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Need details on PVI ablation
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Need details on PVI ablation

My ep said if he did an ablation it would be a pulmonary vein isolation and I read that this is the one where they go thru the wall between the atria to get to the left side of the heart.  Could someone enlighten me as to the difference in this and other types of ablation?  Is is longer, more risky, odds for success more or less, etc.  If you've undergone this procedure, or know about it, I would be grateful for any info you can pass on to me.  I've tended to lump "ablation into one category and did not realize there were different types until just recently when I have been more seriously considering the procedure.  Thanks.  
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1124887_tn?1313758491
I also find this confusing, I thought they went through the femoral artery, aorta, and through left ventricle to left atrium. Turns out they are going through right atrium, but if so they must go through the veins and pierce through the atrial septum. (not really sure about this, though).

Isolation of the pulmonary veins is the "easy" fix for atrial fibrillation. Success rate is from what I understand 70-80%, and depending on how much restructuration has happened in the left atrium. By ablating the pulmonary veins, you are not "fixing" the structural abnormalities that allow atrial fibrillation to maintain - however, you prevent the PACs that usually trigger atrial fibrillation to ever reach the left atrium.

If the left atrium is severely dilated, from what I understand PACs that origin from the left atrium itself is able to cause an arrhythmia (just like people with severe heart failure can get ventricular fibrillation from PVCs - which "normal" hearts never do).

Your doctor should know if an ablation will fix your atrial fibrillation or not, but his evaluation can be made from this criterium.

I don't think the procedure of piercing the atrial septum will cause so much extra risk - unless blood clots have formed, etc. Again, your doctor should know if this is a risk for you and give you the proper advice.

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612551_tn?1247839157
Yes, that is my understanding, in on the right a pierce through to get to the left side of the heart, the left atrium.  Yes too, I believe this increases the risk of complications and yes, the odds on success depend on how "bad" one is.

In my case I have an enlarged left atrium (now stable after mitral valve surgery, but no shrinking back either), even years ago when I was being considered for an ablation by a consulting EP I had long periods of permanent AFib, and given my electrocardioversion during the EP consultation lasted for only 1 week when supported by high dose Rhytmol both the EP and Cardiologist said the risk was too high given a rather low probability of success and the fact I had a "reasonable" quality of life living with "rate control" AFib.

If they had been willing to try I would have taken the risks. Even then I was in my late 60s but I wanted to get back to running (jogging for health and weight control) and serious street bike riding.  These are losses in my QofL that I am just living with.

Good luck, and don't worry too much about the "extra" risk of AFib ablation, it is done every day and I believe the chances of long term relief from AFib is possible or it wouldn't be done.

Good luck,
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Avatar_m_tn
I am wishing you good luck with your procedure!

The study mentioned bellow would give you a clear idea of current success rates for PVI procedures and possible complications that can happen during the ablation.

Here's a summery of a recent trial (RAAFT-2, 2012) comparing the effectiveness of anti-arrhythmic drugs (AAD) to ablation in terms of success and complication rates. This study was conducted at several major centers in Europe, Canada and USA.

The study randomized 127 patients not previously treated with AADs  (87.5% with a history of paroxysmal AF and the rest with persistent AF), either to undergo ablation or to initiate a drug regiment. The patients had normal systolic function, and none had hypertension or heart failure. All were followed with trans-telephonic monitoring.

After a two year follow-up, 45% of patients in Ablation group remained in sinus rhythm. Meanwhile, only 28% in the AAD group were free of any atrial tachyarrhythmias.

In the ablation group, 7.7% of patients had an event in the safety cluster, which included death, tamponade, severe pulmonary vein stenosis, thromboembolism, vascular complications, phrenic nerve injury, or compete AV block within 30 days; tamponade accounted for nearly all of it.
==================================================

I think that it is reasonable to expect a 40-50% chance of being free from atrial arrhythmias two years following the procedure. Of course, ablation does not cure atrial fibrillation and the yearly recurrence rates are around 5-7% after an initially successful procedure.


Reference:
Morillo C, Verma A, Kuck KH, et al. Radiofrequency Ablation vs Antiarrhythmic Drugs as First-Line Treatment of Symptomatic Atrial Fibrillation: (RAAFT 2): A randomized trial. Heart Rhythm Society 2012 Scientific Sessions; May 11, 2012; Boston, MA.






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1569985_tn?1328251082
Thank you all for your comments.  I am going to be evaluated at the Cleveland Clinic and see what they recommend.  I saw some statistics on a site called Afibbers.com that suggest that Cleveland Clinic success rates are exceptional.  I will post when I know more.

Jerry, I am now on 50 mg. of Atenolol, taking 12.5 every 6  hours.  I have been having some dizziness and wonder if you could go over the half-life figures you came up with when you were experimenting with doses.  I'm thinking if it is not out of my system, from the previous dose, at the end of the 6 hours, then the level in my system may be higher for an hour or two when the two doses overlap.  Any advice will be appreciated.  Some of the time I feel okay, but got very tired and dizzy at the garden center -- 82 degree weather may have been a factor -- with just a few minutes of walking around.   I have been on this regimen and off the Norpace or Rhythmol for about 2 weeks, so they should be out of my system.  I'd appreciate any light you can shed on this re dosing.  Thanks.

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612551_tn?1247839157
First, I found the input from RVVq very interesting and will try to remember to save a copy on my "work" computer reference memos.  It seems to be additional to what is-something-wrong and I already gave you.  I can't confirm the numbers personally but they look reasonable with other information my failing memory still remembers.

Remember Atenolol is a beta blocker, not an anti-arrhythmic drug, so the most you can expect from it are: lower blood pressure (that in my experience eases over time- months) and lower heart rate.  It is commonly used for what is called "rate control" treatment of AFib, that is what I am practicing.  

I believe the half life "depends", but will recall that Atenolol (regular release) has a fairly long half life, perhaps as much as 10 hours (which is about what I think it is in my case).  As I have posted I requested a switch from Metoprolol Tartarate 25 mg every 12 hour to Atenolol.  My cardiologist wrote the prescription and left the does the same.  My initial reaction was a too low HR and some increased dizziness (I always have to be careful when I rise from a resting position)  - here I mean a resting HR in the upper 50s,  remember I have permanent AFib so a resting HR in the 70s is more typical and "good" rate control.  

So I, without consultation, decided to go all the way down to 1/2 the total dose level, that is 12.5 mg twice a day.  This seemed to work about as well as the 25 mg of Metoprolol... but I decided to go back to the 25 mg when I had a sleep study coming up.  Following the sleep study I moved down to 12.5 mg at 9 AM and 25 mg at 9 PM (then to bed by midnight).  I also cut my calcium channel blocker in half for the 9 AM, and full at the 9 PM.  I typically see HR in the 60s at night, but rarely anything in the upper 50s.  I check my HR and oxygen levels when I wake up in the middle of the sleep period (call that 3 am).  

In my case I think the 1/2 life of Atenolol is long enough to significantly boost my medication level for a period of time into the start time of the next dose.  If I forget about anything over two half lifes (1/4 or less concentration) I believe at 25 mg 12 hours apart my body may "see" about 10 mg carry over, so if I take 25 mg my new start point is 35 mg... this continues on - I haven't tried to account for carry over from other previous doses, but there is some and I think I may have accounted for them by assuming a 10 mg carry over of 25 mg at the 12 hours point.  Thus, with the 12.5 mg in the morning, and the about 10 mg carryover half life I start my morning at 22.5 mg, and I achieve good rate control and less dizziness.

Hot weather can cause some physical reactions, especially when just coming out of could weather and the body has not yet adjusted to the hot conditions (if it ever does... I don't know if there is any truth in the blood is thicker in cold weather, but the transition to hot weather suggest something like that is going on).
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1569985_tn?1328251082
Jerry -- Thank you for repeating the info -- So it sounds like by taking it every 6 hours I may be creating an overlap. I can't take 25 mg. at one time because my bp would plummet.  Hot weather in my experience does cause my bp to drop and that may account for that one day's dizziness.  My pulse oximeter showed a hr in the 30's which rapidly came up, but that may have been the heat too?  I am solely on 50 mg. Atenolol now, suggested by the nurse 25 mg.  a.m. & p.m. My pcp said the way I am taking it is fine.  My bp tends to drop easily and bp in the 50's is more usual for me.  I sometimes delay the dose if it's in the low 50's, tho the ep says he's less concerned about numbers than how I actually feel and hr in the 40's is not terribly concerning if I feel well. One day I tried 12.5 every 8 hours, but began to get more irregular beats.  I was kept in nsr for 7 years on just a beta blocker, but then it began to be not enough, according to the ER doc when I went in with an episode.  I may have some episodes of svt, as my heart would race without being irregular.  I am going to go back to Atenolol with a larger dose and see if it works.  If it doesn't, my next step would be an ablation if they think I am a good candidate -- hence the Cleveland Clinic evaluation.  One hometown doc says 50-50 1st time, 70% 2nd try.  Other doc says 65% and recommends the mini-maze, which I am not inclined to do if an ablation has a good chance.  I know age and the fact that I now have to be cardioverted is not in my favor.

I appreciate everyone's input and will let you know what transpires.  Thanks again to all of you.
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Avatar_m_tn
If you really want to maximize your chance of a successful ablation, I suggest you look into getting a FIRM ablation instead of a conventional PVI.

Here's a summary of a recent paper by Dr. Narayan about the FIRM technique.

CONFIRM (Conventional Ablation for Atrial Fibrillation
With or Without Focal Impulse and Rotor Modulation) Trial (2012)

107 patients with Paroxysmal and Persistent Afib were divided into two treatment groups. Group I (71 patients) was to undergo a standard PVI. Group II (36 patients) would undergo PVI+FIRM.

Patient Characteristics:

                   Group I - PVI      Group  2 - FIRM+PVI

Paroxysmal                34%          19%      
Persistent                   66%          81%
Age                             61             63
LA diameter, mm        43             48
LVEF                           55             53
Hypertention               70%          86%
Diabetes mellitus        31%          33%
Prior Stroke/TIA          17%          17%
Coronary disease        28%         50%
Hypercholesterolemia 68%          86%

During a median 273 days (interquartile range: 132
to 681 days) after a single procedure, 82.4% of patients in FIRM group were free of AF. In the conventional PVI group only 44.9% were free of AF.

Complications:

8% of patients from the PVI group experienced the following complications:
Cardiac tamponade: 2
Groin bleeding requiring transfusion: 3
Pulmonary vein stenosis requiring a stent: 1

6% of patients from the FIRM+PVI group experienced the following complications:
Cardiac tamponade: 1
Groin bleeding requiring transfusion: 1
===========================================

As we can see ablating the triggers of atrial fibrillation (rotors and focal beats) in addition to isolating the pulmonary veins almost doubles the success rate of the procedure.
It is not a cure, but would probably offer patients more Afib-free years and decrease their chances of needing more ablations in the future.

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1569985_tn?1328251082
RVVq -- impressive statistics.  Thanks for the info.  I've read about this procedure and that it was being done by a doctor in San Diego, California.  I believe his excellent results were replicated in other centers that used his technique.  Not sure what my LA Diameter is, but will check my records and if LVEF is ejection fraction, mine is in the 60's. It seems to me I read that the procedure allowed a very quick end to afib due to his technique.  Is Dr. Narayan the inventor of this technique?  Do you know where this procedure is available and how long it has been done?  I haven't heard anything about it lately.  Thank you so much for this valuable information.  I will look into it further.  
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1569985_tn?1328251082
I googled, emailed  and got a reply from Dr. Narayan and found there are at least 2 centers fairly close to me -- in Indiana and Ohio.  I will post details when I receive them for others who are interested in this procedure.  Thanks again for your help.
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612551_tn?1247839157
I have read over the past year or two some long threads on the 5-box procedure, which may be what is being discussed.  I have read only good reports.

However, I wonder if it offers anything over a mini-maze, which I have undergone.  If it does, why my Cardiologist hasn't even mentioned the procedure - he quickly give me a referral when I need open heart surgery. That surgeon is a advocate of robotic surgery, but did an open heart to repair my mitral valve.

I believe my left ventricle is in the neighborhood of 5 cm diameter, I believe/recall 4 cm being the upper range (for all or just me, don't know).

All this noted, my heart surgeon gave the maze procedure about a 60% change of success, and a the valve repair may cause my enlarged left ventricle to shrink back some.  Neither worked out in my favor, the NSR lasted about 30 days and the left ventricle remains the same size, now 5 years later.  Hey, I'm still alive and reasonably physically active, for a guy my age, that is.

Good luck, it may be helpful if you can clarify or dispute my assumption on the 5-box issue.
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1569985_tn?1328251082
There is information on the Ohio State University website about Dr. Sirak's 5 box procedure, describing it and case histories telling how well it worked.  I was under the impression it was the same as a mini-maze, but I am not sure of this.  The one case history I read said the patient was up and about and out of the hospital in 2 days, and able to exercise within a week.  I am sure it depends on one's individual problems, but it sounds good.  I went back into afib this afternoon, and am awaiting a call from the cardio nurse re cardioversion, sigh.  VERY discouraged . . .  There was nothing about FIRM on the site, but that is where the California doc referred me.  I am awaiting a call from their nurse to send records, etc.  - perhaps not a moment too soon:)
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1569985_tn?1328251082
What do you take in addition to the beta blocker to keep your heart rate down?  I am going nuts here.  Hopefully the doctor will come up with something.  I cannot go on with as 150-180 resting heart rate.  Any ideas would be appreciated.
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Avatar_m_tn
FIRM was invented by Narayan's team, but right now there several labs in US that do it. Soon they will publish a large multi-center trial of FIRM+PVI vs PVI outcomes for Afib ablation.

Recently, Narayan presented the results of PRECISE trial, which purpose was to evaluate the efficacy of FIRM only ablation, no PVI in paroxysmal AFIB patients. The results were that over 80% of patients were free from AF (with very intense monitoring - 65% with implantable loop monitors).

My advice to you would be get in contact with the closest center to you to get FIRM ablation as soon as possible.

Good luck!
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1569985_tn?1328251082
I have been cardioverted and am back on Norpace, and holding in nsr so far.  It has been one week since I had an email saying OSU's clinical nurse would contact me for the next step.  I will call them tomorrow.  Dr. Sirak (who does the 5 box maze) is also at OSU.  I'm kind of amazed I got a reply right away from Dr. Narayan.  The results you just quoted are pretty amazing.   Thank you for your information.  Without your input, I might have missed this opportunity.  I knew about FIRM, but didn't know where else it was being done or that the results were so good.  I'm impressed. Thanks again -- I'l post what I find out.
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612551_tn?1247839157
Sorry for my delay, it seem your research has moved past the point of your question to me.  But answer is I take:
Atenolol 12.5 mg AM, 25 mg PM (25 mg is prescribed for both periods)
Diltiazen  60 mg AM, 120 mg PM (120 mg prescribed for both periods)

As you know the first is a BB, the second is a CCB. These do not provide "rhythm control" for me, they do provide "rate control".

When I discuss with my cardiologist, I do not plan to discuss before my next 6 month check, I will confess that I have reduced the AM dose and that I carefully monitored my HR and got very good results.  My data/experience strongly suggests Atenolol is more effective for me than is Metoprolol.
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