Dr Boullin - What to expect after ablation for atrial fibrillation…
I recommend taking a 2-4 weeks off after the procedure. This may vary amongst people and usual light activities will be fine after a day or two, but don’t go back to full exercise for a few weeks. It’s a big procedure typically taking between 2 to 4 hours depending on the approach used and exactly what’s needed to be done.
Chest pain is common:
The majority of patients have chest pain for a few days after the procedure. The severity of the pain varies a lot. Most often, it hurts to take a deep breath or cough. Some patients say their chest feels tight. These symptoms are likely due to irritation of the lining of the heart, called the pericardium. It’s hard to predict who will get post-procedural chest pain. Sometimes you do extensive ablation and there is no pain, while other times you have an easy ablation and there is severe pain. It resolves over days.
Pain at the insertion site in the groin:
It’s common to have soreness at the insertion site in the groins. I access the heart by inserting 2 or 3 sheaths/plastic tubes in the leg veins at the groin. To prevent clots from forming in the heart, we perform AF ablation without stopping anticoagulation. This means firm pressure will be required when the sheaths are removed and I usually use a stitch to maintain pressure for a short period (typically 2 hours) after the sheaths are removed. This causes varying degrees of soreness in the groin region over the following days. Bruising is common, which will follow gravity, so it’s common for black-and-blue areas to move down the leg. Sheath placement or removal may also irritate the nerves that run alongside the leg (femoral) vein and therefore also cause some pain.
Although most patients have discomfort at the insertion site, persistent pain (for more than a week) or swelling may be cause for concern. One of the most common complications of AF ablation is injury to the blood vessel in the groin area. In these cases, please do let me know and I will likely want to review you to have a look at the site. Occasionally, I might arrange for an ultrasound scan of the area.
General anaesthesia effects (my usual approach for AF ablation):
Some people recover from the gas and drugs easily but others do not. Many people feel nausea and groggy for hours, whilst others experience these symptoms for days. It’s also common to have a sore throat or cough from the (endotracheal) tube that sits in the back of the throat for the duration of the procedure. There is a great deal of variation in how people tolerate anaesthesia.
Arrhythmias:
It’s actually very common to have palpitations and sometimes arrhythmias in the initial period after AF ablation. Remember that this was a big procedure. The many burns or freezes it takes to isolate pulmonary veins can irritate the heart, which in turn may cause arrhythmia.
Although having AF after an ablation is a risk factor for a future recurrence, it doesn’t mean the procedure did not work. The ablates areas of the heart are inflamed and irritable; as they heal, over days to weeks, the irregular rhythm will often resolve. This is why we have what’s called a “blanking period” (6-8 weeks) after the procedure before we assess the degree of success. AF that occurs in the early post-procedure period is rarely dangerous because all patients are kept on anticoagulation and most patients remain on rate-slowing meds. Persistent high heart rates (which sometimes indicates atrial flutter) can be more difficult to control and will sometimes require cardioversion.
Resting heart rate changes:
The resting heart rate can increase in the weeks or months after ablation. The increase is usually 10-20 beats per minute more than pre-procedure levels. This phenomenon usually resolves.
We do not fully understand the way in which AF ablation works. It’s not as simple as just building an electrical fence around pulmonary veins. One effect of ablation in the region of pulmonary veins is changing nerve messages to the heart. Bundles of nerves, called ganglia, reside close to the origin of the veins. Ablation at these sites can alter nerve control of the heart. Some experts believe this is a positive effect in that it may predict ablation success.
Exercise Level:
The ability to sustain exercise can be decreased for weeks to months after the procedure. It will usually come back. The reasons AF ablation transiently decreases exercise tolerance are numerous: it is a big procedure, the lesions can cause stunning of the atria, there is deconditioning that occurs before and after the procedure, and many patients remain on AF drugs for a month or two after the procedure. The main message here is be patient. Give yourself weeks to months to recover.
Fluid overload/Oedema:
It is not uncommon to develop extra fluid after your ablation procedure. This can result in as swelling of the hands or feet. It may also cause transient shortness of breath, cough or high blood pressure. The cause for this is that you will often be given saline (salt water) for the ablation and the anaesthesia often requires saline infusions to maintain blood pressure, whilst the heart can be stunned after ablation. Swelling and volume excess is not heart failure per se, but it usually responds to a few days or weeks of taking a diuretic medication (often called a “water tablet”).
Digestive problems:
Occasionally patients have trouble moving food through their GI tract after ablation. Symptoms include reflux, feeling bloated, and intolerance of big meals, while signs may include distention of the abdomen. AF ablation may damage nerves that control motility of the GI tract for a short time. The good news is that these effects resolve with time. I usually recommend small meals, and an stomach acid blocker such as omeprazole or lansoprazole.
This is a compilation of common issues I’ve come across in the last 15 years and 800 or so left atrial ablations. It should be self-evident that if you experience severe new symptoms or signs, such as stroke, oesophageal swallowing pain, fever, unremitting chest pain, breathing problems, or expansion of swelling in the leg veins you should contact me, the arrhythmia nurses or seek medical attention elsewhere (via 111, A & E or your GP).
