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Heart Disease (Expert Forum)
Consequences of substrate scarring following rf ablation
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Consequences of substrate scarring following rf ablation
by va_tony, Nov 15, 2004 12:00AM
Thanks for taking my question, doctor.
I'm a 62 year old male with atrial fibrillation that has been reasonably well controlled with Rythmol (225 mg/3X daily)for the last two years (still experience self-converting episodes every month or so). I had previously suffered from chronic/continuous afib prior to treatment. I'm considering having an rf ablation but am concerned about the unavoidable scarring that takes place during rf ablation as a by-product. In my case, with an enlarged left atrium (5.2 cm dia.), rf ablation would likely involve PVI as well as extensive substrate modification. I've read, for example, that scarring as a result of the PVI will sometimes lead to pulmonary stenosis.
1. Have there been reports of negative consequences due to the extensive scarring that takes place following substrate modification?
2. Would you expect any long term negative consequences from such scars?
3. Does rf ablative scarring have a different character than say that resulting from a myocardial infarct?
4. I've read that surgical scars on the ventricles will sometimes act as rentrant circuits, causing PVCs and VT. Would atrial substrate scarring be less likely to cause further arrhythmia than rf ablative scarring on the ventricles?
5. What of the more usual focal point ablation without substrate modification? Could that scar ultimately form a troublesome reentrant circuit?
6. Would scarring using other procedures, for example crygenic ablative therapy, lead to less scarring?
Thanks again to CCF for providing this wonderful service!
I'm a 62 year old male with atrial fibrillation that has been reasonably well controlled with Rythmol (225 mg/3X daily)for the last two years (still experience self-converting episodes every month or so). I had previously suffered from chronic/continuous afib prior to treatment. I'm considering having an rf ablation but am concerned about the unavoidable scarring that takes place during rf ablation as a by-product. In my case, with an enlarged left atrium (5.2 cm dia.), rf ablation would likely involve PVI as well as extensive substrate modification. I've read, for example, that scarring as a result of the PVI will sometimes lead to pulmonary stenosis.
1. Have there been reports of negative consequences due to the extensive scarring that takes place following substrate modification?
2. Would you expect any long term negative consequences from such scars?
3. Does rf ablative scarring have a different character than say that resulting from a myocardial infarct?
4. I've read that surgical scars on the ventricles will sometimes act as rentrant circuits, causing PVCs and VT. Would atrial substrate scarring be less likely to cause further arrhythmia than rf ablative scarring on the ventricles?
5. What of the more usual focal point ablation without substrate modification? Could that scar ultimately form a troublesome reentrant circuit?
6. Would scarring using other procedures, for example crygenic ablative therapy, lead to less scarring?
Thanks again to CCF for providing this wonderful service!
Doctor's Answer
by CCF-M.D.-MJM, Nov 15, 2004 12:00AM
Hi Tony,
radiofrequency ablation as used for pulmonary vein isolation to treat atrial fibrillation is a successful procedure. The first procedures result in 70-80% cure of atrial fibrillation and a second procedure for failed first procedures hit 90% success.
1. Have there been reports of negative consequences due to the extensive scarring that takes place following substrate modification?
The scarring is localized to around the pulmonary veins. The most common significant complication is pulmonary vein stenosis, albeit we have not seen many significant cases of the that here. There have been about 20 cases reported of left atrial esophogeal fistulas. This is a dangerous complication, but fortunately is very rare.
2. Would you expect any long term negative consequences from such scars?
I don't expect it. It is a relatively new procedure and only time will tell what complications will surface.
3. Does rf ablative scarring have a different character than say that resulting from a myocardial infarct?
In the sense that a scar is dead myocardial tissue, yes it is the same. But this is a localized scar of the atrium and not thought ot be of clinical significance.
4. I've read that surgical scars on the ventricles will sometimes act as rentrant circuits, causing PVCs and VT. Would atrial substrate scarring be less likely to cause further arrhythmia than rf ablative scarring on the ventricles?
We have not seen complications of reentry from PVIs.
5. What of the more usual focal point ablation without substrate modification? Could that scar ultimately form a troublesome reentrant circuit?
same as answer as 4. We have not seen this.
6. Would scarring using other procedures, for example crygenic ablative therapy, lead to less scarring?
Not sure about this one, but I am not sure that this is a clinically relevant point. The scar created are small and localized and do not appear to have the same clinical impact as scars from heart attacks.
I hope this helps and good luck with the PVI if you choose to go forward.
radiofrequency ablation as used for pulmonary vein isolation to treat atrial fibrillation is a successful procedure. The first procedures result in 70-80% cure of atrial fibrillation and a second procedure for failed first procedures hit 90% success.
1. Have there been reports of negative consequences due to the extensive scarring that takes place following substrate modification?
The scarring is localized to around the pulmonary veins. The most common significant complication is pulmonary vein stenosis, albeit we have not seen many significant cases of the that here. There have been about 20 cases reported of left atrial esophogeal fistulas. This is a dangerous complication, but fortunately is very rare.
2. Would you expect any long term negative consequences from such scars?
I don't expect it. It is a relatively new procedure and only time will tell what complications will surface.
3. Does rf ablative scarring have a different character than say that resulting from a myocardial infarct?
In the sense that a scar is dead myocardial tissue, yes it is the same. But this is a localized scar of the atrium and not thought ot be of clinical significance.
4. I've read that surgical scars on the ventricles will sometimes act as rentrant circuits, causing PVCs and VT. Would atrial substrate scarring be less likely to cause further arrhythmia than rf ablative scarring on the ventricles?
We have not seen complications of reentry from PVIs.
5. What of the more usual focal point ablation without substrate modification? Could that scar ultimately form a troublesome reentrant circuit?
same as answer as 4. We have not seen this.
6. Would scarring using other procedures, for example crygenic ablative therapy, lead to less scarring?
Not sure about this one, but I am not sure that this is a clinically relevant point. The scar created are small and localized and do not appear to have the same clinical impact as scars from heart attacks.
I hope this helps and good luck with the PVI if you choose to go forward.
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I probably wasn't as clear as I should have been when I asked the first part of my question. By "substrate modification", I was referring to a relatively new procedure by that name which seeks to electrically isolate various portions of the atria from each other and thus prevent multiple reentrant wavelets from establishing a fibrillation. This would be desirable in the case of patients with enlarged atria, like myself. As I understand it, the procedure would be similar to a Maze procedure, except involving rf ablation, and would be performed in addition to the PVI. Obviously, such a procedure would involve a greater amount of scarring than usual.
However, you answered all my other "scarring" questions which were of a more general nature and I am reassured that ablative scarring is not clinically significant and associated complications are generally rare. This helps to put my mind at ease about having an ablation in the future.
Thanks for taking time out of your busy schedule to reassure and educate folks like me. I really appreciate it.
Regards,
Tony
You're right, of course. I'm fairly satisfied with the current ability of my meds to control my afib. So, I'm not in any hurry to have an ablation, considering the complications of the enlarged atria. However, from everything I've read, the antiarrhythmic meds lose their effectiveness with time. So at some point in the future, I'll probably be faced with a decision between opting for an ablation or accepting permanent afib with rate control management (I'm already on coumadin in any event). Hopefully, at that time, Centers like CCF and Johns Hopkins, closest to me, will have made procedural improvements in curing afib via ablation and that will present me with a tempting option. In the meantime, I'm just trying to get as much info as I can.
Best wishes,
Tony
Erik
I'm not quite ready to go for it yet. I'm the kind of guy that drives car salesmen nuts, trying to get the best deal possible. The quoted odds for a successful ablation on a first try are like 70-80% (actually less for someone with enlarged atria like me) and a major complication rate of 1-3%. I'm holding out for technical improvements leading to success rates approaching 95%. The field is so new, I expect that EPs will achieve better numbers with time. Given that my afib is fairly well controlled by Rythmol at present and with no side-effects, I'm willing to wait.
But if my situation changes (e.g., meds start to lose effectiveness), I'll quickly make a decision.
Best wishes,
Tony
Talk to you again!
Erik
That's useful info. It's a royal pain taking Rythmol three times a day at 8 hour intervals. I usually take mine on or about 6 am, 2 pm and 10 pm. It's so easy to forget the afternoon dose. But with twice a day, one can take a pill at breakfast and dinner time. Very convenient. I'll have to ask my cardio to write a prescription for Rythmol SR325. Cost shouldn't be a problem. I'm already paying the maximum co-pay my insurance requires for the regular Rythmol ($80/3 month supply), so the cost to me should stay the same.
Best wishes,
Tony
I've been lucky I guess. I have almost no side-effects from either Rythmol, coumadin, altace and cardizem. The cardizem (calcium channel blocker) did seem to make my ankles swell at times, so my doc prescribed HCTZ, a diuretic, and I don't have that problem anymore.
I've been on anti-couagulation therapy for about two years. No real problems with that. I pretty much eat what I want (the so-call seafood diet - "see food, eat it") and don't see large fluctuations in my PT/INR. I do eat the same foods from week to week, though, and the "dose adjusted" nature of coumadin, allows for stabilization. It is a royal pain to have to be PT/INR tested every month. But I don't see any excessive bleeding because of the coumadin. I've had a number of hand cuts, etc. and saw no problem. During the summer I was ocean kyaking about the time there were hurricanes far to the south and the waves were pretty rough. Coming into shore I totally wiped out one time, the boat bouncing off me a couple of times and getting all scraped up rubbing along the bottom. But I didn't see any excess bleeding or bruising.
My symptoms with afib vary from not noticeable(except by taking my pulse) to experiencing severe palps. I believe I've had afib on and off for 30 years or so. In my early 30's, I used to run 5 miles a day and work out in martial arts in the evenings. I started getting severe runs of palps then, went to a cardiologist, but only saw occasional PACs on Holter monitor (the Holter missed the afib events, I believe). The cardiologist convinced me that these extra beats were harmless, so I tended to down play what I felt. I would get palps a few times a year and then it would disappear for several years and then repeat the cycle. I would complain to doctors about it, but they never caught it on the ekg. Finally about 2 1/2 years ago during a routine medical exam I complained again about it. The ekg showed that I was in continuous afib and, apparently, had been for several months. During that time I was in very good shape, working out at a gym nearly every day, jogging and participating in cardio-kickboxing. But I did notice that there were times that I felt that I was about to faint when I pushed too hard. Now that I take Rythmol, I only have an event once every month or two, generally triggered by exercise. This has really affected my ability to exercise because I'm afraid of triggering an episode. I still work out at a gym 3 times a week, lifting weights and slow jogging 2 miles (10 min/mile pace) on a treadmill. If I maintain a set routine, I seem to be OK. If I feel real good on a given day and accidently push too hard, I have an event that evening.
To answer your question, absense of symptoms doesn't insure that you don't have afib. In fact my cardio tells me that it's common to have short lived events especially when sleeping.
Frankly, if I were you, with a prior TIA and afib, I would take coumadin. If you already had one TIA, why risk another (or worse)? Sure taking coumadin is a pain but think of the alternative.
Good luck on your decision,
Tony
My understanding is that the clots like to form in a small outcropping that lies on the left atrium (called the left atrial appendage). When in fibrillation, an eddy forms that traps particles and a clot can form around them - - much like an eddy in a running stream can trap a leaf, etc. When normal sinus rhythm is restored, this mini-clot (assuming one is there) is washed away. As to how long it takes to form such a clot varies from person to person. Generally, the rule of thumb is 2-3 days. However, it can form very quickly (I think) in some people. Your previous TIA indicates, I think, that you are susceptible to clot formation.
Besides the CHADS data, which I think is pretty convincing, the following site (http://www.affacts.org/Questions/af_and_strokes.html) states:
"Not all patients with atrial fibrillation are equally at risk of blood clot formation in the atrium. It has been shown that a previous history of a stroke or a transient stroke (called a transient ischemic attack), high blood pressure, diabetes, congestive heart failure, or certain other structural heart diseases increases the risk of stroke markedly."
You'll notice they specifically mention TIAs.
By the way, the probability of having a stroke (assuming the yearly probability is 2.8%) over 28 years is 55%. See my reply to your probability calculation in the coumadin thread.
Best wishes,
Tony
I also suffered from atrial flutter and numerous PAC's. They were able to ablate those areas as well, and the PAC's have diminished immensely, and to my knowledge I have not had any flutter.
I didn't run for about 3 months after my ablation, and now I'm back to continuous running for 24 minutes and then intermittant running/walking for the next 16 minutes. Goal is continuous running at an easy pace for 40 minutes at least 3 times a week.
I am still on 50 mg of atenolol as a precaution and since I feel fine on atenolol they figure why mess with success.
One thing that did occur after my ablation is that my resting heart rate went up about an average of 10 beats per minute. It has continued higher than in the past. Not quite sure why this occured, although they say it is common.
Tony
I saw this thread and the comments made by va_tony concerning his detection of Afib by measuring pulse rate and using a Polar HRM. His experience matches mine when I have had an Afib event except that I also feel the variable beats as a "rumbling" sensation in my chest.
The variation that he reports that he observes with his HRM also matches what I see during an event. Although the number of values he reported are limited, the variation (+/- 20 bpm) are very similar to what I detect with my Polar HRM during Afib. I have a Polar Accurex Plus with which I store and download rates to my computer so I have hundreds of data points from which my averages are calculated depending upon the length of the event.
It also sounds like we are all similar in age and have suffered with Afib about the same length of time. I am not symptomatic to the extent that I need medicines. (Played two hours of hard tennis this evening.)
Good luck.
I recall you telling me about your ablation six months ago. You were happy back then with the results and apparently still are. That's great. I love hearing success stories!
Thanks for the info about ablating a large circle away from the pulmonary vein opening rather than the usual PVI. That's very interesting and makes a lot of sense. Evidently, they know what they are doing at the Mayo.
It is strange about your increased heart rate. Have you taken into account that you are now probably taking less meds? I'm sure it's not an important issue.
It's also great that you are able to get back to running. Keep it up.
Stay well,
Tony