Atrial Fibrillation: What if Medication or Ablation Aren’t Working
Atrial fibrillation, often called AF or AFib, is one of the most common heart rhythm disorders. It may be found during a routine check or cause noticeable symptoms such as a racing heartbeat, fluttering in the chest, breathlessness, fatigue, dizziness or reduced exercise tolerance.
Treatment usually begins with medication, management of contributing health conditions and, in selected patients, catheter ablation. These treatments help many people. But AF can continue or return after a period of improvement.
If medication or ablation has not worked as expected, it does not mean you have run out of options. Your AF may need reassessment to identify why it is continuing and which treatment could come next.
Ask your GP or cardiologist about a referral to Dr Adrian Pick to discuss atrial fibrillation treatment options in Melbourne.
Why AF can be difficult to treat
Atrial fibrillation is not always caused by one simple electrical fault. Abnormal electrical signals commonly begin near the pulmonary veins, which bring oxygen-rich blood from the lungs into the heart. This is why catheter ablation commonly targets this area.
AF can become more complex over time. Electrical activity may spread past the pulmonary veins, and the upper chambers of the heart may become stretched, scarred or electrically unstable. Valve disease, coronary artery disease and heart failure can also contribute.
A person with short, occasional AF episodes may respond differently to someone with persistent or long-standing persistent AF. Longer-lasting AF is generally harder to control.
Why medication may not be enough
Medication remains an important part of AF treatment. Rate-control medicines slow the heartbeat, rhythm-control medicines help maintain a regular rhythm and anticoagulants reduce stroke risk in patients who need them.
Medication does not always stop AF symptoms. Palpitations, breathlessness or fatigue may continue and side effects can make long-term treatment difficult. Medication may also control the heart rate without restoring a regular rhythm.
Please do not stop or change AF medication without speaking with your GP, cardiologist or treating specialist.
Why catheter ablation may not last
Catheter ablation is performed by an electrophysiologist. Energy is delivered through thin tubes passed through the blood vessels to create controlled scar tissue inside the heart. This blocks electrical signals that trigger or sustain AF.
AF can return when treated areas recover electrical conduction, new abnormal signals develop or electrical circuits outside the pulmonary veins continue to drive the rhythm.
Repeat catheter ablation may be suitable. Persistent AF after one or more catheter procedures can also prompt discussion about surgical rhythm treatment.
When surgical treatment may be considered
Surgical treatment may be considered when AF remains symptomatic despite medication or catheter ablation. It may also be performed alongside surgery for mitral valve disease, coronary artery disease or another cardiac condition.
Dr Adrian Pick’s AFib Clinic assesses patients whose AF has continued after medical or catheter-based treatment.
Surgical procedures create a broader pattern of lesion lines to interrupt the electrical circuits sustaining AF. Options include minimally invasive AF surgery, the Mini Maze, TT-Maze, Open Maze or AF treatment performed during another cardiac operation.
What is the TT-Maze procedure?
The TT-Maze, or totally thoracoscopic maze procedure, is a minimally invasive surgical treatment for selected patients with persistent or long-standing persistent AF. It uses keyhole access through the chest rather than a sternotomy.
The procedure treats areas beyond the pulmonary veins and creates a more extensive lesion pattern than catheter ablation alone. It may be assessed after AF has continued following catheter ablation.
Patients who have been advised to consider AV node ablation and a permanent pacemaker may also seek assessment to find out if a rhythm-focused surgical option remains suitable.
Not every patient with recurrent AF needs surgery. Suitability depends on the duration and type of AF, previous procedures, heart structure, associated cardiac disease and general health.
What happens next?
Assessment may include your ECGs, Holter monitor results, echocardiogram, scans, medication history, ablation reports and current symptoms.
Treatment may involve medication changes, further catheter treatment, management of sleep apnoea, blood pressure, weight or alcohol intake, or surgical assessment.
When to speak to your GP
Please speak with your GP to request specialist referral if:
- Symptoms continue or become more noticeable
- AF returns after cardioversion or catheter ablation
- Medication side effects affect daily life
- Your exercise tolerance has declined
- You want another opinion about the next treatment step
For patients in and around Frankston or Moorabbin, ask your GP or cardiologist for referral to Dr Adrian Pick for cardiothoracic assessment.
Already have a referral? Contact Dr Pick’s rooms to book your consultation.
Frequently asked questions
Yes. Electrical conduction can recover, or AF may be driven by areas that were not treated during the original procedure.
No. Surgery is one treatment option. Your previous procedures, symptoms, AF duration and heart health guide the recommendation.
Your stroke risk determines the need for anticoagulation. Successful rhythm treatment does not automatically mean blood thinners can be stopped.
Please seek urgent medical attention if you experience chest pain, fainting, severe breathlessness, stroke symptoms or sudden worsening symptoms.
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.
References:
Kistler, P. M., Sanders, P., Amarena, 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, 33(6), 828–881. https://pubmed.ncbi.nlm.nih.gov/38702234/
European Society of Cardiology. (2024). 2024 ESC guidelines for the management of atrial fibrillation. European Heart Journal, 45(36), 3314–3414. https://www.escardio.org/guidelines/clinical-practice-guidelines/all-esc-practice-guidelines/atrial-fibrillation/
Tzeis, S., Gerstenfeld, E. P., Kalman, J., et al. (2024). Oxford Academic. EHRA/HRS/APHRS/LAHRS expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace, 26(4), euae043. https://academic.oup.com/europace/article/26/4/euae043/7639428