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).
Atrial Fibrillation and The Electrical System of The Heart
When the heart beats normally, the electrical impulse begins at the sinoatrial (SA or sinus) node in the right atrium. The SA node produces the electrical impulses that set the rate and rhythm of the heart beat. The electrical activity spreads through the walls of the atria and causes them to contract. The electrical impulse then crosses the AV node and spreads down to the ventricles, causing them to contract. This creates the heart beat.
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 illustration to the right shows a normal heart rhythm (also called normal sinus rhythm).The electrical activity in the heart is following the normal pathway, and the rhythm is relatively slow and regular (about 50 to 100 beats per minute).
In patients with atrial fibrillation, the SA node does not direct the heart’s electrical rhythm. Instead, many different impulses rapidly fire at once. This causes a very fast, chaotic rhythm in the atria. Because the electrical impulses are so fast and chaotic, the atria cannot contract and/or effectively squeeze blood into the ventricle.
Atrial Fibrillation Electrocardiogram
In patients with atrial fibrillation, many different impulses rapidly fire at once. This causes a very fast, chaotic rhythm. The heart beat is irregular and fast (100 to 200 beats per minute).
Treatment for Patients with Atrial Fibrillation
Treatment goals for patients with atrial fibrillation include restoring a normal heart rhythm (sinus rhythm), controlling the heart rate, reducing symptoms, and reducing the risk of blood clots and stroke. Many treatment options are available, including lifestyle changes, medications, catheter-based procedures and surgery.
The type of treatment that is best for you depends on the severity of your symptoms, prior treatments, and other medical conditions you may have. Medications are the first step in treatment. These may include:
- Medications to slow your heart rate
- Medications to control your heart rhythm (antiarrhythmic drugs)
- An anticoagulant (blood thinner) to reduce your risk of blood clots and stroke
Who should have pulmonary vein ablation?
Pulmonary vein ablation may be the best treatment option for patients who:
- Still have symptoms of atrial fibrillation, even after treatment with medications
- Cannot tolerate antiarrhythmic drugs, or have had complications from these drugs
Research has shown that atrial fibrillation usually begins in the pulmonary veins or at the point where they attach to the left atrium. There are four major pulmonary veins. All may trigger atrial fibrillation.
Patients who have treatments for atrial fibrillation often ask about Left Atrial Appendage (LAA) Closure.
Are you a candidate for pulmonary vein ablation?
To determine if ablation is an appropriate treatment, you will have a thorough evaluation. This 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, your doctor will talk with you about what your best treatment option is and whether you are a candidate for this procedure.
How effective is the ablation procedure in treating atrial fibrillation?
Cleveland Clinic has extensive experience with atrial fibrillation ablation procedures. We carefully track our patients to be certain our data are accurate.
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. Between 75 and 80 percent of these patients whose atrial fibrillation is not related to any other heart disease are completely cured with one pulmonary vein ablation procedure.
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 1 ablation procedure.
Success rate for repeat ablation procedure
Approximately 20 to 30 percent of patients need 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 have one or more ablation procedures.
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 an anticoagulant a few months after the procedure because their risk of stroke is lessened.
Even patients who are not completely cured of atrial fibrillation may benefit from the ablation procedure. The procedure helps them have a better response to medications that weren’t effective in the past.
It is difficult to predict whether your atrial fibrillation will be completely cured or if you will need to keep taking medication after the procedure. Our goal is to eliminate the need for medications. This goal is achieved in most patients.
Experience is Important
Pulmonary ablation requires special expertise. Physician credentials and experience lead to better outcomes. At Cleveland Clinic, more than 6,500 pulmonary ablation procedures were performed since 2004.
The vast experience Cleveland Clinic physicians have helps 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.
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, including medication 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: The medication you receive to relax you may cause you to fall asleep at times during the procedure. You will feel a burning sensation when the doctor first injects medication in the area where the catheter will be inserted.
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 feel pain, the doctor or nurse can give you more medication.
An anesthesiologist is available if you need to be more heavily sedated to stay comfortable.
Please note: In some cases, general anesthesia is used. Your doctor will discuss the type of sedation that will be used during your procedure, as well as the risks, before you have the treatment.
What happens during the ablation procedure?
After you become drowsy, the doctor injects medication to numb the catheter insertion sites. The doctor inserts several catheters (long, flexible tubes) into large veins in both sides of your groin and possibly 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. This is used for intracardiac ultrasound. The ultrasound lets the doctor see the structures of the heart and correctly position the catheters.
A catheter in the left atrium is used to find (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 does the procedure last?
The pulmonary vein ablation procedure may last 4 to 6 hours. Each patient is different. Please let your family know that the preparation and recovery time take several hours. They should plan to be at the hospital all day. You will stay in the hospital overnight.
Monitors used during the procedure
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 (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 a 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 positioned above you to help the doctors see the leads on an X-ray screen during the procedure.
- Intracardiac ultrasound: Performed using 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 for observation. Most patients go home from the hospital the next morning.
Your heart rate and rhythm will be constantly monitored during your recovery. This is done using telemetry. A a small box is connected by wires to your chest with sticky electrode patches. The box sends the information about your heart rhythm to several monitors in the nursing unit.
The doctor will remove the catheters and put pressure on the insertion site to prevent bleeding. No stitches are needed. Bandages are placed on the insertion sites to reduce the risk of bleeding and bruising.
You will stay in bed for 6 to 8 hours after the procedure. Keep your legs still during this time to prevent bleeding.
How will I Feel After the Procedure?
You may feel general soreness, fatigue or chest discomfort during the first 48 hours after the procedure.
It takes several weeks for the lesions to heal and form scars. So, it is common to have 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 anticoagulant medication. This prevents blood clots from forming and reduces your risk of stroke. You may need to take this medication for longer than 3 months, depending on your individual risk of stroke. You also may need to take an antiarrhythmic medication for 2 months after the procedure. This medication controls abnormal heartbeats.
Your doctor will give you all the prescriptions and medication instructions you will need. If you think you will have any problems paying for your medications, please let us know. We may be able to help.
Ask your doctor if you should keep taking the medications you took before you had the procedure.
Blood Tests: You must have frequent blood tests (called INR/Protime) to evaluate your dosage of your anticoagulant medication. 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 two follow-up visits at Cleveland Clinic after your procedure. The first appointment will be 3 to 4 months after your procedure. You will receive a reminder card for this appointment. If you don’t get an appointment notice within 3 weeks after your procedure, please call our appointment offices: 216.444.6697 or 800.223.2273, ext. 46697.
The second follow-up visit will be one year after your procedure.
Please bring your telephone transmitter to your Cleveland Clinic follow-up appointment.
These tests may be performed at your follow-up appointment:
- Spiral computed tomography (CT) scan* to evaluate the presence of pulmonary vein narrowing: You will need to fast (not eat or drink anything) for 6 hours before this appointment.
- 2-D echocardiogram (Echo) or transesophageal echocardiogram (TEE)
- Electrocardiogram (EKG)
- Other blood tests/lab work
*The CT scan involves the use of an intravenous contrast material. If you are allergic to contrast material, dye or shellfish, please notify us immediately so you can receive a medication to take before the test.
Risks / Benefits
What are the possible risks of the procedure?
Your doctor will talk with you about the specific risks and potential benefits of pulmonary vein ablation. The procedure is generally very safe. However, as with any invasive procedure, there are risks that we track very carefully. The risk of a severe or life-threatening complication associated with pulmonary vein ablation is about 1 to 3 percent. These complications include, but are not limited to:
- Stroke (approximately 0.5 percent risk)
- Pulmonary vein damage (1 percent risk)
- Perforation of the heart (1 percent risk)
- 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.
- Bloating and abdominal distension after the procedure. This rare complication may be related to injury to nerves that control the contraction of the stomach muscles. The condition 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 helped 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.
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
Schedule an evaluation for pulmonary vein isolation
Our Center for Atrial Fibrillation physicians specialize in the diagnosis and treatment of atrial fibrillation.
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.
You may also visit: eclevelandclinic.org. This service allows you to get a second opinion from one of our medical specialists from the convenience of your home. To learn more about this service, please visit: eclevelandclinic.org 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.
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 requestan 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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