Atrial Fibrillation

Atrial fibrillation is an irregular and often rapid heart rate that can increase one’s risk of strokes, heart failure, and other heart-related complications. During atrial fibrillation, the two upper chambers of the heart (the atria) beat irregularly and chaotically out of sync with the two lower chambers (the ventricles) of the heart. Atrial fibrillation symptoms often include heart palpitations, shortness of breath, and weakness.

Although atrial fibrillation itself usually is not life-threatening, it is a serious medical condition that sometimes requires emergency treatment. Atrial fibrillation may be temporary, but some episodes won’t end unless treated. A major concern with atrial fibrillation is the potential to develop blood clots within the upper chambers of the heart. These blood clots forming in the heart may circulate to other organs and lead to blocked blood flow (ischemia).

Treatments for atrial fibrillation may include medications and other interventions, such as ablation to try to alter the heart’s electrical system.

What is the Best Treatment for Atrial Fibrillation?

The most effective treatment for atrial fibrillation is ablation. Atrial fibrillation ablation has been shown to be extremely effective in treating A-Fib. Most importantly, the risks of the procedure are quite low, especially compared to other heart procedures.

Timing is very important in diagnosing and treating A-fib. The first several months are crucial in achieving a normal rhythm. This is because, unlike medications, ablation can alter the natural history of the condition in a positive manner. Not only is long-term remission possible, but patients with other cardiovascular risk factors such as age over 65, high blood pressure, diabetes, etc. are able to improve their quality of life and live longer after an ablation. More and more studies are showing that attempting to eradicate atrial fibrillation significantly improves patients’ quality of life. In conjunction with an ablation, it is important to modify lifestyle and risk factors that may contribute to the presence of atrial fibrillation. This often includes (i) reducing alcohol intake, (ii) not binge drinking, (iii) losing weight, (iv) controlling blood pressure, and (v) diagnosing and treating sleep apnea, if present. In general, thyroid function should also be normal as part of the management of atrial fibrillation. Electrical cardioversion and medications are also excellent short-term treatments that should be paired with a discussion with one’s Electrophysiologist regarding ablation. Anticoagulants (blood thinners) need to be discussed as well.

What are the Main Causes of Atrial Fibrillation?

The most common cause of atrial fibrillation is aging. Atrial fibrillation can also be caused by sleep apnea, high blood pressure, diabetes, being overweight, alcohol consumption, and extreme stress. Atrial fibrillation may also occur while being ill from pneumonia or viral pneumonia or having undergone major surgery for a major illness. Overactive thyroid commonly causes atrial fibrillation as well. Atrial fibrillation can run in families but usually, it is most prominent if a parent or first-degree relative had atrial fibrillation at the age of 40 or younger. Although very rare, atrial fibrillation can also be caused by extreme exercise.

Can Atrial Fibrillation be Cured Naturally?

Atrial fibrillation is very difficult to cure naturally. However, one should make a concerted effort to do so. Natural treatments include daily meditation. Cutting back alcohol to less than seven drinks a week, abstaining from binge drinking and sometimes cutting out alcohol altogether can reduce the frequency of atrial fibrillation. Checking for or treating sleep apnea could also be a natural way of treating atrial fibrillation. Paying attention to a good night’s sleep, stress reduction, and regular exercise can help reduce atrial fibrillation as well. Of note, unfortunately atrial fibrillation can occur despite having a healthy lifestyle.

How Often Does A-FIB Recur?

Left untreated, atrial fibrillation will usually recur frequently unless it is caused by a one-off, unusual circumstance. Of course, every patient is different and atrial fibrillation can as little as once a year to, every few months, to every week, to every day. Medication can reduce the number of times atrial fibrillation recurs. However, when compared to medications, ablation therapy is much more effective in reducing recurrences and in many cases can eliminate recurrences.

If atrial fibrillation occurs due of an unusual situation, such as open-heart surgery, thyroid dysfunction, excessive alcohol intake, viral infection or other major surgery, then atrial fibrillation may not necessarily recur. In such situations, longer term monitoring needs to be done to make sure atrial fibrillation does not recur. Patients may experience recurrences of atrial fibrillation if they drink alcohol. Episodes could also recur if sleep apnea is not treated or thyroid function becomes abnormal.

Recurrences of a-fib can be reduced by weight loss. However, however, in general, once atrial fibrillation occurs due to weight, it is difficult to control recurrences. The best way to reduce recurrences is to have an ablation done in conjunction with weight loss. Ideally, anyone should lose 10% of their current weight over a 1-year period.

How Serious is an Ablation Procedure?

Heart ablation is a procedure that thankfully is very minimally invasive and has a very low risk of complications. In general, the risk of serious complications nationwide is approximately 1%. Choosing an experienced surgeon is important and can reduce the complication rate to even less than 1%. An ablation is done by inserted a catheter through the vein at the leg. There is no major cutting done during the procedure. Patients can get up and walk within just a few hours after the procedure and can go home the same or the next day. The “biggest” limitation is no exercise for one week after the procedure! Some people may have a sore throat and mild chest discomfort for a few days after the procedure. The most common complication is a slight bruising at the leg where the catheters were inserted. This can be accompanied by mild tenderness that usually resolves within just days.

How Successful is Ablation for Atrial Fibrillation?

Atrial fibrillation ablation has a very high success rate. Success after an ablation depends on the severity of the A-Fib. In patients with otherwise no other cardiovascular risk factors, the success rate can be as high as 90%. For patients that have atrial fibrillation that lasts for hours or up to a day or two, the success rate for ablation is 80%. Patients can be completely cured of atrial fibrillation with an ablation. However, ablation is not considered a permanent “cure” because atrial fibrillation has the potential to come back after several years. In general, if no atrial fibrillation recurs within one year, remission from atrial fibrillation can last up to 10 years or more. The success rate for treating patients with persistent atrial fibrillation is variable. The outcome of the procedure is influenced by the duration of the atrial fibrillation prior to the procedure. If ablation is performed within 6 months of diagnosis, the success rate can be as high as 75%. With a longer duration of atrial fibrillation, the success rate is lower and in general, usually requires two procedures if atrial fibrillation has been continuous for more than 6 months or a year.

In patients that have a recurrence of atrial fibrillation after ablation, a second procedure is usually recommended. A second ablation procedure builds on the first procedure and success rates are even higher. Only a handful of people require a third procedure and people who have more than three procedures constitute less than 3% of the people getting ablations.

Can Ablation be Done While a Patient is in A-FIB?

Ablation for atrial fibrillation can be done while someone is in atrial fibrillation or out of it. The cornerstone of ablation for a-fib is the electrical isolation of the pulmonary vein. What this means is that the procedure targets the veins that connect the heart to the lungs. In the overwhelming majority of patients, this is the location that triggers atrial fibrillation and it does not matter whether the patient is in a-fib or not during the ablation. It is sometimes the case that after the ablation is done on this area, the patient remains in atrial fibrillation. This signifies to us that other areas of the heart have also been affected and will also need treatment.

Frequently, ablation is also done at the posterior or back wall of the heart. In some cases, sophisticated computer-based mapping of the atrial fibrillation is done to find other potential sites for ablation. Again, it is important to note that one does not need to be in atrial fibrillation in order to perform a successful ablation.

Is it Normal to Have A-FIB after an Ablation?

In general, ablation for atrial fibrillation is highly efficacious. However, many, about 10-20% of people, may have recurrent atrial fibrillation and may need repeat ablation. It is important to note that after an ablation procedure there is a healing phase of approximately two months. During the healing phase period, atrial fibrillation may recur but does not mean that the procedure was a failure or needs to be repeated. In approximately 10% of people, atrial fibrillation may actually recur within the first week or two only because of inflammation induced by the ablation. These episodes almost always self-resolve but occasionally require cardiac cardioversion to reset the heart while it is healing.

If I get an Ablation, How Long Will It Last?

Ablation for atrial fibrillation (A-FIB) can last for more than a decade! In most cases, patients achieve long-standing remission from atrial fibrillation. When ablation is done in conjunction with lifestyle modification, complete remission may be achieved. In some cases, a second procedure is required within the first year to treat the atrial fibrillation. After the second procedure, one should expect many years of normal rhythm without atrial fibrillation. In many cases, a-fib ablation can dramatically improve people’s quality of life. This is because a-fib episodes will not occur, and if they do, they may occur very rarely. Also, episodes could have less symptoms associated with them. In addition, after ablation, many of the medications can be stopped, also improving patients’ quality of life. In general, there is a “resetting of the clock” after a successful ablation and atrial fibrillation no longer becomes front and center of a person’s life.

What are Palpitations a Sign Of?

Palpitations are a sign of a potential arrhythmia in the heart. Arrhythmia refers to abnormal heart rhythm. Palpitations may be caused by extra heartbeats, sustained multiple heartbeats and abnormal very fast heart rates. Palpitation sensations should prompt medical evaluation. Although many types of arrhythmias can cause palpitations, and most are benign, it is very important to ascertain if one has atrial fibrillation, as a-fib has implications for stroke and heart function. Today, thanks to new, sophisticated wearable technology, we can readily record a modified EKG that patients can show to their doctor for evaluation.

What Types of Ablation are Being Used Today?

Two major ablation technologies are being used for atrial fibrillation ablations today. These are Radio Frequency Ablation and Cryo Ablation.
Today, the most common technology is Radio Frequency Ablation. This is so called “heat” ablation. This technique has undergone several revolutionary changes in the last five years (even though it has been constantly improving over the last twenty years). These revolutionary changes include using computer assisted algorithms to deploy precise radiofrequency energy at the area(s) that cause atrial fibrillation. This technique allows for precision within less than ½ millimeters and can fix atrial fibrillation despite tremendous variability of the heart’s anatomy. Newer techniques also allow for the near elimination of a rare complication that is harder to avoid in Cryo Ablation.

Cryo ablation is a very effective method that uses freezing balloons to freeze tissue that causes atrial fibrillation. The majority of major academic medical institutions favor radiofrequency ablation over Cryo ablation because of the versatility of radiofrequency ablation and the ability to avoid most complications. Both procedures can be performed in approximately an hour and are very well tolerated by patients and generate excellent results. For patients that have persistent atrial fibrillation (atrial fibrillation that does not go away on its own), radiofrequency ablation is the favored method because it can treat a variety of areas of the heart that can cause atrial fibrillation.

What Does the Watchman Device Do for Patients with A-FIB?

The Watchman device is an excellent device used to reduce the chance of developing a stroke for atrial fibrillation for patients that are not able to take anticoagulants or “blood thinners”. The Watchman device can also be used for atrial fibrillation. If one cannot take blood thinners, the Watchman device is an excellent treatment modality for reducing stroke risk. When atrial fibrillation develops in the heart, there blood tends to pool in a part of the heart called the left atrial appendage. One can think of the left atrial appendage as something of a Christmas stocking, an outpouching from the heart. The Watchman device plugs the opening of the outpouching, thereby preventing blood clots from coming out. The Watchman device does not affect the electrical triggers for atrial fibrillation, which occur at a different location, not in the atrial appendage.

Can One Live a Long Life with Atrial Fibrillation?

People diagnosed with atrial fibrillation can live long lives as long as they seek medical attention. Atrial fibrillation is normally a manageable condition. One of the most important things to discuss with your doctor when atrial fibrillation is diagnosed is stroke prevention. The cornerstone of stroke prevention for atrial fibrillation is anti-coagulant medication otherwise known as blood thinners. Without blood thinners, stroke rates for patients with atrial fibrillation can be up to 5 times as high as that of the general population. In addition, atrial fibrillation can lead to heart failure if left untreated. With treatments that range from medication, cardioversion, and ablation, atrial fibrillation can be readily controlled. In some cases, atrial fibrillation leads to a very slow heart rate and a pacemaker is necessary for a normal life.

Recent studies have also demonstrated that performing an ablation for atrial fibrillation in the right patient can prolong life and reduce hospitalizations. This is especially true in patients already suffering from mild, moderate or severe heart failure symptoms. In addition, restoration of normal rhythm within the first 12 months after the diagnosis of atrial fibrillation in patients who are older than 65 and have other cardiovascular risk factors such as high blood pressure, can also prolong life and reduce hospitalization.

Can Atrial Fibrillation Go Away?

Atrial fibrillation can often go away with proper lifestyle modification and will go away with ablation therapy. Examples of lifestyle modification include reducing alcohol intake to less than 7 drinks a week, weight reduction of at least 10% of one’s weight within a year, achieving blood pressure control at 120/80 mmHg or lower, treating sleep apnea, stress reduction, and regular exercise. Currently, there is strong evidence that atrial fibrillation should not be left alone if present and either a cardioversion or an ablation should be done in order to restore the normal rhythm of the heart.

Proper Care Starts With Early Education and Relevant Information

For additional resources and information, please visit the following websites: The Heart Rhythm Society,  Atrial Fibrillation Risk Assessment, and Medtronic.