Catheter ablation for atrial fibrillation: what happens, risks and recovery

In atrial fibrillation chaotic electrical signals make the upper chambers of the heart quiver, so the pulse is irregular and often fast. NHS.UK lists medicines to control rate and rhythm, anticoagulants to lower stroke risk, and other treatments including ablation, electrical cardioversion and devices. The British Heart Foundation says arrhythmias are usually treated with medicines first and ablation may be offered when medicines do not work or cannot be used.

The Worcestershire leaflet is explicit that ablation is an option for controlling symptoms and is rarely strictly necessary. It says that in people with no symptoms the AF often does not need specific treatment, with rate control and stroke prevention managed by tablets. Because AF can return after ablation and stroke risk stays higher in people who have had AF, anticoagulant advice continues even if the rhythm looks normal.

The Worcestershire leaflet describes electrical cardioversion, which is very effective at ending an episode but does little to stop it recurring, and anti-arrhythmic drugs, which it calls only moderately effective, with a 50% chance of sinus rhythm a year after starting the most powerful medicine, along with side effects. A pacemaker followed by a simple ablation to control the rate is another strategy it mentions.

Choosing between drugs and ablation involves weighing the long-term risks of medicine against the risks of a single procedure, and the leaflet advises pausing if you are not completely comfortable.

The most important preparation is anticoagulation. The Worcestershire leaflet says you must have been taking an adequate blood thinner for at least four weeks beforehand and must not miss doses, otherwise the procedure may be postponed. People on warfarin have regular INR tests before the date. The leaflet usually asks you to continue other heart rhythm medicines and gives separate advice for diabetes treatments and fasting based on admission time.

The BHF suggests organising transport and time off work, bringing a recent prescription of your medicines, and asking what you can eat and drink and which medicines to keep taking. Unwell on the day with a cough or cold? Tell the unit, since the procedure may be delayed.

• Never stop an anticoagulant without being told to by the team.

• Bring a list of all medicines and any alert cards.

• Arrange for someone to stay with you the night after; the Worcestershire leaflet recommends not being alone.

The Worcestershire leaflet describes a cannula in the arm, a cath lab with X-ray equipment, light sedation and local anaesthetic at the top of the leg, and thin wires passed through the femoral vein into the heart. The BHF says some units use general anaesthetic, which it mainly links to ablations needing chest surgery, and that you may need to lie flat and keep still for some time.

The energy source is either freezing, with a balloon inflated around each pulmonary vein in turn, or burning with radiofrequency energy after a map of the atrium is built. You may feel chest discomfort or a headache during freezing, which can be eased with more pain relief. Afterwards you lie flat for two or more hours while the groin sites settle, and then get up and eat when awake enough.

The Worcestershire leaflet quotes these approximate figures: death up to 0.1% (1 in 1,000), stroke about 1%, bleeding around the heart needing a drain about 1%, damage to blood vessels up to 1%, a pacemaker needed about 1 in 500, and phrenic nerve injury causing breathlessness 0.5%. It says the complications are uncommon and can generally be treated. Other units quote different figures, so ask yours.

Common after-effects include groin bruising, which can reach down towards the knee, mild chest discomfort, headache, abdominal discomfort related to irritation of the gullet and, according to the Sussex leaflet, palpitations that usually settle within 12 weeks. A stomach-acid tablet is usually given to protect the gullet.

The BHF says recovery usually takes a few days to a week, though tiredness can last weeks. The Sussex leaflet suggests about a week off work and avoiding heavy lifting for a week, while the BHF suggests at least two weeks of avoiding heavy lifting. Continue your anticoagulant: the Worcestershire leaflet says for at least one month, and the Sussex leaflet notes an increased stroke risk in the first weeks. A detailed timeline page follows each stage.

The Sussex leaflet says that if a puncture site bleeds heavily you should lie flat, have someone press on it, and call an ambulance if bleeding has not stopped in ten minutes. It also asks you to seek urgent help for new weakness in an arm or leg, fever, or feeling very unwell. NHS.UK says call 999 for a fast or irregular heartbeat with chest pain, breathlessness, fainting, severe headache, weakness on one side or difficulty speaking, and not to drive yourself.

Ask which energy source is planned, what success rate your type of AF has, what the unit's own complication figures are, how long you will stay, and who to ring in the first week. Also ask how the rhythm will be monitored afterwards.

The BHF and the Worcestershire leaflet both place ablation after medicines have been considered, so ask your cardiologist how the timing of the decision is made in your case. Whether care is NHS or private, the technique and aftercare questions are the same, and the decision belongs to you and your cardiologist.