Ablation questions

Can a successful AF ablation be expected to eliminate ectopics? I'm on 300 mg of flecainide & 25 mg extended release metoprolol daily, and want to get off of both, as I'm young and my exercise tolerance is really crappy on these drugs. Even though my EP indicated that flecainide should eliminate PACs, even at the max dose, I still experience frequent PACs, pauses, strong beats, short runs of SVT (and feel them all); and it's starting to look like decreasing my doses just isn't ever going to happen without an increase in symptoms. But, I haven't really gotten a straight answer ever on what the expected outcome of a successful ablation is. Is there a straight answer to be had, or is this going to be the 7000th "it depends" with respect to afib? (Getting so tired of "it depends".)

Does anyone have any recommendations re: where to get an ablation in Chicago? I had a flutter ablation at Northwestern in February, and was disappointed to observe that it seemed a fellow was handling everything. I've requested a copy of the medical records to verify, but he was the person who had me sign the consent form, made the groin incisions in the EP lab (last thing I remember before the sedation kicked in), came and talked to me in recovery, etc., so I'm thinking it's pretty clear he was the operator. I'd asked my EP if she would be doing the procedure, and her answer had been, "Yes." And then, a moment later, "Well, we are a teaching hospital, so I am always working with medical students, but I supervise and am responsible for everything." Somehow, I didn't think "working with medical students" meant the student would take the lead, but I think that's what happened, and I don't think there's a way for me to stop it from happening again, so I'm shopping for alternatives.

If one goes outside of their insurance network to Cleveland or Mayo or Natale... is there a way of knowing ahead what one's medical out-of-pocket charges will be? This seems the unavoidable problem with seeking out the best care, if you aren't lucky enough to be local to them.

Ablation CAN eliminate all ectopics, but I wouldn't use the word "expected". The primary goal of ablation is to stop the AF or, more precisely, to stop the ectopics from being able to initiate AF. That is what the EP world will call a success. In my own case, I suffered ectopics for pretty much an entire year after ablation. I credit careful supplementation with their subsequent reduction over the past year and a half. Of course, if you've read my posts, I did have a breakthrough AF episode last month that lasted about 7 hours. So, as you can see and as much as you'll hate to hear it, it depends. Our bodies are not machines but rather ever-changing pieces of biology. At some point, they're going to do what they're going to do. We can influence outcomes with careful choices but we can't dictate them.

I am not familiar with the Chicago area at all, I'm afraid. However, I asked a similar question regarding teaching hospitals in another thread. You'll want to establish parameters. If you don't want students involved in the procedure, get agreement on that beforehand. Find another provider if you're not satisfied with the answer.

As for costs, just call the providers and your insurer and ask. You should be able to put a number on that very quickly.



Edited 1 time(s). Last edit at 05/29/2018 04:27PM by wolfpack.

Yes, this thing is very frustrating....

I spoke directly with Natale's office in Austin a couple of months ago. They said the cost for the ablation procedure for cash-paying patients is around $40,000.

I don't believe this includes the cost of your initial appointment with Natale, and there's probaly a few additional costs that one finds out about only by going through the process.

I expect this cost would differ somewhat if you went got the procedure with Natale at either of his California locaitons; costs are dictated by the specific hospitals, so I'm sure they differ somewhat

If you sign up with Dr Natale at any of his center’s I can totally confirm that only he will be working inside your heart. His centers are NOT classic teaching hospitals and no fellows take over performing a Natale ablation. That is a cardinal rule of his that he has maintained since early in his unprecedented career as the world’s most prolific and experienced AFIB ablationists ... bar none! Dr. Natale has frequently reinforced to me over the years that especially since so many patients seek his expertise out specifically and often travel a long way to put their heart’s care into his hands, that he feels obligated and dedicated to making sure each patient gets 110% of his effort with no one else taking over for him in mid-ablation.

One of his assistants may help thread the sheaths and catheters into the femoral veins near the groin and jugular vein, but he always takes over from there advancing the catchers first into the right atria followed by dual transeptal punctures for advancing the lasso mapping catheter and ablation catheter into the left atria of each patient’s heart and then withdraws all catheters from his patient’s body at the end of each procedure.

That is all very comforting to know. I don’t care how much a given mentor may be in the same EP-Lab, it only counts who is actually controlling the catheters inside one’s heart that determines the outcome. And so unless you have fully expected and signed off on allowing a trainee/fellow to perform ablation work inside your heart from the outset, I would not agree ... nor be happy at all ... to find out after the fact that someone other than the mentor I fully expected to perform my ablation did anything less that the complete job by him or herself!

Shannon



Edited 1 time(s). Last edit at 05/29/2018 08:40PM by Shannon.

This issue of ectopics interests me greatly.

I can get hundreds (or occasionally a few thousand) ectopics (almost all PACs) per day as well as runs of ectopics of all varieties in terms of how they 'feel'. I've had several whilst writing and editing this post.

Thankfully 99.99% of the time they do not put me into AF.

However, when the 'ground' (atrial heart tissue as a whole) is 'fertile' for AF, then ONE ectopic can put me into AF - I've felt it happen. For me 'fertile' can be encouraged by a MSG-laden meal, too much spirits, large late meal or a combination thereof. I suppose I'm 98% of the way to having AF all of the time with it being the aforementioned triggers that push me to that 100% breaking point.

To reiterate; the thing is, that set against the backdrop of the right (wrong!) conditions atrial heart tissue-wise, ONE ectopic will put me into AF. Therefore, to my mind at least, how is it that an ablation that doesn't eliminate all ectopics prevent AF??

Or; is it that even with a PVI alone (all one will get here in the UK as a first ablation if paroxysmal as I am) the atria is still sufficiently scarred so as to make it far more difficult for an ectopic to initiate and/or maintain AF??

If one ectopic can put me into AF, then to truly eradicate any chance of AF ALL ectopics need to be eliminated OR scar tissue created that renders the atria incapable of sustaining AF.

This is why I'm very sceptical that in my case (as in I get a lot of ectopics) a PVI would be enough to prevent AF. If anything, lots of ablatees report more rather than less ectopics after an ablation.

At Bordeaux for a first procedure for paroxysmal AF they do also go looking for non-PV triggers as well as doing a PVI only. This is what most encourages me to go to Bordeaux for a first ablation for paroxysmal over and above getting one done here in the UK.



Edited 2 time(s). Last edit at 05/30/2018 08:18AM by mwcf.

mwcf, this is why I'm full of doubts about ablation.
Before my PVI, I had no ectopics. I just had about 20h afib 2x/month despite taking meds. I guess a single PAC was able to trigger afib.
After my PVI, I had lots of ectopics, anyday, and they used to trigger 1-2h afib about 2x/week despite taking meds.
Since my recent touch up, I've still lots of ectopics which only triggered afib in the first couple of weeks after the procedure. Now it seems I'm afib free, but I'm still taking meds because of the ectopics.
Where's the difference ? Afib was dangerous, PACs and PVCs are not.
Nevertheless, my days and nights are about as ruined as before those procedures.

AF is a re-entrant rhythm (as is flutter and even v-tach). It is the ability of electricity to flow around and around in a circuit consisting of autonomous cardiac muscle cells rather than being "pulsed" from the SA node to the AV node. In flutter that circuit is often a circle in the right atrium. In AF, it's some kind of a mess in the left atrium. The PVI is supposed to introduce enough "impedance" in that mesh of a circuit such that re-entry is no longer possible. Ectopics, sure, but nothing that self-sustains.

Pompon, ectopics can be ablated, but it takes a very skilled EP who knows how to find non-PV sources. I had PACs that would come in a bigeminal pattern (meaning every other beat was a PAC) that would go on continuously for weeks. Three EPs were unable to eliminate them but Natale managed to do so along with two separate flutter circuits and a PVI reconnection. If you consider the ectopics just as bad as afib and you're taking meds to control them, then I'd say that's a pretty big quality of life issue and justifies a procedure to eliminate them. Just don't expect the average EP to be able to do so. You need the best if you go that route.

Thanks for all of your posts!

I guess I'm pretty lucky that the loads of meds I am on have, in fact, kept AF at bay. The truth is that it was a precipitous descent into afib for me, from "a few palpitations every few months" to "AF every other day" very suddenly. I still recall what it is like to be completely symptom-free, and feel kind of shortchanged (as I'm sure all of us do) to be dealing with so many ectopic beats when I've stopped running, eliminated alcohol, eliminated coffee, have been faithfully taking supplements, getting sleep, eating clean. Frankly, I also feel surprised and angry that there are so many doctors that seem perfectly content with the status quo re: afib, even though they don't know what causes it or how to cure it. Seems like that would be job #1!??!?

Anyway. Sounds like I have to keep looking for the right local cardiologist or EP, and keep asking questions to hopefully get some kind of answer about ectopics and ablation. I'm seeing a new cardiologist at Northwestern next month, in an effort to establish a new relationship to have someone manage my case. Fingers crossed that works out, since I have no idea where I will go next if it does not. I feel like it shouldn't be this hard to find a good doc in Chicago. (I will not even go into the nightmare of my overnight experience at the hospital after the ablation.)

And geez, I can't imagine many people can afford to pay $40,000 out of pocket for a medical procedure (myself included)!!! I'm happy to hear about how Natale operates... I'm sure that kind of care is a big differentiator to people.

Quote
wolfpack
AF is a re-entrant rhythm (as is flutter and even v-tach). It is the ability of electricity to flow around and around in a circuit consisting of autonomous cardiac muscle cells rather than being "pulsed" from the SA node to the AV node. In flutter that circuit is often a circle in the right atrium. In AF, it's some kind of a mess in the left atrium. The PVI is supposed to introduce enough "impedance" in that mesh of a circuit such that re-entry is no longer possible. Ectopics, sure, but nothing that self-sustains.

Interesting assertion. And as I alluded to as a possibility in my post above (para 6). I’ve never seen it written as such previously - I.e. that a PVI doesn’t only seek to prevent ectopics coming down from the PVs into the atria but also plays a significant role in preventing the re-entrant arrhythmia AF itself.

Quote
kbog
And geez, I can't imagine many people can afford to pay $40,000 out of pocket for a medical procedure (myself included)!!! I'm happy to hear about how Natale operates... I'm sure that kind of care is a big differentiator to people.

I didn't pay $40K out of pocket. My insurance covered almost the entire cost since I had already met my deductible for the year. Generally, the only people paying for an ablation out of pocket are non-Americans with no US health insurance. For Americans who have plans that won't cover it, it's cheaper to drop that insurance and buy your own coverage through someone else for a year. As you would expect, Natale is in-network with most of the major medical plans, and insurance companies don't usually care where you go for a procedure since they don't cover travel costs anyway.

Quote
mwcf
Interesting assertion. And as I alluded to as a possibility in my post above (para 6). I’ve never seen it written as such previously - I.e. that a PVI doesn’t only seek to prevent ectopics coming down from the PVs into the atria but also plays a significant role in preventing the re-entrant arrhythmia AF itself.

A well-done PVI blocks all electrical signals from the PVs, so that prevents both reentrancy and ectopics from that area. The problem is the PVs are often not the only source of ectopics. They can come from almost anywhere in either atrium. Any average EP can do a PVI, but it takes a very experienced, well-trained EP to locate and ablate ectopic sources elsewhere.

Quote
Carey

A well-done PVI blocks all electrical signals from the PVs, so that prevents both reentrancy and ectopics from that area. The problem is the PVs are often not the only source of ectopics. They can come from almost anywhere in either atrium. Any average EP can do a PVI, but it takes a very experienced, well-trained EP to locate and ablate ectopic sources elsewhere.

What % of ectopics would you say Carey.....or anyone else.....come from other than the PV?

I guess that's a great Q. for Dr. Natale....i would love to hear that answer...i wonder if Shannon has ever asked that Q. of him....cause thinking about it that's a HUGE Q. considering some people with complex cases like i believe i have (i had a cyro 6 months ago PV's only and did not get 1 lick of improvement...get about 2 AR a week before and since)......to get ablated up here (RF this time) in Canada and MAYBE fix my AR problem but possibly leave K's of Pac's to run on daily which frankly is not much better if at all in the quality of life scale.....or forego that and go straight to Natale knowing he will leave no stone unturned to fix BOTH.



Edited 4 time(s). Last edit at 05/30/2018 08:13PM by vanlith.

Quote
vanlith


A well-done PVI blocks all electrical signals from the PVs, so that prevents both reentrancy and ectopics from that area. The problem is the PVs are often not the only source of ectopics. They can come from almost anywhere in either atrium. Any average EP can do a PVI, but it takes a very experienced, well-trained EP to locate and ablate ectopic sources elsewhere.

What % of ectopics would you say Carey.....or anyone else.....come from other than the PV?

And... the only way to capture information re: the source is through mapping during an EP study or ablation procedure, yes? When asking doctors whether they will search for additional non-PV sources during an ablation, are there important ways to phrase the question that might distinguish between similar but not equivalent responses?



Edited 1 time(s). Last edit at 05/30/2018 08:59PM by kbog.

Quote
kbog
What % of ectopics would you say Carey.....or anyone else.....come from other than the PV?

And... the only way to capture information re: the source is through mapping during an EP study or ablation procedure, yes? When asking doctors whether they will search for additional non-PVI sources during an ablation, are there important ways to phrase the question that might distinguish between similar but not equivalent responses?

I don't know what percentage come from non-PV sources. That's definitely a question for an EP and perhaps Shannon has asked Natale. But considering that a standard PVI alone has about a 60% success rate with paroxysmal patients, I'd guess probably around 40% of patients have non-PV sources. For persistent patients, I think it's a much higher percentage because a PVI alone rarely achieves success for persistent afib.

Yes, mapping during an EP study is the only way to find ectopic sources. I think if you ask any EP if they look for non-PV sources during an ablation, they'll all say yes. But that's like asking a pilot if they're cautious. Every single one of them will say yes, including the ones who are now dead due to pilot error. So I wouldn't rely on an EP's self-assessment to judge whether they're capable of finding and ablating non-PV ectopics. I would rely on experience and track record. For starters, if their previous ablation left you with unrelenting ectopics then I'd say they've proven they're not capable. After that, I would look at how many ablations they do. Have they done hundreds in their career or thousands? You want the one who's done thousands, not hundreds. You want the one who knows how and when to isolate the left atrial appendage. That's a no-go for many EPs, which means a lot of patients will be left with less-than-successful ablations because the LAA is a common source of ectopics (it was for me). And, frankly, just ask here. Natale isn't the only elite EP in the US, but it is a small club. You might have to travel, but so what? That just adds a few hundred bucks to the cost.

Quote
Carey

As you would expect, Natale is in-network with most of the major medical plans, and insurance companies don't usually care where you go for a procedure since they don't cover travel costs anyway.

Huh. I will hope that the Provider Finder on my insurer’s web site isn’t comprehensive then... maybe it only lists local providers but covers others nationwide. That thought had not actually occurred to me.

Ty Carey and others in this fab. thread.
You pretty much decided/confirmed what i am going to do.
You know when i had my followup 5 months after my failed cryoablation in nov. 2017 in Canada...this took place 2 months ago.....the EP up here had no idea if his handiwork 5 months earlier worked until he walked in the waiting room i was in and found out NOTHING had changed with me + the 1st thing he said was "there must a gap in the PV scarring"......i don't think he even thought of any other possible sources that caused the total failure of his cryo procedure like you mentioned with you Carey the LAA or somewhere else in the Atrium and i was in the room with him for about 90 sec. ya 90 sec. before he got up and left saying "we will schedule you again this time for a RF ablation" and about 5 hours after i got my cyroablation 5 months earlier i was lying in bed recovering and some other doctor came to the foot of my bed and talked to me for about 45 seconds telling me that the EP only ablated 2.5 out my 4 PV and when asked why she had no idea but said the EP deemed it a success.....then in the 90 sec. interview 5 months later when the acting EP visited me in the waiting he said NO i did all 4 PV's....so that's what we are dealing with up here....they don't call it assembly line medicine for nothing...even when it comes to serious heart procedures like this. I could get this next procedure done for nothing, but i figure it's more maybe much more than a 50% chance of NOT eliminating both my AR's and Pac's so i am perfectly willing to pay the roughly 60K Canadian Dollars factoring everything in to get Picasso instead of a paint by numbers doctor up here to help me get my life back. We all know the old saying...something like...one can never spend his money better then to do it on their own or a loved one's health. Well count me in...i don't know how many of Dr. Natale's patient's have come from Canada or other country's where they don't have to spend a dime to get this procedure done 5 min. away from their front door but considering everyday in this state of misery is not much on the Q. of life scale and i know how everyone reading this feels the same way why chance another miserable exp. and hopefully get it done right... so i hope that gives him an idea of how badly i want this great man's expertise....now i know there is no gaur. but if Dr. Natale cannot fix me nobody can...least of all the paint by # doctors up here, so i'll take that chance in Dr. Natale"s hands. Considering there is about a 5 month wait i will contact Shannon in the next week or 2 as a mid. nov. or so date in Austin sounds about right and that gives me a little more time to find a supl. or some other miracle cure in the interim as my latest Taurine exper. recently failed.
Sorry for rambling on as this was kinda piece meal written....love the site for many reasons and esp. since i found Dr. Natale here.



Edited 5 time(s). Last edit at 05/30/2018 10:15PM by vanlith.

My opinion. RF is better than cryo.

That being said, operator experience matters. RF can blow a hole in your heart if done improperly. RF can also pinpoint spots of activity whereas cryo can only isolate the pulmonary veins. So, more powerful tool but larger risks if in the hands of the wrong person.

As always, use wisely the power of choice!

Carey, Wolfpack,
I'm sure you're right saying the best EP can ablate any ectopic he wants. But this supposes any ectopic showing up while the patient is in the room. I'm sure the best EP can make them showing up.
But I think it's not that simple.
My experience makes me think new ectopics may appear in the weeks or months following the ablation. We're all different. In my own case, it's like a battery charging (I don't know how and why) then needing to discharge when it's full. Now that the easiest paths (PV's) are ablated, the battery searchs for other paths. The smaller, the harder they are, the more I have PACs. Some days, I may have ten thousands of them. The following day, my heart would hardly miss a beat. Just like the day following afib. So, what discharged in less than 1hr of afib before my recent touch up procedure now needs hours and hours of ectopics.

Carey:

"I think if you ask any EP if they look for non-PV sources during an ablation, they'll all say yes." Well actually here in the UK they all say 'no'! All's you'll get is a PVI end of with anything else (assuming that they can do it... - not always a given by any means) being reserved for a second (or third, fourth...) procedure.

vanlith,

So far as I'm aware from years of reading (and corresponding with EPs - including Prof Jais at Bordeaux), for paroxysmal AFrs almost all ectopics come down from the PVs - hence why a well-done PVI will sort things out 70-80% of the time (and into the 80s and 90s % after a touch-up as and if required) - Prof Jais gives me an 80% chance of success with one thoroughly carried out first ablation. At Bordeaux they DO go actively looking for and ablating non-PV ectopics as part of a first procedure. But they don't here in the UK where most procedures are done with cryo that doesn't/can't address non-PV foci anyway.

If I were you, I'd move heaven and earth to go see Natale whatever it takes. As for me I'll be over to Bordeaux and pay out of my own pocket when the time comes (likely not far off) even though I could get a PVI here in the UK on the NHS for free. So; 'a free ablation' or 'a free from AF ablation'... not so tough of a choice!



Edited 1 time(s). Last edit at 05/31/2018 04:30AM by mwcf.

Quote
Pompon
Carey, Wolfpack,
I'm sure you're right saying the best EP can ablate any ectopic he wants. But this supposes any ectopic showing up while the patient is in the room. I'm sure the best EP can make them showing up.
But I think it's not that simple.
My experience makes me think new ectopics may appear in the weeks or months following the ablation. We're all different. In my own case, it's like a battery charging (I don't know how and why) then needing to discharge when it's full. Now that the easiest paths (PV's) are ablated, the battery searchs for other paths. The smaller, the harder they are, the more I have PACs. Some days, I may have ten thousands of them. The following day, my heart would hardly miss a beat. Just like the day following afib. So, what discharged in less than 1hr of afib before my recent touch up procedure now needs hours and hours of ectopics.

I understand your battery charging analogy. I was the same way. Nevertheless, they're gone now. It's more possible than you think.

Pompon,

It is true, the EP can only ablate what he or she can see during the procedure. "Rooting out" ectopic sources involves careful stimulation and mapping of the entire left and right atria. This all speaks to skill of the operator.

I'm my case, that wasn't done. I was PVI-only by an operator with somewhere around 1,000 cases under his belt. My choice given the locality (Duke University). I still get PACs and actually had an AF breakthrough a month ago. I'll continue to manage this with careful supplementation and PIP when necessary, but when the burden becomes too much I will seek out a more skilled EP. No doubt about it.

Quote
vanlith

You pretty much decided/confirmed what i am going to do.

Not to dissuade you from going to Dr. Natale, but if you don't have US health insurance, the team in Bordeaux with Drs. Haïssaguerre, Hocini, and Jaïs are excellent and at a material cost advantage. My understanding is the cost is in the $20,000US range. In my subjective ranking, I'd put them a tiny bit below Natale, but still at the top of the ablating EP heap in the world.

George

Carey, Wolfpack,

Thanks for your answers and your encouragements. You know how frustrating things can be when you discover you're unluckily among the 30% for whom ablation didn't work the way they hoped.
I'm sounding pessismistic, but I've to say I've no regrets. What's done is done, and I think following the ablation way was a good choice. Hadn't I did it, I surely would have regrets today.
I keep in mind it may work after more than three procedures. I've read it on this great forum.

George, ‘just’ Jais and Hocini performing ablations these days to the best of my understanding.

Quote
Pompon
I keep in mind it may work after more than three procedures. I've read it on this great forum.

I had five that failed. Number six was the charm and that was entirely due to whose hands were on the catheters.

And I'm not the record holder. I know Natale had a guy who failed seven before coming to him.

Quote
GeorgeN


You pretty much decided/confirmed what i am going to do.



Not to dissuade you from going to Dr. Natale, but if you don't have US health insurance, the team in Bordeaux with Drs. Haïssaguerre, Hocini, and Jaïs are excellent and at a material cost advantage. My understanding is the cost is in the $20,000US range. In my subjective ranking, I'd put them a tiny bit below Natale, but still at the top of the ablating EP heap in the world.

George

Ty George.....well that's something to think about....it would be 3 x further for me as i live in a perfect str. line 1,400 miles north of austin.....well considering this site is world wide and many people from non france europe, the middle east, isreal ect. has gone to bordeaux to have this exact procedure done i would love to hear from them to confirm the FINAL cost is around the 20-25k usd mark compared to around 40-45 usd i would expect to pay in austin. Would be worth 20K US for only the slightest drop off if any of expertise.
Anyone?

Although my heart screams Natale Natale no matter what....i can only picture/dream of myself lying on the gurney and seeing the face of an angel with an italian accent walking in the EP room.



Edited 3 time(s). Last edit at 05/31/2018 08:10PM by vanlith.

vanlith,

Cost at Bordeaux is 16,555 Euro 'all in' including 4 nights stay in hospital accommodation for you and your partner (they monitor you via telemetry for 3 days after the procedure).

One needs to bear in mind, however, that a second 'touch-up' procedure - as and if required - would cost the same again. To the best of my knowledge a typically paroxysmal AFr would be looking at a 70-80% success rate for one procedure alone at Bordeaux.

Repeating the shout-out for any recommendations for EP in the Chicago area, though perhaps I should start a new thread. Are there folks who maintain any kind of list of things like this?

Quote
mwcf
vanlith,

Cost at Bordeaux is 16,555 Euro 'all in' including 4 nights stay in hospital accommodation for you and your partner (they monitor you via telemetry for 3 days after the procedure).

One needs to bear in mind, however, that a second 'touch-up' procedure - as and if required - would cost the same again. To the best of my knowledge a typically paroxysmal AFr would be looking at a 70-80% success rate for one procedure alone at Bordeaux.

Ty again George + MWCF

Makes 1 Q. why most americans without health ins. esp. the one's on the east coast don't just go to France and save at least 20K with such incred. quality of care there only surpassed and by a very slight amount by Dr. Natale at st. david's in austin.

I wonder how long a period it takes from the opting in to the time your on the gurney?

Another interesting Q. is that roughly 20k usd. charge.....does that cover any complications during or after the procedure?

Also 3 day's post op. sounds nice but i would not want to stay there that long......if my procedure is on a wed. lets say i want to be on a plane sometime on friday for my long journey home....i wonder if they would have a problem with that.



Edited 1 time(s). Last edit at 06/01/2018 12:29PM by vanlith.

Quote
mwcf
vanlith,

Cost at Bordeaux is 16,555 Euro 'all in' including 4 nights stay in hospital accommodation for you and your partner (they monitor you via telemetry for 3 days after the procedure).

One needs to bear in mind, however, that a second 'touch-up' procedure - as and if required - would cost the same again. To the best of my knowledge a typically paroxysmal AFr would be looking at a 70-80% success rate for one procedure alone at Bordeaux.

Hey Mike, do you know if they ablate inside the LAA as Natale does (obviously neither would likely do that on pass #1 since that is the most conservative approach)?

Quote
Pompon
Carey, Wolfpack,
I'm sure you're right saying the best EP can ablate any ectopic he wants. But this supposes any ectopic showing up while the patient is in the room. I'm sure the best EP can make them showing up.
But I think it's not that simple.
My experience makes me think new ectopics may appear in the weeks or months following the ablation. We're all different. In my own case, it's like a battery charging (I don't know how and why) then needing to discharge when it's full. Now that the easiest paths (PV's) are ablated, the battery searchs for other paths. The smaller, the harder they are, the more I have PACs. Some days, I may have ten thousands of them. The following day, my heart would hardly miss a beat. Just like the day following afib. So, what discharged in less than 1hr of afib before my recent touch up procedure now needs hours and hours of ectopics.

My heart works exactly the same way WOLFPACK...it seems after i PIP with chewing 3/4 of a 150 mg propafenone within 5-7 min. of the start of my ARR ( that kills it in about 45 min. usually).....i am symptom free certainly the rest of that night because 95% of my ARR's happen in bed...so i can go back to bed (after the termination) and lie on my back or left side the rest of that night that are normally mostly no no's any other time but not right after an ARR. and that feels great knowing i can get relief for 1 night anyway and sleep well. Also as you said the next day is pretty much pac free and extrem. rare to get back to back ARR on consecutive days....but around the 48 hour mark it starts building again and the pac's return in earnest then usually between the 3-6 day mark when the heart is "fully charged" as you said its off to the races again.

I just noticed on another thread WOLFPACK you take Propafenone also....do you PIP with it or do the normally 150mg every 8 hour thing....i gave that try for a short period but did not prevent my ARR's...works incred. well for me to convert out after i go into an ARR. but cannot prevent that from happening in the 1st place.



Edited 1 time(s). Last edit at 06/01/2018 01:01PM by vanlith.

I only took the one PIP propafenone last month and haven't had to again. Prior to my ablation, I was on the XR version 2x/day.

Quote
GeorgeN
Hey Mike, do you know if they ablate inside the LAA as Natale does (obviously neither would likely do that on pass #1 since that is the most conservative approach)?

They don't ablate inside the LAA. They isolate it, much as they do the pulmonary veins, although unlike the PVs where you want 100% isolation,
they try to minimize the amount of isolation in order to retain as much contractility within the LAA as possible. And it is sometimes isolated during index ablations, especially with persistent afib.

George,

That's a question I don't know the answer to I'm afraid. I'll ask next time I email Prof Jais and let you know. I suppose as a fairly straightforward paroxysmal AFr it hadn't occurred to me that I might need any ablating of the LAA.

Mike

Quote
mwcf
That's a question I don't know the answer to I'm afraid. I'll ask next time I email Prof Jais and let you know. I suppose as a fairly straightforward paroxysmal AFr it hadn't occurred to me that I might need any ablating of the LAA.

He won't know if he needs to isolate the LAA until he gets in there, but given his success rates I'm sure he sometimes does, just as Natale does.
And as I said, they never ablate inside the LAA. They only ablate around it to isolate it.

Carey, my mistake, thanks.

Yes, I'm guessing they do isolate if they need to, but a good question to ask.