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Doug asks…
I have had paroxysmal atrial fibrillation for about three years now and I’m starting to get more frequent episodes despite the drugs I’m taking. My EP is recommending an ablation. I’ve read the success rates aren’t that great. How can I increase my odds of having a successful afib ablation?
This is a great question! To answer it I’m going to rely heavily on an article Shannon Dickson wrote for my blog a couple years ago as well as my many conversations with Shannon over the years.
Shannon is the Editor of afibbers.org, the oldest afib forum online. The forum has been around now for 19 years! Shannon himself has over 15 years of experience dealing with afib personally and is a walking encyclopedia of afib. He attends several afib conferences throughout the year and can carry on intelligent, complex conversations with some of the brightest minds in the EP world. In short, he knows his stuff!
Before I tackle the topic of how to increase your odds of having a successful atrial fibrillation ablation, I think it’s important to set realistic expectations when you’re considering having an ablation. Shannon always tells people, and I do as well, regardless of success rates, expect two procedures with a true expert ablationist who does almost nothing else but afib or atrial flutter ablations. Patients with advanced persistent and long-standing persistent afib may need even a third ablation to achieve durable freedom from all arrhythmia.
You might want to read that paragraph a couple more times and let it sink in. Even if you work with an elite-level EP, you should still go in expecting you’ll need two procedures (and possibly even three depending how complex your afib case is) to be freed of all arrhythmia.
Slaying the beast, or getting rid of afib, is a process. It is rarely a quick fix. Yes, there are stories of afibbers who have had one ablation and they’re good to go for many years. Those people are the exception, however, not the rule! For most of us, it’s going to take at least a couple procedures even with an elite-level EP to slay the beast.
O.K., but how do I increase my odds of success and reduce the risk of having complications?
Choosing an Expert EP Ablationist
Choose an EP who’s main focus is afib ablation and preferably whose caseload includes a large percentage of persistent and long-standing persistent afib with a successful track record of excellence in these very challenging cases.
Side Note: Let’s quickly define the three main categories of afib:
Paroxysmal afib: Episodes, regardless of their duration, end on their own within seven days.
Persistent afib: Episodes last more than seven days.
Long-standing persistent afib: Continuous afib that lasts longer than one year
Practically speaking then, how do you find an expert or elite-level EP? Ask questions and do your research!
There are five primary questions you want answers to when talking to an EP or researching a potential afib center to have your ablation. They are:
- How many afib-only ablations do you do a year? (you hope at least a couple hundred)
- How many afib-only ablations have you done in your career? (you hope at least a couple thousand)
- Of those afib-only ablations, what percentage of them are complex cases of afib (i.e. persistent or long-standing persistent)? (you hope at least 50%)
- Do you ablate beyond the pulmonary veins? Will you, for example, ablate both atria, the posterior wall, the left atrial appendage (LAA), or any other trigger sources in the heart if necessary? (you MUST get a yes to this question!)
- Do you use RF or cryoballon when ablating? (you hope RF exclusively or both)
If your EP or afib center passes the test, you have just found an EP or afib center you can trust to give you the best odds of having a successful ablation with little to no complications. In the coming paragraphs I’ll break down why the answers to these questions are so important.
Shannon’s criteria is even stricter than what I’ve outlined above. He broadly defines “elite-level EPs” as those having many years of dedicated focus on almost exclusively afib ablations, with a large percentage of those ablations being successful persistent and long-standing persistent afib cases, and a rough minimum of several thousand afib ablations under their belt!
Your odds of finding such an elite expert increase dramatically if you stick with high-volume centers or EPs who do very little else beyond catheter ablations for afib. A good indication that you’ve found the right center or EP is if the waiting list to have an ablation is three months or more. If you don’t have an urgent case (i.e. you have early stage paroxysmal afib) and they can “easily” get you scheduled to be ablated within a month, keep looking! A long wait time is a great indicator of how in demand that center or EP is.
Shannon says there are exceptions to his criteria. Younger EPs with excellent training at high volume persistent afib ablation centers often do great work as well, particularly when afib ablation is their primary focus and they also have a growing reputation for excellence.
There is no doubt that this very stringent criteria will automatically eliminate the lion’s share of EPs to choose from. Odds are your local EP just isn’t going to cut it. That’s why it’s important to be willing to travel if necessary to find one of these elite-level EPs.
Why Most EPs Don’t Pass the Test
Most EPs focus primarily on anatomical only ablations, specifically PVI (pulmonary vein isolation) only ablations. Before they know anything about your case, or I should say regardless of your specific case, they know they are only going to ablate your four pulmonary veins in the left atrium. They will not do any “real-time electrophysiology sleuthing” to look for triggers beyond the pulmonary veins like an elite-level EP will always do.
Side Note: During a pulmonary vein isolation (PVI) ablation, the EP will encircle the four pulmonary veins in the left atrium with one or two circular lesions using radio frequency (RF) or cryoballoon catheter systems.
While it’s true the pulmonary veins are a primary trigger source for afib, they are not the only source. In fact, in approximately 30% of cases the trigger sources are found in areas beyond the pulmonary veins! For those with persistent and long-standing persistent afib, for example, the primary trigger source is often the left atrial appendage, or LAA.
What do you suppose happens if your primary trigger source is the LAA but your EP only ablates your four pulmonary veins? You find yourself right back in afib shortly after your ablation! Then what happens? You return to your EP who then recommends a second ablation assuming there must just be some areas around the pulmonary veins he missed or the lesions have healed so well that the afib signals were able to cross over. No problem, the EP thinks, we’ll just go back in and button everything up.
A second, third, fourth, or even fifth ablation is done and yet your afib is still rearing its ugly head. Why is this? While the EP has likely successfully isolated the four pulmonary veins after so many procedures, the elephant in the room (in this example the LAA) remains untouched. The primary trigger source hasn’t even been looked at let alone attempted to be ablated.
In this scenario, the EP will usually conclude they’ve done everything they can for you. You’re told to be happy with a possible reduction in your overall afib burden and then you’re put on a blood thinner and a rate control and/or anti-arrhythmic drug for the rest of your life. Sound familiar?
I’ll admit this scenario isn’t always what happens. PVI-only ablations can be very successful for those with early to middle stage paroxysmal afib – particularly those that don’t have episodes lasting longer than 20 hours and who have had afib for less than 5 years. In these types of cases the trigger source is usually limited to just the pulmonary veins so it stands to reason if the EP does a solid PVI-only ablation it’s going to be successful.
What It Takes to Be an Elite-Level EP
It takes natural talent and ability, passion, and dedication to be an elite-level EP who can comfortably and consistently address whatever degree of arrhythmia your heart might present to him with a high degree of success. It is not unlike any other profession. If you want to be the best you need a certain degree of natural talent and ability combined with a passion that will drive you to be dedicated to your craft.
Successful ablations require an unbelievable level of skill and experience. Think about how ablations are done. Your heart is about the size of your fist. An EP has to carefully burn areas on the inside of your heart via a long thin wire that is snaked up from your groin to the inside of your heart. And it’s not like your heart is split open for the EP to look at and maneuver the wire. He has to do all the work looking at the inside of your heart via a video on a computer monitor. When you really think about it, it’s miraculous that God has blessed people with this kind of talent and ability.
It’s simply not possible to become an elite-level EP without dedicating nearly all of one’s time and effort to mastering afib ablations, especially those for complex cases of afib where the EP needs to ablate beyond the pulmonary veins to address all the potential trigger sources.
Given what it takes, it’s no surprise that many EPs choose not to focus so deeply on ablations, let alone advanced afib ablations (i.e. those that require ablating areas beyond the pulmonary veins). They dabble in afib ablations and stick with more basic anatomical PVI-only ablations.
These types of EPs will typically only offer afib ablations only to those who they do not expect to have a high percentage of non-PV triggers. This is why so many EPs will not recommend an ablation to someone who has persistent afib. They don’t have the skills or experience to ablate the non-PV triggers that persistent afibbers will most certainly have.
Instead, they will typically only recommend an ablation to those patients who they believe will have the best odds of success with PVI-only ablation. They basically screen out cases where patients have advanced paroxysmal afib, persistent afib, or long standing persistent afib as a PVI ablation is less likely to work.
Most of these types of EPs are still excellent, extremely smart, and very well-meaning and caring EPs. They can provide an invaluable role in your overall AFIB management care. You just don’t want to listen to them when they tell you an ablation isn’t an option, and you certainly don’t want them doing your ablation!
Radio Frequency (RF) vs Cryoballoon Ablations
Up until this point I think I have adequately covered why it’s so important to get answers to the first four questions in the opening, “Choosing an Expert EP Ablationsist,” section of this article. Now I want to cover RF vs. cryoballoon so you understand why the fifth question is so important.
I could write an entire article on this topic, and I probably will in the near future, but for now I just want to highlight the two most important things you need to know.
- Cryoballoon has made it easier for inexperienced or less skillful EPs to provide safer and more successful PVI-only ablations.
- Cryoballoon cannot be used on non-PV trigger sources.
If you’ve read this far, you should understand why point #2 is a potential huge red flag, especially if you have advanced paroxysmal afib or persistent or long-standing persistent afib. If your afib is being triggered beyond the four pulmonary veins, your EP will not be able to ablate them if he’s only using cryoballoon. This is why the truly elite-level EPs only use RF! They can ablate all trigger sources if necessary.
RF ablations require an EP to have exceptional skills and experience. With RF, an EP is ablating “dot-by-dot,” or “point-to-point.” Cryoballoon on the other hand, allows an EP to ablate an entire “line” at once. Here is a video demonstration of cryoballoon (note how the entire vein is isolated in one step):
Here is a video demonstration of RF (note how the EP needs to encircle the vein point-to-point towards the end of the video):
Which method looks easier to do? Obviously cryoballoon. With cryoballoon, the EP just touches the surface with the balloon and a solid lesion line is created. And because it’s not dot-by-dot like RF, there is less chance that there will be gaps in the line where the afib signals can get through. You can see why cryoballoon is so popular and used by so many EPs. As I mentioned previously, it allows even inexperienced and less skilled EPs to do durable PVI-only ablations.
Some elite EPs have modified the point-to-point method via RF by dragging the RF catheter to create the same solid lesion line a cryoballoon catheter creates. This method eliminates any advantage the cryoballoon catheter has over RF in limiting gaps along the line. This is yet another reason why it’s a huge advantage choosing an elite-level EP! They can use radio frequency as effectively as cryoballoon.
If an EP only uses cryoballoon he is probably inexperienced or doesn’t have the skills to do RF ablations effectively, and he probably only does PVI ablations. If you have early to middle stage paroxysmal afib, a cryoballoon ablation might be successful but likely wouldn’t be for any other type of afib case.
Why Even “Simple” Cases of Afib Require Elite-Level EPs
You may think you have a “simple” case of paroxysmal afib but that might not be reality. Take my case, for example. I had paroxysmal afib for eight years. Up until the middle of the eighth year, I only had four episodes. When I had my episodes, they lasted less than six hours. In the middle of the eighth year I started having more frequent episodes but they still never lasted more than six hours.
Given the progression of my afib, I scheduled an ablation. I thought for sure I had a simple case of afib; the type of case just about any EP could handle. I certainly didn’t think I needed to see an elite-level EP but Shannon convinced me otherwise and I’m so glad I listened to him. I almost made the mistake of settling with a local EP who only did cryoballoon ablations and did less than 12 ablations per year!
It turned out I had a complex case of afib. My EP had to ablate several areas beyond the pulmonary veins. The only area that wasn’t ablated was the LAA. If I need a second ablation, that will likely be the only thing that will need to be done. All other potential trigger sources have been addressed.
Because of the very thorough ablation I had, I have been 100% afib-free without any drugs for three years now! Had I settled with the local EP, where only the pulmonary veins would have been ablated, I would have been right back in afib and on my second or third ablation by now – and still battling afib.
By working with an experienced elite-level EP, you’ll be assured that no matter what your case presents the EP during the ablation, he’ll be able to handle it.
Increase Your Odds of Success by Choosing an Elite-Level EP
If you want to up your odds considerably of enjoying the best success with the least total amount of ablation work needed inside your heart to achieve durable freedom from all atrial arrhythmia, regardless of what degree of afib your heart may present to the EP, then demand the most experienced and highly regarded ablation expert that you can possibly arrange for yourself!
The bonus in choosing such an advanced ablation expert is that the work done on an initial ablation will be so thorough that if a second ablation is needed, and it often is, it will only require a true touch up. What that means is a second ablation will only require a little more than a handful of additional burns and minimal overall added ablation burden to your heart.
It makes all the more sense for even the early to middle stage paroxysmal afibber to seek out the very best and most experienced EP they can find from the very beginning of their “ablation process.” This will ensure the least amount of total ablation work needed, in the least possible number of total ablations, and with the greatest odds of freedom from all arrhythmia long-term.
There you go, Doug…that’s my very long-winded answer to your short and simple question. If you have a question you’d like me to answer, please contact me at!
Hello Travis
I know this is an old thread but hopefully my comment will pop up. I have been hearing about the latest and greatest in mapping technologies and am aware that in some cases, mine perhaps, it would greatly increase my odds if I went to a center that had the most up to date ablation technologies.
I am referring to FIRM-guided (Topera/Abbott) as well as Rhythmia (Boston Scientific) and others. I have a very complex atypical left atrial flutter and have had 2 ablations – all the usual trigger areas have been ablated. I definitely would opt for a high-volume and expert EP but would also add latest and greatest technologies. Any thoughts? I looked. but could not find any answers anywhere.
Mary
Mary:
I can’t speak to the Rhythmia mapping technology but I can FIRM. It’s a very long story but in a nutshell, FIRM does not provide any additional benefit at all. In fact, it causes patients to be under anesthesia much longer than they would be if they didn’t use it and there is ZERO additional benefit.
While some of these mapping technologies are great, they aren’t the answer just yet. At the end of the day it still comes down to the experience and expertise of the operator. You want to see an EP who’s primary case load is dealing with complex cases of afib such as your’s. There are only a handful of these types of EP’s so it will likely require you to travel to another state to be treated unless you’re fortunate enough to live in a state where these operators are.
If you are able and willing to travel, please contact me via my blog and I will give you some names.
Thanks,
Travis
I’m in LA and just had my first ablation for paroxysmal AFib that never lasted longer than 4 hours and started 1.5 years ago. Dr. Natale has recently opened a practice just a few minutes from my home and my first impulse was to go to him but my EP told me that his reputation among the reps who accompany him in the OR is that he runs a “factory operation” – performing many procedures rapidly and ablating very heavily which is why he has such a high success rate.
I chose someone else who did cryo around all 4 veins. It’s only been 3 days so I don’t know yet how successful it was but I’m obviously hopeful. The thought of doing another ablation is daunting…minor surgery is surgery someone else is having. This was not a cakewalk. Just wanted to share those thoughts…and to say that a list of Elite EPs would be enormously appreciated. It’s not easy to ascertain who is the best choice as a patient.
J:
I hope your ablation is a success and you have many years of NSR!
Regarding Natale, I have no idea what that EP is talking about. While it’s true Natale’s index ablation is much more thorough than most EP’s PVI only ablations, he only ablates what needs to be ablated. And because he’s so thorough (i.e. careful) there are only so many ablations he can do in a day. It’s not like he’s “churning” through patients willy nilly.
And because Natale’s index ablations are so thorough, his patients typically have far greater success. I’m 3 1/2 years out from my Natale index ablation and I haven’t had a single blip of afib and I haven’t been on any drugs. It’s not uncommon for afibbers to go 5-10 years after just one Natale ablation. After a touch up with Natale most people are done for good:)
I would love to put together a list of elite EPs but it has proven next to impossible to do so. I can’t get the cooperation of anyone. Nobody is willing to say, “these are the best EPs in the country.” Trust me, if I was connected enough to know who the elite EPs are, I wouldn’t hesitate in a minute to share such a list.
Travis
Is the Hospital of the University of PA a good choice to have a PVI? I have had afib for 1 yr and the cardiac EP advised the procedure to be done by him. Figuring I should get a 2nd opinion, I am to see a EP that was highly recommended by my neighbor who had 2 not so good experiences locally and another hospital that is supposed to be experts in the field.
Finally, she was helped at HUP. I am glad I now have important questions to ask when I see the HUP EP. Thank you for the info. I am on Cartia and Propranalol once each day, Praxada 2x a day, and since being discharged at the end of February after an episode of CHF, I take furosemide 2x a day along with K.
I feel nearly back to my old self and can do nearly all of my previous activities since being discharged and taking the above med. My BP has been consistently on the low side; I have lost a total of 40 lbs. since the middle of Feb. and have little to no symptoms now. My pulse ranged from mid 40s to mostly 70s or 80s.
Interestingly, my pulse ox also ranges from about 88 to 96 with the lower number usually at bedtime when I prepare to fall asleep. My next appt. with the cardiologist that follows me is next week. My consult @ HUP is 6/11. I am eating a very healthy diet now and take short walks with a neighbor nearly every day or go to the gym and walk in the pool or do simple exercises in the pool to help with balance and flexibility since I have some arthritis.
I use acupuncture for pain relief which is mostly back and base of my thumbs. Last May was my first experience with any medical problems and having to take meds on a regular basis. Pretty good for being 71 at the time. Any other suggestions for the consult EP? Thank you so much for your website and the thorough information.
Joan:
You’re in luck! Two elite-level EPs practice at Penn. They are doctors Fermin Garcia and Pasquale Santangeli. You’d be in good hands with either doctor. However, I would lean more towards Santangeli only because he has worked under Dr. Natale, who did my ablation. Dr. Natale is THE best EP in the world so any doctor good enough to work under him is pretty good. Here are links to their profiles:
https://www.pennmedicine.org/providers/profile/fermin-garcia?fadf=pennmedicine
https://www.pennmedicine.org/providers/profile/pasquale-santangeli?fadf=pennmedicine
I wish you the best!
Travis
Very informative! Thanks Travis and Shannon and all. No one ever mentions cost – and what the cost of a 2nd ablation may be by the same EP? Does the cost go down if you need a 2nd or 3rd? Shouldn’t it if the doctor took too long or something in the first one, or a similar problem/delay not related/caused by you and or your afib problem?
I have heard that Medicare only pays for entitlements, and if you cannot afford it, then what? How can you choose the best in that case even though it is always suggested to choose the best so you would automatically feel negative if you could not choose the best. Also, I live in England now and they want to get me in quickly but I am not that bad and even though it would be free, they, the EPs get money for their hospital; the more they do.
I could afford to go to France (Bordeaux) even though I would like Andrea Natale, but that is probably too costly. Do they negotiate? What do you you suggest? There are good EPs here in England but I have my doubts.
Thanks and cheers. Please write back.
Stephen:
In theory, 2nd and 3rd ablations should be cheaper but unfortunately that’s not reality. There is just as much pre and post op work required for a “quick” touch up as there is for an initial ablation. Furthermore, the same expert EP and his/her supporting team is required no matter how quick the ablation is. The only difference between an initial ablation and any subsequent ablations done by an elite-level EP is the actual burn time taking place. An initial ablation may have 40 minutes of burn time. A touch up ablation may only require 5-10 minutes of burn time. All other things before, during, and after the ablations stays the same. Bottom line, you’ll pay the same for your second or third ablation as you will your first ablation.
If you can pay cash, an ablation done by an elite-level EP is typically between $42,000 – $45,000.
You hope that whatever health coverage you have allows you to be treated by an elite-level EP but if that’s not possible, then you only have two other options. You either do whatever it takes to come up with the cash OR you settle for the best possible EP you can find within your coverage. Admittedly, those options stink but they are what they are. I’m just grateful we still have a health system that gives us a choice or an opportunity to be treated. In some countries (i.e. Canada) they don’t have the freedom to be treated by any EP they want. They are stuck with the EPs in their province, or they too can come up with the cash and come to the U.S. to be treated (which many of them do).
I’ve got good news for you, however. Outside of Natale’s group, Bordeaux is probably the second best afib center in the world! The Bordeaux group pioneered ablations. They were the first to do them. Steve Ryan of a-fib.com had his ablation at Bordeaux back in 1998. He’s been afib-free (without drugs) ever since! He flew to France to have his ablation because back then Bordeaux was the best at doing ablations. I refer all European afibbers to Bordeaux.
Here is a link to one of Steve’s articles on the Bordeaux group:
http://a-fib.com/faqs-a-fib-ablations-the-bordeaux-group/
I wish you well!
Travis
Travis,
After reading your questions to ask I asked my EP who was suggesting ablation, how many he had done and he said “Lots.” So I later asked his assistant how many and she said 100. That doesn’t seem like a lot.
Thank you for the article.
Cantrell
Cantrell:
No, that isn’t a lot by any stretch of the imagination. As per my post above, you want the EP to have at least a couple thousand ablations under their belt with the majority of those being ablations for complex cases of afib. Literally anything less is a red flag. Again, this is only for consideration of an ablation.
As a general EP to help you manage your afib or do follow up with, the number of ablations doesn’t really matter.
Travis
Travis,
Give me your thoughts on an ablation for afib. I am scheduled to have one next Tuesday and I am not sure I am making the right decision. I have been in and out of hospital now for the last 3 years for afib with RVR. It’s scary at times. I am taking Sotalol which should control it but it does not. I had an ablation for Atrial Tachycardia 3 years ago, but did not help is why I am on Sotalol.
Mary:
I moved your comments to this blog post because it was more appropriate than the one you originally left your comments on. I hope that is o.k. Since you originally left your comments on a different blog post, I encourage you to read the blog post above or listen to the audio version of it.
I would just advise that if you have another ablation you make sure it’s done by an elite-level EP to ensure your best odds of success.
Travis
I have been in persistent afib for over 2 years (with tachycardia). I believe, looking back, that I probably have had afib episodes for many years prior, but I just waited for them to pass At a guess, I would say that I probably had at least one episode a month for 10 years or so. 2 years ago, I went into afib, with a very high heart rate, and didn’t come out. I had 3 cardioversions, but in each case I was back in afib within 36 hours. I was also unaffected by various anti-arrhythmia drugs (I cannot remember which ones I tried). So, for the last 2 years, I have been in afib, taking only metroprolol and xarelto. It is believed that my afib is a result of both apnea, and severe, chronic, sleep deprivation (resulting from an issue separate from the apnea). My afib was quite persistent, in that tests showed that I simply never went into sinus rhythm.
Last November, I had a pvi ablation. My cardiologist is very well-respected, and works out of a very well-respected hospital. He felt that in my case, it was better to go ahead and just do the pvi ablation, and then go from there, as opposed to the longer procedure where they look for triggers. Prior to the ablation, I was cardioverted again, and given amiadarone. Amazingly, I started going into, and, more importantly, out of afib (a first for me, in a long time). This went on for a couple of weeks. I decided to go ahead with the ablation, after consulting with both the electro-cardiologist, and my primary cardiologist.
After the ablation, I immediately went back into afib, and stayed there for a couple of weeks. However, I started coming out of afib periodically, and would only stay in afib for ~36 hours, which was viewed as a positive by both cardiologists. That was a few months ago, now. At this point, I am going into afib about every week or so, for about 24 hours (sometimes, it has gone away within an hour). Something has clearly changed, and for the better.
Sorry for the length of this question, but that is all of the background. My gut feeling is that, since my sleep issues are getting better, I may continue to get better (especially since I am eating a healthy, primal, diet, and I am otherwise in good shape). I don’t want to push off a second ablation for too long, but I also want to give my body the best chance for my heart to reprogram on its own. What is more, my insurance has changed, and finding a good electrocardiologist is not going to be easy.
I know I need to get off of the amiadarone, and the combination of medications is both energy-sapping, and depressing. But I cannot shake the feeling that the ablation *was* successful, and that, because of the length of time that I was in afib, and the persistence of it, it is taking a while for my heart to reprogram itself (this is the opinion of my non-ablation performing cardiologist, and also the one who performed the ablation).
Interestingly enough, my trigger now seems to be any sugar, with the exception of coke (acidic?), and any artificial sweetener, including quest bars and xlear nasal spray. I can avoid all of these easily.
Once again, sorry about the length of the question. In your opinion, is it likely that my heart *is* reprogramming itself, as both of my cardiologists believe, or is this unlikely, in your opinion?
BTW — thanks a lot for the blog, from a 2 year lurker. Hope you are doing well.
Richard:
Thanks for sharing your story. As long as you are on the amiodarone you won’t really know if the ablation was a success or not. The reason being is amiodarone is a very powerful antiarrhythmic. It’s possible any success you’re experiencing is because of the drug. The true test, or marker, that will determine how successful the ablation was will be when you are weaned completely off the drugs by your doctor.
It’s very possible that between the ablation and the amiodarone your heart is being remodeled “back to normal.” Again, you won’t really know until more time passes and you are not on amiodarone. A successful ablation can definitely help reverse the remodeling that has taken place because of afib.
Travis
Great info. I am new to afib. I was first hospitalized for it in September of ’17. My E.P. is suggesting to have an ablation done and suggested I sign up for the Amaze study. Any thoughts on the Lariat procedure?
Joe:
Do you have persistent afib? If so, then you very likely have triggers beyond the pulmonary veins. What they do for the Amaze study is what an elite-level EP would do for you – ablate your pulmonary veins and your left atrial appendage (LAA) – IF in fact the LAA was a trigger source. An elite-level EP will be able to determine that.
Once the LAA is ablated, or isolated, a large percentage of people will need to be on a blood thinner for the rest of their lives. However, those that can’t tolerate blood thinners or simply don’t want to be on them for life can have the Watchman device put in or have the LAA closed off entirely via the Lariat.
Texas Cardiac Arrhythmia is Dr. Natale’s afib center in Austin, TX. They are one of the centers conducting the study. If you can go there go for it! Whether you go for the study or not, the most important thing you can do is ensure the EP is elite-level and meets the criteria outlined above.
If you have any other questions, fire away.
Travis
Great article indeed about choosing the specialist to perform the procedure.
However, for a town not too big, like Columbia, South Carolina, how many specialists can even match part of the criteria you have discussed? And I am sure many more patients with AFiB are living in a smaller town in the states which do not attract and or cannot afford to pay such specialists. So what do we do?
Can you please provide more info for such patients.
Ark:
You bring up some great points. As I mentioned in my article, most local EPs, especially those in small towns like you’re talking about, are not going to be “elite-level” EPs. This is why I said you have to be willing to travel. I’m not necessarily saying you’ll have to travel across the country but you will absolutely have to travel “some” distance if you want to be treated by one of the best. There is no way around it. As you’ve pointed out, small towns just aren’t going to be able to attract top talent and even if they could the case load wouldn’t be large enough to sustain the centers they practice in.
I wish I had an easy answer but that’s just reality.
Travis
I lived in MN where we have great specialists. However, when it came to having the best person possible for an ablation I traveled to have it done. It was my second ablation (Mar 2017) as my first one in MN (Aug 2016) with someone I really thought knew his stuff (after my research and questions and prior to knowing Travis and Shannon), was a complete failure. I ended up hospitalized with worse symptoms the following week for 4 days to get tested for what drug would work to control the arrhythmia and high heart rate!
When I then went in for additional follow up after my first ablation with my MN EP, he advised that I probably would need a second ablation and that he would do the very same procedure again – just the 4 PVI! Thank goodness I had started chatting with Travis and then with Shannon and was blessed to be able to see Dr Natale who performed the more complex ablation that Travis talks about in this article.
I have been AFib-free now for a year and have had a touch up (Jan 2018) to ablate the left atrial appendage which was misfiring and causing SVTs although not creating AFib. There might be a small chance of a last touch up yet doing great and maintaining diligence. Luckily my health insurance covered most of the expense for the medical procedures and hospital and as to expense of a specialist like Dr Natale? Minimal as far as I am concerned based on expertise and dedication to his field and concern for his patients. I have gone from being a recluse due to fear to more and more recovering my old self although very aware of the least change in heart rate, pressure etc.
Now if I could just get this inner ear crystal issue fixed that causes vertigo/balance issues from time to time! Just wonder if there is a Dr Natale for that!
Thanks for your great conversations everyone.
Blessings everyone and best wishes
Hey Carol! Great to hear from you. I’m so glad you are doing so well these days. You’re an inspiration for many who are reading this. Thanks so much for sharing your story.
For everyone reading this, I want to recap Carol’s story to be sure you understand what happened. She did a bunch of research and thought the “local EP” she chose here in Minnesota was more than qualified to do her ablation. She had the ablation but it was a total failure. She also had to spend 4 days in the hospital afterwards to control her high heart rate. This is NOT normal, folks.
Once the dust settled she went back to the doctor to see what he recommended. He recommended another ablation! She found out he was just going to repeat what he did the first time – just ablate the pulmonary veins. It was after that when she found my blog and we started going back and forth and I introduced her to Shannon. Then Shannon directed her to Dr. Natale.
Dr. Natale did his standard index ablation, which includes the pulmonary veins and other trigger sources except the LAA. Things went pretty good for a while but then Carol developed SVT. She went back to Natale who advised a second ablation. During that ablation he isolated the left atrial appendage. Carol has been doing awesome ever since. There is a small chance she’ll need a third (and very likely final) ablation to touch up the LAA ablation and put all this behind her.
So in all, she has had 3 ablations – one with a “local EP” and 2 with an elite-level EP. After the elite-level ablations she had been doing great and is now living her life to the fullest. It wasn’t until she saw an elite-level EP that she was able to get her life back. Had she stuck with the local EP there is no doubt she would still be battling afib!
Travis
Dear Ark,
You have an outstanding dr in your backyard…Dr John Marcus Wharton at MUSC.
Need more information! We could spend years and dollars interviewing EP’s — there are many! Information regarding volumes of procedures performed are not readily available with the only exception being Cleveland Clinic. Please give some more guidance. Know of Dr Natale but who else?? Will happily receive a private email. Also within the parameters of the Cleveland Clinic, there are lots of EP drs but since it is a teaching hospital an ablation could be done by one of the fellows — then all the due diligence is for naught!
I hear your frustration. I have been trying to get Shannon to help me put together a list for the past year but he’s super busy so that list hasn’t been put together yet. He knows the names of many of the “elite-level EP’s” throughout the country. I encourage you to contact him via private message at the afibbers.org forum. The link to the forum is here:
http://www.afibbers.org/forum/list.php?9
You also bring up a great point about EP’s “in training.” It’s not uncommon for an EP to sometimes have a “trainee” do the ablation while he supervises and provides guidance during the procedure. There should probably be a 6th question added to the list: Will you be doing the ablation yourself or will someone else? You obviously want the EP to be doing the ablation himself!
Travis
Thank you…esp for answering late last night! Will contact Shannon re the search for the right ep ablationist. Your columns are alway informative and a great help.
Trish
Thanks Trish. If for some reason Shannon doesn’t get back to you within a week, let me know. You can always contact me privately via my blog here.
Thanks,
Travis
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