Atrial Fibrillation
 RESOURCES FOR PATIENTS

BORDEAUX PROCEDURES AND COST
 

CATHETER ABLATION OF ATRIAL FIBRILLATION

Currently the only treatments that cure atrial fibrillation (AF) are:
    a) Surgery (such as the Cox Maze operation and its variations)
    b) Catheter Ablation

The main goals of catheter ablation of AF are to:
    1) restore the heart to normal sinus rhythm, thereby eliminating the symptoms of AF.
    2) relieve the patient from the associated risks of AF, such as blood clot formation, stroke, cardiac failure, and increased mortality.
    In the catheter ablation procedure a catheter, a soft, thin, flexible tube with an electrode at the tip, is inserted through a large vein in the groin and moved into the heart. This catheter delivers Radiofrequency (RF) energy to cauterize and eliminate the sources or spots in the heart (ectopic foci or wavelet circuits) that are triggering or maintaining the episodes of AF. These sources or spots in the heart are usually found in the pulmonary vein openings. The catheter also makes linear lines or lesions to segment the atrial tissue, thereby interrupting the errant electrical waves responsible for maintaining AF.
    This isolation of the pulmonary veins cures the intermittent (paroxysmal) form of AF in 80% of patients (without having to take any medications). An additional 10% of patients are improved---an antiarrhythmic drug keeps them is sinus rhythm without the need for blood thinners.
    For patients with permanent or persistent AF (lasting more than 48 hours or who have had Electrocardioversion), isolation of the pulmonary veins is less effective and should be combined with linear lines or lesions. This is because the longer one has episodes of AF, the more the sources or spots in the heart which produce AF signals tend to spread outside the pulmonary veins.
    Ablated heart tissue has a tendency to heal itself and recover. For this reason and to increase the success rate to 90%, a second ablation is required either in the first week or after 1-3 months of follow-up.

Pre-ablation Management

    For safety reasons (to avoid clot formation during the catheter ablation procedure) the patient should take oral anticoagulation (coumadin, not aspirin) at an optimal therapeutic range (INR 2-3) for at least 1-2 months before the procedure. In addition, a transesophageal echocardiogram should be performed a few days before hospitalization to make sure there are no clots in the heart, particularly in the left atrial appendage. If clots are found, the procedure must be postponed a few days until these clots can be dissolved by blood thinners.
    Anticoagulants should be interrupted 48 hours before the day of the procedure. If the patient is taking antiarrhythmic drugs, they should be stopped on admission.

Catheter Approaches

    General anesthesia is rarely performed on adult patients, in order to minimize the associated risks of anesthetic drugs. The patient is slightly sedated and a local anesthetic is applied to the groin area. Usually three catheters for mapping and ablation are inserted through one or two femoral veins in the groin and moved up into the heart.
    The mapping catheters have multiple electrodes mounted in a longitudinal or circumferential shaft. (Other configurations including investigational designs may be used for individual situations.) The ablation catheter has an irrigated tip to prevent local clot formation and to allow greater energy delivery if needed (at thick parts of the cardiac tissue). To insert these catheters into the left atrium, it is usually required to make a puncture of the transseptal wall between the two upper chambers (atria) at what is called the foramen ovale. After the ablation procedure, this foramen ovale closes back up and heals over. (In 20% of patients this foramen ovale hole never closes up completely and remains open, creating a pathway between the two atria chambers.)
    Two or three physicians usually perform the catheter ablation procedure. They are involved in positioning the catheter, and in the collection, analysis and interpretation of heart signals obtained during conventional or computerized mapping.
    RF ablation is performed around the openings of the pulmonary veins, one by one or two by two, using a limited level of energy to avoid swelling of the pulmonary vein openings or atrial perforation. Isolation of the pulmonary vein openings is successfully performed in 100% of cases.
    In paroxysmal (occasional) AF, PV isolation cures AF in 60-70% of cases. Ablation of the appropriate site in the right atrium (Cavotricuspid Isthmus) is also performed to prevent right atrial flutter. Linear block here is successfully achieved in 99% of cases.
    In persistent AF (lasting more than 48 hours or with a history of electrical cardioversion), PV isolation is rarely sufficient. Additional RF applications are required to eliminate spots of AF activity outside the pulmonary veins. In the most resistant cases (usually long lasting AF), linear ablation similar to surgical incision is performed in the left atrium between the two superior PV and/or from the vein to the mitral annulus (mitral "isthmus"). This achieves linear block in 90% of cases. The success depends on achieving continuous and coalescent cauterizing lesions to create a complete barrier. Any gap in the lesion line, even of a millimeter size, allows AF signals to cross thereby keeping the heart in AF. A gap in the lesion line is due either to a too thick atrial wall or recovery of atrial tissue during the 1-4 week healing process following ablation.
    Pain and discomfort associated with ablation are controlled by Midazolam and Morphine. Because there are no nerve endings in the smooth tissue of the heart and veins, the pain and discomfort are minimal and usually well tolerated.

Duration of Operation and Hospital Stay

The duration of the procedure varies from one to four hours depending on individual conditions:
    -the number of ectopic sources in the atrial tissue (outside the pulmonary veins) may require more mapping time.
    - successful lineal ablation lines depend on the thickness of the heart wall which varies from one patient to another and can not be precisely determined by pre-ablation imaging.
    The end point or goal of the procedure is the achievement of local block in all targeted structures (veins and isthmuses) so that no AF signals travel through the heart. In addition, after the ablation multiple pacing maneuvers are used to try to induce sustained AF. In paroxysmal AF, multiple pacing maneuvers do not induce AF in 90% of cases.
    A second procedure may be needed within 3-5 days in 25% of AF patients due to partial recovery of ablated tissue and/or secondary AF sources not ablated in the original procedure. In difficult cases of multiple or unmapable ectopic foci (heart tissue generating AF signals), a second linear ablation may be required in the left atrium.
    Patients are hospitalized 4 to 6 days depending on the number of procedures required. Typically they return to the normal care unit after ablation and are ambulatory 12 to 24 hours later. They are monitored by telemetry during the next 3 days when any recurrence of arrhythmia is most likely to occur. The likelihood of recurrence decreases over the next month.
    Patients are usually admitted on Monday and can leave the hospital for the week-end, if there are no complications. They must stay in the region during the week-end and must return the following Monday for outpatient evaluation, which could result in re-hospitalization if needed.
    The occurrence of complications may increase the duration of the hospitalization and therefore the cost. In our experience, this happens to 2.5% of patients.
    If AF symptoms do not reoccur, patients can return home and resume normal activities. Anticoagulants are recommended for at least 1-3 months after ablation, and can then be stopped if there is no AF or other risk factors. In persistent AF, antiarrhythmic medications are recommended for 1-3 months after ablation to enable the atria to return to normal (this process is called "remodeling.")

Population of Patients

    Catheter ablation of AF has been performed since 1994 in Bordeaux. As of October 2005, over 4000 patients have been treated. At least ten cases of atrial fibrillation or flutter are treated every week. The clinical characteristics of patients cover a wide spectrum of age (15-84 years old, average 52 years old). 78% of patients are male, while 22% are female. 80% have paroxysmal (occasional) AF, 20% have persistent AF. All patients were resistant to or intolerant of an average of 4 antiarrhythmic drugs and experienced at least weekly episodes of AF at their referral.
    Some patients had documented pauses in their sinus heart beat after an attack of AF. They were cured by AF ablation, and thus avoided pacemaker implantation.
    12% reported a previous embolic event (stroke), most in the circulation of the brain.
    In patients with heart failure and permanent AF, the restoration of sinus rhythm (normal heart beat) is associated with a significant improvement of ventricular function in 80% of the patients.

Risks Associated with AF Catheter Ablation

    Currently no one has died of a catheter ablation procedure in our department. Compared to other catheter procedures a 0.1% risk of death is a reasonable estimation.
    The other risks of catheter ablation of AF are:
    -bleeding in the pericardial sac surrounding the heart and requiring drainage (~0.5%)
    -embolic event (stroke) (0.2%)
    - groin access hematoma (bruising) (4%)
    There is no risk of sinus node or AV node damage by ablation which would require implanting a pacemaker.
    World-wide there have been deaths reported by the use of high wattage catheters (50 watts or higher) creating a fistula (burn through) to the esophagus, usually 2 days after the procedure. We have not observed this complication.
    Pulmonary vein narrowing (stenosis), if it did occur, would not usually cause symptoms. Out of 4000 patients treated in our institution, 5 developed symptoms due to PV narrowing (>70% of lumen [opening] diameter) and required angioplasty and stenting.
    The above risks compare very favorably with the risks involved in living with untreated AF. The risks of catheter ablation also compare very favorably with the risks involved in taking antiarrhythmic drugs and anticoagulants.

    This cost is fixed by the public health administration: 1039 euros per day (around $1,380 US dollars), 4000 euros (around $5,300) for all single use catheters including Lasso and irrigated tip catheters. The cost for a private service (operators: Drs. M. Haissaguerre/P. Jais/ M. Hocini) is 4000 euros (around $5,300) (hospital and physician charges). The total cost of AF catheter ablation depends on the duration of one’s stay in the hospital, which depends on the difficulty of individual ablation cases.
    The typical hospital stay of 5 days with an ablation including pulmonary vein isolation and ablation of the right and left atria would cost about 13700 euros (around $18,200). One day more or less would by 1120 Euros ($1,490).
    The current waiting time for a procedure is 6 months.
    For patients accompanied by a family member and without local accommodations, a bed and breakfast is provided in the same room (67,45 euros/day).
    Patients should come with personal clothes, since it is possible to walk outside. Patients are generally expected to wear their own clothes, including pajamas. Since the hospital only provides small towels, you may wish to bring your own towels.

    Cardiologic Hospital of Haut-Lévêque is a 300 bed hospital entirely dedicated to medical and surgical cardiology. It is located in Pessac and is a 20 minute drive from the airport, and a 20-30 minute drive from the center of Bordeaux and the TGV station.
    (languages spoken: English and Spanish)