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Atrial Fibrillation Ablation

Last updated May 4, 2018

Approved by: Maulik P. Purohit MD, MPH

Atrial Fibrillation Ablation (Afib Ablation, or AF Ablation) is an invasive procedure that involves removing the cells that give rise to atrial fibrillation, and/or the cells that help in its continuation.

Background Information:

What are the other Names for the Procedure?

  • AF Ablation
  • Catheter Ablation
  • Surgical Ablation of Atrial Fibrillation

What is Atrial Fibrillation Ablation surgical procedure?

  • Atrial Fibrillation Ablation (Afib Ablation, or AF Ablation) is an invasive procedure that involves removing the cells that give rise to atrial fibrillation, and/or the cells that help in its continuation
  • It is used when medications have failed to treat atrial fibrillation (Afib)

What part of the Body does the Procedure involve?

  • Ablation procedures mainly involve the left upper chamber of the heart (the left atrium), most often at the site, where the pulmonary veins open into the atrium. The pulmonary veins are blood vessels that bring oxygen-rich blood to the heart from the lungs
  • This is the most common origin point of the aberrant electrical impulses that give rise to atrial fibrillation
  • However, other localized sources giving rise to Afib, may be found throughout both the atria

Why is the Atrial Fibrillation Ablation surgical procedure Performed?

Atrial Fibrillation Ablation procedures are performed in individuals, when atrial fibrillation cannot be controlled with medication, or if they cannot tolerate the side effects of the drugs.

What are some Alternative Choices for the Procedure?

For patients not responding to medications, or not tolerating the side effect of drugs, Atrial Fibrillation Ablation procedure remains the only choice.

What are the Recent Advances in the Procedure?

  • Traditionally, doctors used fluoroscopy x-ray to help them manoeuvre the catheter inside the body. This generates only 2-D images, and it also involved the use of ionizing radiation
  • Some centers now have electroanatomic mapping systems that aid in navigating the catheter to the heart, by generating 3-D images. This also reduces the radiation-exposure
  • Some centers have robotic catheter ablation - this offers better manoeuvring of the catheter and shortens the procedure time

What is the Cost of performing the Atrial Fibrillation Ablation surgical procedure?

The cost of Atrial Fibrillation Ablation procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

  • It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Atrial Fibrillation Ablation procedure and what needs to be done
  • If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
  • Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

Stop Afib.org
P.O. Box 541, Greenwood, Texas 76246-0541
Website: http://www.stopafib.org

Heart Rhythm Society
1325 G Street, NW, Ste 400 Washington, DC 20005, USA
Phone: (202) 464-3400
Fax: (202) 464-3401
Email: info@HRSonline.org
Website: http://www.hrsonline.org

Prior to Atrial Fibrillation Ablation surgical procedure:

How is the Atrial Fibrillation Ablation surgical procedure Performed?

An Atrial Fibrillation Ablation procedure may be carried out via catheter or surgery.

Catheter Ablation:

  • This is done by passing a flexible wire (catheter) through a vein, usually in the groin (or even neck/arm) and guiding it right up to the heart
  • The tip of the catheter then uses, either radio waves/heat/intense cold/ultrasound waves to ablate the source of the atrial fibrillation, or block the conduction, once it has been guided into the heart

Surgical Ablation:

  • Two open heart procedures, Cox Maze III and Maze, help in Surgical Ablation of Atrial Fibrillation
  • The open heart procedures are usually performed, when an individual needs another surgery, such as valve repair or replacement, or coronary artery bypass grafting.

Cox Maze III procedure:

  • The surgeon opens the chest cavity, enters the heart and scars the source of Afib, or blocks conduction, by making a series of “cuts and sews”
  • Although, this is considered the gold standard for surgical treatment of Afib; it is a very complicated procedure and hence, rarely performed

Maze procedure:

  • The surgeon opens the chest cavity, enters the heart, and creates a conduction block with an energy source

Mini Maze procedure (minimally-invasive surgical ablation):

  • In this procedure, the surgeon makes small incisions on the chest, places ports, to pass a camera (thoracoscope), surgical instruments, and an ablation device, into the chest
  • Using the camera to visualize the inside of the chest and heart, the surgeon creates a conduction block, to treat atrial fibrillation
  • To be a candidate for the mini maze procedure, no prior open chest procedures should have been performed
  • During surgical ablation procedures, the surgeon may also remove/block a small flap of the left atrium, called the left atrial appendage, to reduce the risk of clots and strokes

Where is the Procedure Performed?

Atrial Fibrillation Ablation is performed in a hospital.

Who Performs the Procedure?

Catheter ablations are performed by a cardiac electrophysiologist, while surgical ablations are performed by cardiothoracic surgeons.

How long will the Procedure take?

Ablation for Atrial Fibrillation surgical procedure may take anywhere between 2-4 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

  • Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
  • If you are allergic to any specific medication or food items
  • If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
  • If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
  • If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
  • If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
  • If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
  • A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

  • The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
  • Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
  • Some recent data, however suggests that carrying out the ablation procedure, while on blood thinners, reduces the risk of developing strokes
  • Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
  • Normally, local anesthesia is not used; however, do inform the physician, if you are allergic to any local anesthetics, lidocaine, etc.
  • Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
  • It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
  • Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
  • The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
  • For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Ablation for Atrial Fibrillation procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Atrial Fibrillation Ablation surgical procedure?

Prior to the ablation procedure, the individual may have to undergo certain tests, such as:

  • Complete physical
  • Electrocardiogram (EKG)
  • Echocardiogram
  • Transesophageal echocardiogram (TEE)
  • Holter monitor test
  • Computed tomography (CT)
  • Stress Test
  • International normalized ratio (INR)
  • Blood work-up

The physician may suggest further tests depending on the health of the individual and their medical history.

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

  • What is an Atrial Fibrillation Ablation procedure?
  • Why is this procedure necessary? How will it help?
  • How soon should I get it done? Is there an emergency?
  • Will it cure my atrial fibrillation?
  • What should I do to prepare myself for the procedure?
  • What kind of anesthesia will be used?
  • What should I expect during the procedure?
  • What are the risks while performing the procedure?
  • What are the complications that might take place, during recovery?
  • How long will it take to recover? When can I resume normal work?
  • Are there any lifestyle restrictions or modifications required, after the procedure is performed? 
  • Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
  • Is there any medication that needs to be taken for life, after the procedure?
  • How many such procedures have you (the physician) performed?
  • What are the costs involved?

During the Atrial Fibrillation Ablation surgical procedure:

What kind of Anesthesia is given, during the Procedure?

  • Catheter ablations are performed under sedation. A local anaesthetic is injected at the site, where the catheter is introduced
  • The surgical procedures require general anesthesia

How much Blood will you lose, during the Procedure?

  • While catheter procedures do not involve any blood loss, open heart procedures do cause some loss
  • However, any major injury to the heart chamber (atria), or a major blood vessel could result in substantial blood loss

What are the possible Risks and Complications during Atrial Fibrillation Ablation surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

  • Obesity: Generally greater the degree of obesity, greater is the surgical risk
  • Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
  • Advancing age
  • Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
  • Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
  • Poorly functioning liver, as evidenced by increased blood liver function tests
  • Hypertension (increased blood pressure), especially if it is poorly controlled
  • Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
  • Poor lung function, as evidenced by abnormal lung function tests
  • History of bleeding disorders
  • Longstanding illness, such as autoimmune disorders, chronic infections
  • Poor immune system due to a variety of causes

The possible risks or complications that may arise during the surgery are:

  • Puncture of the atrial wall, leading to rapid pooling of blood in the chamber around the heart, causing a serious condition called cardiac tamponade
  • Puncture of the posterior wall of the atrium and entering the food pipe (esophagus) forming an atrioesophageal fistula
  • Damage to the heart or blood vessels, bleeding
  • Stroke
  • Heart attack
  • Damage to nerves that results in paralysis of the diaphragm (the muscle that helps with breathing)
  • During mini maze procedure, deflation of the lung could result in its collapse
  • In some rare cases, death is a possibility.

What Post-Operative Care is needed at the Healthcare Facility after Atrial Fibrillation Ablation surgical procedure?

  • Once the catheter ablation procedure is over, the individual is transferred to a recovery room or cardiac care unit. For individuals undergoing surgical ablation, post-procedure ICU stay may be mandated - anywhere from a few hours, to a day or even more
  • The heart rate, rhythm, and blood pressure, are constantly monitored
  • Medications to manage pain are administered, as necessary
  • Following catheter procedure, the individual is advised to lie still a few hours, to avoid any bleeding from the puncture site
  • Other medications, such as drugs, to prevent infections, anti-nausea medications, are also administered
  • Exercises to prevent fluid accumulation in lungs may be given, while recovering from general anesthesia

After the Atrial Fibrillation Ablation surgical procedure:

What are the possible Risks and Complications after Atrial Fibrillation Ablation surgical procedure?

Post Atrial Fibrillation Ablation procedure, the following complications may arise:

  • Narrowing of the pulmonary veins (pulmonary vein stenosis)
  • New rhythm disturbances of the heart
  • Inflammation of the covering of the heart (pericarditis) following mini maze
  • Inflammation of the vein (phlebitis), due to catheter manoeuvring

What is the Prognosis after the Surgery?

  • The outcomes of the procedure depend on the type of atrial fibrillation, the age of the individual, and the presence of any other medical conditions
  • Research has shown that patients with paroxysmal atrial fibrillation (sudden, intermittent, and lasting less than 7 days) have very good outcomes, with more than half of the patients responding to the catheter procedure, the very first time it was done, and almost 80% responding to two or more procedures

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

  • Chest discomfort/pain
  • Fast heartbeat
  • Shortness of breath
  • Weakness or numbness of limbs
  • Dizziness
  • Fever
  • Any swelling or drainage from the wound, following a surgical ablation procedure

What Post-Operative Care is needed at Home after Atrial Fibrillation Ablation surgical procedure?

At home, the following post-operative care is recommended, after Atrial Fibrillation Ablation procedure:

  • Avoid strenuous work or lifting heavy weights for some time post-procedure
  • Avoid activities, such as swimming, for a while
  • Do have follow-ups with your physician, at regular intervals
  • Continuation of blood thinners and/or anti-arrhythmic medications, for as long as it is deemed necessary

How long does it normally take to fully recover, from the Procedure?

  • Catheter ablation calls for a stay in the hospital for a day or two. Some chest discomfort and palpitation may be experienced after the procedure. These symptoms subside once the heart fully heals, which may even take up to 3 months
  • The Maze procedure calls for a week long hospital stay; recovery takes about 6-8 weeks
  • The Mini Maze procedure requires a hospital stay of 2-4 days. Normally, recovery takes a few days, post-procedure

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

No tissues are taken out during the procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is taken out during this procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Atrial Fibrillation Ablation surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

  • The hospital
  • An anesthesiologist
  • Cardiovascular surgeon/electrophysiologist

Individuals are advised to inquire and confirm the type of billing, before the Atrial Fibrillation Ablation procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: Dec. 18, 2013
Last updated: May 4, 2018