I keep reading posts where the decision is made to hold off on an ablation as the medications are working well. My meds are doing a great job and I have been in the hold off camp.
I have just read a cardiology review 'Ablation as First-line Therapy for Atrial Fibrillation' by Jason G Andrade where he states:
In contrast to antiarrhythmic drugs, catheter ablation appears to be disease-modifying, significantly reducing the progression of disease.
The way I interpret this statement is that medications stop episodes but do not stop the progression of AF, which is I assume is why my EP said it is better for me to have an ablation early while the meds are working well rather than later.
The article also mentions Pulsed Field Ablation.
Pulsed-field ablation may offer an improved safety and efficacy profile relative to thermal ablation energies, potentially positioning it as the preferred ablation energy for first-line AF ablation procedures.
Now that Pulsed Field Ablation is now becoming more widely available and is so much safer, will people who control AF with meds be thinking of getting an Ablation earlier than previously considered?
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OzRob
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My AF is super well controlled. I only get it when I push it when exercising, and I take a beta blocker prior to exercise to give me a bit more buffer. Alcohol reduces the trigger threshold, particularly red wine. I've only had it once when not going hard, and that was at lunch during a 4 day cycling tour on the 3rd day.
However, in the last 2 years the threshold for triggering has dropped. It's gone from an all out effort for say 8 mins down to a 1 min effort. And last time it lasted for 36 hours (80-100 bpm, not super high). And training for long events I was more worried about triggering and took the enjoyment out of achieving. And given that I exercise 6 days per week, then that's 6 days of slight drowsiness in the arvo caused by the beta blocker.
So I could just drop it further, take it easy, reduce cycling intensity. However I am mindful that it will progress as I get older, and I'm only 49. At 36 hours then they want you to take additional medication, which then has further impacts. So knowing that I will eventually end up in permanent (like both my parents), then I've signed up for PVI in July.
If you asked me 2 years ago I would have said to manage it. But I've reached the crossover point that I'm willing to take the risk on the 70% success rate, increasing to 85 - 90 with the second. Probably higher as my understanding is the mechanism for my AF is well aligned to PVI.
Everyone has different drivers, but for me when my cardiologist told me that it was time to go and see the EP I was in agreement - I also trust him as he sees quite a few other cyclists / runners and so understands. So I would have a discussion with your cardiologist about a referral to an EP to chat about the success rates and then make a decision. In Australia most of my op will be covered by private health insurance (other than excess and $$ for the anesthesiologist), which made it easier.
There's several ways of interpreting the statement. I'm not a medical professional but I think anything that reduces the impacts of AF on the heart assists in slowing the progression of AF. So for me, the statement means ablation is more effective at slowing the progression of AF than medication but that doesn't mean that medication doesn't slow AF progression.
In my case, almost 5 years since diagnosis and being medicated, I have no signs of AF progressing (still several episodes a year that end within 2 - 14 hours) or any structural changes to my heart. However, that could change next week, next month or next year. Who knows? It can also be the case for ablations too - apparently.
"will people who control AF with meds be thinking of getting an Ablation earlier than previously considered?"
I don't look forward to any form of ablation to be honest so I still wouldn't have one until my quality of life deteriorated i.e. medications were clearly losing effectiveness. However, a safer procedure, with higher success rate and faster recovery would certainly make the decision easier.
Yes, a safer procedure, with a higher success rate and faster recovery has made me think that the decision is easier. Still, as Pulsed Field Ablations have only become available in my area I will still hold off another 8 months.
Also, my EP wishes to intervene with an ablation before the quality of life deteriorates. It may be a new way of thinking now that Pulsed Field Technology is available?
Yes, research appears to favour early intervention with ablation. However, there are too many unknowns for me to commit to an ablation while medication provides a quality of life solution. Especially when you read of the ablation experiences of some people i.e. impacts following the procedure, failed procedures and AF returning within a year or two.
PFA becoming more commonplace might help improve the reputation of ablations in my eyes but I'll have to wait and see. From what I've read, if I have an ablation it will be PFA so holding off also allows local experience to develop in performing PFA before I take the plunge.
To have an ablation is a decision you must make in consult with your EP. Keep in mind everyone's experience is different
Have you had a recent echocardiogram to determine the effect of afib (if any) on your heart ? This is key.
And you seem to have done research and be well read on the subject, but also research the minimaze procedure. At your age (61) the success rate for an ablation or minimaze may be higher than if you waited, but that is a subject to discuss with your EP.
They don't offer minimaze here, but to now have pulsed field available may be a game changer in making an ablation a safer operation.
I estimate my EP is just under 40 years of age and is the best in our entire region, keeps up with the latest information and looks at early ablation as a complement to medication with the plan that meds can be dropped entirely.
I have not had any AF for almost 2 years, but know that if I dropped the meds it would be back. So technically I still have med controlled AF bubbling below the surface and developing slowly.
So the current thinking is to ablate early before it manifests itself.
That’s the way I understand it. Wasn’t an issue for me as I wasn’t able to take any rate control meds - had ablation in Dec 23 and no AFib I’m aware of for the last 4 months. Would be useful if the medical teams could make it clearer on this point so people can make the best choice for themselves armed with a full understanding as I also understand that there is thought that Ablation works better the earlier it is tackled - good luck mate, bitch of a condition
Hi, this was my dilemma, and even the doctors don’t agree on the answer. My local cardiologist was of the opinion that 50mg of Flecanide twice a day that have stopped my episodes of Paroxysmal AF all of 2024 was the way to go. However my EP recommended a pulsed field ablation. I decided that I would rather have the ablation at 65 before developing any other conditions, and reading the same study as you. I had the ablation 9 days ago under my first ever general anaesthetic and came home the same day. Apart from fatigue I have had an easy recovery. Minimal bruising and they even did the echocardiogram through my groin, so no need for omeprazole or a sore throat
At the 3 month post op review after the blanking period. All seems quiet on the heart front, wearing my apple watch to confirm, I have seen an improvement in my respiratory rate over night which sometimes dropped to 7. Not been below 12 which I had also read about. Resting heart rate up a bit from 53 to average 59 so all improvements
Normal is normal for you. A lower heart rate can be due to a more efficient heart, being fitter etc. The key is your low heart rate not causing any symptoms.The increase in your heart rate might be a temporary response to having surgery. Don't be surprised, or disappointed if it drops back in due to your pre-surgery norm.
7 weeks ago I had my RF ablation in Glenfield, Leicester, UK. I had this dilemma as I have paroxysmal AF. My EP told me AF is more treatable with a better success rate if carried out in the early stages. Once it becomes persistent it has a much lower success and becomes difficult to treat, hence my decision.I also want to come off the powerful anti arrythmic drugs 🤞
Another Australian on the Forum was seriously considering the well-trodden path of travelling to Tokyo for a minimaze procedure with Dr Ohtsuka, a colleague of Dr Wolf in Houston. So it's not completely out-of-the-question.
Just saying, as Australia is closer to Tokyo than London or say Greece from where saulger travelled for his minimaze.
If you are interested, saulger 's Posts provide a helpful mine of information on his journey.
I was taken down the medication route, but no beta blockers as I am asthmatic. My cardiologist talked about ablations, but at the time he did , about fifteen years ago, he didn't consider that they were worth considering in my case.The Flecainide worked perfectly well, reducing episodes to one or two ten-minute episodes a year, which all came late at night while still awake. Then between 7 and 8 years ago my infrequent paroxysmal AF became asymptomatic and persistent, since deemed permanent as nothing is going to return my heart to normal sinus rhythm. I take only an anticoagulant, Warfarin.
At the time I considered an ablation, long before I went into persistent, though asymptomatic AF, it was the time it would take to see improvements to my life, which was my main consideration. I am single and live alone, with two cats which I care for. My sister and bother live a three hour drive away. I have no family members who I can call upon if I need help, and no close friends . It seemed that having an ablation, or two or three wouldn't improve my quality of life.
With hindsight, I wonder if that was the right decision, but accept that I am where I am. Permanent AF causes no problems. Most of the problems I have are due to having foot drop of my right foot, which means I can no longer drive and am reliant on public transport. A journey to see a friend who lives two miles away, which before I had foot drop I could have walked to, took the best part of 2 hours, due to missing buses. ( It means a bus eastwards for four miles, and then a bus north westwards for 5 miles).
I might have done had I respected the practitioner but I’m 80 now and have chronic fatigue too so can’t think it would improve my life even if it were successful!
Rob I’m in the same boat waiting for PFA to improve. They have already improved the catheters a few times in the short time that they’ve been around there’s lots of competition. The other thing around is an Aussie company Imracor they’ve produced a catheter that’s guided by live MRI they expect it to be much better than the scans that are used today, better in obvious ways like accuracy and seeing the errant culprits. Anyway it’s in Trials so may be a few years from approval. I can’t understand if the drugs are keeping the AF away how can the condition progress?
My understanding is that the meds stop the sparks very effectively as only a few cylinders are firing early on when AF is diagnosed. For some this may last many years.
As AF progresses another engine block or perhaps two engine blocks are added to the pulmonary veins entering your heart with many more cylinders than before and more many more sparks produced that the meds cannot control leading to persistent AF.
The question is, if you ablate before the second engine block is added it will never be in a position to add those extra sparks that will lead to persistent AF.
So how does AF return and/or progress after "successful" ablation? My understanding is that ablation is more effective at slowing the progression of AF i.e. ablation is not a cure, yet some people no longer have episodes. I know this sounds contradictory.... because it is. Anyone know the answer?
My understanding is that the first ablation blocking scar ring fails due to tiny gaps missed in the process,which then give a route for the errant signals to pass back through from the pulmonary veins,hence need for top up.
Extract from a paper published last year titled "Decision-making for recurrent atrial fibrillation after catheter ablation"
"Catheter ablation for atrial fibrillation (AF), especially pulmonary vein (PV) isolation, is widely used for rhythm control. However, AF recurrence remains a challenge, affecting 20% to 50% of cases. This review focuses on AF recurrence after catheter ablation. AF recurrence can be categorized into early recurrence (ER) within 3 months after index procedure, late recurrence (LR) within 1 year, and very LR (VLR) occurring beyond 1 year. ER has emerged as a significant predictor of LR, contrary to the traditional understanding. LR is primarily caused by PV reconnection, while VLR more involves non-PV triggers or substrates."
interesting that my GP and Cardio Dr’s feel the opposite in my case. I am also a prolific 69 year old cyclist/hiker, and have had 2 episodes in 4 years. The first was triggered by food, while the second was because I hadn’t had an episode in years, they though lowering my dosage of channel blockers was warranted. I have no other health issues. Interesting that most here are saying they have been advised that paroxamyl AFIB never gets better, always gets worse with age, and early ablation is the answer. Yet, so many here have had no success or worsening of attacks and symptoms after many failed ablations, so where is a person to stand on this issue? I asked my EP about ablation, and he said “no, your stress test shows you have the heart of a 40 year old, no damage or abnormalities.”
Yes, I hear you. I am convinced AF has many more classifications than just paramoxal and persistant AF.
I believe AF should have at least 5 labels to cover every individual that has varying degrees of AF. Many disagree and think if you have AF then you have AF, final. You are a classic example of someone that is not the same as most on this forum
I myself have a very different AF where it is entirely Vagal, before meds I could stop an episode in it's tracks with a simple vagal maneuver.
There are a lot of very successful ablations out there and only people with problems usually come on the forum. Lots of people have left the forum as they no longer have Afib episodes. It’s not all doom and gloom 😊
First of all ablation is NOT automatically the best for everyone.
In NZ one has to prove that first your heart has to be structurally sound.
Then better that your AF has not been with you long term. But a friend had AF a long time and on 5 different meds. His came and went with pill Flec.. in the pocket.
Finally they went in. They found he had two AFs playing up in two areas, They blasted both. He has been free od them now for 2.1/2 years.
Trouble is it causes scarring of the heart which cannot be reversed.
I cannot have an ablation for the above 2 reasons.
My rapid AF is controlled by Diltiazem 120mg AM daily
and Bisoprolol at PM for BP control.
From what I've read from others if the ablation causes low pulse then its down the road of a pacemaker.
In the future there will be new more safe procedures.
Unfortunately it is you that can make the decision with your EP persuading you to have it done. Another job for him.
I get only get one episode a year, although last year I had two. The second was after covid. I’ve also had AF nearly 20 years. My last episode was in January. However, I’m having an ablation next month. I can also (usually) stop an episode within minutes with a valsalva manouvre and I’m on daily 1.25 mg Bisoprolol.
I was offered an ablation last year, despite them knowing my episodes are infrequent. I think there has been a recent change in the direction of our NHS regarding Afib, as this wouldn’t have been offered to me previously a year before. We were always made aware up to that time, that an ablation was only offered when episodes progressed or when someone was unable to take medication. I know it is still a decision for the person who is affected by their AF and how it affects their quality of life at the end of the day as to them having an ablation,
For me, my quality of life is affected in just knowing it might happen,. I know it’s never going to go away on its own. It causes me a lot of anxiety and I have modified my life to cater for the possibility. I want to try and have a chance at a normal life again, without it hanging over me and for that reason, I’m having it done.
It makes sense to me: the sooner the better. My understanding is that the heart can “remodel” itself over time, and if it does, ablation can no longer be an effective treatment.
Afib begets afib, as the oft-repeated saying goes.
To me, drugs are my LAST resort. They make me feel crummy with side effects that affect more than just one’s heart. These heart drugs also affect one’s brain, liver, kidneys, thyroid, and on and on.
Meanwhile the drugs don’t correct the substrate of Afib, its causes. But ablation can and statistically often does even though it takes two to reach a 90 percentile success rate.
I liken it to having a broken arm. I can leave it be and take drugs to cover up pain from the basic problem, or I can choose to fix the problem with physical intervention such as surgery to reset the bone. I choose physical intervention over drugs. I choose to correct faulty electrical signals in my heart, just as I would if the wiring in my house needed fixing: go straight to the core of the problem.
My choice has been ablation as soon as I can get it. I’ve had two, am in NSR, off all betas and ccblockers. Delightedly so. No, it’s not been an easy journey, but my destination is quality of life, and to me that means having a healthy heart without drugs. We each make our own decision. Good luck in making yours.
I'm replying from the coronary care unit at greenslopes private hospital in brisbane I had 1st ablation literally 7 hours ago and am now in recovery.
I'm 50yo male have had afib for 5 or so years . Had episodes every 4 - 8 weeks. Most lasted between 1 - 3 days. April 23 I had one for 2 weeks that finally got me prescribed flec (previously I was just on atenolol which did nothing to stop afib).
Flec was a miracle. Stopped episode within 2 hours. Then 75mg a day (25 morning, 50 at night) stopped episodes from even starting. I was really happy with that and was happy to just keep going with it.
Spoke to my EP about whether I really needed an ablation. She strongly recommended it for the reasons you mentioned. Better long term outcome and you can get off meds that can have consequences (like ototoxicity which doesn't affect you until it does).
I didn't have health insurance to cover the procedure, so I added it to my policy and had to wait a year for it to kick in. As of May 24 I was insured.
This morning, just outside the operating theater as i was about to go in, my Dr said since last month they started doing pulse field ablation instead of radio frequency. I was all psyched up for the rf ablation but had really wanted the pulse field. She said the delay waiting for my insurance really worked in my favor.
Now 7 hrs post op I feel fine. Just being kept in hospital to check the veins where the catheters go in are healing well. Also now all the anxiety about having the procedure is gone and I'm feeling very positive about it and really glad I had it done. Looking forward to getting off the meds!
It sounds like you have had a great experience. Good to hear your EP is of the same view as my EP, I think Pulsed Field is the reason everyone is more proactive towards an Ablation. I have private health insurance, but it is useless up here in Cairns, as the public hospital has a brilliant Cardiac Catheter Laboratory.
Great the public health system has pulse field ablation available now too! I don't know why I went private. Maybe i like to spend money unnecessarily but it worked out well in the end.
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