Atrial fibrillation (AF or AFib) is one of the most common heart rhythm problems in Australia. Medication may help control symptoms for some, but for others, ongoing palpitations, breathlessness, fatigue, dizziness or reduced exercise tolerance, can lead to discussions about ablation.
Two options are catheter ablation and AF surgery. Both are used to treat abnormal electrical signals in the heart, but they are not the same procedure. They differ in how they are performed, who performs them, the areas of the heart they treat and the patients they are suitable for. Neither treatment suits everyone, so this article clearly explains the differences to support patients in having more informed discussions with their cardiologist, electrophysiologist or cardiothoracic surgeon.
Cardiothoracic Specialist in Melbourne, Dr Adrian Pick, sees patients with complex atrial fibrillation, including persistent AF, long-standing AF and AF that has continued after catheter ablation.
What is catheter ablation?
Catheter ablation is usually performed by an electrophysiologist, a cardiologist who specialises in heart rhythm disorders. Thin catheters are passed through blood vessels, commonly from the groin, into the heart. Energy is then used to create controlled areas of scar tissue to block or isolate abnormal electrical signals.
Catheter ablation focuses on the pulmonary veins, a common source of abnormal electrical triggers in atrial fibrillation. It is less invasive than surgery, involving a shorter hospital stay and recovery, and commonly considered for patients with symptomatic AF, especially paroxysmal AF, where episodes come and go. In some cases, more than one catheter ablation can be needed.
When is catheter ablation recommended?
Catheter ablation may be discussed when AF symptoms continue despite medication, medication is not well tolerated or rhythm control is preferred after discussion of the likely benefits and risks.
It can be a reasonable first procedural option for some people with paroxysmal AF and is also used in persistent AF. Outcomes can vary, depending on how long AF has been present, left atrial size, and other heart conditions, sleep apnoea, weight, blood pressure and alcohol intake.
Catheter ablation treats AF from inside the heart without chest incisions. Some patients, especially those with more complex AF, might continue to have symptoms and may need repeat procedures.
What is AF surgery?
AF surgery is performed by a cardiothoracic surgeon. It can be performed as part of another heart operation, such as valve surgery or coronary artery bypass surgery, or as a minimally invasive stand-alone procedure.
Minimally invasive AF surgery, including the TT-Maze Procedure, uses small incisions between the ribs to reach the outside surface of the heart. The surgeon creates a pattern of ablation lines designed to interrupt the circuits that sustain atrial fibrillation. The left atrial appendage can also be managed during surgery for certain patients, as this area is linked with clot formation in AF.
Surgery can allow broader treatment of the atria than standard pulmonary vein isolation alone, for when AF is persistent, long-standing or has returned after catheter ablation.
When is AF surgery considered?
AF surgery is not usually the first treatment for every patient with atrial fibrillation. It may be considered in situations such as:
- Patients already having heart surgery
- Persistent or long-standing persistent AF
- AF that has continued or returned after catheter ablation
- Patients who have been told their next option may involve AV node ablation and a permanent pacemaker
- Patients seeking a surgical opinion before further rhythm procedures
For patients already undergoing cardiac surgery, surgical ablation can sometimes be added during the same operation if it is suitable for their condition.
Which treatment fits your AF?
The question is not “Which procedure is best?” It is “Which procedure fits this patient’s AF?”
The answer depends on the pattern of AF, how long it has been present, previous ablation history, heart structure, stroke risk, other health conditions and personal priorities.
If you have persistent AF, AF that has returned after catheter ablation (recurrent AF) or have been advised that a pacemaker may be the next step, a cardiothoracic surgical opinion can help you understand your treatment options.
Ask your GP or cardiologist about a referral to Dr Adrian Pick to discuss atrial fibrillation surgery in Melbourne.
Frequently asked questions
Is catheter ablation less invasive than AF surgery?
Yes. Catheter ablation reaches the heart through blood vessels and does not require chest incisions like minimally invasive AF surgery.
Can atrial fibrillation return after either procedure?
Yes. AF can return after catheter ablation or surgery. In patients whose AF has returned after catheter ablation, surgery can provide a greater chance of remaining free from AF than another catheter ablation. Outcomes vary on the type and duration of AF, previous treatment and individual heart health.
Can AF surgery be performed without open heart surgery?
Thoracoscopic maze, or TT-Maze surgery, could be an option for selected patients which is performed through small incisions between the ribs rather than a full sternotomy.
What are the recovery expectations for both?
Recovery after catheter ablation is shorter, with most patients returning to light activities sooner. Some people experience palpitations during the healing period, and follow-up rhythm monitoring is required.
Recovery after minimally invasive AF surgery is longer. Patients may need time for incisions to heal, discomfort to settle and energy levels to improve. Hospital stay and return to activity vary with the procedure, patient health and any other heart condition being treated.
When is it worth getting a surgical opinion?
Surgical review can be discussed for persistent or long-standing AF, AF that has returned after catheter ablation, or when AF surgery is being considered alongside another heart operation.
Specialist AF care in Melbourne
Dr Adrian Pick is a Cardiothoracic Specialist in Melbourne with experience in minimally invasive cardiac surgery and surgical atrial fibrillation treatment. Dr Pick’s AFib Clinic provides assessment for patients with persistent or recurrent AF, including those who have not achieved lasting rhythm control with medication or catheter ablation.
If you have persistent atrial fibrillation or AF that has returned after ablation, ask your GP or cardiologist about a referral to Dr Adrian Pick.
Reference:
Kistler, P. M., Sanders, P., Amerena, J. V., et al. (2024). 2023 Cardiac Society of Australia and New Zealand expert position statement on catheter and surgical ablation for atrial fibrillation. Heart, Lung and Circulation. https://doi.org/ 10.1016/j.hlc.2023.12.024
This article is for general information only and should not replace medical advice from your GP, cardiologist or treating specialist. All medical and surgical procedures carry risks and outcomes vary between patients. Consult with Mr Adrian Pick MBBS, FRACS | Gen Surg, FRACS | Cardiothoracic (MED0001117736) is a Cardiothoracic Specialist for personalised treatment and advice.