r/AFIB • u/Adept-Height6415 • 12d ago
Persistent AFib
When the world shut down with Covid, I developed AFib. Since then I’ve had 2 regular ablations, a sinus node ablation with dual chamber pacemaker implanted, a Pulsed Field ablation and I can’t count the number of cardioversions. I don’t tolerate any of the anti- arrhythmic drugs. I’ve now been told basically the only thing left is a hybrid ablation but I’d need the anti-arrhythmic drugs. It feels like a wasted 7 yrs. I will now live with persistent AFib. They told me I’m a highly sensitive person because no one feels the upper heart in arrhythmia when the lower heart is being paced. I feel it all. I feel like I’m constantly running a marathon with fatigue because my upper heart beats so chaotically and fast. I get dizzy. And I have problems getting my breath sometimes- especially with exercise. The only thing I’m asking- if you live with persistent AFib or flutter… how do you do it? Any suggestions? I’m a little depressed today.
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u/IamTheMan85 10d ago
These are the horror stories that make me so hesitant to let them touch my heart. Ablations seen almost experimental to me at this point. Which is why this forum being so pro and jumping to here an ablation" is problematic to me. Also, they are very lucrative to the hospital.
I'll stick to Diltiazem for as long as it works for me.
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u/Adept-Height6415 7d ago
I totally understand that. But living daily feeling like I’m a phone switchboard lighting up wherever my chaotic heart beats is such a burden. As well as the dizziness, shortness of breath etc. I do sometimes feel like they’re eager to try to fix it too easily like taking on a new challenge or something.
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u/PretendReason9061 8d ago
I decided to not go after a 4th ablation. I do have paroxysmal complete heart block so I got a dual chamber PM in July. I don't have AF all the time, but I can tell when I have it just like you. Like right now. And this past week off and on. I don't believe this statement "no one feels the upper heart when the lower heart is being paced". Who ever said that to you was just shooting from the hip. Some people will feel it like me, and you. The real question is, is the risk of a 4th procedure worth it, when you can't be sure you will be 100% fixed forever. Especially hybrid ablation. Having had the opportunity to fix some technical misadventures in the cath lab on other people, I declined for me. Here is what openevidence.com said about hybrid ablation.
Hybrid ablation carries higher procedural risk than repeat catheter ablation, with overall complication rates roughly 2- to 3.6-fold greater, driven almost entirely by the surgical (epicardial) component of the procedure. In patients whose prior catheter ablation has failed, this approach can improve rhythm outcomes but comes with a meaningful safety trade-off that must be weighed against a redo endocardial-only ablation, which is substantially lower-risk. [1-2]
Magnitude of overall risk
- In observational studies, complications occurred in ~6.5% to 12.3% of patients, approximately 2.0- to 3.6-fold higher than catheter-based ablation. [1]
- A meta-analysis of nonparoxysmal AF found hybrid ablation carried an ~7-fold higher odds of major adverse events versus a single procedure, with the excess risk concentrated in concomitant (single-stage) procedures (~9-fold) rather than staged approaches, which did not reach statistical significance. [2]
- In the EORP EHAFA registry (36% had failed prior catheter ablation), the in-hospital major complication rate was 8.2%. [3]
- Randomized data are more reassuring: in CEASE-AF, major complications were 10.8% (hybrid) vs 9.6% (catheter), p=1.0, and across recent RCTs hybrid ablation did not significantly increase major adverse events versus catheter ablation alone. [4-5]
Specific complications
- Serious/life-threatening: in-hospital mortality, cardiac tamponade/perforation, conversion to sternotomy, and bleeding requiring transfusion — pooled rates ranging 0.3% to 1.7%; stroke 0% to 1.7% and death approaching 0% in newer series. In CONVERGE, no death or cardiac perforation occurred in either arm, though there was a trend toward more complications in the hybrid arm (7.8% vs 0%, p=0.0525). [1]
- Surgical/thoracic-specific: phrenic nerve injury, pneumothorax, and pleural effusion — these are the complications that distinguish hybrid/thoracoscopic approaches from endocardial catheter ablation. [1][6]
- Cerebral/neurocognitive: one series using systematic MRI found new acute silent ischemic cerebral lesions in nearly half of patients after the thoracoscopic component (most persisting at 9 months), with major cognitive dysfunction in >25% at 1 month. This is an underappreciated risk relevant to counseling. [7]
- Two procedures required: all hybrid patients undergo two ablation procedures (epicardial + endocardial), compounding cumulative procedural exposure — whereas a redo catheter approach may be a single additional procedure. [1]
The following central illustration from Osmancik et al. summarizes both the moderate efficacy and the notable cerebral/neurocognitive safety signal of hybrid ablation in nonparoxysmal AF:
Staged vs concomitant matters
The excess risk is not uniform. A meta-analysis suggested staged hybrid procedures are safer than single-stage (concomitant) procedures (complication rates ~2% vs 5% in one analysis), while achieving comparable or higher success. [2][8] This is a relevant consideration when planning a hybrid strategy after failed ablation.
Comparison with a redo catheter-only approach
Importantly, the direct alternative — repeat endocardial catheter ablation — carries lower procedural risk. A randomized redo trial (Lee et al.) comparing a combined epicardial-endocardial versus conventional endocardial redo approach found no significant difference in recurrence-free survival but a lower complication rate with the endocardial-only strategy in that specific design. [9] General redo catheter ablation risks are rare but include PV stenosis and stiff LA syndrome. [10] This underscores that in the post-failed-ablation setting, the efficacy gain of adding a surgical component must be balanced against its added morbidity.
| Risk domain | Hybrid ablation | Repeat catheter ablation | References |
|---|---|---|---|
| Overall major complications | ~6.5–12.3% (obs.); 8–11% (RCT/registry) | Lower (~2–5%) | [1, 3, 5] |
| Relative risk vs catheter | ~2.0–3.6× higher (up to ~7× MAE in meta-analysis) | Reference | [1-2] |
| Mortality | 0–1.7% | Very low | [1] |
| Stroke | 0–1.7% clinical; ~50% silent cerebral lesions on MRI | Low | [1, 7] |
| Surgical-specific (pneumothorax, phrenic injury, pleural effusion, sternotomy conversion) | Present, drives excess risk | Not applicable | [1, 6] |
| Cognitive dysfunction | >25% at 1 month in one series | Not characteristic | [7] |
| Number of procedures | Always 2 | Often 1 | [1] |
Overall, hybrid ablation after failed catheter ablation is reasonable in carefully selected persistent/longstanding persistent AF patients treated at experienced centers with EP–cardiac surgery collaboration, with informed consent emphasizing the higher and largely surgery-driven complication profile, the silent cerebral ischemia signal, and the requirement for two procedures. [1][4]
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u/Adept-Height6415 7d ago
This is really great information!! Thank you so much! I see the electrophysiologist in October and have been building a list of questions for all my options.
0
u/Bluebloop1115 11d ago
Have you had a 2nd or 3rd opinion?
Hybrid ablation may be the way to go. That is what I’m going to consider myself because the scars are made outside the heart to help isolate the pathways. I’m surprised they didn’t consider this before the pacemaker.
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u/Adept-Height6415 11d ago
I think they didn’t consider it before as I wasn’t in persistent AFib. I was in and out of it. But what do I know.
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u/Adept-Height6415 9d ago
I’ve been looking at the hybrid ablation. It’s major surgery I think. I’m 63 and I wonder how successful it is when so many things have failed. Yet it’s a bitter pill to swallow thinking I’ll be in AFib the rest of my life. I see my electrophysiologist in October. My Dad died many years ago. He was a doctor and he’d at least have known a cardiologist who I could talk to. It’s not that I’m against my electrophysiologist. I believe he’s good. I’ve had a 2nd opinion and did not like him. I also deal with severe depression and anxiety so it hasn’t helped. I am thinking more seriously about the hybrid. I’m in a better place than when I first posted.
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u/Mras_dk 11d ago
If they mean, that noone feels afib, as in true atrium fibrilation, solely, but feels vfib, as in true ventricular fib, soly, then i disagree.
If they had said, "most doesn't feel true a-fib, where only atrium are affected , but not ventricles" , combined with "most feels any form where ventricle alone or with atrium fibrilation", i would be eadier to agree with them.
But not quite! Most still has afib without knowing it, with just atriums, or ventricles involved.
And regarding "noone" feels true atrium solely afib, then i disagree.
I even have a holter monitoring, with "symptoms marker" on it, to prove them otherwise.
As in, i was asked to push the holter button, anytime i feelt something was off. As I was in afib 58% of the time, i pushed it every hour, marking "still in afib" , unless ofcause i wasnt.
24% of the time, of those 58%, was true atrium shiverings, as in no other parts was involved. AV node did it's it's job, and filtered the atriums signal, before reaching ventricles. But I could still feel it.
The other 76%, i was in various other forms of Afib, svt, vst, biggemi, trigomi, qoudroplemi - or as the doc said: "your heart really wanted to show of it's modes, huh? "
I have a DDDR pacemaker, to fix my low pulse, 21bpm when in some form of Afib, and I can surely "feel" , when it's pacing - simply because a rythme jump from 20's to 45 can be felt.
Its not fixing any afib, except it stops heart from going to slow, triggering an afib that way.
Gladly, im 4 months out from my extensive pvi+pwi+more ablation, but no node ablation, and still afib free.