Ablation

You probably won't remember a thing...

by crustyg - 2020-04-02 12:30:59

I've had two, both with midazolam and fentanyl.  The midazolam specifically prevents you from creating memories of the event, and the fentanyl should avoid too much reaction to the pain (increased HR, inc. BP, sweating etc.).

I asked my EP doc if I could have my second one without sedation (the midazolam) and he was *very* reluctant to do it - he said that it would feel like a heart attack.  As my first ablation had involved extensive RF burning he wasn't keen on me possibly feeling and remembering something like that.

Recovery - apart from freezing my butt off on the second one (practically naked under the A/C outlet above me, covered in leads (using an EP mapping tool)) is very quick.  I was driven home a couple of hours later and was wandering about that PM and drove the next day (later discovered that I shouldn't have) and worked from home that day.  I actually woke up during the second one and had a brief chat with the nurse who explained that she was going to give me some more midazolam (and fentanyl) and then I was away with fairies again.

The EP docs like 'conscious sedation' - you will usually do as asked, don't have much pain reaction and don't have memories of any pain that you do suffer.

For me, biggest PITA was the oral anti-coag for 1 month before and 2 months after - but such a tiny problem - 5mg apixaban orally twice a day, so small I could swallow without water!

Of course, it *can* be a bit more exciting than this - but why frighten you with medical horror stories!  It *should* be a breeze.

HTH.

Not as bad as a cavity filling

by AgentX86 - 2020-04-02 13:53:31

I've had three ablations for Aflutter, one a cardiac catheterization (they hit the motherlode), and one for a carotid stent (which they ended up not doing).  The cardiac cath was done through the wrist and the carotid stent was done through the femeral (thigh/groin) artery.  Aflutter/Afib ablations are done into the femoral vein.  Vein caths are simpler since the vasular pressure is lower in the veins.

The cardiac cath was done with some pretty good stuff.  While I was in a fog (twilight sedation), I do remember exactly what took place. Really nothing to write home about except for the invitation to see the thoracic surgeon in a couple of weeks.  They released me whithin an hour with a slick "pressure bandage" thingy around my wrist.  I had to leave that on for a few hours, then a regular bandage for a day or so.  I was back at work the next day.

The carotid angiogram (started out as a stenting) was a little more diffiult since they gave me nothing except for a local.  I had to be lucid during the procedure so they'd know they hadn't had an "oops" and knocked something loose and into the brain.  I was probably about where you are - wondering what the hell was going to happen to me.  After was the worst of it.  During the procedure they give you a lot of fluids to make sure the arteries are good and full so they can navigate easier.  Well, that fluid has to go somewhere and the kidneys are the place. Since they had to go into an artery, after the procedure I had to lay flat on my back for five hours while the wound closed.  I don't know which was in more pain, my back or my bladder.  After the five hours I went home.  I think my wife drove me to work the next day and I was back to driving the day after.

The ablations were really simple.  Mine were for atypical atrial flutter, so they did have to pierce the septum to access the left atrium.  These were done with local anesthetic only.  The only pain I had was during the second I felt like they were burning my back with a woodburning pencil as he moved the RF probe around my heart.  That wasn't comfortable at all but I was fully awake.  Most are under at least some sedation. Again, the hardest part of these precedures was laying on the back, though only for three hours because it was a vein and not an artery that they pierced. I understand that some EPs now use coligen plugs to speed up the recovery time.

During the third ablation they had to cardiovert me, so lights out for that.  Well, it didn't quite work because I was awake when they plugged me in.  That hurt! I think I put a curse on all of their ancestors.  The next day one of the nurses said "We didn't think you'd remember that".  Well...

For the third, I was overnight in the hospital.  After the time in the recovery room (waiting for the wound to stabilize) I went home.  In all cases I as back to work the day after leaving the hospital.  I could have gone back that day but no point (time).

Now, these ablations were for Aflutter so they were entering the right atrium (then through the septum to the LA).  Since the vena cava (the body's major vein) connects to the RA, the access is through the veins and the largest in the limbs is the femoral artery, which is good because, as I said above, it's simple to access and plug the hole.  I assume, but could be smoking weed, that they'll do the same if they have to access the RA.  If it's the LV, then I'd expect they'd go through the aorta (the major artery), which means the access would be through the femoral artery, which is more difficult (for you - not necessarily them).

Unlike Crusty, I remembered everything from all of my caths.  My cardiologist and EP don't use sedation unless it's necessary but do have an anesthesiologist around if needed.

Bottom line:  If you're worried, ask your EP.  If everything goes as planned (and it does 99% of the time), it's not a big deal at all.  It's a lot easier than having a tooth pulled. Except for the back time, it's probably easier than a good cleaning.

Just wanted to add, that the above is for Afib or Aflutter.  Ventricular access and ablation may be more complicated.  I don't know about that.  Again, ask.

My experience

by IAN MC - 2020-04-02 14:49:48

I feel like a real amateur but I've only had one ablation.

I did every bit of research I could in finding out which EP's are considered to be the best in the UK and it paid off.  The one I chose claimed to have a 95% success rate for my condition ( atrial flutter ) and he stressed that I would be be able to stop taking a blood-thinner ( warfarin in my case ) almost immediately.

I was given the choice of being conscious or having a general anaesthetic. When he said " some patients experience pain "  my decision was clear....I opted for a general.

The procedure took 45 minutes and I woke up with normal sinus rhythm which I have now had for almost 10 years.

Taking a blood-thinner is a distant memory !

I returned home after one overnight stay .The incision wound in the groin healed very quickly and I resumed running after a few days.

Having an ablation was a great decision for me,   and i hope it goes just as well for you .

Ian

ablation

by islandgirl - 2020-04-02 21:44:52

I've had at least 15, with the most recent one 6 weeks ago today.  Mine are usually with general anaesthesia, but I've had them awake during mapping and then general once the ablation begins. Some arrhythmias are affected/supressed with sedation.  I had over 110 areas ablated this past time, with a total time of 7 hours.  They put large cold pads on your back.  After I'm asleep they put catheters in each groin, a arterial line for bp monitoring, a urinary catheter.  Not able to get out of bed for a few hours afterwards to make sure groins heal/clot. I am kept overnight as I live 2 hours from my EP/hospital.  Groins are bruised feeling.  Lifting restrictions.  Takes 3 months for the heart to heal.  Can have varying arrhythmias during the healing process.  I'm pretty squeamish, but it's not too bad.  No real pain afterwards.  You will feel exhausted afterwards.  I hope they can find your ventricular arrhythmias, as mine have not emerged during my ablations.  

Ablations

by Selwyn - 2020-04-03 07:45:39

Had 3 - one for flutter, 2 for fibrillation.

Was advised to have a general anaethetic (GA) as the procedure can be painful and prolonged ( see island girl is talking of 7 hours of lying on a table). Off to sleep in a few seconds, wake up and like magic, all is done It takes a good day or two to get the drugs out of the system so if you have a GA you will be tired for a few days. 

Entry, with a catheter puncture, via the right upper leg (groin)  femoral vein. Results in bruising.

Anticoagulation is needed, if I remember rightly ( I am anticoagulated anyway). 

I don't remember having any restictions afterwards, just got back into sporting activities asap. Shame about the bruising!

Generally speaking the whole business is a piece of cake for anyone that has experienced a pacemaker. If you look on YouTube there are excellent videos of the procedure.

Anticoagulation

by AgentX86 - 2020-04-03 11:50:03

No, anticoagulants are not to be taken before any surgery, particularly ablations since they go into a major vein. I was taking Eliquis at the time and took my last dose the morning of the day before surgery (skipped the night before and morning of), then continued the evening after.  Eliquis has the advantage (and disadvantage) of having a very short half-life (24hrs, IIRC), so clears from the system quickly and the coverage gap in minimal.

Some who have a high risk of clotting, can't take even the 48hr gap, so will take short-term anticoagulation IV or sub-Q (heparin).  They'll have to give themselves a shot every few hours to cover the before and after surgery while their normal anticoagulation is suspended.

I didn't have much bruising but there was a weight lifting restriction (10lbs, or something like that) but I don't recall how long (week?).  While the wound is closed at that point, there is a small risk of tearing it open for the first couple of days (falling off rapidly). It's advisable to take it easy for a few days.

Ablation

by Dave H - 2020-04-03 12:29:51

I had four of them in the time frame of 2011 - 2012.  Felt nothing, remember nothing!  BTW: Due to my allergy to heparin analoges, argatroban was my clot buster of choice if needed.

Cryo ablation

by Booster - 2020-04-03 15:07:48

I’m having my first ablation on this coming week and it’s a cryo ablation. I’m not sure if it’s the type of procedure or the Dr’s choice.  I was told he would acces both femoral arteries and one in the shoulder. He said expected 4-6 hrs and then 4 hrs lying flat. I’ve had about half dozen cardiac ablations and my wife’s nerves are always worse than the procedures!

Cryo and Femoral arteries

by AgentX86 - 2020-04-03 15:55:45

I'm surprised they're doing a cryo-ablation after even one RF ablation, much less six.  As far as I know, cryo-blatoins are only useful for pumonay vein isolation (PVI) and that's the first thing done in even an RF ablation.  The pumonary veins are the source of most of the trouble so they're done prophylacticly, even if not needed at first.  Odd.

Are you sure they're using the femoral arteries rather than the femoral veins?  The arteries don't lead to the atria at all.  They can access the left ventricle but not the atria (nor the RV).  They could, I guess, sneak past the valve into the LA but I've always had them go into the RA via the veins and punch through the septum to get to the LA.  Very odd.

It's also odd that they need to punch three holes in you to get access.

Veins

by Booster - 2020-04-04 01:02:33

Yes it’s the femoral veins. Not my my sixth (the half a dozen references cardiac caths for stents and to find blockages for bypass surgeries)  This said it will be my first ablation and the last was supposed to say cardiac caths.  Dr. told me he would access 3 different sites don’t know if that part was his preference or how it’s normally done.   He did mention heat and cold therapies but said he would be doing cryo. 

Ok, that clarifies things

by AgentX86 - 2020-04-04 12:08:54

I've still never heard of using three veins, particularly the two femoral veins (they come together long before the heart) but your doctor has a lot more experience than I do.  ;-)  No, that's not how it's normally done but he may be doing something extraordinary - perhaps doing more mapping of the electrical activity?  I'd be asking, just out of curiousity, if for no other reason.  I like to understand what they're doing to me.

Heat and cold:  Yes, the "heat" is done with an RF (radio frequency) probe.  It causes RF burns that scar over and become "dams" which the electrical signals can't cross.  That's why there is a "blanking period" after the ablation, where you still may have arrhythmias. The scars need to form to create the electical isolation lines to stop the errant signals.

Cryo-ablation is similar except that it uses extreme cold (cryogenics) to kill the fibers and creat these isolation lines.  Like I said, I think this is only done for PVIs.  Again, AIUI, cryo is simpler but more of a sledge hammer.  RF is more of a scalpel but is more flexible and useful for more complicated ablations.

In any case, since you've had six cardiac caths, just think of this as your seventh.  Though it usually takes (perhaps a lot) longer, it's really no more difficult for you.  Personally, I wouldn't go for a general anesthetic.  If you (or your surgeon) are squeamish about being awake, go the conscious sedation route if you have a choice. The recovery is much easier and that's really the hardest part of an ablation.

Ablation and anticoagulation

by Selwyn - 2020-04-04 13:29:28

"Catheter ablation of atrial fibrillation is typically performed with uninterrupted anticoagulation with warfarin or interrupted non–vitamin K antagonist oral anticoagulant therapy. Uninterrupted anticoagulation with a non–vitamin K antagonist oral anticoagulant, such as dabigatran, may be safer; however, controlled data are lacking.

One of the most feared complications of ablation of atrial fibrillation is stroke. Previous clinical trials have shown that continuous vitamin K antagonism is associated with fewer embolic events than interrupted treatment."

Direct quotes from the paper in 2017  New England Journal of Medicine, a peer reviewed journal of high regard, medically speaking.

( https://www.nejm.org/doi/full/10.1056/NEJMoa1701005).

 Please note :AgentX86's view (above) , as a patient, does not necessarily apply to most centres practicing evidence based medicine.

Atrial fibrillation (AF) catheter ablation is an effective treatment for selected patients with symptomatic, drug resistant AF . To minimize procedure-related thromboembolism most operators fully anticoagulate patients with oral anticoagulants (OAC) pre-procedurally and administer high-dose heparin during the procedure, maintaining an activated clotting time (ACT) of at least 300 s 

(https://www.sciencedirect.com/science/article/pii/S0972629216314516)

Anti-coagulants and Ablations

by IAN MC - 2020-04-04 14:48:14

As Selwyn says ...my understanding also is that  it is good medical practice to carry on with  blood-thinner cover prior and during ablations.

I had my ablation done by an eminent  E.P. , at one of the leading heart centres in the UK, and in my pre-procedure letter the EP wrote " If I.N.R is kept between 2 and 3 , there are fewer complications following an ablation " so I remained on  warfarin during , and for a few weeks after the procedure !!!

I had a very happy ending .. normal sinus rhythm ,  no stroke , no more warfarin . I don't think Agent's comments reflect best medical practice.

Ian

Ablation and anticoagulation

by AgentX86 - 2020-04-04 20:21:17

Selwyn, we'll have to disagree.  That's not what the text of your link says.  You even quoted it; "Catheter ablation of atrial fibrillation is typically performed with uninterrupted anticoagulation with warfarin or interrupted non–vitamin K antagonist oral anticoagulant therapy." It's saying that it's not normal for ablations to be performed without halting NOACs, though perhaps it should be.  That's only one study but it obviously hasn't been excepted by the vast majority of EPs.  It may be a UKUS thing but it's just not done here, at least for NOACs.  'I've fogotten a lot of my experiences with warfarin (likely a sanity protection mechanism).  This is rather like using NOACs for heart valve replacement patients.  It's probably a good idea but there hasn't been enough study to show that it's safe and effective so it isn't done (at least in the US - I have no idea what you folks do).

Read the stopafib forum.  This is probably one of the more common threads and I don't remember anyone saying that they hadn't stopped NOACs before ablatoins.  Some have gone into great detail on how they've bridged the gap (self administered heparin shots).

Yes, clotting in the heart, particularly the LAA can be quite rapid.  Anytime blood is pooling (still) there is a very good chance for clotting.  That's the whole reason behind the LAA clip and Watchman devices and the reason that those with an isolated LAA have to by hyper-vigilant with their OACs.