Pulmonary Vein Antrum Isolation
(also called pulmonary vein isolation, pulmonary vein ablation or PVAI)

What is atrial fibrillation?

Atrial fibrillation is the most common irregular heart rhythm in the United States. Atrial fibrillation is an abnormal heart rhythm originating in the atria (top chambers of the heart). Instead of the impulse traveling in an orderly fashion through the heart, many impulses begin and spread through the atria, causing a rapid and disorganized heartbeat. (Click here to learn more about atrial fibrillation).

Electrical System of the Heart

Medications, Ablation and other treatments for atrial fibrillation

The goals of treatment for atrial fibrillation include regaining a normal heart rhythm (sinus rhythm), controlling the heart rate and preventing blood clots and strokes. Initially medications are used to treat atrial fibrillation. The medications may include:

• Rhythm control medications (antiarrhythmic drugs)
• Rate control medications (to slow the heart rate)
• Coumadin (warfarin – an anticoagulant or blood thinner) to prevent blood clots and stroke

Other treatments for atrial fibrillation, such as pulmonary vein antrum isolation (PVAI) are appropriate for patients who:

• Have a history of chronic or paroxysmal atrial fibrillation
• Have continued symptoms of atrial fibrillation, despite treatment with medications
• Can not tolerate antiarrhythmic drugs, or have had complications from these drugs

What is pulmonary vein ablation (pulmonary vein antrum isolation)?

Research has shown that almost all atrial fibrillation signals come from the four pulmonary veins. Pulmonary vein antrum isolation (PVAI), also called pulmonary vein ablation, is a treatment for atrial fibrillation. During pulmonary vein ablation, a doctor inserts catheters into the blood vessels of the atrium.

A special machine delivers energy through the catheters to the area of the atria that connects to the pulmonary vein (ostia). This energy (ablation) produces a circular scar that blocks any impulses firing from within the pulmonary vein, thereby "disconnecting" the pathway of the abnormal rhythm and preventing atrial fibrillation. In some cases, pulmonary vein ablation also may be performed in other parts of the heart such as the superior vena cava.

How can I be evaluated for the pulmonary vein antrum isolation (or pulmonary vein ablation)?

If you are currently being treated outside the Cleveland Clinic Foundation:

• If you are currently being treated outside of The Cleveland Clinic Foundation, please call Cardiology Appointments at 216/444- 6697 or toll-free at 800/223-2273 ext. 46697 to schedule an evaluation for ablation. Or, you may Click Here to request an appointment online. 
• Or, you may use our web-based second opinion service, eClevelandClinic.org. This service offers a second opinion from one of our medical specialists from the convenience of your home. To learn more about this service, please visit the web at
  www.clevelandclinic.org/services/eclinic.htm or call 800/223-2273 ext. 43223.
• If you already are a patient of The Cleveland Clinic and are receiving treatment for your atrial fibrillation, talk to your cardiologist  about whether PVAI is an option for you.
• Please call the Center for Atrial Fibrillation at 216/444-9162 or 800/223-2273, ext. 49162, or you may call the Heart Center Resource and Information nurse toll free at 866/289-6911 or locally at 216/445-9288 if you have additional questions regarding PVAI (pulmonary vein ablation), making an appointment or the evaluation, or Contact Us through the website.

Evaluation

To determine if ablation is an appropriate treatment, a thorough evaluation will be performed, which may include:

• A review of your medical history
• Complete physical examination
• Electrocardiogram (ECG)
• Echocardiogram (Echo)
• Holter monitor test

After the evaluation, the doctor will discuss your treatment options and together, you will determine if you are a candidate for this procedure.

Are there any risks?

The PVAI procedure is generally very safe. However, as with any invasive procedure, there are risks to ablation. Special precautions are taken to decrease these risks. Your doctor will discuss the risks of the procedure with you.

Before pulmonary vein antrum isolation (or pulmonary vein ablation): What tests may be performed?

In some patients, a transesophageal echocardiogram (TEE) or a spiral computed tomography (CT) test may be performed before  the procedure. If you take Coumadin, the results of your INR test (a blood test to evaluate blood clotting) must be within a suitable  range before the procedure can be performed.

Should I take my medications?

Your doctor may ask you to stop taking certain medications. Do not discontinue any of your medications without first talking to your health care provider. Ask your doctor which medications you should stop taking and when to stop taking them.

If you have diabetes, ask the nurse how you should adjust your diabetes medications and/or insulin.

Can I eat?

Eat a normal meal the evening before your procedure. However, DO NOT eat, drink, or chew anything after 12 midnight before your procedure. This includes gum, mints, water, etc. If you must take medications, only take them with a small sip of water. When brushing your teeth, do not swallow any water.

What should I wear?

Remove all makeup and nail polish before coming to the hospital. Wear comfortable clothes. You will change into a hospital gown for the procedure. Please eave all jewelry (including wedding rings and watches) and other valuables at home. The clothing you are wearing that morning will be returned to the person who accompanies you or placed in a locker.

What should I bring?

You will not need a robe or toiletries when you first arrive. Your family member can keep these items to give you after the procedure.

Bring your prescription medications with you, but do not take them without first talking to your health care provider.

You may bring guided imagery tapes or music and the appropriate player to listen to before the procedure.

What happens when I arrive?

Before the procedure begins, a nurse will help you get ready. You will lie on a bed and the nurse will start an IV (intravenous line) in a vein in your arm. The IV is used to deliver medications and fluids during the procedure.

A medication will be given through your IV to make you feel drowsy. Your neck, upper chest, arm and groin will be cleansed with an antiseptic solution. The catheter insertion site(s) will be shaved. Sterile drapes will be placed to cover you from your neck to your feet.

During pulmonary vein ablation: Where is the procedure performed

The PVI takes place in a special room called the EP (electrophysiology) lab.

Will I be monitored?

The nurse will connect you to several monitors that will check your heart rhythm and your body's responses to any arrhythmias during the procedure. The nurse will constantly assess you during the procedure. The following are the monitors that will be used during the procedure:

• Defibrillator/pacemaker/cardioverter: Attached to one sticky patch placed on the center of your back and one on your chest. This allows the doctor and nurse to pace your heart rate if it is too slow, or deliver energy to your heart if the rate is too fast.
• Electrocardiogram or EKG: Attached to several sticky electrode patches placed on your chest, as well as inside your heart.  Provides a picture on the monitors of the electrical impulses traveling through the heart.
• Blood pressure monitor: Connected to a blood pressure cuff on your arm. Checks your blood pressure throughout the ablation.
• Mapping system: State-of-the-art technology that helps your doctor locate the exact area of your arrhythmia.
• Ablation machine: Attached to another sticky patch on your back.
• Oximeter monitor: Attached to a small clip placed on your finger. Checks the oxygen level of your blood.
• Fluoroscopy: A large X-ray machine will be positioned above you to help the doctors see the catheters on an X-ray screen  during the procedure.
• Intracardiac ultrasound, performed by a catheter transducer inserted into the heart: Used throughout the procedure to view the  structures of the heart and the catheter when it is in contact with the heart lining.

How does the doctor insert the catheters into the blood vessels around my heart?

After you become drowsy, the doctor will numb the catheter insertion site by injecting a medication. The doctor will insert several catheters into large veins in both sides of your groin and in your neck.

A transducer is inserted through one of the catheters so intracardiac ultrasound can be performed during the procedure. The ultrasound allows the doctor to view the structures of the heart and evaluate pulmonary blood flow on an external monitor.

The catheters will be advanced through the blood vessels to your right atrium. A needle is then used to place the catheters through the septum into the left atrium.

After the catheters are in place, the doctor will look at the monitor and assess your heart's conduction system. Energy is delivered through the catheters to the area around the pulmonary vein openings to stop the abnormal impulses.

Once the ablation is complete, the electrophysiologist uses monitoring devices to observe the electrical signals in the heart.

How will I feel during the procedure?

You may fall asleep at times during the procedure, due to the medication given to make you relax. You will feel an initial burning sensation when the doctor injects medication in the catheter insertion site.

You may feel some discomfort or a burning sensation in your chest when the energy is applied through the catheter. It is important to remain quiet, keep very still and avoid taking deep breaths. If you are feeling pain, ask your doctor or nurse to give you more medication.

How long does the procedure last?

The PVAI procedure may last from 3 to 5 hours.

After pulmonary vein antrum isolation: What should I expect?

The doctor will remove the catheters and apply pressure to the insertion site to prevent bleeding. No stitches are needed. A pressure dressing (bandage) will cover the insertion sites.

You will need to stay in bed for 6 to 8 hours after the procedure. You'll need to keep your legs still during this time to prevent bleeding.

When will I find out the results?

After the procedure, the doctor will discuss the results of the procedure with you and your family.

How will I feel after the procedure?

You may feel fatigue or chest discomfort during the first 48 hours after the procedure. Please tell your doctor or nurse if any of these symptoms are prolonged or severe.

Will I have to stay in the hospital?

Yes. You will be admitted to the hospital and stay overnight after the procedure.

In your hospital room, you will be placed on a special monitor, called a telemetry monitor. Telemetry consists of a small box connected by wires to your chest with sticky electrode patches. The box displays your heart rhythm on several monitors in the nursing unit so the nurses will be able to observe your heart rate and rhythm.

Will I be taking new medications?

For at least three months after the procedure, you will need to take an anticoagulant (blood thinning) medication, such as Coumadin (warfarin), to prevent blood clots. You must have frequent blood tests,(called an INR/Protime) to evaluate the dosage of Coumadin. Your doctor will tell you how often to have this test. Please schedule these tests with your local doctor's office.

You may also need to take an antiarrhythmic medication to control abnormal heartbeats for two months after the procedure.

You will receive the necessary prescriptions and medication instructions from your doctor. Ask your doctor if you can continue taking your previous medications.

In some cases, your doctor may recommend cardioversion to control abnormal heartbeats.

Will I be able to drive myself home?

No, for your safety, a responsible adult must drive you home. We request that your ride be ready to take you home by 10:00 a.m. on the morning of your discharge day.

If you live more than two hours from the Cleveland Clinic, we suggest that you stay in the hotel overnight for your comfort. Then you can have your family member drive you home after you have rested. During your ride home, please stop every hour and walk for 5 to 10 minutes.

If you are flying home, you may want to order a wheelchair to take you to and from the plane. Once you are on the plane, stand up in the aisle and stretch your legs for a few minutes every hour.

Plan to rest when you arrive home.

Click here for assistance with travel arrangements

Follow-Up Care at Home after pulmonary vein antrum isolation: When can I shower?

You can shower as soon as you go home. Do not take baths, including Jacuzzi baths. Avoid water temperature extremes. Do not swim for five days after the procedure. Keep the procedure site clean and dry.

When can I return to my normal activities?

Your doctor will tell you when you can resume your normal activities, including driving. Usually you can return to your normal activities within 48 hours after the procedure. For one week after the procedure, do not lift anything that weighs more than 10 pounds.

What symptoms should I expect?

You may experience skipped heartbeats or short episodes of atrial fibrillation during the first two months after the procedure. These symptoms are common due to inflammation (swelling) of the heart tissue and are treated with medications. After your heart has healed, these abnormal heartbeats should subside.

When these symptoms occur during your recovery, it is important to document them. Your doctors and nurses will provide you with the instructions on how to document your symptoms using a telephone transmitter, and how to call our Arrhythmia Lab.

What symptoms should I report?

Please call the Center for Atrial Fibrillation if you have:

• A temperature of more than 101 degrees Fahrenheit or 38.4 degrees Celsius (a possible sign of infection).
• Redness, swelling or drainage at the procedure site (call right away).
• Atrial fibrillation symptoms (remember to call the Arrhythmia Lab to document these symptoms using the telephone transmitter).

Follow-up visit

A follow-up visit will be scheduled three months after your pulmonary vein antrum isolation (PVAI) procedure. You will receive a reminder card for this appointment. However, if you don't receive an appointment notice within six weeks after your procedure, please call the Center for Atrial Fibrillation. Please bring your telephone transmitter to your follow-up appointment.

During this visit, you can expect to have these tests:

• Electrocardiogram ( ECG)
• 2-D echocardiogram (echo) or transesophageal echo (TEE)
• Spiral computed tomography (CT) scan to evaluate the presence of pulmonary vein narrowing. The CT scan involves the use of an intravenous contrast material. If you are allergic to contrast material, dye or shellfish, please notify the Center for Atrial Fibrillation immediately, so you can receive a medication to take before the test.
• INR/Protime test - if you have been taking a blood thinning medication
• Other blood tests/lab work

You will need to fast ( not eat or drink anything) for 6 hours before your follow-up appointment

If you are still experiencing atrial fibrillation at the time of your follow-up visit, a repeat ablation may be needed.

Pulmonary Vein Ablation Procedure Innovations at the Cleveland Clinic
The circumferential mapping technique used during the pulmonary vein ablation procedure was pioneered in the Cleveland Clinic Electrophysiology (EP) Lab. Research has shown that almost all atrial fibrillation signals come from the four pulmonary veins.

The use of intravascular ultrasound (IVUS), also called Intracardiac Echo (ICE), during the PVAI procedure was pioneered in the EP Lab. An IVUS catheter is placed into the heart to aid in visualization of the heart structures and catheters. IVUS assists the physician in performing transseptal punctures to gain access to the left atrium. IVUS also is used to evaluate and direct the amount of power used to ablate, as well as aid the detection of microbubbles.This is important to help prevent pulmonary stenosis, micro- embolic events and other complications.

Please see our Cardiovascular Medicine outcomes information for information about statistics and success rates.

Click here to learn more about:

• Atrial fibrillation
• Innovations in the treatment of atrial fibrillation

Click here to find a Cleveland Clinic Heart Center doctor who performs this procedure

Center for Atrial Fibrillation home page