Types of Ablation for A-Fib

[rowjo]

My Mom is having pulmonary vein ablation later this week in Rockford, IL...we wanted to ask last minute questions of doctor now that we know a little more from reading.  She's 64, paroxsymal a-fib for about 3 years, very toxic reactions a couple of years ago to Pacerone (she was overdosed by inexperienced doctor...800-1200mg/day for 8 months...lost use of her thyroid, no structural or other heart problems except some high blood pressure.  She's still having brief episodes 4-5 times daily during waking hours even with several combos of meds.  Here goes the questions:

1.  What is the most accepted form of ablation these days:  focal point (I hear that's an older method?), circumferential (more problems with stenosis?), and segmental (involves more mapping?)?  What are the main differences/advantages/disadvantes?

2.  What is the most common method used in ablation also...RF, microwave, cyrotheramy?  Differences/advantages/disadvantages?  Should a cool tip catheter always be used in RF ablation?

3.  Should a TEE always be down prior to the procedure to check for clots in the heart?  What's the difference between a TEE and a regular echo?

4.  How can stenosis be prevented and monitored for?  How common is that?

5.  How long have ablations been performed as a procedure in hospitals?  

6.  What is a good rule of thumb for how many ablations an electrophysiologist should have performed already to be considered "experienced"?

Thanks so much...you guys are great! If my folks lived closer, we'd be seeing you!

rowjo

[CCF-M.D.-MJM]

Hello,

These are very complicated question and without knowing the very specifics of the case, near impossible to answer.  For example, the approach ablation is dependent on the mechanism of her AF (i.e. is it from a focal point based on mapping, if it is, than focal ablation is the right approach).  Many doctors are experienced in one technique and may be biased to there approach.  At the clinic, we use radio frequency and segmental mapping with ablation.  

2. Some RF catheters use a cool tip.  There is no standard of practice yet.

3. TEE is done for anyone in atrial fibrillation at the time of procedure.  If they are in normal sinus rhythm, it is up to the doctor on whether they think it is necessary.

TEE looks at the heart through the esophagus and is better at seeing clots in the atrium.  transthoracic is better less invasive.  TTE views the heart through the thoracic wall.

4. Stenosis is a known complication of PVIs.  Even a perfectly done procedure can lead to PS.  Typically a TEE follows the procedure at 3-6 months to assess for PS.  Some hospitals do CT instead of TEE.  It is not standardized.  The incidence of PS is 1-3%.

5. I actually don't know the answer to this one.  It is a relatively new procedure.

6. There is not standard yet.  The procedure is too new.  I think 50 is a good number, but there is no data to back that up.  We do about 5 per day here.  As always, high volume centers with high volume operators usually have better outcomes.

You might be amazed  at how far and how often people travel to Cleveland to have their procedures.

I hope this helps and good luck!

[dquenzer]

I had a pulmonary vein ablation at Mayo.

They explained to me that that there are two basic approaches.
1.  One approach is to ablate where the vein goes into the atrium.
2.  Another approach is to do a big circle around the area where the vein comes into the atrium but not go to the edge where the vein meets the atrium.

Mayo did the second approach for two reasons:
1.  They have found it to be as successful as the first.
2.  They have found little or no complications with vein stenosis.

I also had some focal point ablations done that were creating some atrial flutter and PAC's.

At Mayo I had the following tests before the procedure:
A cat scan of the heart, an echocardiogram, a lung scan, an esophagal echo (TEE), a chest exray, and ecg, etc.  They were done primarily to make sure I had no underlying heart disease or blood clots.  

At the end of 3 month period I went back and had essentially the same tests except I didn't have the esophagal echo or the chest xray.

According to the Mayo doctors these type of ablations have been around for about 5 years.  It is still a fairly new technology and there is no definite understanding of how long they last.

So far I have done very well.  

Expect the following however:
1)  The heart will be irritated and you will probably have some weird irregular beats for awhile.  Doesn't mean it has failed.
2)  My heart rate increased after the procedure and came down some, but is still higher than it was.  This is normal.
3)  You will be tired for about a month after the procedure.  I was at least.  But then after a month I was pretty much back to normal.
4)  Also after the procedure my back hurt real bad.  On table for 7 hours.  So you can expect some significant back discomfort.  You want to be able to take some hefty pain killers.

Also ask about whether you will be anesthetized our simply sedated.  I was sedated.  Slept through the entire procedure.  You DON'T want to be awake if possible.  

[trudyjh]

My two cents as a layperson -

1. My impression is that just focal point is basically not done any more.  The ablations that target the pulmonary veins seem to have higher success rates.  I believe those also check for foci elsewhere in the heart and try to get those as well.  Something to ask the doc.

2. Cryo ablations are new, but seem to be a little safer since they can temporarily stun the areas first and make sure they have the right places.  Particularly important if they are working anywhere near a node.  I don't think many places do these yet.  It is early to tell about their success rates.

3. A TEE is done if there is reason to be concerned about clotting, for example, if the person was in afib long enough within, say, the past 30 days.

4. The abations that work right at where the heart joins the pulmonary veins or inside the pulmonary veins I think have a higher risk of stenosis.  So they try to work just outside that area now.

5. Some number of years.  The techniques currently used have developed rapidly in the past 2-3 years.

6. You really want to to be sure your Mom has a good doctor doing this.  Dr. Natale at the Cleveland Clinic is highly thought of in the yahoo afibsupport group, but there are other good docs as well.  50 ablations sounds like a small number to me.  The specialist docs are doing one or more a day, typically, it seems like.  If you hop over to us at http://health.groups.yahoo.com/group/AFIBsupport and post, someone may know about your doc.

7.  Be aware that it is usual for the patient to have more trouble immediately after the ablation than before, because the heart has to heal.  It can take 1-3 months for things to settle down, and it is not unusual for a second "touchup" ablation to have to be done because the docs are conservative about what is basically making small burns in the heart.  I don't mean to scare you, most people in the support group who have had ablations are very happy with the results.

[jpin]

As a sufferer of AFIB I see it this way.  The medical profession doesn't have their sh$t together when it comes to the answers to important questions we need to make informed decisions.  It's time for direct comparison studies to tell us what is more efficacious, the French procedure or the Italian procedure.  The comments "There is no standard of practice yet", "There is no standard yet" and  "there is no data to back that up." brings up the question of: why the hell not? It's time for doctors to put aside their personal "biases" and give us, their patients, some definitive answers.  I make these comments while risking my health taking the toxic drug Amiodarone <pacerone> after being electrocardioverted 7 times in the last year for persistent AFIB and trying not to put my life on hold while trying to decipher all this confusion before being ablated.

[Konopka1955]

Hi,  I read your post and wondered are you getting cardioverted by an ICD for afib?   Amiodarone I know is a rather toxic drug - but I know some people who have had wonderful outcomes from this drug in preventing them from getting shocks.  Especially, doses in the 100 mg or so.  I ask because I have an ICD and I know the ICD's work on 'rates' but I would think 'good' programming would be helpful.  

I can understand your frustration - I've been shocked myself 6 times.  But I would not be alive today if not for the wonderful medical professional care I have gotten.  You may have gotten some bad doctors..  They say 50% graduate in the top of their class and the other 50% you don't want..  I know I've had a couple docs that were in the bottom 50% - but luckily I have the TOP 50% today..  I know this website that has wonderful support for ICD patients..  Its not easy dealing with shocks.  They are very painful and can leave alot of anxiety..   But alot of people go through shocks - technology has only come so far and that's not the doctors fault.  I know this one lady who had 35 shocks in one night..  

Best Wishes
Konopka1955

[jpin]

No, I don't have an ICD.  I was shocked at the ER a few times and in the EP lab a few times.

And I've been to three of the top EP's in the US, including the master at the CC.   I've based my opinions from their comments after consults with all of them.

[Konopka1955]

They shocked you in the ER for A-Fib !!   I've heard many people go to the EP lab and get cardioverted but they are put to sleep first and I know this little old lady - who had it done and she felt fine afterwards.  They also loaded her up on amiodarone before she left the hospital.  I know its a hard drug - but I've heard some good reports about it and some bad reports.  I myself don't tolerate drugs well so it would be my last choice.  But I know others who do just fine on the drug.  Everything has to be monitored..  

I've been dealing with various arrhythmias for YEARS as I have an ICD for vt's.  Of all the research I've done - A-Fib has gotten the most attention and the most research money...  This is one area (a-fib)I think that has gotten alot of statistics done and a much faster progress on curing it in the past few years.  I know because I'm always trying to find out what research is being done on vt's and usually all I see is research and progress on A-Fibs.  I don't have it - but I know the medical community has worked hard to find a cure.  
I'm sure its just as frustrating for a doctor to not be able to cure it.

But I was told by other people that they were knocked "OUT" when they were cardioverted in the EP lab.  

If there is one thing I have learned - when I'm in the hospital - I'm the one in control.  There are such things as patient rights and I've refused many times many meds and procedures.. I ask right up front what's going to happen.  I've had 3 ablations and I never felt any pain.  

Its easy to be intimidated by all the equipment and personnel and the 'you' have to have this done.  But, when push comes to shove - I walked in the hospital and I'm sure I can walk out..  I'm the one that dictates my medical care.  I can either take the care, refuse it, get a second opinion or just plain ignore the problem.  Its MY CHOICE..  I could tell you plenty of nightmare stories.. many times I just plain got out of bed, got dressed and walked out..  I've done it many times in the past.  I wouldn't hesitste to do it again.  But fortunately for ME I NOW get excellent care - as I switched hospitals and doctors..  

If they shocked you while you were awake - I'd fire the guy..  There is no need to do that.  But just because one doc screwed up doesn't mean they are all awful. I once felt just like you did - but I finally got a new doctor and I've gotten the best care.  I was once offered amiodarone when I first got my vt's.  I refused it - as I had done some research on the drug before my appt with the doc and I didn't want that drug to be the 'first' choice - so I said:  No, lets try another drug.  The doctor didn't force me to take amiodarone.  The doctor said "fine" - so we tried atenolol.  But his first selection was amiodarone.  I thank god I had done some research on the drug..  There are alot of other drugs on the market.  I would think with A-fib - there would be other drugs available.  

Sorry, to hear about your 'events' and I hope things get better for you.  These things can be so upsetting and sometimes its hard to get on with your life.. But life is so short - to live one day with so much anger is to waste a precious day of life..  and one should ask - is it really worth getting all upset over - I can change my course of action and let go of the past and get a better future.  I just have to let go of the past.  Remember You are in control.  Its your life and your health.  Remember that.. and I pray things get better for you as well as millions of other people with A-Fib.

Best Wishes
Konopka1955

[koko528]

My history is a mild  heart attack  back in 98 resulted in stenting of lad and a branch,I was  fortunate that i had no other damage, EF was at 60  and no problems  otherwise I passed each years stress  with no incident and no changes.Hoever this past April I had a stress/echo with Dobutamine, the attending felt it was  too slow  so he added atropine, thus my  first incident  with AFIB...I shot  up into  the 200s,  they gave lopressor   and I converted on my own. In June I had another mild heart atack  this  time it was a clot in  the right artery,they did a thrombectomy  and stented . Since then I have been in AFIB.I had one incident of  what  they termed heart failure, difficulty breathing  and fluid  which was  corrected  almost instantly They loaded me on Amioderone , sent me home  with Amioderone 400 mg Toprol 100 mg Accupril 20 mg  Ecotrin 325, Plavix 75 mg Lasix 20 mg and  last but not least  wafarin ....to keep my inr at 2.50   I had a follow  up echo which I was told was "normal"  ha ...my ejection f  was back  to  60..
Even with  the Amioderone I have many breakthroughs.....perhaps 4 out of 6 pulse readings are high  and  irregular.
I  find this so debillitating, I have become fearful  of  going places  never knowing  when this monster  will hit...it frightens me thinking  this condition could also bring  on heart failure. I have thought and prayed long and hard which  do I fear most the  condition or  the procedure? I think the procedure is  the way  to go. Now the question....I did  see an electrophysiologist  at Massachusetts General Hospital  in Boston. He has  done 300 procedures.Since Im just a layperson  how does this  sound ? Also are you on Wafarin  and anti arrythmics  ? H e says  I will still have  to take  them  after the procedure. Perhaps he's  just  conservative? This is a tough decision..I think  I could get a referral  to Cleveland  even  though it's  offered here,   perhaps  based on  the way  the procedure is  done...My pre testing  will be  an MRI and Blood work.I will have  to  stop  wafarin  a week prior to surgery and inject  with Fragmin  for a few days.Another  issue , I have  had endartorechtomy on  the right carotid....the left is  totally occluded, so I worry about  precautions being taken during the procedure I almost  forgot  I did wear a loop monitor  for 30  days it  shows  daily  incidents....some lasting  5 to 6  hours...some less. Any advice  you can  give will be greatly appreciated.  Thanks  in advance  ...I HAVE  TO ADD  DESPITE ALL  THESE ISSUES  WHEN I'M NOT IN AFIB  I FEEL  GREAT !! KOKO

[dquenzer]

Should you have an ablation?
First, you have far more medical problems than when I had the ablation.  So I think you should get a number of opinions on the risks involved.  The biggest risk I read is blood clotting and the attended consequences.

Second, the EP was fairly certain that my AFIB was caused by the stretching of the pulmonary veins.  I had been a track athlete for many years, and AFIB is common among highly conditioned athletes.  So the EP specialist believed success was going to be very good because the cause was clear.

I was on warfarin after the procedure.  Sometimes they keep you on an anti-arrythmic for awhile because the heart muscle is irritated an the anti-arrythmics help even things out. I chose not to be on one, and just took a bit more atenolol.  I am no longer on an anti-arrythmic nor on warfarin.  I had some AFIB after procedure, but not much.  It's been about 7 months now.

My EP specialist at Mayo was one of the tops in the nation.  I had to wait 6 months to get the procedure done because he's so good.  It was worth the the wait.  I would say 300 procedures is pretty good, but who knows?  What do other doctors say about him?

I was fortunate to have a cardiologist in the Mayo system who referred me to one of the best in the country.  Talk to your cardiologist to see what he/she thinks.

[koko528]

I have researched , asked a gabillion  questions,my cardiologist approves  since despite my cardiac events my heart is still strong. However in the past few hours something has come  to my attention  re: amioderone  or any antiarrythmic....I will still be taking mine  Am. right up  to the day before  the procedure.....I have now been told that by taking it  right up  to  the day will interfere with the pacing and the procedure will not have a good result ! Were  you taken off your antiarrymic meds   before   your procedure?

I will be off the plavix and Warfarin   and  ....taking  Fragmin injections a few days  prior  to the event !  thanks  for  your previous reply  ....koko

[dquenzer]

I was taken of the anti-arrythmic 1 week before the procedure, the warfarin 1 week before, and off any atenolol about 4 days before the procedure.

I would think that being on an anti-arrythmic would make finding the hot spots more difficult.  

However it could be that amiodorane doesn't have much more than a one day carry over.  So I would surely ask doctor "why" when "most" are taken off.

Wishing you well.  

PS.  Make sure they sedate you so you can sleep.  I was.  Didn't know a thing happened.  I've heard of people awake the whole time.  Mine took about 7 hours, so I couldn't imagine being awake.  It would have been miserable.

[Konopka1955]

Hi, I read your post and having spoken with several people who take amiodarone -  I believe they said it could take up to 6 mos to get it all out of your system..   Depending on how much doseage you take and how long you've been on it..  What good is an ablation if the meds are still in your system that stops the possibilty of starting up the rhythm..  

I would do a search on this drug or ask the CCF doctor.  There might even be a post on this web board in archives from the doctor to someone else regarding the longevity of this drug in your system..

I've had 3 ablations and personally I wouldn't waste my time trying for another ablation if I still had left over antiarrhythmic meds in my system stopping me from getting the rhythm "induced" and possible causing a failed ablation...

Good Luck
Konopka1955

[dquenzer]

I just thought of the fact that if you are going into AFIB as often as you said, I think the doctors feel the amiodorane isn't really doing much good and probably won't affect the EP study much.

I'd still ask the doc.

[dquenzer]

I just thought of the fact that if you are going into AFIB as often as you said, I think the doctors feel the amiodorane isn't really doing much good and probably won't affect the EP study much.

I'd still ask the doc.

[rowjo]

Thanks to everyone who supplied information regarding ablation.  My Mom had her surgery last week and is doing well...she is having some episodes of afib as expected and her heartrate is somewhat elevated over the pre-procedure rate.  I found out that Mom had the "Pappone Style" procedure.  Does anyone have any additional information regarding this...I believe it is also referred to as the Italian style and that it helps reduce the chance of stenosis.

Thanks again!

rowjo