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Catheter ablation

Objectifs 

Tachyarrhythmia, or more than 100 heart beats per minute, can be treated with antiarrhythmic drugs. However, sometimes these are ineffective or cause undesirable side effects. Catheter ablation is the next suggested course of treatment, as it can definitively eliminate most cases of tachyarrhythmia.

The goal is to stop the arrhythmia by destroying the electrical cells responsible for the condition and re-establish a normal heart rhythm.

The doctor may decide to conduct radiofrequency ablation (using heat) or cryotherapy ablation (using cold). The technique is chosen depending on the site and type of arrhythmia. Sometimes both techniques are combined depending on the results obtained.
Preparation 

Preparation for the ablation procedure (note that some tests may be done during pre-admission):

  • ECG
  • Blood tests
  • Urinalysis
  • Chest X-ray
  • Pregnancy tests in fertile women
  • Follow-up by a nurse
  • Follow-up by a doctor (explanations, risks and benefits and signature of consent form)
  • Take your usual medication according to your prescription
  • Be fasting from midnight the night before the exam, but note that this does not apply to medication (follow your doctor's instructions)
  • Shaving of the chest and groin area (to create a sterile area and better adherence for electrodes and dressings)
  • Shower with an antiseptic soap

Recommendations to prepare for the procedure:

Bring your:

  • Health insurance card.
  • Montreal Heart Institute (MHI) card.
  • An updated list of medications provided by your pharmacy.
  • Your medication (not all medications are available at the MHI).
  • Comfortable clothing: dressing gown, slippers, tissues, books, etc. However, do not bring jewellery, extra cash, credit cards or valuable objects.
  • If you have sleep apnea, bring a continuous positive airway pressure (CPAP) machine.

On the day of the procedure:

  • Remain fasting; however, this does not apply to certain medications.
  • An IV line is inserted into the arm. 
  • Take the time to go to the bathroom and put on a hospital gown. Remove your underwear.
  • You will be taken to the EPS room on a stretcher or in a wheelchair.
Steps 

The procedure is conducted in the EPS room in an aseptic environment:

  • Patients lie down on their backs on the exam table.
  • Electrodes are placed on the chest for the external ECG.
  • A blood pressure cuff is placed around the arm.
  • Splints are placed around the arms and knees to remind the patient not to move. Do not hesitate to advise staff of any discomfort.
  • You may be given medication to help you relax.
  • The groin area is disinfected with a liquid antiseptic and then covered with a large sterile field.
  • The doctor applies a local anesthetic to the groin area.
  • Through an incision in either a vein or an artery, the doctor will insert a wire that will guide the insertion of the catheter. The doctor uses fluoroscopy (X-rays) to move the catheters to specific areas.
  • When everything is in place, the programmed stimulation begins and the heart's electrical activity is recorded. If the stimulation triggers an arrhythmia, the patient may feel the normal symptoms of this condition. If this happens, the doctor can re-establish a normal rhythm right away. 
  • When the arrhythmia's site of origin is located, the electrophysiologist inserts the ablation catheter into one of the guide wires inserted into the groin. Using fluoroscopy, the doctor guides the catheter to the arrhythmia site.
  • A hot (radiofrequency) current or cold (cryotherapy) current is then sent through the catheter. The current may need to be applied a number of times to destroy the electrical cells responsible for the arrhythmia. Sedation is administered for the patient's comfort.
  • When the procedure is finished, the catheters are removed. The doctor applies pressure to the groin area to prevent bleeding. A compression dressing is applied.
Follow-up and side effects 

When you go back to your room:

  • Remain lying down for approximately 4 to 24 hours, depending on your doctor's orders and keep your leg(s) still to avoid any bleeding or hematoma at the puncture site(s).
  • A heart monitor is set up.
  • The nurse regularly checks your vital signs (blood pressure, heart rate, breathing, temperature), your dressings, and your foot temperature and pulses to ensure that there is good circulation.
  • Eat a light meal shortly after you return to your room.
  • Each dressing is changed the night of or day after the procedure.
Contact 
Electrophysiology
Recovery 

Recommendations for discharge:

  • Remove any adhesive bandages the day after the procedure.
  • Take a shower instead of a bath for the first 3 days following the procedure.
  • Avoid intense physical exercise or exertion during the first week.
  • You can go back to work or school according to your doctor's orders (approximately one week).
  • Driving a vehicle: 2 to 3 days after the procedure or according to your doctor's orders.
  • If bleeding develops at one of the puncture sites (right and/or left groin area), lie down on your back and put pressure on the site for at least 10 minutes until the bleeding stops. Apply pressure directly on the site with your fingers and a compress or towel. If the bleeding is abundant or persistent, go to the closest emergency room.
  • It is normal to have bruising at the puncture site. The skin may become bluish or yellow in color and it may be slightly sensitive to the touch. However, if your thigh or groin area swells (edema) or becomes painful, you must contact a nurse at the Atrial Fibrillation Clinic. Outside of clinic hours, go to the closest emergency room.
  • If you have a fever above 38 °C, contact the nurse at the Atrial Fibrillation Clinic. Outside of clinic hours, go to the closest emergency room.
  • At the emergency room, it is very IMPORTANT to specify that you have recently had a pulmonary vein ablation procedure and that IN NO CASE are you to undergo a transesophageal echocardiogram or gastroscopy, as these procedures are contra-indicated for 2 months following the ablation.
  • Go to an emergency room if you experience palpitations that last over 24 hours or that are very uncomfortable.
  • Continue taking your medication as prescribed.
  • Continue taking any anticoagulants, such as Coumadin® (warfarin) or Pradax™ (dabigatran), as prescribed before the procedure. You must take anticoagulants for as long as the electrophysiologist decides and for a period of at least 3 months. 
  • A medication called Pantoloc® (pantoprazole) is prescribed for the first month following the ablation to protect the stomach. If you have heartburn, contact the nurse at the Atrial Fibrillation Clinic. 
  • In the first week following the ablation, it is normal to feel mild to moderate pain in the chest, which may increase when you breathe inward or are lying down. If you develop severe pain, go to the closest emergency room.
  • If you have pain, take 1 to 2 tablets of acetaminophen (Tylenol®) every 4 hours.
  • Contact your doctor if:

- The pain in your groin area gets worse and is not relieved by Tylenol® (acetaminophen).
- You have a hematoma (edema or swelling) or if bleeding develops at the puncture site(s).
- You have difficulty walking.
- You experience shortness of breath, chest pain, dizziness or vertigo.
- You have a temperature of 38 °C (100.4 °F) with chills.