DECIDING WHEN OR WHETHER TO HAVE A CATHETER ABLATION OR SURGERY

This decision will involve a number of factors:

1) Estimates of the changes to your heart that have taken place (structural remodeling) because of the total amount of AF you have experienced.
 

Making this estimate is difficult because inflammatory processes affecting the heart may have preceded the appearance of AF and patients do not always notice episodes of AF (“silent AF”).

If your doctor is settling for rate control rather than taking steps to get you into NSR and keeping you there, ask him or her for his estimate of the changes that have or will take place and their consequences if your AF continues.

2) The likelihood that CA or surgery will be successful and without complications.

Success will depend somewhat on factors such as type of AF ( paroxysmal vs persistent/permanent), and the extent of structural remodeling that has taken, such as fibrosis and atrial size. Unfortunately, the extent of fibrosis/scarring and other cellular changes cannot, in most cases, be determined until the heart is explored during a procedure. (MRI has been used experimentally to make this determination.)

4) How much AF affects your quality of life. As implied above, even if AF does not reduce your QOL now, it may in the future, at which time the best time for CA or surgery may have passed.

5) The accessibility of top-tier EPs or surgeons. Success- and complications rates depend on the experience and skill of the EP or surgeon. This is especially true for persistent/permanent AFers who are considering ablation because the EP may need to do work that is technically challenging. The playing field may level once robotics come into widespread use. The learning curve is shorter, and the procedures are potentially safer and more effective because of the steadiness of robotic “hands”.

6) Whether approaches short of EP or surgical interventions have worked for you (see below for some ideas).

7) Whether there are medication or EP/surgical procedures under in the pipeline that would make waiting worthwhile.

The treatment of AF is a rapidly developing field, for example, in these sub-areas: a) antiarrhythmic medication (more atrial specific with less side effects); b) anticoagulation medication (alternatives to toxic warfarin, such as dabigatran); c) 3-D mapping and imaging; d) robotics (for CA and surgery); e) catheter features (tip design); and, f) type of energy used (RF, cryo, HIFU, microwave, laser). For more on this see Trends in the Treatment of AF.

In my opinion, a young person would not want to plan on staying on any of the antiarrhythmia medications that now exist for the long term. On the other hand, a young person would not want to risk the effects of long-term AF burden.

In practice, this means trying various strategies to stay in rhythm (as below). If these do not work or if further waiting is judged to reduce the likelihood of successful CA or surgical treatment, I would go one of the top-tier practitioners -- even if the waiting list might be longer than that of an EP that is suggested by your cardiologist. You can always cancel, and you may be able to get a consultation fairly soon which will answer some of your remaining questions.
 

You may want to consider these findings from a study of the progression of paroxysmal to permanent AF in making your decision:

Editor's Comment: This study resulted in two important findings. Firstly, afibbers whose episodes change from paroxysmal to persistent or permanent should get in line for a possible ablation as soon as possible and those already in permanent afib should delay as little as possible in order to improve their chances of a successful outcome. Secondly, a measurement of AFCL on a standard surface ECG will give a good indication of whether an ablation procedure is likely to be successful in the case of permanent afib. Put another way, if the AFCL is below 142 ms then as many as 4 procedures may be required.

…from the AFIB Report November 2009 p 1

For a list of EPs and surgeons, see here.

For questions to ask on your initial visit, see this list.

Information in these articles may also be helpful.

1) This article offers advice for people newly diagnosed with AF, focusing on steps that he or she can take that are easier and less costly financially and in terms of side effects than CA or surgery.

2) This one describes how to decide among various CA or surgical interventions and how to select the practitioner to perform the procedure.