Northside Hospital Gwinnett Family Medicine Residency Program, Strickland Family Medicine Center, Lawrenceville, GA (Dr. Osayande); Northside Hospital Cardiovascular Institute, Atlanta, GA (Dr. Sharma) amimi.osayande@northside.com
Dr. Osayande reported no potential conflict of interest relevant to this article. Dr. Sharma received a grant from Biotronic in 2019 to support an educational conference; was provided with honoraria in 2019 for serving on the speakers’ bureaus of Pfizer and Bristol Myers Squibb; and received financial support for education and training from Medtronic (2018) and from Abbott, manufacturer of the EnSite Precision Cardiac Mapping System described in this article (2018 and 2019).
There is no absolute age or comorbidity contraindication to ablation. The patient should be referred to a cardiologist who has received appropriate training in electrophysiology, to identify comorbidities that (1) increase the technical difficulty of the procedure and baseline risk and (2) affect long-term outcome,12 and who performs the procedure in a center that has considerable experience with catheter ablation.33
Once the decision is made to perform ablation, you can provide strategies that optimize the outcome (freedom from AF episodes). Those tactics include weight loss and screening evaluation and, if indicated, treatment for sleep apnea.3
Protocol.Prior to the procedure, the patient fasts overnight; they might be asked to taper or discontinue cardiac medications that have electrophysiologic effects. Studies suggest a low risk of bleeding associated with catheter ablation; anticoagulation should therefore continue uninterrupted for patients undergoing catheter ablation for AF3,4,34,35; however, this practice varies with the cardiologist or electrophysiologist performing ablation.
Patients whose ablation is performed at an institution where the volume of such procedures is low are at higher risk of early mortality.
Because of the length and complexity of the procedure, electro-anatomical mapping and ablation are conducted with the patient under general anesthesia.3 The patient is kept supine, and remains so for 2 to 4 hours afterward to allow for hemostasis at puncture sites.3
Patients might be monitored overnight, although same-day catheter ablation has been shown to be safe and cost-effective in select patients.36,37 Post ablation, patients follow up with the cardiologist and electrophysiologist. Long-term arrhythmia monitoring is required.3 Anticoagulation is continued for at least 2 months, and is discontinued based on the patient’s risk for stroke, utilizing their CHA2DS2–VASc score.3,4
CASE
At Mr. Z’s 6-month primary care follow-up, he confirms what has been reported to you as the referring physician: He had a successful catheter ablation and continues to have regular follow-up monitoring with the cardiologist. He is no longer taking amiodarone.
At this visit, he reports no recurrence of AF-associated symptoms or detectable AF on cardiac monitoring. He has lost 8 lbs. You counsel to him to continue to maintain a healthy lifestyle.
CORRESPONDENCE Amimi S. Osayande MD, FAAFP, Northside-Gwinnett Family Medicine Residency Program, Strickland Family Medicine Center, 665 Duluth Highway, Suite 501, Lawrenceville, GA 30046; amimi.osayande@northside.com
