Catheter ablation for atrial fibrillation is a nonsurgical procedure in which the areas of the atrium responsible for the generation of arrhythmia are mapped and then destroyed using either radiofrequency energy (heat) or cryoenergy (freezing).
Tune into SMG radio to hear Jonathan Steinberg, MD explain how Catheter ablation is used to help treat atrial fibrillation.
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Catheter Ablation for Atrial Fibrillation
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Learn more about Jonathan S. Steinberg, MD
Jonathan Steinberg, MD
Jonathan S. Steinberg, MD joins Summit Medical Group from the Arrhythmia Institute at the Valley Health System in Ridgewood, NJ and New York, NY. He is also a Professor of Medicine (adj) at the University of Rochester School of Medicine & Dentistry. Dr. Steinberg specializes in the diagnosis and treatment of heart rhythm disorders, and has an international reputation for expertise in catheter ablation of cardiac arrhythmias.Learn more about Jonathan S. Steinberg, MD
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Catheter Ablation for Atrial Fibrillation
Melanie Cole (Host): Atrial fibrillation is an irregular heartbeat that can increase the risk of stroke and heart disease. My guest today is Dr. Jonathan Steinberg. He’s a cardiac electrophysiologist with Summit Medical Group. Welcome to the show, Dr. Steinberg. Just give us a little working definition for the listeners of what atrial fibrillation or AFib is.
Dr. Jonathan Steinberg (Guest): One has to understand that the heart has four chambers. The two upper chambers are called the “atria”. The two lower chambers are called the “ventricles” and they are the pumping chambers. The normal rhythm is carefully coordinated by an electrical system within the heart. So, the upper chambers start and the lower chambers finish by pumping. When atrial fibrillation develops, there is a very rapid and chaotic electrical sequence in the upper chambers that then drives the lower chambers to beat quickly and irregularly and the heart loses its overall efficiency and that’s the underlying electrical problem of AFib.
Melanie: So, people have heard the words catheter ablation and we’ve talked about treatments on our shows before. But, tell us about catheter ablation. What is this treatment for atrial fibrillation?
Dr. Steinberg: Catheter ablation is used for patients who have atrial fibrillation that is bothersome, that causes symptoms, that is disruptive to their quality of life. Often they’ve had some attempt at treatment with medication that has been ineffective or poorly tolerated. Many medications do not work particularly well for atrial fibrillation. It is a very resistant arrhythmia to adequate treatment by standard medical treatment programs. Catheter ablation is a nonsurgical interventional approach that allows the atrial fibrillation to be eliminated in many, many patients. It is accomplished by placing catheters or thin wires that are advanced up through the veins in the lower part of the body and then into the heart. And once inside the heart, certain regions of the heart are either frozen or cauterized so that atrial fibrillation can no longer be triggered.
Melanie: So, you’re literally cutting off this electrical conduction that goes on that makes this irregular arrhythmia or irregular heartbeat. How does that work if it’s cauterized? Are you creating scar tissue in there? What happens?
Dr. Steinberg: Yes. So, it actually shuts off the starting mechanism, the ignition system of atrial fibrillation, which typically occurs in a specific part of the heart that’s very predictable. That part of the heart is called the “pulmonary veins” which normally are electrically inactive, have no electrical activity within the vein and instead, they’re just passive conduits delivering blood to the heart. But, when atrial fibrillation develops, those veins become electrically active independent of the heart’s electrical system so that they initiate or trigger atrial fibrillation. So, we want to squash those areas so that they stop firing. And, yes, with cautery or with freezing energy, those areas which are quite tiny in the target zone, are scarred so that the electrical signal cannot arise and pass into the heart.
Melanie: So, it’s basically like putting cones or blockage in that electrical conduction as people might think of electricity traveling down a wire. You’re just sort of stopping it in its tracks so it cannot continue on. How well does this work?
Dr. Steinberg: It works very well. Roughly, in our experience, about 80% of patients will stop having fibrillation completely and will no longer need medications to control the fibrillation. That compares very favorably to the response to medications which is only, at best, around 50% and it’s been clearly established that catheter ablation is superior to medical treatment options, so it works quite well. And beyond the 80% who fully respond, an additional 15% of patients will get much better. So, perhaps their atrial fibrillation is not completely eliminated but it is greatly reduced or becomes very easily controllable by medications that previously did not work. So, overall, about 95% of patients improve after catheter ablation.
Melanie: Might it have to be repeated?
Dr. Steinberg: Yes, on occasion, it does need to be repeated. About 15% of patients, in my own experience, will need a repeat ablation within the first year. Usually that is done when the patients have not fully responded to the procedure and the occurrence of atrial fibrillation is symptomatic enough to warrant a return to the laboratory. Most of the time, it’s predictable what the problem that you need to address in a repeat procedure is and it’s typically that an area that was previously targeted has recovered electrical function and you simply touch up that area and restore the previous result. The majority of patients who undergo this repeat or redo procedure will then fully respond and have complete suppression of atrial fibrillation.
Melanie: And, you mentioned medications, Dr. Steinberg. Does that include blood thinners to reduce that risk of stroke? Do they get to go off of blood thinners if they’ve had the ablation?
Dr. Steinberg: That’s a complicated question. So, the answer is as follows: in patients who are at low risk of stroke based on typical risk scoring system, when they undergo ablation, we typically place them on an anticoagulant or blood thinner a little bit before and a month or two after the ablation. Once the ablation has healed and the patient’s responding nicely, in these low risk patients, we discontinue the anticoagulant therapy. On the other extreme where patients have very high risk of stroke, perhaps they’ve had a prior stroke or they have multiple risk factors and are older, in those patients, we take a conservative approach and we generally recommend continued use of anticoagulants or blood thinners indefinitely as long as there are no contraindications or bleeding problems. The rationale behind continuing it is that in some patients even a long, long time after the ablation procedure, the atrial fibrillation may recur and we prefer to have the patient protected rather than not against the risk of stroke. But, it’s very important to emphasize that the data on the benefits of catheter ablation for preventing stroke after a successful procedure are very ambiguous at the present time. We don’t have the typical randomized clinical trial data that is definitive and unambiguous that we use to guide our approaches to management of medical therapy in this context. Those sets of data will be available as large scale clinical trials are being completed over the next year or two and that will guide us very much more definitively in how to manage patients’ anticoagulant regimen after the procedure. Many of us suspect that stroke risk is reduced but we would like to have definitive proof before making blanket recommendations. And, finally, there’s a middle group of patients who are at lower but not zero risk of stroke and we often take an individualized approach with these patients. We have a discussion with them about the potential risks of continuing anticoagulant therapy including bleeding versus the potential benefits of stroke prevention; maybe do more intensive monitoring and take a variety of approaches to individualize our recommendations in that context. And, that’s where the bulk of patients fall after catheter ablation.
Melanie: What is life like for them after the ablation and how would they know? Do you follow up with them on a regular basis? How would they know if their AFib came back?
Dr. Steinberg: Yes, so it’s my personal preference that patients will then have regular follow up with me indefinitely. I like to know how my patients are feeling. I like to interview them carefully to make sure they’re not having subtle symptoms of recurrent atrial fibrillation. Atrial fibrillation is the great masquerader. It can produce a variety of symptoms and not necessarily the classic rapid pounding heartbeat but symptoms that are much more difficult to identify as AFib such as just simple fatigue or weariness. So, I like to know how my patients are feeling, number one. Number two, I like to regularly monitor them, usually with an EKG monitor of some sort. We often use smartphone ECG monitors, sometimes patch monitors that a patient can wear for a number of days or weeks, and some patients even get little tiny implanted monitors. That helps confirm that the atrial fibrillation has gone away.
Melanie: And, in just the last few minutes, wrap it up for us, your best advice for people that do suffer from AFib and what they should think about when they’re considering the various treatments.
Dr. Steinberg: If a patient is having AFib and it’s causing bothersome symptoms, it’s a reasonable consideration for catheter ablation to play an important role in their treatment. It can improve the quality of life dramatically and lessen the need for a variety of medications. And, for many patients, particularly patients who are active and want to feel well as much of the time as possible, catheter ablation is an extremely reasonable option for them and we strongly consider it when it’s the patient’s preference.
Melanie: Thank you so much for being with us today, Dr. Steinberg. You’re listening to SMG Radio. And for more information, you can go to www.summitmedicalgroup.com. That’s www.summitmedicalgroup.com. This is Melanie Cole. Thanks so much for listening.
Catheter Ablation for Atrial Fibrillation
Melanie Cole (Host): Atrial fibrillation is an irregular heartbeat that can increase the risk of stroke and heart disease. My guest today is Dr. Jonathan Steinberg. He’s a cardiac electrophysiologist with Summit Medical Group. Welcome to the show, Dr. Steinberg. Just give us a little working definition for the listeners of what atrial fibrillation or AFib is.
Dr. Jonathan Steinberg (Guest): One has to understand that the heart has four chambers. The two upper chambers are called the “atria”. The two lower chambers are called the “ventricles” and they are the pumping chambers. The normal rhythm is carefully coordinated by an electrical system within the heart. So, the upper chambers start and the lower chambers finish by pumping. When atrial fibrillation develops, there is a very rapid and chaotic electrical sequence in the upper chambers that then drives the lower chambers to beat quickly and irregularly and the heart loses its overall efficiency and that’s the underlying electrical problem of AFib.
Melanie: So, people have heard the words catheter ablation and we’ve talked about treatments on our shows before. But, tell us about catheter ablation. What is this treatment for atrial fibrillation?
Dr. Steinberg: Catheter ablation is used for patients who have atrial fibrillation that is bothersome, that causes symptoms, that is disruptive to their quality of life. Often they’ve had some attempt at treatment with medication that has been ineffective or poorly tolerated. Many medications do not work particularly well for atrial fibrillation. It is a very resistant arrhythmia to adequate treatment by standard medical treatment programs. Catheter ablation is a nonsurgical interventional approach that allows the atrial fibrillation to be eliminated in many, many patients. It is accomplished by placing catheters or thin wires that are advanced up through the veins in the lower part of the body and then into the heart. And once inside the heart, certain regions of the heart are either frozen or cauterized so that atrial fibrillation can no longer be triggered.
Melanie: So, you’re literally cutting off this electrical conduction that goes on that makes this irregular arrhythmia or irregular heartbeat. How does that work if it’s cauterized? Are you creating scar tissue in there? What happens?
Dr. Steinberg: Yes. So, it actually shuts off the starting mechanism, the ignition system of atrial fibrillation, which typically occurs in a specific part of the heart that’s very predictable. That part of the heart is called the “pulmonary veins” which normally are electrically inactive, have no electrical activity within the vein and instead, they’re just passive conduits delivering blood to the heart. But, when atrial fibrillation develops, those veins become electrically active independent of the heart’s electrical system so that they initiate or trigger atrial fibrillation. So, we want to squash those areas so that they stop firing. And, yes, with cautery or with freezing energy, those areas which are quite tiny in the target zone, are scarred so that the electrical signal cannot arise and pass into the heart.
Melanie: So, it’s basically like putting cones or blockage in that electrical conduction as people might think of electricity traveling down a wire. You’re just sort of stopping it in its tracks so it cannot continue on. How well does this work?
Dr. Steinberg: It works very well. Roughly, in our experience, about 80% of patients will stop having fibrillation completely and will no longer need medications to control the fibrillation. That compares very favorably to the response to medications which is only, at best, around 50% and it’s been clearly established that catheter ablation is superior to medical treatment options, so it works quite well. And beyond the 80% who fully respond, an additional 15% of patients will get much better. So, perhaps their atrial fibrillation is not completely eliminated but it is greatly reduced or becomes very easily controllable by medications that previously did not work. So, overall, about 95% of patients improve after catheter ablation.
Melanie: Might it have to be repeated?
Dr. Steinberg: Yes, on occasion, it does need to be repeated. About 15% of patients, in my own experience, will need a repeat ablation within the first year. Usually that is done when the patients have not fully responded to the procedure and the occurrence of atrial fibrillation is symptomatic enough to warrant a return to the laboratory. Most of the time, it’s predictable what the problem that you need to address in a repeat procedure is and it’s typically that an area that was previously targeted has recovered electrical function and you simply touch up that area and restore the previous result. The majority of patients who undergo this repeat or redo procedure will then fully respond and have complete suppression of atrial fibrillation.
Melanie: And, you mentioned medications, Dr. Steinberg. Does that include blood thinners to reduce that risk of stroke? Do they get to go off of blood thinners if they’ve had the ablation?
Dr. Steinberg: That’s a complicated question. So, the answer is as follows: in patients who are at low risk of stroke based on typical risk scoring system, when they undergo ablation, we typically place them on an anticoagulant or blood thinner a little bit before and a month or two after the ablation. Once the ablation has healed and the patient’s responding nicely, in these low risk patients, we discontinue the anticoagulant therapy. On the other extreme where patients have very high risk of stroke, perhaps they’ve had a prior stroke or they have multiple risk factors and are older, in those patients, we take a conservative approach and we generally recommend continued use of anticoagulants or blood thinners indefinitely as long as there are no contraindications or bleeding problems. The rationale behind continuing it is that in some patients even a long, long time after the ablation procedure, the atrial fibrillation may recur and we prefer to have the patient protected rather than not against the risk of stroke. But, it’s very important to emphasize that the data on the benefits of catheter ablation for preventing stroke after a successful procedure are very ambiguous at the present time. We don’t have the typical randomized clinical trial data that is definitive and unambiguous that we use to guide our approaches to management of medical therapy in this context. Those sets of data will be available as large scale clinical trials are being completed over the next year or two and that will guide us very much more definitively in how to manage patients’ anticoagulant regimen after the procedure. Many of us suspect that stroke risk is reduced but we would like to have definitive proof before making blanket recommendations. And, finally, there’s a middle group of patients who are at lower but not zero risk of stroke and we often take an individualized approach with these patients. We have a discussion with them about the potential risks of continuing anticoagulant therapy including bleeding versus the potential benefits of stroke prevention; maybe do more intensive monitoring and take a variety of approaches to individualize our recommendations in that context. And, that’s where the bulk of patients fall after catheter ablation.
Melanie: What is life like for them after the ablation and how would they know? Do you follow up with them on a regular basis? How would they know if their AFib came back?
Dr. Steinberg: Yes, so it’s my personal preference that patients will then have regular follow up with me indefinitely. I like to know how my patients are feeling. I like to interview them carefully to make sure they’re not having subtle symptoms of recurrent atrial fibrillation. Atrial fibrillation is the great masquerader. It can produce a variety of symptoms and not necessarily the classic rapid pounding heartbeat but symptoms that are much more difficult to identify as AFib such as just simple fatigue or weariness. So, I like to know how my patients are feeling, number one. Number two, I like to regularly monitor them, usually with an EKG monitor of some sort. We often use smartphone ECG monitors, sometimes patch monitors that a patient can wear for a number of days or weeks, and some patients even get little tiny implanted monitors. That helps confirm that the atrial fibrillation has gone away.
Melanie: And, in just the last few minutes, wrap it up for us, your best advice for people that do suffer from AFib and what they should think about when they’re considering the various treatments.
Dr. Steinberg: If a patient is having AFib and it’s causing bothersome symptoms, it’s a reasonable consideration for catheter ablation to play an important role in their treatment. It can improve the quality of life dramatically and lessen the need for a variety of medications. And, for many patients, particularly patients who are active and want to feel well as much of the time as possible, catheter ablation is an extremely reasonable option for them and we strongly consider it when it’s the patient’s preference.
Melanie: Thank you so much for being with us today, Dr. Steinberg. You’re listening to SMG Radio. And for more information, you can go to www.summitmedicalgroup.com. That’s www.summitmedicalgroup.com. This is Melanie Cole. Thanks so much for listening.