- Consultation for Catheter Ablation
- Preparing for the Ablation Procedure
- Day of the Ablation Procedure
- Hospital Stay After the Ablation Procedure
- After the Ablation Procedure
Consultation for Catheter Ablation
At UCSF, there is a team of doctors, nurses, and technicians who all play a role in performing your procedure. We perform more than 500 ablation procedures each year. You will first meet with one of the UCSF heart rhythm physicians and nurse practitioners to discuss whether you are a candidate for an ablation procedure. This depends on what symptoms you have from from your fast heart rhythm, whether there is a serious or life-threatening risk, and if you have any other coexistant heart disease. We also see many patients for second opinions about ablation, particularly if you have have complex heart disease or recurrences of your arrhythmia after ablation at other centers. You will discuss with your physician what to expect during and after the ablation procedure, and what are the benefits and risks. Your physician and nurse will discuss what tests are needed prior to ablation (generally an echocardiogram, stress test, ECG and and blood tests). If your doctor has already performed these tests, bring copies of the results and any relevant records of prior treatment of your heart or heart rhythm to your visit.
Your physician will also discuss with you the risks of catheter ablation. The risks are infrequent, but potentially serious, and vary depending on the ablation procedure. Some possible risks your doctor may discuss include bleeding in the groin at the catheter puncture sites, damage to the heart or blood vessels, or heart block requiring placement of a pacemaker.
Preparing for the Ablation Procedure
If you and your physician agree to have an ablation procedure, you will meet with one of the electrophysiology team nurse practitioners, Pat Malone, RN, MSN, NP or Lutsiya Ibragimova. They will review what to expect before, the day of, and following the ablation procedure. Most ablations are performed as outpatients, however after ablations for atrial fibrillation (AF) and ventricular tachycardia (VT), patients generally stay for one night in the hospital following the ablation. UCSF will check with your insurance company that the procedure is covered, and obtain pre-approval before your arrival.
During the week prior to ablation, you will receive a phone call from the PREPARE clinic, when you will discuss your history with an anesthesiologist. Most ablations are performed with sedation delivered by an anesthesiologist. Ablations for supraventricular tachycardia (SVT) are generally performed with conscious sedation in which you are awake but relaxed, while more complicated ablations such as AF or VT are performed under general anesthesia.
During your prepare phone call, the anesthesiologist will discuss the anesthesia to be used and can answer any concerns you may have about the anesthesia. If you have significant heart or lung disease, the anesthesiologist may ask to meet you in person before the procedure. If you are having an AF ablation, you will also undergo a CT scan or MRI of the heart prior to the procedure. This is to determine the anatomy of your pulmonary veins (everyone has a different branching pattern); your doctor can use the image during the procedure to guide the ablation. You will also receive a lab slip to have blood drawn during the week prior to ablation. This is to make sure there are no abnormalities with your electrolytes, blood count, or blood thinning before the ablation procedure.
If you are on a heart rhythm medication, you will be asked to stop it several days before the procedure so your doctor can be sure to localize and ablate all the AF triggers. If you are on a medication to control the heart rate, you will be asked to hold it the day of the procedure. If you are on warfarin, it may be continued through the ablation procedure or held for several days before, depending on your doctor’s preference, blood thinning level, and whether you have an artificial heart valve. Other blood thinners such as dabigatran or rivaroxaban are generally held the day of the procedure. You should not eat anything after midnight on the day prior to your ablation procedure. If you are taking other medications, you may take these the morning of the procedure with a sip of water. The cardiac electrophysiology nurse will review with you what medications you should take the morning of the procedure. If you wish to come to the UCSF area the night before, a list of discounted area hotels can be provided.
Day of the Ablation Procedure
The day of the procedure you will be asked to come to the hospital at 6:30 a.m. You will meet the anesthesiologist attending your procedure, have an IV placed, and have your chest and groin shaved. If you are undergoing an AF ablation, you may also need a transesophageal echocardiogram (TEE) prior to the procedure. This is performed after you are asleep by inserting a small tube into your esophagus (swallowing tube) to be sure there are no clots in your heart before performing the procedure.
You will meet the TEE fellow and attending in the morning. You will also meet the electrophysiology fellow involved in your procedure with your attending physician. The idea that trainees are involved in the procedure sometimes leads to some anxiety. You should rest assured that have a second physician involved in the procedure is actually a great help to your attending physician. The fellows at UCSF are some of the best in the country. The fellows involved in AF ablations have completed a general cardiology fellowship, and already have extensive experience performing electrophysiology procedures, including AF ablation. There are multiple sources of information being monitored, including the electrical signals recorded inside your heart, the mapping system, intracardiac echocardiography, fluoroscopy, etc. Having a second doctor contributing to the procedure makes it easier for your attending to perform the procedure. The length of the procedure may vary from 1-2 hours to 6-8 hours, depending on the complexity of the procedure. There is a waiting room outside the electrophysiology laboratory available for family members.
Hospital Stay After the Ablation Procedure
After the procedure, you will be taken to the holding area if you received conscious sedation, or to the post-anesthesia care unit (PACU) if you received general anesthesia. Some nausea and grogginess is normal. Even though your doctors may talk to you after the procedure, you may not remember this – short-term memory loss can be an effect of the anesthesia. You will need to lie flat for 4-6 hours after ablation to allow the groin sites to heal. These are not stitched closed; pressure is merely help after the catheters are removed. If your ablation was a straightforward ablation for SVT, you may be discharged home from the EP recovery area. The EP team will give you a list of medications to continue and prescriptions for any new medications, as well as instructions for any restrictions. If any questions or concerning symptoms occur after discharge, you can call one of the EP nurses during the day at 415 476-5706. After hours, the EP fellows and an attending EP physician are on call for emergencies.
If you are having an AF or VT ablation, you will spend the night in a hospital bed while we monitor your heart rhythm. You may be started back on some of your outpatient medications. If you had a Foley catheter placed in your bladder at the beginning of the procedure, this will be removed once you can get out of bed.
You will be monitored by the electrophysiology staff after the procedure. A determination will be made if it is safe for you to go home. Prescriptions will be given to you for any new medications, and your medical regimen reviewed. You will be given a list of your medications, follow-up appointments, and any instructions and important contact numbers when you leave the hospital.
After the Ablation Procedure
It is normal to feel “out of sorts” for a few days after the procedure. You may also have some discomfort in your chest when taking a deep breath for a few days – this is related to inflammation around the heart after the procedure. You should call your nurse or doctor if you experience:
- Worsening chest pain
- Bleeding from your groin puncture sites 30 or a fever higher than 100 degrees F°
- Pain or difficulty swallowing
- Difficulty or pain with urination
- Worsening shortness of breath
- Worsening swelling, particularly if asymmetric
- Worsening cough, particularly if coughing up colored or blood-tinged sputum.
During the few weeks after an AF ablation procedure, it is possible that you may still have some episodes of AF. This is related to irritability and should improve during the healing process. You will be sent home with a small heart card monitor so that you can transmit your heart rhythm to us over the phone with any AF symptoms. Call you doctor if you feel you are back in AF persistently. We generally favor early cardioversion if the AF persists to help facilitate the remodeling process and help your heart learn to stay in a normal rhythm. You will typically remain on a blood thinner for at least the first month after an AF ablation. You should have an appointment with your doctor within 4-6 weeks of hospital discharge.
Can anticoagulation be stopped after catheter ablation of AF?
Regardless of your stroke risk profile (see medical management of AF), your physician will typically place you on anticoagulation for at least 1-3 months following ablation. According to the AHA/ACC guidelines, anticoagulation after AF ablation should be guided by the CHADS2 risk score rather than AF symptoms. However, at some point one must weight the risks of anticoagulation against the benefits in the absence of clinical AF.
Drs. Randy Lee and Nitish Badhwar are pioneering a new technique combining removal of the left atrial appendage with pulmonary vein isolation to treat AF. The left atrial appendage, in addition to being the main source of clot formation in AF, can also be a common trigger site in persistent AF patients. Dr Lee has developed a procedure to allow removal of the left atrial appendage using catheters similar to those used in ablation, without needing to open the chest (see LAA removal below). By combining this procedure with AF ablation, we hope to be able to improve the success rate of ablation in persistent AF patients and eliminate the need for anticoagulation.