The following blog post was written by my good friend and editor of Afibbers.org, Shannon Dickson. This is a long post but if you’re considering an ablation to treat your atrial fibrillation, or if you’ve had an unsuccessful ablation, you must read this post! Without further ado, I’ll let Shannon take it from here…
As Travis as noted throughout his blog, we tell all our readers at Afibbers.org forum to expect two procedures with a true expert ablationist who does almost nothing else but AFIB/Flutter ablations in their careers.
As a rule of thumb, when looking for the most experienced possible EP to be in charge of your hearts care, the active afibber is better off choosing an EP whose main focus is AFIB ablation and preferably whose caseload includes a large percentage of persistent and long standing persistent AFIB (LSPAF) cases with a successful track record of excellence in these most challenging classes of patients.
The majority of EPs in the typical towns, cities and regions of the US doing AFIB ablations focus primarily on an anatomical-only ablation protocol in which they basically know exactly what they are going to limit a given patient’s ablation to before they ever meet you or review your records. Most EPs are trained to do the basic PVI-only (pulmonary-vein isolation)-only ablation.
Such PVI-only anatomical ‘ablationists’ will typically only offer an ablation to those patients that have the best odds of success with this more basic and limited ablation procedure. As such, the majority of such typical AFIB ablation EPs try to screen their caseloads so as not to include too many cases with advanced paroxysmal up to, and including, persistent and LSPAF cases that are progressively less likely to be successful with an anatomical PVI-only approach.
During a PVI-only ablation, the EP will encircle your four pulmonary veins with one or two circular lesions, either a segmental PVI or wide antral PVAI approach and using typically radio frequency (RF) or Cryo-balloon catheter systems. After confirming acute by-directional block in all four veins, most ablation EPs who usually also offer a wide array of other EP procedures in addition to occasional AFIB ablations they perform in their overall practice, will end the PVI-only ablation procedure after completing anatomical PVI and confirming bi-directional block.
Only more advanced ablationists typically even perform extensive real-time electrophysiology sleuthing in looking for ‘Non-PV’ triggers as part of their AFIB ablation protocol. Non-PV triggers are those real-time detected trigger sources that extend beyond the anatomical PVI-only protocol. To be sure, a PVI-only protocol can indeed work well with early to middle stage paroxysmal AFIB, particularly for those who do not have longer episodes exceeding 20 hours and who have not had slowly progressive AFIB for 5 or more years, as a broad general rule of thumb, with exceptions.
Keep in mind that even in early stage paroxysmal AFIB, generally under 5 year’s duration and with less frequent and shorter episodes, preferably episodes under 10 hours and not exceeding 20 hours duration, the same general rule applies that one should be prepared for two procedures total and be happy as a clam if it all gets done in one shot for the long term as will most often be the case with an experienced operator and more basic level of paroxysmal AFIB.
But the real key here in minimizing the ultimate amount of ablation work needed inside your own heart to achieve durable freedom from all atrial arrhythmia, is our strong advice that each smart afibber be discriminating in who they choose to be in charge of their own ‘expert ablation process.’ There is a big difference in choosing an EP who does only anatomical PVI-only ablations, especially when such a physician more or less dabbles in AFIB ablations doing them only occasionally as an adjunct to performing the full array of general EP procedures during any given month in their own practices.
If you want to up your odds considerably of enjoying the best success with the least total amount of work being required, regardless of what degree of AFIB your heart may present to the ablationist, then demand the most experienced and highly regarded ablation expert that you can possibly arrange for yourself and be willing to travel for up to a week’s time to be able to access such a true expert who does almost only bi-atrial ablations (both left and right atria) and who also may perform VT (ventricular-tachycardia) ablation as well, yet who focuses on very little else in their own practices.
It takes near total dedication and a real passion for excellence to become an elite-level advanced ablationist who can comfortably and consistently address whatever degree of arrhythmia your heart might present to him or her with a high degree of success.
Using this, admittedly, very tough criteria will automatically filter out the lion’s share of EPs who simply cannot demand enough ablation patients to fill their schedules and keep the doors to their practices open based solely on their reputations and demand for their skills as a catheter ablationist for AFIB/Flutter.
More specifically, by demanding a maestro-level ablationist, you will insure that even if you have a modest to advance level of paroxysmal AFIB, that may well include Non-PV triggers in other parts of the left and right atria away from the four pulmonary vein antrum area, your condition will not present a challenge beyond such an experts comfort zone and which they will be fully skilled in handling.
The typical anatomical-based PVI-only ablationist will usually vet their patients carefully so as not to even offer an ablation to those whose medical history of AFIB and symptoms, plus other possible co-morbidities, suggest to them that this patient may well have Non-PV triggers well beyond what the anatomical PVI-only protocol is designed to address.
And such EPs will typically want to avoid choosing too many patients that may well require a lot or real-time EP sleuthing in the right and left atriums to detect and then discriminate in real time which of those Non-PV triggers are likely good candidates to ablate from those voltage-map triggers which may be just artifacts that are better left alone.
This advanced stage of AFIB ablation often can give more basically trained ablationist pause for thought, and many excellent, very smart and very well meaning and caring physicians simply choose to not focus so deeply on advanced AFIB ablation in their careers, and thus stick to the more basic anatomical approach as well as becoming proficient in the plethora of other EP procedures. In such cases, the EP will typically try to offer AFIB ablation only to those who they do not expect to have a high percentage of PV-only triggers driving their arrhythmia.
Such ablationists who, by far, represent the majority most afibbers are likely to be referred to within their local or regional referral network, will typically then be offered up to a maximum of three ablations total overtime before the EP determines that there is no further improvement that can gained by those patients via more ablation if the patient has not yet been rendered free of all arrhythmia, even after a total maximum of three PVI-only procedures. It goes without saying that any extra ablation(s) only come into consideration if the initial (or index) ablation was not fully successful.
Following an index ablation, if the patient returns with recurrent AFIB/Flutter any time after the three month blanking period following that first procedure, they the patient will offered up to two more complete repetitions of the same anatomical PVI-only process under the rational that this failure is likely due to reconnections of one or more PV-encircling lesion sets that were performed in the prior ablation(s).
If, after the third attempt at redoing PVI-only ablation, the patient is still struggling with periodic or persistent atrial tachyarrhythmia then typically the patient will usually be told, “that is the best we can offer you via ablation at this stage of our understanding and technology. Be happy with what hopefully will be a significant reduction in your arrhythmia burden overall and we will keep you on some combination of a blood thinner in many cases, a rate control drug and/or an anti-arrhythmic drug for life.”
While this scenario is certainly better than a poke in the eye, they have basically admitted failure to end the person’s life with arrhythmia, and are thus moving to a life-long management phase of AFIB, somewhat akin to parking you out on an ice flow with the elderly Eskimos, in my view.
Alas, this lack of success beyond the first or second anatomical PVI-only ablation procedure, is not always only driven by reconnections of the PV lesions already performed. Just as often, and increasingly so the longer one has had AFIB and the longer and more frequent are the individual episodes, it becomes increasingly likely that Non-PV triggers that in many of these anatomical-only procedures are never even looked for, much less detected, have been the prime culprit spoiling the party all along.
And such undetected Non-PV triggers will continue to remain the elephant in the room most anatomical PVI-only ablationists will often not recognize until, and unless, they begin to look beyond the more limited anatomical-only ablation protocol.
Hence, the great wisdom, even for modesty progressive paroxysmal afibbers, to seek out the very best and most experienced operators they can find from the very beginning of their ‘expert ablation process’ in order to insure the least amount of total ablation work needed in the least possible number of total ablations and with the greatest odds of durable freedom from true arrhythmia long term.
It makes a very big difference, too, going to the most experienced operators who will address not only the PVI plus expert posterior wall isolation in an index procedure, but who are experienced and skilled enough to search out and address any and all non-PV triggers that will clearly be strong candidates to spoil your life if not addressed at all.
The bonus in choosing such an advanced ablation expert is that even when a second procedure is needed, as not infrequently is the case, the good news is that both a second ablation, which does the trick in the vast majority of those cases that are not fully successful and ‘done in one,’ the elite level maestro ablationists typically do such a thorough and excellent job during the index ablation that any follow-up procedure that might yet be required to truly lock down the arrhythmia for the long haul usually require only a true touch up in nature.
A ‘touch-up’ requiring little more than a handful of addition burns and minimal overall added ablation burden to the heart. Much more rarely, a third usually even more minimal touch up might also be required to achieve durable freedom from all arrhythmia. Even though a third procedure is only occasionally required with a true maestro doing all three, more often it will be among those patients with advanced persistent and LSPAF (long-standing persistent AFIB).
This scenario above is predicated on choosing an EP with not only a track record for excellence in advanced ablation overall, but also who achieves a low percentage of reconnections being found during repeat procedures in patients in whom they did the initial ablation. Again, your odds of finding such an elite expert increase exponentially when you are very discriminating in choosing only high volume operators who are constantly in demand with at least a two or more months waiting list and who do very little else beyond catheter ablations as the sheer demand on their time to perform such ablations precludes focusing on much else.
Plus, as noted earlier, it’s simply not possible to become an elite-level AFIB/Flutter/VT ablation EP without dedicating nearly all of one’s time and effort to mastering these highly challenging and skill dependent advanced ablation procedures.
In closing this overview on how to make the best choices from oneself when approaching AFIB ablation, I do want to underscore too that there are many excellent EPs who do not offer AFIB ablation, and yet who can provide an invaluable role in one’s overall AFIB management care. Also, while I have emphasized the time-honored wisdom in being very discriminating by choosing the most experienced AFIB ablation EP that one can arrange for themselves, even if one has to travel for up to a week total in order to work with such a true expert in this field, as so many of us from our Afibbers.org forum have discovered over the last 17 years of our forums existence, there are also very good ablation EPs with less than elite levels of experience.
I broadly define elite-level experience as many years of dedicated focus on AFIB ablations almost exclusively, including a rough minimum of several thousand AFIB ablations under their belt, preferably with a large percentage of those ablations being successful persistent and LSPAF cases, in order to reach my strict definition of ‘elite-level’ AFIB ablation experience. However, these are admittedly tough guidelines and there are exceptions, too, where younger EPs with excellent training at high volume persistent AFIB ablation centers often do great work as well, particularly when AFIB ablation is their prime focus and they have also a growing reputation for excellence.
I hope that clarifies the scene and gives some nuance for your consideration in choosing a top level expert to guide one’s AFIB ablation process.
Finally, it is possible to get very good results for many patients with an anatomical PVI-only when the EP performs a solid transmural ablation so long as the patient has triggers limited only to the anatomical area of successful PVI ablation. However, in our long forum experience we have learned from the school of hard knocks that one can greatly up their odds of long term success regardless of how advanced one’s AFIB has become, and with the least amount of total work being required, by considering that you only have one heart.
As such, why not demand the very best that you can possibly arrange for yourself and then follow through with the completion of your expert ablation process even if it requires a second, or more rarely, a third progressively more minor touch up procedure in order to button down every last gremlin for the long haul.