Pulmonary Vein Isolation Procedure (PVI)
What is a pulmonary vein isolation (PVI) procedure?
PVI is a procedure designed to stop or reduce the amount of atrial fibrillation that you are suffering from. Increasingly it is being used in some patients as a first line treatment but is primarily used in patients who have tried drugs to control their atrial fibrillation which have failed. It is not a treatment designed to get people off anticoagulation. The treatment stops electrical signals (pulmonary vein potentials) that come out of the pulmonary veins which then enter the left atrium. It is often these signals that arise from the pulmonary veins that trigger patients’ atrial fibrillation and by stopping them with the PVI procedure it is often effective at stopping atrial fibrillation. Please see diagram which shows the four chambers in the heart (two atria and two ventricles) with the left atrium, located above the left heart valve (the mitral valve) being the heart chamber being we work within to block the AF signals.
From consultation through to treatment you will receive professional care throughout.
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David is one of the UK’s most active doctors in the field, performing an impressive volume of procedures each year.
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Once a full discussion has been had and all your questions are answered about the procedure we will arrange a date for you to be admitted for your PVI procedure. Normally a week to ten days before that date we would offer you a preoperative assessment.
This involves a general health questionnaire with a senior nurse, some routine blood tests being taken and some swabs to make sure that you do not have MRSA (standard skin swabs to ensure you do not have methicillin-resistant staphylococcus aureus which is a bacteria found on some patients skin).
At the time of your preoperative assessment you will be given information about what to do with your drugs but in general terms you do not stop your anticoagulants (warfarin or one of the new anticoagulants such as Rivaroxaban or Apixaban, , Edoxaban or Dabigatran). You will be given instructions of when you will be admitted to the ward which is usually a few hours before the planned time of the procedure.
We generally do not want you to have anything to eat 6 hours prior to the procedure start time. Drinking water only is permissible providing small sips are taken and not large volumes. It is not appropriate to drink other drinks such as tea, coffee or squash drinks.
When you arrive on the ward you will be admitted by one of the sisters on the ward who will run through the admission process with you which will include any allergies you may have or any procedures that you have had in the past.
This is performed with either a freezing balloon (CRYO balloon) or with radio frequency energy from the top of the right leg under local anaesthetic with sedation. We sometimes use general anaesthetic but in the vast majority of cases intravenous sedation is used. The precise technique we use in your case will be discussed before we list you for the procedure. Local anaesthetic is injected into the top of the right leg which numbs and freezes the area then a series of small tubes called sheaths are inserted into the vein at the top of your leg (right femoral vein) which will then allow us to introduce flexible catheters and wires into your heart. We do this under X-ray guidance. We then make a small hole from the right atrium into the left atrium via a transeptal puncture. This allows us to introduce all necessary catheters into the left atrium to allow us to isolate the pulmonary veins.
If CRYO ablation is used it is common for patients to get a headache during the procedure and in the later stages of the procedure an intermittent twitching sensation. This is because we stimulate the phrenic nerve on the right side of the heart to ensure that you are breathing sheet (diaphragm) continues to work when we do the freezing procedure. We test the signals in the pulmonary veins during the procedure to ensure that they have all gone by the end which is the objective of the pulmonary vein isolation. With radio frequency energy sometimes patients get a discomfort in the chest but in this instance don’t tend to get a headache or twitching sensation which is usually a symptom of CRYO ablation. These procedures typically take 2-3 hours to complete.
It is generally accepted that ablation for paroxysmal or intermittent atrial fibrillation principal goal of the ablation is to isolate the pulmonary veins. In patients who have persistent atrial fibrillation it may be appropriate to not only isolate the veins but to perform additional ablation within the atrium itself. This can mean that procedures for persistent atrial fibrillation can take longer and may take between 3 and 4 hours to complete.
Immediately after the procedure the tubes that were used in the right groin to access the heart will be removed. It’s very common that we put a pressure device over the groin called a FemStop to prevent the groin from bleeding. The normal practice is to continue the blood thinners that you were prescribed – ie warfarin or one of the newer drugs such as Rivaroxaban/Apixaban after the procedure. We would typically keep you in overnight and aim to discharge you the following day. It is very common to get some chest tightness or some fleeting pains in the shoulder and chest. The groin may be uncomfortable for 2-3 days after. It is not uncommon to have ectopic or extra beats in the first few weeks after the ablation procedure. If you get a prolonged abnormal heart rhythm (ie; for longer than an hour) please don’t hesitate to contact the centre at which your procedure was performed. Short runs of palpitations however are to be expected.
DVLA currently recommend that patients do not drive for 48 hours after an ablation procedure. If you do have a HGV licence then you will not be able to drive for 6 weeks after an ablation procedure. DVLA guidelines are available on the DVLA Government website.
We generally recommend that blood thinners are continued after the procedure itself. If you have a very low CHA2DS2-VASc score then after around 12 weeks following the procedure blood thinners can be discontinued but generally patients with a moderate to high CHA2DS2-VASc score we would continue the blood thinning medication indefinitely.
With respect to the heart rhythm tablets that you may be on (drugs such as beta-blockers, Flecainide, Dronedarone, Sotalol) we would normally continue these tablets after the PVI procedure but in the follow-up period in outpatients we would discuss with you the prospects of reducing and coming off these medications in the medium term.
Success of a pulmonary vein isolation procedure depends on several factors. It is widely accepted that patients with paroxysmal or intermittent AF have a higher chance of cure than those who have more established patterns of AF such as persistent or permanent AF.
We would generally expect at least 80% of patients with paroxysmal AF to have a significant reduction or cure from their atrial fibrillation with one procedure. One in five to one in six patients will need a second procedure.
Patients with persistent AF have lower success rates. Around one in three patients will need more than one procedure and the overall success rate in the medium term is thought to be around 70%. Your exact success rates also depend on a variety of factors such as age, comorbid conditions (such as the presence of coronary artery disease, structural heart disease, high blood pressure and dilatation of your left atrium – discovered on echocardiogram). Sometimes the AF is not completely cured but generally patients will get much less atrial fibrillation and for shorter bouts after an ablation procedure.
Occasionally after an ablation procedure patients can develop a problem called “left atrial flutter” which can make the heart go fast and can require treatment in it’s own right.
Unfortunately all medical/surgical procedures do carry a small risk of complication. The overall typical complication rate for an AF ablation would be quoted at between 2 and 3%.
The common risks associated with this procedure are stroke, or TIA (mini-stroke) – around 1/500, cardiac tamponade (bleeding in the sac around the heart) – around 1/150, pulmonary stenosis (narrowing of the pulmonary veins which can cause breathlessness later on) – around 1/200, paralysis of the right diaphragm (which may cause difficulty breathing) – around 1/100 – this typically recovers over time and femoral vascular injury (damaging the blood vessels within the groin) – around 1/00 – usually settles with some additional bruising and bleeding but occasionally can require surgical intervention.
The overall complication rate of a PVI procedure is around 2-3%. Very occasionally other complications that can occur with pulmonary vein isolation can be life threatening. This is less than 1/1000.
After the procedure you will gradually (over 30-60 minutes) recover from the sedation we have administered you. All the tubes and catheters are removed from your groin and we often put a pressure device called a FemStop on the groin itself to apply gentle pressure and to reduce the risk of any bleeding. Very frequently you will have an oxygen mask on for the first hour or so after the procedure and the nursing staff will closely monitor your pulse, blood pressure and oxygen levels.
You will also have some electrodes placed on your skin so we can remotely monitor your heart rhythm in the recovery period. You will be given clear instructions by the nursing staff of when you can sit up and eventually get out of bed. Do not attempt to get out of bed until the nurses inform you that it is okay to do so.
Patients are generally kept in overnight after the PVI procedure. You cannot drive for 48 hours after the ablation itself. You will need somebody to take you home. The nursing staff will give you advice and an information sheet with telephone numbers to contact in the event of any problems when you do get home. The doctor will make it clear to you what drugs you will need to take after the procedure but we always continue blood thinning (anticoagulation) after the pulmonary vein procedure. The length of time you will need to take these anticoagulants will be discussed at your follow-up appointment. You will have a small clear dressing over the groin puncture site. This can safely be removed the following day after the pulmonary vein procedure itself. You should wash your groin every day and keep it clean and dry until it has healed.
If you notice any bleeding, swelling or oozing lie down and press on the area with three fingers for up to 10 minutes. If things do not settle then please contact the Ward (whose number is on the information sheet provided) for advice. It is common for patients to get superficial bruising around the site of the puncture. This is largely due to the fact that 2 or 3 tubes are placed into the groin and patients are on blood thinning medication. Time to have concern about the groin would be if a large lump the size of a golf or tennis ball appears in the groin. If that occurs then attend your local A&E for an evaluation.
Patients generally return to work after 2-3 days. Driving cannot take place until 48 hours has elapsed after the PVI procedure. Try and avoid lifting heavy objects for up to a week and generally take things easy for the first 2-3 days after the ablation procedure itself. You do not have to inform the DVLA about the procedure.
It’s common to feel a little chest discomfort after the procedure. In particular if you take a very deep breath in often there can be a sensation of tightness in the chest. This is normal in the majority of patients. If you experience very heavy central crushing pain you should obvious seek medical attention particularly if it lasts more than 20 minutes. Simple analgesic medicines such as paracetamol (under direction) can be used.
It is not unusual to have some short lived palpitations after the PVI procedure. These can often occur for 2-3 months after the procedure itself particularly when the heart is in the healing phase. Naturally if any of the symptoms are prolonged and are distressing you should seek medical advice but very short runs of palpitation lasting a matter of seconds (likely ectopic or extra beats) are normal and are nothing to worry about.