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!