Catheter Ablation

What is Catheter Ablation?

Catheter ablation is an effective treatment to correct or control arrhythmias originating from the heart chambers. The basic strategy of ablation is to destroy the areas that cause palpitations in the most effective and safest place. During this procedure, the areas causing the abnormal rhythm are found by electrophysiologic study (EP studies), then heat or cold is applied to damage the target area to treat the arrhythmia.

In this video I have tried to give basic information about ablation.

How is catheter ablation performed?

Catheter ablation is also known as burning or freezing therapy. Thermal energy (Radiofrequency or Cryo) or electrical energy (pulsed field ablation) is used as the energy source.

What is Radiofrequency Ablation?

Radiofrequency ablation is an ablation procedure performed by applying heat energy to the damaged area with the help of catheters with a 4 or 8 millimeter metal part at the tip. It is also called RF ablation.

How is Radiofrequency Ablation Performed?

After the location causing palpitations is found with electrophysiologic study, the metal part at the tip of the catheter is heated with low-amplitude, high-frequency electrical energy, creating a controlled damage to the tissue it contacts. The area with the arrhythmia is burned and the rhythm disorder is prevented from occurring there.

RF ablation can be performed in the angiography device under the guidance of the imaging method we call scopy, or it can be used with 3D mapping systems. An appropriate method is selected for the rhythm disorder to be ablated.

Each ablation procedure has a target and strategy. These are called endpoints. When that target is reached, the procedure is terminated. After the burning process, palpitations are tried to be recreated. When it is seen that they do not occur, the target is reached.

What is Cryo Ablation?

In radyofrekans ablation, diseased tissues are treated by burning, while in cryoablation, diseased tissues are treated by freezing. It is also called coldablation.

How is cryoablation performed?

Cryoablation can be used in the treatment of many arrhythmias. It can be applied in two ways: focal cryo or cryoballoon. The shapes of the catheters used in these two methods are different from each other.

Focal cryo is used to treat supraventricular tachycardias (SVT) or accessory pathways (wpw) close to the heart’s main conduction system. Cryoballoon is used to freeze the mouths of pulmonary veins that cause atrial fibrillation. Cryoballoon is sometimes used to treat atrial tachycardia.

How is focal cryo applied?

Electrophysiological study determines the mechanism of palpitations and their origin. If the area causing the rhythm problem is close to the conduction system of the heart, there is a risk of heart block, that is, the risk of pacemaker implantation. To reduce this risk, cryoablation may be preferred instead of radiofrequency ablation.

Cryoablation involves cooling in two stages. First, it is cooled down to -30 degrees centigrade and the catheter is allowed to adhere to the tissue (like when you touch ice with your hand). If the rhythm disturbance improves but there is no block, it is cooled down to -80 degrees centigrade. In this way, permanent damage is done to the abnormal area. The most important advantage over radiofrequency ablation is this gradual ablation approach.

Cryoablation offers a safer ablation approach in patients with higher pacemaker risk. Cryoablation is used more frequently in children to be safer. The disadvantage is that the possibility of recurrence is slightly higher than radiofrequency ablation.

How is cryoballoon applied?

It is used for ablation of atrial fibrillation. After entering the left atrium, the prepared balloon system is advanced into the atrium. In front of the balloon system, there are electrodes that are advanced into the veins we call pulmonary veins. These record the signals and measure the effect of the ablation. The balloon is inflated and the freezing process is started based on the mouth of this vessel. This process is repeated for all four vessels. It takes 5-6 minutes on average to freeze each vessel.

Depending on the patient’s anatomy, whether there are other rhythm disturbances, whether there is an area other than the pulmonary vein that causes AFib, it is decided whether radiofrequency or cryoablation will be applied.

There are also ablation systems that use electrical energy (PFA) as a new technology.

Which ablation method will be used in your case? The answer to this question depends on the type of arrhythmia, where it originates and how close the abnormal area is to important structures in the heart. Based on these factors, your doctor will decide on the most appropriate choice of energy.

What are the Benefits of Catheter Ablation?

In a significant number of heart arrhythmias, ablation is now either a first-line treatment or one of the treatments that should be applied in the early period. Because the success rate increases and the risk rate decreases with new technologies. The success rate of ablation in most SVTs is 99%.

With catheter ablation therapy, most arrhythmia are eliminated with high success. This does not mean that ablation should be performed in every rhythm disorder. Arrhythmias that do not cause complaints, do not impair heart functions and do not pose a life threat can be followed up with or without medication. As with any treatment, in ablation, the risks and symptoms caused by your disease are placed on one side and treatment options on the other. The most effective and least risky treatment is the right one for you.

Apart from this, there are some situations where ablation should be considered in the first place. If your arrhythmia;

  • It has caused heart failure.
  • If it poses a life threat and is a problem that can be eliminated by ablation.
  • If it causes feeling faint or fainting symptoms
    ablation should be considered in the first plan.

What are the Risks of Catheter Ablation?

With catheter ablation treatment, the life threat in most procedures is 1 per thousand. Risks such as entry site complications, need for pacemaker, emergency surgical intervention, stroke are important complications and their incidence is less than 1 per cent. In radiofrequency ablation of atrial fibrillation, there is a risk of oesophageal damage with a frequency of 1 per thousand. Depending on the disease and the type of ablation, your doctor will inform you about the risks.

Every interventional procedure has risks. In general, the risk of ablation is determined by

  • The general condition of the person
  • Which rhythm disorder is treated
  • Where the rhythm disturbance originates from

With the developments in ablation technologies, the risk of the procedure is also decreasing. We can now make a three-dimensional map of your heart with mapping systems and find the places where the rhythm disorder originates with very sensitive catheters. We can also see how many grams of pressure we apply when we touch your heart with the catheter we ablate. All these technological developments increase the success of the procedure.

In Which Rhythm Disorders Is Ablation Performed?

Many heart arrhythmias, whether originating in the atria or ventricles, can be treated with catheter ablation. Arrhythmias that can be treated with catheter ablation are as follows.

They can be treated with catheter ablation.

How Many Hours Does Catheter Ablation Treatment Take?

Ablation of some arrhythmias takes 20-25 minutes, while others may take several hours. Factors determining the ablation time;

  • Type of arrhythmia
  • The size of the affected area causing the arrhythmia
  • Whether the ablation site originates from an easily accessible part of the heart and whether it is close to important structures in the heart

Even if the arrhythmias in the patients are the same, there may be differences in the procedure times due to these reasons.

Is There Pain in Catheter Ablation? Is the patient anaesthetised during ablation?

If ablation is performed for SVT, WPW or AT (atrial tachycardia), general anaesthesia is not performed. The procedure is performed under local anaesthesia and light sedation. Little or no pain is felt. If ablation is performed in a location where pain is likely to be felt, anaesthetic drugs with pain-relieving properties may be used.

Atrial fibrillation and VT (ventricular tachycardia) are usually performed under general anaesthesia or deep sedation. This prevents pain during the procedure. You may feel pain for the first few days after the ablation, which is controlled with painkillers.

Why do we use local anaesthesia?

We need to clarify a basic principle of electrophysiology. In most arrhythmias, for the ablation to be successful, we want the palpitations to be revealed in the electrophysiology procedure. In this way, we find the mechanism of the flutter and burn it where it originates. We then try to recreate the palpitations, and if we cannot, we are successful. General anaesthesia can disrupt this pattern. Under general anaesthesia, it is difficult to create some rhythm disorders or the existing rhythm disorder may be suppressed. For this reason, we do not use general anaesthesia for the success of the procedure in rhythm disorders where we think the target area will be small. We use local anaesthesia and sedation.

Does palpitations recur after ablation treatment?

The risk of arrhythmia recurrence after ablation depends on the cause of palpitations and the severity of the underlying heart disease, if any. The recurrence rate in SVTs is less than 1%. In atrial fibrillation, it is 10-15% in the first year, but the risk of recurrence increases over the years. This is because SVTs originate from a small, dot-like area, whereas atrial fibrillation can theoretically originate anywhere in the atria.

One of the factors determining the success of ablation in atrial fibrillation is early intervention. The earlier the atrial fibrillation is treated, the better the outcome. The most important thing to remember is that whether ablation or drug therapy is performed, you should definitely adjust your lifestyle to reduce the chance of recurrence in atrial fibrillation.

  • If you drink alcohol, you should stop
  • You should exercise regularly
  • If you have a weight problem, you should solve it
  • If you have concomitant diseases such as high blood pressure and diabetes, you should control them.

Regular exercise is very beneficial. Instead of doing intense exercise for 1-2 days on the weekend, you should do regular exercises of at least 30-45 minutes each, spread over the whole week.

When will I be discharged after ablation?

If you have had ablation for SVT, you will be discharged on the same day or 1 day later, and if you have had ablation for atrial fibrillation, you will be discharged 1 day later unless there is no other reason for discharge. In ventricular tachycardia, this period is adjusted according to the condition of your disease.

How Long Does Recovery After Ablation Take?

You usually return to your normal life a few days after the ablation. This process varies depending on the complexity of the procedure and your general condition.

What Should Be Considered After Ablation?

It is important to adjust your lifestyle after ablation. Keeping your weight at ideal levels, quitting smoking and engaging in regular sports activities will greatly improve your quality of life.

Do I Need Medication After Ablation?

If you have had ablation for SVT, you usually do not need to take palpitations medication after ablation. If you had ablation for atrial fibrillation, you will need to take blood thinners for at least 3 months and maybe for life, depending on your risk status. Your doctor may also ask you to take a rhythm regulator, at least for a while. If you have had a successful ablation for VES or atrial premature beats and have no concomitant heart disease, you usually do not need to take palpitation medication.

Can I Play Sports After Ablation?

Regardless of the ablation, you should avoid competitive sports if you have severe structural heart disease.

If you have had SVT ablation, you can participate in any sport at any time. If you have had atrial fibrillation or flutter ablation, yes, we strongly recommend that you play sports. If you have had Ventricular tachycardia or Ventricular extrasystole ablation and you do not have serious structural or electrical heart disease, you can of course play sports. If you have serious structural or electrical heart disease, you should follow your doctor’s advice.

Atrial fibrillation ablation - Hot (RF) ablation
Atrial fibrillation ablation - Hot (RF) ablation

Reference: Ablation

Update: Feb 14, 2024

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Picture of Prof. Dr. Taylan Akgün
Prof. Dr. Taylan Akgün

He is a cardiologist specialised in the diagnosis and treatment of heart rhythm problems (ablation), pacemaker procedures.
He works in Istanbul province.

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