, etc. If you must take medications, only take them with a small sip of water.

What happens when I arrive?

Before the procedure begins, a nurse will help you get ready. You will lie on a bed and the nurse will start an IV (intravenous line) in a vein in your arm. The IV is used to deliver medications and fluids during the procedure.

A medication will be given through your IV to make you feel drowsy. Your neck, upper chest, arm and groin will be cleansed with an antiseptic solution. The catheter insertion site(s) will be shaved. Sterile drapes will be placed to cover you from your neck to your feet.

Where is the catheter ablation procedure performed?

The procedure takes place in a special room called the EP (ElectroPhysiology) lab.

Will I be monitored?

The nurse will connect you to several monitors that will check your heart rhythm and your body's responses to any arrhythmias during the procedure. The nurse will constantly assess you during the procedure. The following are the monitors that will be used during the procedure:

• Defibrillator/pacemaker/cardioverter: Attached to one sticky patch placed on the center of your back and one on your chest. This allows the physician and nurse to pace your heart rate if it is too slow, or deliver energy to your heart if the rate is too fast.
• Electrocardiogram or EKG: Attached to several sticky electrode patches placed on your chest, as well as inside your heart.  Provides a picture on the monitors of the electrical impulses traveling through the heart.
• Blood pressure monitor: Connected to a blood pressure cuff on your arm. Checks your blood pressure throughout the ablation.
• Mapping system: State-of-the-art technology that helps your physician locate the exact area of your arrhythmia.
• Ablation machine: Attached to another sticky patch on your back.
• Oximeter monitor: Attached to a small clip placed on your finger. Checks the oxygen level of your blood.
• Fluoroscopy: A large X-ray machine will be positioned above you to help the physicians see the catheters on an X-ray screen  during the procedure.
• Intracardiac ultrasound, performed by a catheter transducer inserted into the heart: used throughout the procedure to view the  structures of the heart and the catheter when it is in contact with the heart lining.

How does the physician insert the catheters into the blood vessels around my heart?

After you become drowsy, the physician will numb the catheter insertion site by injecting a medication. The doctor will insert several catheters into large veins in both sides of your groin.

A transducer is inserted through one of the catheters so intracardiac ultrasound can be performed during the procedure. The ultrasound allows the physician to view the structures of the heart and evaluate pulmonary blood flow on an external monitor.

The catheters will be advanced through the blood vessels to your right atrium. A needle is then used to place the catheters through the septum into the left atrium.

After the catheters are in place, radiofrequency energy is delivered through the catheters to the area around the pulmonary vein openings to stop ("ablate") the abnormal impulses that cause atrial fibrillation (figure 3).

Once the ablation is complete, the electrophysiologist uses monitoring devices to observe the electrical signals in the heart.

How will I feel during the procedure?

You will fall asleep during the procedure due to the medication given to make you relax. You will feel an initial burning sensation when the physician injects medication in the catheter insertion site.

You may feel some discomfort or a burning sensation in your chest when the energy is applied through the catheter. It is important to remain quiet, keep very still and avoid taking deep breaths. If you are feeling pain, ask your physician or nurse to give you more medication. Our goal is to have all patients deeply asleep so they feel no pain and have no recollection of the procedure.

How long does the procedure last?

The procedure may last from 3 to 5 hours.

After pulmonary vein isolation, what should I expect?

The doctor will remove the catheters and apply pressure to the insertion site to prevent bleeding. No stitches are needed. A pressure dressing (bandage) will cover the insertion sites.
You will need to stay in bed for 6 to 8 hours after the procedure. You'll need to keep your legs still during this time to prevent bleeding.

When will I find out the results?

After the procedure, the physician will discuss the results of the procedure with you and your family.

How will I feel after the procedure?

You may feel fatigue or chest discomfort during the first 48 hours after the procedure. Please tell your physician or nurse if any of these symptoms are prolonged or severe.

Will I have to stay in the hospital?

Yes. You will be admitted to the hospital and stay overnight after the procedure.

In your hospital room, you will be placed on a special monitor, called a telemetry monitor. Telemetry consists of a small box connected by wires to your chest with sticky electrode patches. The box displays your heart rhythm on several monitors in the nursing unit so the nurses will be able to observe your heart rate and rhythm.

Will I be taking new medications?

For at least one to three months after the procedure, you will need to take an anticoagulant (blood thinning) medication, such as Coumadin (warfarin), to prevent blood clots. You must have frequent blood tests,(called an INR/Protime) to evaluate the dosage of Coumadin. Your physician will tell you how often to have this test.

You may also need to take an antiarrhythmic medication to control abnormal heartbeats for two months after the procedure.

You will receive the necessary prescriptions and medication instructions from your physician. Ask your physician if you can continue taking your previous medications.

In some cases, your physician may recommend cardioversion to control abnormal heartbeats.

Will I be able to drive myself home?

No, for your safety, a responsible adult must drive you home.

When can I return to my normal activities?

Your doctor will tell you when you can resume your normal activities, including driving. Usually you can return to your normal activities within 48 hours after the procedure. For one week after the procedure, do not lift anything that weighs more than 10 pounds if possible, just to avoid putting strain on the catheter insertion sites in the groins.

What symptoms should I expect?

You may experience skipped heartbeats or short episodes of atrial fibrillation during the first two months after the procedure. These symptoms are common due to inflammation (swelling) of the heart tissue and are treated with medications. After your heart has healed, these abnormal heartbeats should subside.

What symptoms should I report?

Please call Capital Cardiology Associates and ask to speak with a nurse if you have:

• A temperature of more than 101 degrees Fahrenheit or 38.4 degrees Celsius (a possible sign of infection).
• Redness, swelling or drainage at the procedure site (call right away).
• Significant atrial fibrillation symptoms.
• Significant chest pain
• Difficulty or pain swallowing

Follow-up visit:

A follow-up visit will be scheduled at three to four weeks after the procedure. You will be asked to get a blood draw for coumadin dosing (called an INR test) the first week after leaving the hospital.

This information is provided for education purposes only and is not intended to replace the medical advice or informed consent discussion of your physician. While we strive to keep our website current, medical practices sometimes change quickly. Please consult your physician for advice about a specific medical condition or procedure.