Catheter ablation: the recovery process and what to expect

Transcription

1 Catheter ablation: the recovery process and what to expect Mark O Neill DPhil FRCP FHRS Consultant Cardiologist & Professor of Cardiac Electrophysiology Division of Imaging and Biomedical Engineering & Division of Cardiovascular Medicine Department of Cardiology St. Thomas Hospital & King s College London mark.oneill@kcl.ac.uk

2 Outline Understanding a catheter ablation Advice following a catheter ablation

3 Understanding an AF ablation procedure 1. Vascular access 2. Transeptal puncture 3. Anatomical map 4. Catheter ablation 5. Sheath removal 6. Post operative anticoagulation

4 Steps in an AF ablation procedure 1. Vascular access 2. Transeptal puncture 3. Anatomical map 4. Catheter ablation 5. Sheath removal 6. Post operative anticoagulation

5 Vascular Access The most common complication in AF ablation procedures Incidence of 1-2/100 Rarely requires intervention to repair Very rarely a reason for life threatening injury

6 Transseptal puncture 1. Vascular access 2. Transseptal puncture 3. Anatomical map 4. Catheter ablation 5. Sheath removal 6. Post operative anticoagulation

7 Transeptal puncture Required in >80% of patients to access the left atrium Usually done under x- ray guidance Often done under echo guidance with general anaesthesia Carries a risk of collateral injury

8 Accessing the left atrium A controlled situation High level of operator experience crucial Cardiac pressure monitoring Echo guidance under GA X-ray monitoring Complication rate of 1 in 100 including tamponade, aortic puncture or abandonment of procedure Surgical back-up highly desirable

9 Accessing the pericardium Heart border Pericardial border If this happens, you may have pericardial pain following the procedure for 7-10 days

10 Steps in an AF ablation procedure 1. Vascular access 2. Transeptal puncture 3. Anatomical map 4. Catheter ablation 5. Sheath removal 6. Post operative anticoagulation Provides a 3D shell within which to do the procedure Is created by manipulating the catheter within the atrium Computer-generated Reduces X-Ray dose substantially

11 Mapping the left atrium

12 Steps in an AF ablation procedure 1. Vascular access 2. Transeptal puncture 3. Anatomical map 4. Catheter ablation 5. Sheath removal 6. Post operative anticoagulation Multiple modalities available RF energy Cryoenergy Laser Intentional and controlled destruction of cardiac tissue

13 Steps in an AF ablation procedure

14 Harmful effects of catheter ablation Injury to Pulmonary veins (<0.5%) Oesophagus (<1/600) Phrenic nerves (<1/500) Mitral valve (<1/500) Cardiac perforation Stroke

15 Steps in an AF ablation procedure 1. Vascular access 2. Transeptal puncture 3. Anatomical map 4. Catheter ablation 5. Sheath removal 6. Post operative anticoagulation etc.usf.edu

16 Sheath removal Often the most unpleasant part for the patient The only visible remnant of the procedure for the patient Bruising 1-2 weeks post procedure can be dramatic Completely reversible Dagres et al. JCE 2009:20;

17 Understanding an AF ablation procedure 1. Vascular access 2. Transeptal puncture 3. Anatomical map 4. Catheter ablation 5. Sheath removal 6. Post operative anticoagulation

18 Procedural anticoagulation Before & during Therapeutic anticoagulation according to stroke risk score Warfarin NOACs Ablation on warfarin Ablation with interrupted warfarin i.v. heparin during procedure After 1. If stopped, restart warfarin within 4-6 hours 2. Continue anticoagulation for at least 2 months 3. The first 2 weeks post procedure is crucial 4. Use CHADS2VaSc score 5. Discuss future plans for anticoagulation with your electrophysiologist

19 Post procedure recommendations

20 What will I feel? Side effects of the ablation will depend on: The extent of ablation performed Pre-existing heart and general health status The type of ablation performed Complications incurred during the procedure There may be some chest and groin pain Inflammation of the pericardium Bruising in the groin Significant complications after discharge are uncommon

21 When can I drive?

22 When can I go back to work? It depends on your job! It depends on your recovery from the procedure When you feel ready to go back to work No heavy lifting for at least 1 week

23 What if I get palpitations? Palpitations in the days and weeks post ablation are common They are typically managed with anti-arrhythmic medication and/or cardioversion They do not necessarily indicate a poorer long term outcome If persistent, get an ECG done and keep it Contact your arrhythmia care team

24 Any serious symptoms to look for? Unexplained fevers, chills or shakes (rigors) Weakness of one side of the face, arm or leg Altered speech Altered vision Unexplained breathlessness Contact your arrhythmia care team

25 Who should not have an ablation? Asymptomatic patients with AF who are appropriately anticoagulated Is this your doctor? Symptomatic patients who are now asymptomatic on medication and happy to remain so Patients with an acutely reversible cause (hyperthyroidism/alcohol) Most patients with very long lasting persistent AF (>4 years)

26 Who to consider for an ablation Paroxysmal AF Symptomatic Keen to pursue a rhythm control strategy (ie AADs or ablation) Non-Paroxysmal AF Symptomatic Difficult to rate control (β blocker/ccb/digoxin) Willing to consider rhythm control (DCC/AAD & ablation)

27 Summary Everybody is different A more extensive ablation will likely require a longer recovery A complication will change recovery time Don t expect miracles!

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29 Wilber et al. JAMA 2010;303(4): Morillo et al JAMA 2014;311: