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AF ablation Atrial fibrillation

Ten things to expect after AF ablation

Here is a list of ten things to say about the experience of having an AF ablation.

(Note: This list concerns standard radio frequency catheter ablation for AF.)

1. AF ablation is a big deal:

The first thing to say about AF ablation is that it is a big procedure. I tell patients to expect AF ablation to be hard on them. How could it be easy to undergo hours of general anesthesia, insertion of big tubes in the leg veins, 50-75 burns in the atrium and hours of bed rest? Although a minority sail through the recovery without complaints, most patients tell me they were surprised at how hard it was on them. I recommend taking a few weeks off after the procedure. Specifically, I say…read books, watch movies, write a blog, take short walks. but don’t go back to full-gas exercise or work for a couple of weeks.

2. Chest pain is common: 

A majority of patients have chest pain for a few days after the procedure. The severity of the pain varies a lot. Most often, it hurts to take a deep breath or cough. Some patients say their chest feels tight. These symptoms are likely due to irritation of the lining of the heart, called the pericardium. It’s hard to predict who will get post-procedural chest pain. Sometimes you do extensive ablation and there is no pain, while other times you have an easy ablation and there is severe pain. It resolves over days.

3. Pain at the insertion site in the groin:

It’s common to have soreness at the insertion site in the groins. We access the heart by inserting multiple sheaths (essentially big IVs) in the leg veins at the groin. To prevent clots from forming in the heart, we perform AF ablation without interrupting anticoagulation. This means firm pressure will be required when the sheaths are removed. And that causes varying degrees of soreness in the groin region over the following days. Bruising is common. And bruising will follow gravity, so it’s common for black-and-blue marks to move down the leg. Sheath placement or removal may also irritate the nerve bundle that runs adjacent to the leg (femoral) vein.

Although most patients have discomfort at the insertion site, persistent pain (for more than a few days) or swelling are causes for concern. One of the most common complications of AF ablation is injury to the vein or artery in this region. In these cases, a caregiver will likely want to take a look at the site. Occasionally, we might order an ultrasound.

4. General anesthesia effects: 

Most electrophysiologists use general anesthesia for AF ablation. Some patients chew up (metabolize) the gas and drugs easily; others do not. Many patients feel nausea and groggy for hours. Some patients experience these symptoms for days. It’s also common to have a sore throat or cough from the (endotracheal) tube. There is a great deal of variation in how people tolerate anesthesia.

5. Arrhythmia: 

Do not expect to have a flawless rhythm after AF ablation. Remember that this was a big procedure. The many burns it takes to isolate pulmonary veins can irritate the heart, which in turn may cause arrhythmia. Other possible disruptions to the rhythm include prolonged bed rest, effects of anesthesia, and pain.

Premature beats in the hours to days after the procedure are common. Atrial fibrillation can occur. Although having AF after an ablation is a risk factor for a future recurrence, it doesn’t mean the procedure did not work. The burns irritate the heart, and as they heal (expand), over days to weeks, the irregular rhythm can resolve. This is why we have what’s called a waiting period (6-8 weeks) after the procedure before we declare success–or not. AF that occurs in the post-procedure period is rarely dangerous because all patients are kept on anticoagulation and most patients remain on rate-slowing meds. Persistent high heart rates (which sometimes indicates left atrial flutter) can be more difficult to control, sometimes requiring cardioversion.

6. Resting heart rate changes: 

The resting heart rate can increase in the weeks or months after ablation. The increase is usually 10-20 beats per minute more than pre-procedure levels. This phenomenon usually resolves.

We do not fully understand the way in which AF ablation works. It’s not as simple as just building an electrical fence around pulmonary veins. One effect of ablation in the region of pulmonary veins is changing neural input to the heart. Bundles of nerves, called ganglia, reside close to the origin of the veins. Ablation at these sites can alter neural control of the heart. Some experts believe this is a positive effect in that it may predict ablation success.

8. Exercise Tolerance:

The ability to sustain exercise can be decreased for weeks to months after the procedure. It will likely come back. The reasons AF ablation transiently decreases exercise tolerance are numerous: it is a big procedure, the burns can cause stunning of the atria, there is deconditioning that occurs before and after the procedure, and many patients remain on AF drugs for a month or two after the procedure. The main message here is be patient. Give yourself weeks to months to recover.

9. Fluid overload/Edema:

It is not uncommon to develop volume excess. This can manifest as swelling of the hands, feet, or face. It may also cause transient shortness of breath, cough or high blood pressure. Reasons: ablation catheters deliver saline (salt water) with each burn; anesthesia often requires saline infusions to maintain blood pressure, and the heart can be stunned after ablation. Swelling and volume excess is not heart failure per se, but it usually responds to a few days or weeks of taking a diuretic medication.

10. Digestive problems:

I have seen, in a handful of cases, patients have trouble moving food through their GI tract after ablation. Symptoms include reflux, feeling bloated, and intolerance of big meals, while signs may include distention of the abdomen.

Ablation in the left atrium may transiently damage nerves that control motility of the GI tract. The good news is that these effects resolve with time. I usually treat this problem by recommending small meals, and an acid blocker.

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Note that this is not a complete list of complications, but a compilation of common issues I’ve come across in the last ten years and 800 left atrial ablations. It should be self-evident that if you experience severe new symptoms or signs, such as stroke, esophageal swallowing pain, fever, unremitting chest pain, breathing problems, or expansion of swelling in the leg veins you should contact your doctor or seek medical attention.

JMM

I closed the comment section on this post in an effort to avoid patient-specific experiences. Posts such as these are meant as informational and do not constitute specific medical advice.