top of page

Atrial Fibrillation (AF) Explained

Dr Finlay's approach to AF
My 3-Stage approach to treating Atrial Fibrillation

Most patients who come to see me want to get their heart rhythm back to normal, and with it the quality of life they used to enjoy. Catheter Ablation can be a great help for many, and I'm delighted to discuss whether this will be right for you in the clinic, as well going over all the modern approaches to AF. The principles of AF management focus on the key factors for the patient - preventing complications and long-term problems and treating important symptoms. No one approach is right for everyone, I take a personalised view that we should decide together on the best treatment strategy for you. Our first priority is to prevent strokes that may arise if the individual is higher risk, and this is done by anticoagulation. Aspirin does not in fact have benefits above the side-effect risks in preventing strokes in AF and can be avoided unless there is another reason to be taking this. We use the "CHADSVASC" score as a method of working out the rough risk of stroke, and I tend to use one of the non-vitamin K antagonist anticoagulants (NOACs) as these are really now the standard of care. Our second priority is controlling the rate that the heart is in during AF. This is often best done with a betablocker or calcium channel blocker. Digoxin can also be useful, particularly in combination with either one of the other medications. This not only helps with symptoms but helps reduce the risk of developing heart failure as a result of AF. Thirdly, control of the heart rhythm to prevent AF from happening can be provided either by drugs or by catheter ablation. There is increasing evidence that maintenance of sinus rhythm, which is best done by ablation, has benefits for both quality of life and in reducing heart failure. However, in many people, medication can be effective. In my own practice, I have been definitely moving ablation up the list and am keen to ablate early if possible (i.e. offer definitive treatment quickly), but this isn't suitable for everyone. Amiodarone and other antiarrhythmic medications are often prescribed to help regulate the heart's rhythm. While they can be very effective, they come with potential risks like all medicines. Some people taking amiodarone might experience side effects like fatigue, lung or liver problems, skin changes (such as turning bluish or sensitivity to sunlight), thyroid imbalances, and eye issues (cataracts are very common). These side effects really mean that I hate using it for patients in the long term, however, it can be very useful in the short term, especially in the time around the ablation. It's also important to remember that not every antiarrhythmic drug works the same way, and some may have different side effects. For example, other antiarrhythmics can sometimes even cause new or worsened irregular heart rhythms. However, for short- to medium-term use, many people get on well with a combination of, for example, diltiazem and flecainide. The downsides of antiarrhythmic medication really stimulated the development and refinement of ablation treatments. and ablation is a great treatment for many. However, pacemakers sometime have their uses, and this can be the right solution for many people, either in combination with ablation or on it's own.

How I approach AF ablation

AF ablation is a common procedure which is the most reliable way of returning the heart to normal rhythm for AF. I almost always perform this as a daycase (outpatient) procedure or staying just one night in hospital. The procedure is generally done under local anaesthetic with some sedation so the patient isn’t in any discomfort, but in certain situations we may elect to use a general anaesthetic. Tubes are passed from the vein in at the top of the leg to the heart, a long thin needle is used to get from the right side of the heart to the left atrium through the very thin membrane separating the two atria (top chambers of the heart). X-rays and / or a specialized 3D navigation system is used to guide the procedure. Most of the time, the procedure only under one (if freezing is used) or two hours in total, though of course it can take a little longer if there are complexities during the case itself.

Depositphotos_99146864_original (1).jpg
What are the risks of an AF ablation?

An AF ablation procedure is of course not without some risk. There is a small risk of bleeding at the top of the leg and even damage to the veins in the leg. Bleeding around the heart (tamponade) can occur in around 1% of cases which usually requires drainage and a few more days in hospital. Very serious complications such as stroke or damage to the swallowing tube (oesophagus) are now very rare indeed thankfully. Although it is extremely rare, some complications have led to patients dying, and be aware that this has been reported in around 1 in 2000 cases. For comparison, patients having an elective hip or knee replacement have a 1 in 300 risk of dying of complications i.e. much higher than with AF ablation.

How successful is an AF ablation likely to be?

The vast majority of patients now are free of symptoms after a single procedure when AF is paroxysmal, but if AF is persistent (there all the time) then a second procedure is needed in about half of cases. With modern technologies, we are able to successfully perform a "pulmonary vein isolation" in over 90% of cases. But this indicates the proportion of patients in whom the procedure has been a technical success, not the proportion where AF never comes back. Overall success rates from the patient's perspective after these treatments for paroxysmal AF are now over 80%, and in persistent AF over 70%, but in patients who have been in persistent AF for many years such success may not be achievable due to long term scarring effects, and of course, some of these patients still require antiarrhythmics to maintain sinus rhythm.

What if AF comes back after an ablation?

It is common for people who have had an AF ablation to have at least one episode of AF again in the future. Up to 50% of people who had an ablation for persistent AF (AF all the time) will have another episode of AF that requires treatment, a third or so of people in paroxysmal AF (AF which comes and goes) will have one. Usually, this is because of the healing of the ablation, and the second procedure can be considered a “touch-up job”, where specific areas that are key triggers or have healed can be targeted.

What are alternatives to ablation?

Many patients with AF have very mild symptoms and do not require further treatment as long as their heart pumping function is unaffected and their risk of stroke is small. Medicines are a suitable alternative for many patients, but recent evidence suggests that the risks of serious side effects with medicine is comparable to the procedure risks of an ablation treatment. Some medicines such as Amiodarone can be very helpful in the short term but in the longer term side effects can be serious and even life-threatening on occasion. If heart rate control remains difficult for patients in whom AF ablation is not a success or is not possible, then pacemakers can be still be used with AV node ablation (an ablation targeting the normal conduction system between the top and bottom chambers of their heart), but this has downsides of course and would leave the patient's life dependent on their pacemaker for a heart beat. Nevertheless, it can be useful for some patients.

Will giving up alcohol, smoking or losing weight help my AF?

In short, yes. Excess alcohol consumption is clearly associated with AF, and AF ablation is likely to fail unless this is moderated. However, most people with AF can still be able to safely drink alcohol within healthy limits. Similarly, people who are obese are far more likely to have AF and losing weight really does help AF. In some people, this is enough to stop AF from being a problem for them, but in most it can improve the success of other treatments rather than being the most important thing.

Do I need to stay on a blood thinner after my AF ablation?

Do I need to stay on a blood thinner after my AF ablation? If you are on a blood thinner (warfarin or a NOAC) before the ablation, my routine advice is to continue this after the ablation. This is because although a recurrence of AF may only last a few minutes and not be of any importance for your lifestyle, even a short episode could put you at risk of stroke. Another reason to continue with the blood thinner is that the risk of a stroke in patients with AF isn’t only due to the AF. The disease in the heart and vessels that causes the scarring which triggers AF is only partially treated by ablation, and so far we don’t have proof that the risk of stroke returns to normal.

bottom of page