Cardioversion or Ablation? Or Neither? - AF Association

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Cardioversion or Ablation? Or Neither?

GeorgeStevens profile image

This is my first post here! First, some background: I was diagnosed with AF at the end of June 2021 when I went in for a hernia operation and they did an EKG. It came as a total surprise. I’m asymptomatic. My average heart rate is around 68-75 bpm. My AF is persistent. I wore a Zio patch for 14 days, which confirms that it’s persistent. The EP also suspects sleep apnea. The echo found that I have some “mild dilation” of the atria; otherwise, EP says the results raised no significant concerns.

I’ve read the book “The Afib Cure” by John Day and Jared Bunch, and have followed their recommendations regarding life-style changes: I’ve cut out almost all alcohol and sugar (not entirely; I still like an occasional dessert), made other positive dietary changes, reduced stress in my life, lost six lbs (I wasn’t overweight before but did have some Covid weight-gain), and now take a brisk walk of 2.5-3 miles every day.

The decisions I’m confronting now are whether to undergo a cardioversion and then possibly later an ablation. Given that my AF is persistent, I can’t expect my heart to go back into sinus rhythm on its own. But my EP says that neither procedure has been determined to prolong life; the main purpose of each is to relieve symptoms. Since I don’t have any noticeable symptoms, I’m wondering about the benefit-risk ratio in my case. I’ve heard the saying “Afib begets Afib.” So my main concern is the remodeling of the heart that eventually may (will?) take place. I’m also not happy about being on blood thinners for the rest of my life. (I'm currently taking 20mg of Xarelto daily. I’m not on any antiarrythmics).

My EP did not make a strong recommendation for or against either procedure in my case. He asked me, “What do you think?” Well, I don’t know quite what to think! How important is it for me to try to get back to normal heart rhythm? Since my AF is already persistent, I would imagine that it’s not quite so urgent that I have either procedure very soon. But I don’t know. Does anybody out there have any thoughts, advice, or relevant experiences they’d be willing to share? I would be most grateful!

33 Replies
BobD profile image

As you have already been told, any and all treatment is only for quality of life(QOL) i e synmptom control. Since you are asymptomatic (most people in permanent AF are after a while) then provided rate is well controlled and the patient is anticoagulated for stroke prevention then jobs a goodun as we say.

OK you could go for a cardioversion but this is really a diagnostic tool rather than a treatment in my view . It would show two things. a) can you be reverted to NSR (normal sinus rhythm) and b) do you feel better in NSR. If the answer to both those questions is yes then an ablation may work and be beneficial but if either answer is no then stay on rate control and antioagulation and enjoy the rest of your (hopefully ) long and rewarding life.

By the way, the only difference between persistent and permanent AF is that with the latter both doctor and patient accept the staus quo and leave things as they are rather than trying more and often pointless attempts to obtain NSR.

I should confess thaat I am a great fan of ablation having had three and been A free since 2008 but I was highly symptomatic and almost unable to function when events hit me.

GeorgeStevens profile image
GeorgeStevens in reply to BobD

Many thanks, BobD, for your reply, which was quite helpful to me in thinking this thing through. As I understand it, the likelihood of my staying in NSR after a year post-cardioversion is only about 50%. I've been hoping that with my lifestyle changes I might be able to put AF behind me if I were to have a successful cardioversion. But if indeed the cardioversion is, as you say, more a diagnostic tool than a treatment, I'm less inclined to go forward with it. The one question I'm still unclear about is the risk of eventual heart "remodeling," which I've gathered is irreversible and progressive if I leave my AF untreated.

BobD profile image
BobDVolunteer in reply to GeorgeStevens

Rate control and anticoagulation are all many people have and live long and happy lives. Being asymptomatic makes one a "lucky one", not suffering the swings between AF and NSR that most paroxysmal sufferers do with attendant anxiety and panic. In your case a cardioversion might help you decide on a way forward but if unable to obtain NSR then your options are limited anyway and there is no guarantee that it could.

What if... you had not undergone the hernia operation...? You would not know about AF, like millions of others live with it, and don't know that they have it. They benefit in many ways - they are not afraid, they do not adjust the life style, they do not take any drugs, anticoagulants included... I am also asymptomatic, but suffer on AF at night, while during the day my ticker reverts to normal rhythm. I am 69 and refuse to take drugs of any kind.

Let me tell you how I see our being asymptomatic. If the body is not large and the heart is in good condition, than loosing the precharge function (atria perform it) causes certain drop in heart pumping capacity, but the blood flow-rate remains at high enough level, so the patients do not feel any problems. With the time, the heart even gets used to the new, changed way of functioning.

I would not dare to suggest you what to do, but hope to have shed some light...

Thank you, SteelHeart, for sharing your experience. I too am disinclined to a lifetime of daily drug ingestion. Before I was diagnosed with AF, I wasn't taking anything regularly. The point you raise "What if you hadn't had the operation and found out you have AF" gives me pause. I see pros and cons of that newly acquired knowledge. On the downside, it has raised my level of fear. It's also given me another, additional set of problems to deal with, which I'd rather not have. On the other hand, the AF book I'm reading (mentioned above) says AF is "the canary in the coal mine," so it's probably a good thing that it has caused me to step back and change some unhelpful habits (like my daily consumption of a couple glasses of wine or beer before dinner). Also, knowing I'm more susceptible to stroke has allowed me to take measures to reduce that risk (through the anti-coagulant); on the other hand, I now have to be worried about a different risk--namely, internal bleeding. I appreciate your reluctance to offer advice; that's as it should be. However, hearing your perspective has indeed "shed some light." The one thing that continues to concern me is "With time, the heart even gets used to the new, changed way of functioning." I keep hearing, reading about the danger of the heart "remodeling" itself, so I question whether the heart's "getting used to the new way of functioning" is a good thing.

Hi and welcome and please know that many people go through what you are going through at present - and come through.

You have difficult decisions to make but you now have some knowledge.

As I read it your main concerns are

1. Fear of bleeding and what might happen if you do nothing ie: heart remodelling.

2. Fear of what may not happen if you have Cardioversion or Ablation or drugs.

Let’s take risks of bleeding concern :-

Firstly anticoagulants won’t cause a bleed but may make bleeds more difficult, but not impossible, to control in a massive bleed and just a little longer to stop in a minor one.

The risk of bleeding against the risk of stroke is the equation that needs balancing and with AF you are already 5 times more likely to have a stroke than someone with no AF. As you age then the statistics of stroking out with AF rise so as someone who’s already had a TIA when not on anticoagulants - I now think of them as my best friend.

Secondly what might happen if you don’t choose any treatment and heart remodels. From my very limited understanding - your heart wont’ function as well - it won’t push oxygenated blood around your body as well so before making any decisions I would want numbers.

What’s my current ejection fraction? ‘Mild’ dilation of atria - by how much and prognosis of it getting worse?

May I suggest you do some research and good place to start is the AFA and perhaps sign up to Patient Day - coming up in Oct.

You might also want to post on the BHF site.

My husband had a very low Ejection Fraction after having persistent AF for several years and as ablation wasn’t recommended for him, he took the drug route and it worked - took about 3 months and it’s a nasty drug but the improvement in his QOL at 87 years is quite amazing. So you also need to think long term.

The cardioversion will tell you if converting to NSR is possible so that will answer one very important question - ie: it’s possible. In my husband’s case NSR lasted 7 seconds but enough to know NSR was possible.

You may not be symptomatic now but as time goes on, you may find you can do less, become breathless and fatigue easily. Watch for those symptoms

Hope that has helped a little. Best wishes - CD.

Many thanks, CD, for your reply. It contains some information that I think will be very useful to me. Among the things new to me is the term "ejection fraction." I will investigate. You also suggest an obvious question to ask my EP, but one I didn't think of: " ‘Mild’ dilation of atria - by how much and what is the prognosis of it getting worse??" With regard to my worry about bleeding: It's less so about external bleeding and the inability to clot, and more about internal hemorrhaging, especially in the brain. I'd sort of like to keep the few wits I've still got for as long a time as possible. 😊

Glad to help. There are some studies which indicate that anticoagulants can be helpful for dementia. It’s always a balance of risk between clots which cause strokes and bleeds - neither are desirable. The newer DOACs have been shown to have less brain bleeds than Wafarin - I think Apixaban came out the best but you can research that too as information is constantly being updated.

My story is exactly the same as yours . Persistent asymptotic AF diagnosed 6 years ago. I had a successful cardioversion , took blood thinners Apixiban to reduce stroke risk if reoccurrence and bisophersal to help with flutters. 6 years later the same thing happened, routine visit to gp , ecg and told back in AF !

Cardiologist suggested Fleccainide - after 4 weeks heart reverted back to rythmn. Discussed with Cardiologist and agreed to stay on Fleccanaide as best chance of staying in rythmn.

I am 63 and fairly fit generally - don’t like talking the drugs really but prefer to have my heart ticking along nicely and have reduced stroke risk if it clicks out again.

Personal choice - hope that helps.

Thanks, Cricket. Good to hear your story. So far, my EP hasn't suggested an antiarrhythmic. Interesting to know that cardioversion kept you out of AF for a number of years.

Just a personal perspective on the heart remodelling worry. I was diagnosed with heart failure along with afib. Three months after my ablation I had another echo which showed an improvement in ejection fraction. They believe the heart failure was cause by the erratic heart beats not allowing the chambers of the heart time to fill with blood before being pumped out. Once I understood that AF isn’t a life shortening condition my main concern was getting off the drugs, long term, and for me that means a healthy heart in sinus rhythm. However there are no guarantees. After a decent three months it looks like my ablation has failed so I’m now having to explore further options. Whichever path you choose to go down, all the best!

Thanks, Safc, for sharing your experience. I definitely would like to get off drugs in the long term, if possible. At this point, after reading people's various responses and other postings, I'm disinclined to pursue ablation. I am, however, tending toward the cardioversion since it's comparatively non-invasive and will give me perhaps some useful information, even if it doesn't put me back into sinus rhythm permanently. I'm sorry to hear your ablation has failed. I wish you the best as you explore further options!

The name 'Cardioversion' sounds more scary than it is, I think. I went on a routine visit to my cardiologist at which he announced I was in AF - as it happens because of the traffic and limited parking at the hospital where he has his rooms, I got my son to drive me to my appointment. The Cardiologist asked me if I would like a cardioversion - he could do it that afternoon. Not sure what it involved I said, yes. I was admitted to the cardio ward spent the morning chatting to my neighbour - afternoon came I was given a sedative - vaguely recall some wires- next thing I was sitting up and eating a chicken sandwich,! after which I was allowed to dress and phone for my son to fetch me! As I'm asymptomatic I don't know when I'm in AF but my six monthly visit to my GP does not show me to be, and I refused to go near a hospital unless forced during the pandemic, now I have had my 2 Pfizer jabs, I'm seeing the cardio on Weds.!!

Thanks for sharing this story, pusillanimous. Your first sentence addressed my unexpressed immediate reaction when I first heard the name of the procedure: "Cardioversion." I know it involves an electrical shock, but the name conjures up in my mind images of an electrocution causing the heart to do somersaults. Glad to hear you found it to be hardly a disruption of your usual routine. Good luck on your next visit to the cardio!

My cardiologist was not in favour of ablation as it entailed physical changes to the tissue of the heart which couldn’t be reversed, whereas cardio version was, in his opinion, a safer, less intrusive procedure.I’ve had three cardio versions, none of which returned me to sinus rhythm for more than a few hours, but I’m now in permanent af, and can’t have cardioversion anyway as I contracted endocarditis and any physical intrusive action to my heart could allow another infection.

Thanks for your reply, P. I'm sorry to hear that cardioversion has not worked for you. I wish you the best as you consider your next steps.

I'm booked for another cardioversion on Friday. I had an ablation in April and I'm getting episodes of AF again so I'm hoping that the cardioversion will get me back on track again. I am less symptomatic than I was pre ablation. I know its usually viewed as a diagnostic tool but some folk have gone back into NSR and stayed there. My first one only lasted 4 days but I've also had one that lasted 3 years, helped by meds part of the time.

Thanks, Ducky. It is interesting to me to learn that there are many people, like you, who have had repeated procedures. I can't imagine I will go down that path, if only because I'm not experiencing symptoms and therefore don't feel uncomfortable. The main reason I'm considering the two procedures is concern over a worsening condition in the future and my desire not to have to stay on blood thinners if I don't absolutely have to.

Even if you convert to NSR it will depend upon your CHADSVASC score as to whether or no anticoagulants would be indicated.

My CHADS-VASC score is low: it's currently just 1 point, which comes only from my age (67). My EP said that in Europe I'd be put on anti-coagulants; in the US (where I live) he said it's a toss-up: 2 is the threshold where blood thinners are considered a definite recommendation. I decided in favor of it because, as I understand it, the risk of stroke, though low, is cumulative over time. Also, given that I'm in persistent AF I was concerned.

Of course I can’t tell you what to do. All I can do is share my experiences and leave it up to you.

With that said, I’m 62yo now and have been AF free for almost 4 years.

I was first diagnosed with AF at age about age 57. I had debilitating symptoms. Man when it came on all I could do was lay there and wait for my heart to go back into sinus rhythm. Sometimes as quickly as a few minutes but as time progressed it took overnight for my heart to return to normal. Eventually it became so frequent that I had no choice but to have an ablation.

My GP (who had AF too) was avoiding having the ablation and that heavily influenced my reluctance. Add in that I read of others who had to have the procedure multiple times, I put it off as long as I could.

But after having it done, (after two years of suffering) I told the surgeon, he way under sold it. My recovery was quick and my symptoms were gone as well as my AF.

After being AF free for six months my doctors agreed that I could stop the Xeralto and replace it with a daily low dose aspirin.

I ride a motorcycle and lived in fear of having an accident and having trouble stopping bleeding.

Since the ablation my stress levels are greatly reduced.

One of the things I was looking at if I had to stay on Xeralto was having the Watchman procedure. I read some good things about it.

Wishing you well and a positive outcome to your efforts.

GeorgeStevens profile image
GeorgeStevens in reply to sbsr

Thanks for sharing your experience, sbsr. I can well understand the reasons why you would pursue an ablation and be pleased with the results, since you were experiencing very debilitating symptoms. That you were able to put your AF into remission and get off Xarelto gives me hope. As for the Watchman procedure, I looked it up and found a rather persuasive critique of it by cardiologist Dr. John Mandrola. His blog post and recent article is called "The Case Against Watchman."

George, your case exactly mirrors mine and whether to have a cardioversion. Exception, I have mild symptoms (lack of energy) and higher heart rate (avg low 80's (70-85) resting, Occassionallly 90's when very active/stress). But I may be older (74). Diagnosed persistent AF in March '21.

What was your average HR when wearing the Zio patch ? Also, wore the Zio patch which indicated my HR zoomed past 150 for short periods (<30 seconds) on 1 or 2 occassions. I would suggest a followup with the Zio patch between 6 months - 1 year or sooner if you have symptoms if undecided on the cardioversion. Zio answers alot of questions.

I think the key is heart rate control. I am taking .50mg of metoprolol and Eliquis anticoagulant. Favor not having cardioversion at this time. If symptoms worsen, definitely. Would not be concerned about anticoagulants, your doctor knows the risks based on your history.

For you or anyone, what is meant by the term "heart remodeling" ?

GeorgeStevens profile image
GeorgeStevens in reply to mav7

Thanks, mav7. My average heart rate while on the Zio patch was 69 bpm. However, it went up to 176 once and down to 30. I think the upper value came on the day I took a strenuous hike and climbed up a little hill. When I got the report and saw the bottom number of 30 I kind of panicked. But when I saw my EP, he said it had occurred at night, and that it was usual for the HR to decline while sleeping. He wasn't concerned about it. He did, however, show some concern about (what I believe was) a 4 second (or beat?) gap in my heart beats. He suspects sleep apnea. For years I had been sleeping on my back, thinking this was the best position for lower back pain. Most recently I've learned that it's the worst position for someone who has sleep apnea. So that leaves side sleeping now, which is ok, except that my shoulder tends to get sore on the side I'm putting pressure on. So, I sleep for a while on one side, then wake up, go to the bathroom, and then return to bed to sleep on the other side, a pattern that gets repeated throughout the night. Thanks for the suggestion that I request a follow-up of the Zio patch in 6 months to a year. (You mentioned your age as 74. I'm just a few years younger at 67.)

mav7 profile image
mav7 in reply to GeorgeStevens

Wow, I can't believe how we mirror each other with AF.

On my first Zio avg HR was 62 with a high of 178. Also, had a 3 second gap. Second Zio avg was 82 high of 192, no gap but persistent AF.

If you are still able to maintain your excellent exericse regime and other activities with no adverse symptoms, this may affect your decision. From my research cardioversion is not always successful and AF returns. imo, it is meant to relieve major symptoms.

Another alternative is chemical conversion using drugs. I intent to discuss this with my cardiologist in Oct (next appt). See link below. If link doesn't work, just google chemical cardioversion for AF.

When you said "heart remodeling", what exactly is that ?


GeorgeStevens profile image
GeorgeStevens in reply to mav7

Thanks for the additional info and link. With regard to your question, heart remodeling involves the permanent restructuring of the heart, which is not good. I haven't yet researched it, however, so I can't say much more about it than that. There's been so much for me to learn and adjust to since I got my diagnosis on June 24th; plus, I find I need to parcel out the time I spend thinking about my AF so that it doesn't consume my every waking moment.

mav7 profile image
mav7 in reply to GeorgeStevens

need to parcel out the time I spend thinking about my AF so that it doesn't consume my every waking moment.

Great plan ! Since Feb I have became more receptive to my condition and I am sure you will.

Repeating myself, it is amazing how similar are our cases.

Thanks for your reply. Please keep us updated and I will do the same.

Hello George. Although you are asymptomatic, is your persistent AF affecting your ability to exercise and/or engage in extended heavy work? (i.e. any episodes of lightheadedness or breathlessness?). I would think it would, given that your fibrillating left atrium is not providing a normal level of blood volume to your left ventricle. As a former sufferer of PAF (with frequent very symptomatic episodes), I could never imagine having to go through life suffering with persistent or eventual permanent AF.

Luckily for me the cryo-PVI ablation I had done in August 2018 completely resolved my PAF situation - I've been in steady NSR since then and at age 64 I've never felt better.

Although anti-coagulants lessen the risk of ischemic stroke due to AF, they don't eliminate the heightened risk. Personally, if I had persistent AF I would be actively pursuing a cardioversion or an ablation (PVI or other type of ablation) that would put me back in NSR (and in the case of ablation, ideally keep me there).

Good luck with your condition.

Cheers Richard

Hi Richard. Thanks for your input. So far, my AF hasn't affected my ability to exercise or to do "extended heavy work." But I must confess: I've never been a doer of "extended heavy work," nor have I been an avid exerciser. Before Covid, I would go to the gym on a regular basis; now, I just do my daily walks that average around 2.5 to 3 miles. I've been wary of pushing myself to do strenuous exercise since my diagnosis. All this is new to me, so I don't know whether it's advisable or not. While I like my EP, the duration of our appointments is limited. So far, I've only met with him twice: the first time was 40 minutes; follow-up was 20 min; both times we went over. Nevertheless, I haven't been able to get all my questions answered. Good to hear that your ablation was successful and that you're doing well. May it continue!

TracyAdmin profile image

Welcome to the Forum George ! If you require any information or advice, please do contact the A F Association You may also benefit from viewing our online US patient resources

Thanks for the hearty welcome, Tracy. My use of the word "advice" in my original post was perhaps ill-chosen. I realize no one can "advise" me on what to do; that's for me and the medical professionals I consult to figure out. I appreciate your referrals to resources. I'll be sure to check them out!

TracyAdmin profile image

You are welcome, and yes very wise words, always seek medical advice. I would recommend you join us the 'virtual' HRC2021 A F Association Patients Day - launching online on Sunday 3rd October 2021, follow the link for details

Thanks for your recommendation to attend the AF Association Patients Day. The main drawback for me is the time difference: I'm in the US on PST, so when the P Day begins at 10 am (BST), it'll be 2 am for me, which is a bit early for me to be getting up, even on a bad night.

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