AV Node ablation

An atrioventricular (AV) node ablation is usually reserved for patients with ongoing AF who have failed to respond adequately to other treatment strategies. It benefits people with fast uncontrolled heart rates in AF despite medications or people who have severe side effects to using medications. Once exception is people with CRT pacemaker and AF who would benefit from an AV node ablation to allow for >90% pacemaker function. Patients usually have a pre-existing pacemaker , or a pacemaker implanted in view of having an AV node ablation.

The ablation procedure component is considered simple and effective. All the irregular rapid signals from the AF will no longer be able to reach the ventricle. The ventricles will now rely on the existing pacemaker to beat the heart. The heart is expected to beat regularly and allow us to rationalise your medications further. Age and comorbidities influence the management options. Procedural success is estimated at >98% and requirement for repeat procedure varies between 1-2%. Please refer to the catheter ablation section for general information about the admission process and requirements.

It is important to understand that the heart does not beat after an AV node ablation. The pacemaker will pace the heart for you. This is a common scenario, and your pacemaker function will be monitored regularly to ensure normal function. Pacemakers are highly reliable and sophisticated devices with many options to monitor you including remote monitoring. 

What are the risks of having an AV node ablation?

They include but are not limited to the following.

Common risks and complications (more than 5%) include:

• Bruising bleeding at the puncture site. Bruising can extend beyond the puncture site and can take a few weeks to improve in some cases.
• Developing pacing induced cardiomyopathy / weakening of heart muscle
• No significant improvement to symptoms of shortness of breath

Rare risks and complications (Less than 1- 2%) include:

• Development of another arrhythmia.
• Tamponade
• Major bleeding related to the groin puncture site or injury to an artery in the groin. This (rarely) may need surgery and or blood transfusion.
• A stroke. This may cause long term disability (0.5-1%)
• Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may break off and go to the lungs called pulmonary embolus.
• Skin injury from radiation. This may cause reddening of the skin.
• A higher lifetime risk from exposure to radiation.
• Chest pain / Pericarditis. This is an inflammation of the heart sack that can cause chest pain for some weeks after the procedure.
• Damage to the existing pacemaker requiring replacement or reimplantation
• Heart attack.
• Injury to the urinary tract if a urinary catheter is required for the procedure.
• Death because of this procedure is rare

What happens during the procedure?

Local anaesthetic is administered at the groin which numbs the area. Three small tubes called sheaths are passed into the vein in the right groin through which catheters are inserted and gently passed up until they reach your heart. An X-ray machine guides the catheters to your heart. An ablation catheter is advanced into the atrium that applies the radiofrequency energy at the relevant site. The catheter ablation procedure can take about 30mins – 1hr or more in some cases. Rarely, in some cases, we have to access the arterial circulation to achieve success which may be performed at that time or as a staged intervention.

What happens after an ablation?

At the end of your procedure, your doctor will remove the catheters and apply pressure, followed by a dressing. You may have a little device applying pressure at the puncture site for a few hours. You’ll be watched closely in a recovery area, and depending on how you feel, you might need to rest in bed for a while. You will be admitted to the ward for observation overnight with rhythm monitoring. You may be required to lay flat on your back for about 4 hours after your procedure. People are usually discharged the next day.

What happens after discharge?

Follow up:

• An appointment will be made for you to be seen in clinic about 2 months after the procedure
• You will need to have follow up appointment with your usual pacemaker clinic
• If you do not receive a date for an appointment within 8 weeks, please call the clinic and ask to speak to the secretary

Medications:

• Continue your medications as instructed. If you are uncertain about your medications, please ring the rooms for clarification

Postoperative care:

• Avoid strenuous exercise for 1 week
• Start with gentle exercise after 1 weeks – e.g. walking.

Symptoms to monitor:

• It is not uncommon to have a bruise at the groin that extends / spreads after the ablation. This usually resolves over time without any other problems.

Bleeding:

• It is rare to have severe bleeding from the puncture site once you are at home. If bleeding does occur you must: lie flat, apply pressure to the site for 10 minutes. If it continues, call an ambulance for assistance.

Please contact the rooms if you have any questions or concerns at any time.

In recommending this procedure your doctor has balanced the benefits and risks of the procedure against the benefits and risks of not proceeding. Your doctor believes there is a net benefit to you going ahead. This is a very complicated assessment.