What is pulmonary vein ablation?
Pulmonary vein ablation (also called pulmonary vein antrum isolation or PVAI), is a treatment for atrial fibrillation. Atrial fibrillation is an abnormal heart rhythm that originates in the top chambers of the heart (atria).
Electrical system of the heart
The atria and ventricles work together, alternately contracting and relaxing to pump blood through the heart. The electrical system of the heart is the power source that makes this possible.
Normally, the electrical impulse begins at the sinoatrial (SA) node, located in the right atrium. The electrical activity spreads through the walls of the atria, causing them to contract.
Next, the electrical impulse travels through the AV node, located between the atria and ventricles. The AV node acts like a gate that slows the electrical signal before it enters the ventricles. This delay gives the atria time to contract before the ventricles do. From the AV node, the electrical impulse travels through the His-Purkinje network, a pathway of specialized electricity- conducting fibers. Then the impulse travels into the muscular walls of the ventricles, causing them to contract. This sequence occurs with every heartbeat (usually 60-100 times per minute).
With atrial fibrillation, the SA node does not direct the heart’s electrical rhythm. Instead, many different impulses rapidly fire at once, causing a very fast, chaotic rhythm in the atria. Because the electrical impulses are so fast and chaotic, the atria cannot contract and/or squeeze blood effectively into the ventricle.
Treatment for atrial fibrillation
The goals of treatment for atrial fibrillation include regaining a normal heart rhythm (sinus rhythm), controlling the heart rate, reducing symptoms, and reducing the risk of blood clots and stroke. Many options are available to treat atrial fibrillation, including lifestyle changes, medications, catheter-based procedures and surgery.
The type of treatment that is recommended for you depends on the severity of your symptoms, prior treatments, and other medical conditions that may affect the risk of treatment. Initially, medications are used to treat atrial fibrillation. The medications may include:
- Rate control medications (to slow the heart rate)
- Rhythm control medications (antiarrhythmic drugs)
- Coumadin (warfarin – an anticoagulant or blood thinner) to reduce the risk of blood clots and stroke
When is pulmonary vein ablation appropriate?
Pulmonary vein ablation procedure: Energy is delivered through the tip of the catheter to tissue that is targeted for ablation. The energy is applied in a circle around the connection of the left upper and lower pulmonary veins to the left atrium.
Image © Cleveland Clinic Journal of Medicine, 2009. 76(9):545. Used with permission.
Pulmonary vein ablation is one option used to treat atrial fibrillation and may be most appropriate for patients who:
- Have continued symptoms of atrial fibrillation, despite treatment with medications
- Can not tolerate antiarrhythmic drugs, or have had complications from these drugs
Research has shown that atrial fibrillation usually begins in the pulmonary veins or at their attachment to the left atrium. There are four major pulmonary veins and all may be involved in triggering atrial fibrillation.
What happens during the ablation procedure?
During pulmonary vein ablation, a doctor inserts catheters (long, flexible tubes) into the blood vessels of the leg, and sometimes the neck, and guides the catheters into the atrium. Energy is delivered through the tip of the catheter to tissue that is targeted for ablation. The energy is applied around the connections of the pulmonary veins to the left atrium. Frequently, other areas involved in triggering or maintaining atrial fibrillation are also targeted.
Small circular scars eventually form and prevent the abnormal signals that cause atrial fibrillation from reaching the rest of the atrium. However, the scars created during this procedure may take from 2 to 3 months to form. Once the scars form, they block any impulses firing from within the pulmonary veins, thereby electrically “disconnecting” them or “isolating” them from the heart. This allows the SA node to once again direct the heart rhythm and a normal sinus rhythm is restored.
Because it takes several weeks for the lesions to heal and form scars, it is common to experience atrial fibrillation early during the recovery period. Rarely, atrial fibrillation may be worse for a few weeks after the procedure and may be related to inflammation where the lesions were created. In most patients, these episodes subside within 1 to 3 months.
How effective is the ablation procedure in treating atrial fibrillation?
Cleveland Clinic has extensive experience with atrial fibrillation ablation procedures, and we track our patients carefully to be certain our data is accurate.
Left Atrial Appendage (LAA)
Patients who have treatments for atrial fibrillation often ask about Left Atrial Appendage Closure.
How can I be evaluated for the procedure?
How can I be evaluated for the procedure?
If you are currently being treated outside of Cleveland Clinic, please schedule an appointment by calling 216.444.6697 or toll-free 800.223.2273 ext. 46697 to schedule an evaluation.
Or, you may use our web-based second opinion service, eclevelandclinic.org. This service offers a second opinion from one of our medical specialists from the convenience of your home. To learn more about this service, please visit the web at my.clevelandclinic.org/online-services/myconsult.aspx or call 800.223.2273 ext. 43223.
If you are a Cleveland Clinic patient and are receiving treatment for your atrial fibrillation, ask your cardiologist if pulmonary vein ablation is an appropriate treatment option for you.
If you have additional questions about the procedure, please call your physician's office.
Normal Heart Rhythm Electrocardiogram
The heart’s electrical system triggers the heart beat. Each beat of the heart is represented on the electrocardiogram (ECG) by a wave arm. The normal heart rhythm (also called normal sinus rhythm) illustrated above shows the electrical activity in the heart is following the normal pathway, the rhythm is relatively slow and regular (about 50 to 100 beats per minute).
Atrial Fibrillation Electrocardiogram
With atrial fibrillation, many different impulses rapidly fire at once, causing a very fast, chaotic rhythm. The resulting heartbeat is irregular, ranging from about range from 100 to 200 beats per minute.
To determine if ablation is an appropriate treatment, a thorough evaluation will be performed, which may include:
- A review of your medical history
- Complete physical examination
- Electrocardiogram (ECG)
- Echocardiogram (echo - an ultrasound to evaluate your heart function and heart valves)
- Holter monitor test (a 24-hour ECG)
After the evaluation, the doctor will talk with your about your treatment options and together you will determine if you are a candidate for this procedure.
Experience is important
Pulmonary ablation requires special expertise. Physician credentials and experience lead to better outcomes. At Cleveland Clinic, more than 5,700 pulmonary ablation procedures were performed from 2004 to 2010.
The vast experience Cleveland Clinic physicians have helps to reduce procedural risks. We are equipped and prepared to quickly intervene if a complication does occur.
Additionally, the circumferential mapping technique used during the pulmonary vein ablation procedure was pioneered in the Cleveland Clinic Electrophysiology Lab.
What are the possible risks of the procedure?
Your doctor will discuss the specific risks and potential benefits of the pulmonary vein ablation procedure with you. The procedure is generally very safe. However, as with any invasive procedure, there are risks that we track very carefully. These risks are explained below.
- The risk of a severe or life-threatening complication associated with pulmonary vein antrum isolation is about 1 to 3 percent. These complications include, but are not limited to:
- Stroke (approximately 0.5 percent)
- Damage to the pulmonary veins (1 percent)
- Perforation of the heart (1 percent)
- Damage to the esophagus: The risk of damage to the esophagus is difficult to predict because it is very rare, but happens in approximately 1 in 400 patients.
- The risk of dying from a complication is about 0.1 percent.
- There have been isolated reports of bloating and abdominal distension after the procedure. This may be related to injury to nerves that control the contraction of the stomach muscles. It tends to resolve slowly.
- Other uncommon risks, associated with any X-ray procedure, include an allergic reaction to medication or contrast material and skin injury caused by exposure to X-rays.
- There may be other possible risks. When you meet with your doctor, please ask questions to make sure you understand why the procedure is recommended and all of the potential risks.
Physicians take special precautions to avoid all complications, but risks cannot be entirely eliminated. The vast experience Cleveland Clinic physicians have helps reduce procedural risks. In addition, we are equipped and prepared to quickly intervene if a complication occurs.
You should weigh the risks of the procedure with the risks of having atrial fibrillation (which includes spontaneous strokes) and the severity of your symptoms.
Also, please discuss any concerns you may have about lying flat on your back for a prolonged period (3 to 6 hours) during the procedure.
Long-term treatment goal
Long-term treatment goal
The long-term goal of the pulmonary vein ablation procedure is to eliminate the need for medications to prevent atrial fibrillation. Most patients can stop taking Coumadin a few months after the procedure, as long as they do not have a high risk of stroke.
Even patients who are not completely cured of atrial fibrillation may benefit from the ablation procedure because the procedure helps them have a better response to medications that were previously ineffective.
It is difficult to predict whether your atrial fibrillation will be completely cured or whether you may still require medication after the procedure. Our goal is to eliminate the need for medications, and this goal is achieved in the majority of patients.
Success rate for single ablation procedure
The success rate for a single pulmonary vein ablation procedure depends on several factors. The highest cure rate is achieved in patients with paroxysmal atrial fibrillation in whom atrial fibrillation stops on its own within 1 to 3 days. A single pulmonary vein ablation procedure is completely curative in approximately 75 to 80 percent of patients with paroxysmal atrial fibrillation that is not associated with any other heart disease.
A single ablation procedure is less likely to cure patients who have had atrial fibrillation constantly for months or years and in patients who have extensive scarring in the atrium because of other heart disease. Nonetheless, patients with long-standing atrial fibrillation can be cured with a success rate of 50 to 70 percent, depending on their underlying heart disease and other factors. These patients are more likely to require more than one ablation procedure.
Success rate for repeat ablation procedure
Approximately 20 to 30 percent of patients require a second pulmonary vein ablation procedure because of recurrent atrial fibrillation that cannot be controlled with medications. Patients with other types of heart disease are more likely to need a second procedure. Second ablation procedures are generally very successful. Ablation of atrial fibrillation is successful in approximately 90 percent of patients with paroxysmal atrial fibrillation who undergo one or more ablation procedures.
You will receive an instruction sheet that describes how to prepare for the procedure. Here’s an overview of those instructions.
What can I expect during the procedure?
Getting Ready: Before the procedure begins, a nurse will help you get ready. You will lie on a bed and the nurse will start an IV (intravenous line) in a vein in your arm. The IV is used to deliver medications and fluids during the procedure. A medication will be given through your IV to make you feel drowsy. Your neck, upper chest, arm and groin will be cleansed with an antiseptic solution. The catheter insertion site(s) will be shaved. Sterile drapes will be placed to cover you from your neck to your feet.
Symptoms/How You’ll Feel: You may fall asleep at times during the procedure, due to the medication given to make you relax. You will feel an initial burning sensation when the doctor injects medication in the catheter insertion site.
You may feel some discomfort or a burning sensation (like heartburn) in your chest when the energy is applied through the catheter. It is important to remain quiet, keep very still and avoid taking deep breaths. If you are feeling pain, your doctor or nurse can give you more medication.
An anesthesiologist is available to administer deeper sedation if required to help keep you comfortable.
What Happens During the Procedure: After you become drowsy, the doctor numbs the catheter insertion sites by injecting a medication. The doctor inserts several catheters (long, flexible tubes) into large veins in both sides of your groin and sometimes in your neck. The catheters are advanced to the heart.
Two of the catheters are guided into the left atrium through a small hole made with a needle and placed in the atrial septum (wall between the right and left atria).
A transducer is inserted through one of the catheters so intracardiac ultrasound can be performed during the procedure. The ultrasound allows the doctor to view the structures of the heart and evaluate the position of the catheters during the procedure.
A catheter in the left atrium is used to find or map the abnormal impulses coming from the pulmonary veins. Another catheter is used to deliver the radiofrequency energy outside and around the pulmonary veins.
How Long the Procedure Lasts: The pulmonary vein ablation procedure may last from 4 to 6 hours. Each patient is different. Please let your family know that the preparation and recovery time take several hours, so they should plan to be at the hospital all day for your procedure.
Where is the procedure performed?
The pulmonary vein ablation procedure takes place in the Electrophysiology (EP) Lab with X-ray equipment and several monitors.
Monitors used during the procedure
PVI - atrial flutter ablation
Several monitors will be used during the procedure to check your heart rhythm and your body’s responses to any arrhythmias that occur.
- Defibrillator/pacemaker/cardioverter: Attached via wires to one sticky patch placed on the center of your back and one on your chest. This device allows the doctor and nurse to pace your heart rate if it is too slow, or deliver energy to your heart if the rate is too fast.
- Electrocardiogram or EKG: Attached to several sticky electrode patches placed on your chest. Provides a picture on the monitors of the electrical impulses traveling through the heart.
- Blood pressure monitor: Connected to a blood pressure cuff on your arm. Checks your blood pressure throughout the procedure.
- Mapping system: State-of-the-art technology that helps your doctor locate the exact area of your arrhythmia.
- Ablation machine: Attached to another sticky patch on your back.
- Oximeter monitor: Attached to a small clip placed on your finger. Checks the oxygen level of your blood.
- Fluoroscopy: A large X-ray machine will be positioned above you to help the doctors see the leads on an X-ray screen during the procedure.
- Intracardiac ultrasound: Performed by a catheter transducer inserted into the heart: Used throughout the procedure to view the structures of the heart and the catheter when it is in contact with the heart lining.
What can I expect after the procedure?
Discussing the Procedure Results: After the procedure, the doctor will discuss the results of the procedure with you and your family.
Overnight Hospital Stay: You will be admitted to the hospital and stay overnight after the procedure for observation. Most patients are discharged from the hospital the following morning.
In your hospital room, a telemetry monitor will be used to evaluate your heart rate and rhythm during your recovery. Telemetry consists of a small box connected by wires to your chest with sticky electrode patches. The box displays your heart rhythm on several monitors in the nursing unit.
The doctor will remove the catheters and apply pressure to the insertion site to prevent bleeding. No stitches are needed. To reduce the risk of bleeding and bruising, a pressure dressing (bandage) will cover the catheter insertion sites in your leg and neck.
You will need to stay in bed for 6 to 8 hours after the procedure. You’ll need to keep your legs still during this time to prevent bleeding.
Symptoms/How You’ll Feel: You may feel general soreness, fatigue or chest discomfort during the first 48 hours after the procedure.
Because it takes several weeks for the lesions to heal and form scars, it is common to experience abnormal or irregular heartbeats for 8 to 10 weeks after the procedure.
Rarely, atrial fibrillation may be worse for a few weeks after the procedure and may be related to inflammation where the lesions were created.
Driving Home: For your safety, a responsible adult must drive you home.
Activity: Usually you can return to your normal activities within 48 hours after the procedure. For one week after the procedure, you cannot lift anything that weighs more than 10 pounds. You should wait at least three weeks before you resume intense exercise.
Medications: For at least 3 months after the procedure, you will need to take the anticoagulant medication Coumadin (warfarin) to prevent blood clots and reduce the risk of stroke. You may need to continue this medication for longer than 3 months, depending on your individual risk for stroke.
You also may need to take an antiarrhythmic medication to control abnormal heartbeats for 2 months after the procedure.
You will receive the necessary prescriptions and medication instructions from your doctor.
Ask your doctor if you should keep taking the medications you took before you had the procedure. In some cases, your doctor may recommend additional treatments or medications to control abnormal heartbeats during the first 2 months after the procedure.
Blood Tests: You must have frequent blood tests (called INR/Protime) to evaluate your dosage of Coumadin. Your doctor will tell you how often to have this test. Please schedule these blood tests with your local doctor’s office.
You will need to come to Cleveland Clinic for a follow-up appointment about 3 months after the procedure. This appointment is usually scheduled before you go home.
Cleveland Clinic's Center for Atrial Fibrillation is a multidisciplinary specialty treatment group dedicated to the diagnosis and treatment of AF– whether it is chronic (persistent) or paroxysmal (comes and goes). Since 2004, we have seen thousands of patients in the center. This experience and knowledge, combined with a caring staff, provides you with quality patient care.
Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.
Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, please review our Miller Family Heart and Vascular Institute Outcomes.
Cleveland Clinic Heart and Vascular Institute Cardiologists and Surgeons
Choosing a doctor to treat your abnormal heart rhythm depends on where you are in your diagnosis and treatment. The following Heart and Vascular Institute Sections and Departments treat patients with Arrhythmias:
- Section of Electrophysiology and Pacing: cardiology evaluation for medical management or electrophysiology procedures or devices - Call Cardiology Appointments at toll-free 800.223.2273, extension 4-6697 or request an appointment online.
- Department of Thoracic and Cardiovascular Surgery: surgery evaluation for surgical treatment for atrial fibrillation, epicardial lead placement, and in some cases if necessary, lead and device implantation and removal. For more information, please contact us.
- You may also use our MyConsult second opinion consultation using the Internet.
The Heart and Vascular Institute also has specialized centers to treat certain populations of patients:
For younger patients with abnormal heart rhythms:
See: About Us to learn more about the Sydell and Arnold Miller Family Heart & Vascular Institute.
If you need more information, click here to contact us, chat online with a nurse or call the Miller Family Heart and Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
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