2nd Ablation including Mapping?

[Cablecar]

I had my 1st ablation in July of this year - Pulse Field Ablation - which was only partially successful. My EP has offered to do a 'redo' ablation which will involve 'mapping', implying a more targeted approach; this will be via RF ablation. Has anyone else come across this scenario? If so, did this prove to get better results? I wonder why this approach wasn't adopted the first time round. Maybe it wasn't possible with Pulse Field Ablation.

[mjames1]

This is a typical scenario. The reason they didn't use RF the first time is because studies have shown that a basic PVI is all that is needed for first time paroxysm and additional burning can be counterproductive. Therefore extensive mapping is often not used as it can add time and complexity to the procedure.

Now that you're a fib is back, they will go beyond the PVI and do a more targeted approach with RF. Had they used RF instead of PFA for your first ablation, it probably would've been the same scenario meaning doing only a PVI with the RF first time around, again with limited mapping. So do not think you missed out on anything.

Jim

[Cablecar in reply to mjames1]

Thanks Jim. That's reassuring.

[Cliff_G]

I don't know a lot about pulsed field ablation, but the first ablation for AF is often/usually a Pulmonary Vein Isolation (PVI) where a ring of heart tissue around each of the 4 pulmonary veins is cauterised to stop the places in the pulmonary vein connection areas from feeding electrical signals in to the main part of the left atrium and kicking off AF. I suspect your first ablation may have been this.

The EPs decide when to stop ablation based on an acceptable "end point", which is often the inability to provoke fibrillation again (often using a small chemical infusion). If your ablation achieved this, then the EP probably would have stopped. Whether they used a mapping for that ablation I don't know. I would have thought that these days they would. (My first ablation was 2002 when they didn't have the modern mapping systems they have now.)

However, there are several other places where arrhythmias can be initiated, notably in the right atrium "isthmus" next to the valve, which is a common place where atrial flutter can occur, similarly an isthmus in the left atrium, sometimes the back wall of the left atrium, and finally other somewhat random places where spurious beats can start ("foci"). Whilst a PVI 'can' be done without mapping, I would say all these other places would need to be identified and confirmed first, and this is where mapping comes in. They can actually "see" the spurious electrical paths in this way. Search online for Carto mapping; there are many examples. My recent (2 months) ablation found a focus on the back wall and one by the left atrial appendage, and my ablation of these was successful.

There should be no problem with asking your EP about these matters, but hopefully I've outlined some of the issues. HTH

[mjames1 in reply to Cliff_G]

Well explained.

As to poking around and trying to induce afib outside of the pulmonary veins on an initial paroxysm ablation, I've read that there is no association between being able to induce afib this way and final outcome. That's why many ep's don't do it, saving the patient from unnecessary burns and longer procedure times.

On the other hand, if they note scarring in the atrium during the procedure, which is typical of "persistent" afib regardless of history, they might go beyond the pulmonary veins the first time.

Jim

[Cliff_G in reply to mjames1]

Thanks. A lot to learn.

I think a right common flutter cavo-tricuspid isthmus is not uncommon on the first go, certainly was when I had mine in 2002, but that was a long time back. The mapping on my recent ablation showed all the original ablation areas were still holding. Pretty good considering I was basically "permanent" when I had it.

[Cablecar in reply to Cliff_G]

Thanks very much to both of you. There's lot to consider. I can say that the EP was happy with the way the 1st ablation went, without going into any details.

[Jajarunner]

They do just pulmonary veins the first time. Then they map and target more accurately on subsequent ablations whether RF or PFS or mixture which is what my recent one was.

[Cablecar in reply to Jajarunner]

Thanks Jajarunner, it's good to know that nothing is amiss.

[HughPercy]

I had cryo ablation in April and now have same scenario - it worked for a bit but AF is back and I also now have bigeminy - my consultant is doing some mapping and wants to do another ablation - just waiting for a date

[Cablecar in reply to HughPercy]

Thanks and Good luck

[Gladstone001]

Hi Cablecar, I wrote a post on this general subject after my 4th ablation a few weeks back:

healthunlocked.com/afassoci...

Hope this helps.

Gladstone

[Cablecar in reply to Gladstone001]

Thank you Gladstone. It was helpful and I hope things continue to go well for you.

[Guelemon]

I’ve heard of people needing a second ablation with RF after Pulse Field didn’t work completely. From what I understand, Pulse Field Ablation is newer and might not be as precise in some cases, which could be why they didn’t go with RF from the start. RF allows for more detailed mapping, so it might give you better results. I haven't gone through this myself, but a friend had a similar situation and felt the second procedure really helped. It’s definitely worth asking your EP why they’re going with RF now and if it’s something they could’ve used earlier.

[Cablecar in reply to Guelemon]

Thanks Guelemon. I'm pretty sure that I made up his mind for him by asking for PFA from the start. I heard that it was a quicker procedure and leaves the patient with fewer aches and pains afterwards. I've had problems in the past in the operating theatre and wanted to minimise any risks involved.

[Gladstone001]

Hi,

I have just had a "touch-up" or re-do ablation. I wrote about it here:

healthunlocked.com/afassoci...

As I understand it, the current pulsed field catheters are only able to do PV isolations (i.e. they are pushed up or pulled against the vein opening and do a circular lesion) as is the case with the cryo balloon catheters. RF is a single tip and can be used throughout the atria and therefor well suited to block new pathways or re-block old lesions which are now unblocking.