Catheter based Atrial Ablation

You may remember me talking about about A-Fib and A-Flutter episodes I have been having few years ago. Though it is fairly common (prevalence is about 10% of the population), once you have this cardiac issue, it normally tends to occur more often as you age. I had it only about 4 times over the last 7 years. Though my sample size is small, it did look like the frequency is increasing. So, after some deliberation and discussions with multiple cardiologists, I went through the Atrial Ablation procedure on April 15, 2025. Since this is a catheter-based (i.e. not an open-heart surgery) outpatient procedure (i.e. no need to stay overnight in the hospital), it is generally tolerated well, and the recovery time is shorter. I am sending out this email in the hope that it will nudge you to learn about this disorder and this technically sophisticated procedure being used more and more to address it.

I am including a lot of links that I found interesting. Please consider looking through them all, as each one will take only few mins of your time. 

If you have never heard of A-Fib, A-Flutter or SVT (Supra Ventricular Tachycardia), you can take a quick look at this Mayo Clinic explanation. This CDC site has a simple animation explaining A-Fib. It boils down to electrical signals that regulate our heart rhythm finding alternate paths and misfiring that results in heart quivering without periodicity instead of beating regularly.  The Atrial Flutter condition occurs when for no apparent reason, heart starts beating really fast while you are just sitting around (i.e. instead of 50 to 60bpm, it starts racing at 140-180bpm). Both are bad for the body since this may result in stroke, heart just stopping and other serious conditions. Some people do have A-Fib that results in occasional beats just missing but otherwise everything working normally, and they live many decades without the need for any intervention. 

If these unacceptable A-Fib or A-Flutter condition occur frequently and the heart doesn't reset itself back to sinus rhythm after a while, there are increasing levels of interventions suggested. 

- Initially you can take medications (pills) that are called Beta Blockers that will slow down the heart and make sure it never beats too fast. Downside is, since its effect is always on, you blood pressure, heart rate may remain perpetually low, making you feeling tired, slowing down your metabolism resulting in weight gain, etc. 

- If the heart doesn't return to normal rhythm for a long time, you can shock it back into rhythm. But that doesn't guarantee that you won't get into that state again in the next hour or tomorrow or next year.

- If this keeps occurring, pace maker installation is one solution. But that is invasive, need to be maintained and monitored regularly. 

Atrial Ablation is a newer answer to this issue. Ablation in medicine means removing or deactivating some tissue/part. In other ablation procedures, the ablated tissue may be excised. But in atrial ablation, since the amount of tissue ablated is so small, the killed tissue cells are just left to scar and heal. 

You can take a look at this short video to get more background information about the issue and procedure. 

Couple of weeks before the procedure, you are asked to go through a CT scan to make sure you are fit to undergo this treatment, your veins are in good shape, and there is nothing unusual about your heart chambers & access pathways that may prevent a successful procedure. This is followed by a blood test. If everything looks good, you check-in to the hospital one day morning (shouldn't eat or drink during the previous 12 hours), prepped (lot of shaving chest hair that still itches!), given IV, monitored for a while and then moved to the operation theater. There were 7, 8 people in the room working on me, that included the anesthesiologist, OR nurses, cardiologist and even a nurse representing the equipment company that marks different parts of the body to create a 3-D image of the torso. Since the procedure is performed under General Anesthesia, once I had the oxygen mask on me, remember taking couple of deep breaths as instructed and in the next instant waking up in the recovery room after 3 hours! BTW, I was under the impression that just one or two drugs are administered to anesthetize you during the procedure. Actually, a cocktail of 7, 8 drugs calibrated for you is administered and documented minute by min. During the process, I was intubated (to keep the airways open so that I will keep breathing while being unconscious). You can see the actual procedure done on some patient shown in this video, though with all the plastic covering in place, it is not very educational but for understanding how the catheters look on the monitor to the operating team during the procedure. 

Procedure itself involves pasting a lot of markers on you, to be able to get a consolidated 3-D image of your torso on the monitor, then making an incision (more of a small puncture) on the left and right sides of your groin area to access the femoral vein. This vein is big enough and is close to the skin surface and so you can think of this process more like the procedure used to draw blood from your elbow when you go in for blood test, just a little bigger (say the size of a punch hole size opening). A sheath is inserted into this hole that prevents blood flowing through the vein coming out. Then the catheter is inserted into this vein through the sheath. While the sheath provides a nice tight opening, the catheter is slowly pushed all the way through your body until it reaches the inside of your heart. Since I have had both A-Fib and A-Flutter, cardiologist told me that the procedure has to be done on both atrial chambers of the heart. I initially thought this is why we need access from both left and right sides of the groin, using two different catheters. Subsequently when I read the procedure report, saw a line that said, "Left heart catheterization by transseptal puncture through intact septum" that I didn't know was part of the procedure before! 🙂 So, only one catheter is used for ablation that starts from right groin and first reaches the right atrial chamber. The cardiologist then pierces the heart wall (septum) that separates left and right atrial chambers to make a hole, to push the catheter to the left side, repeat the procedure on that side and pull it back out. You can see this process explained in this short video. They then apply Heparin and let the hole heal! Realized the procedure is more invasive than I originally thought! The other catheter inserted is used for multiple purposes such as mapping the chamber, measuring electrical activity as well as possible ablation steps. 

The process of ablation was previously done using extreme heat (e.g. radio frequency rays triggered from the tip of the catheter) or cold (Nitrogen gas) that kills the cells. I was explaining this process as more like heating/cooling the vessel to cook what is inside, where the vessel and adjacent area also gets heated/cooled unnecessarily. Since last year PFA (Pulse Field Ablation) model has become common. Here the catheter emits pulses for very short duration (about 2.5 seconds for each firing) that is repeated about 8 times in two different configurations (called basket and flower) that affects only needed tissue without affecting adjacent cells much. This is more like induction cooking that heats up only the content of the vessel and not the vessel itself. Click on the PFA link to see a very short video that explains the two configurations and the counts. This CT scan picture below shows one of my own heart chambers that went through the procedure. 

Once the process is over (about 2 hours total in the OR), all the catheters are removed in the OR itself, entry point sutured (just couple of stitches) before you are wheeled back into the recovery room. Though the procedure itself is only 2 hours long, there is a 4-hour protocol that is administered during recovery that involves monitoring suture site every 30 mins to make sure there is no bleeding, making you walk for 1 min after 2 hours, walk for 3, 4 mins after 3 hours, then remove the sutures, monitor your heart/pulse/BP, etc. If all goes well, the incision areas do NOT become hard, don't bleed, then you are discharged out of the hospital the same day. Though I was clearly very conscious by the time I was discharged, since the effects of general anesthesia can take up to 24 hours to wear off, Maya had to drive me home. 

I was told not to lift anything that weighs more than 10lbs for couple of weeks. I thought by next day morning I will be back to normal. But had fever, headache for couple of days, sore throat (caused by intubation) for a week, and a lingering muscle ache & tiredness for almost two weeks! Made me realize that the procedure was a big trauma for the body since multiple catheters went in and out, heart chambers were touched, septum pierced and what not, and so it has to take its time to heal and recoup normalcy. Now I am back to normal baseline, except for having to take blood thinner for a month. Since catheters were used a lot, Eliquis is prescribed to ensure that there is no blood clot formation that may result in stroke. My wife suggested I don't cook/shave so that I won't nick myself resulting in non-stop bleeding. Used the opportunity to grow a beard (you can see pictures of bearded Sundar from 1985 to 2025 here! ). I am grateful that I have good health insurance, since I saw videos that said the procedure may cost as much as or even more than $300,000, that stunned me! 

I am really intrigued and impressed by the process & the procedure. Usually, the cardiologists who do the procedure get most of the credit and patient gratitude. Though they do deserve credit, to me, they appear more like skilled technicians executing precise steps they were taught to them. What I am more impressed by is the cumulative domain knowledge that has been developed by the researchers and equipment makers, that makes such a procedure to be executed via catheters even possible! Do check-out the details of the steps, how same catheter tube is used to do multiple steps, how the extremely sharp needle at the tip of the wire that pierces the wall (septum) that separates right and left atriums is designed to immediately bend so as not to accidentally cause any other unintended damage (explained in the video), the flower and basket formations formed by the same PFA catheter and so on! 

The procedure reports I saw does say that electrical conductance tests done after the procedure show electrical isolation that is in place now. Unfortunately, (unlike a clot for which a stent is installed, that very clearly addressing the root cause,) in this procedure, the cause/fix is not very clear. We just hope that this procedure takes care of the issue. That's all. In some cases, the issue returns, and they even do a second procedure. Hopefully in my case, this completed procedure will prevent all future episodes of A-Fib or A-Flutter, allowing me and my wife/family to live worry free! I am hoping to travel, stay alone without worrying much in the future. Wish me luck! 

If you search the web, you will find lot more information such as Watchman implants that are quite interesting to learn about. If you'd like any clarification or need any specific details, please let me know via comments or email.