Has anyone heard of Dr. Paul Zei at Brigham and Women's hospital (Boston)

I had written a post about cardiomyopathy and ablations recently, and now have to ask about the doctor mentioned above. My good friend is in Brigham and Women's hospital in Boston, MA, with a rapid heart rate. She's had 4 ablations, and has been wrestling with a lot of Afib over the past few months..maybe more. I have been trying to encourage her to go see Dr. Natale in Austin, but she has been hesitant to make the trip...she seemed to think there were "a few really good doctors up in Massachusetts", which is where she's originally from. Well while on vacation up there, she ended up with the racing heart and now is scheduled to have an ablation next week with Dr. Zei. She sent me a very long list of his credentials and that he supposedly focuses on complex arrhythmias, with an emphasis on atrial fibrillation, catheter ablation of complex arrhythmias and device implantation. When I asked, she replied that he has done 'a lot" of ablations and specializes in LAA.

I'm wondering if this guy is well known and what his reputation is. I would hate for her to have FIVE unsuccessful ablations......as she's already had 4. Of course, I have little to nothing to say about it, but I know I'd feel better if he has a great reputation and others have had success with him too.

As for me, when it's something like this, Dr. Natale is the only Doctor I would want... Barb

My assessment:

He has impressive academic credentials. He's probably a fine clinical EP. He has minimal ablation experience.

I would not let him do an ablation on me.

They told her that he specializes in LAA.....not sure what that means. I asked her to ask them how MANY ablations has he done, and how many LAA isolations as well? I think she's afraid to ask as her husband thinks this is good enough and she doesn't want to ask more questions.....(she doesn't like to ask anything that might challenge someone)...ahhh...

I'm hoping someone has heard of him and will say he HAS done a lot of them...but it is what it is. I tried...

Barb

I would tell her there have been a lot of great QB's over the years and still are playing today but there is only 1 tom brady.....not only the best QB ever.....most experts would say but the key is.... HE STILL IS (voted #1 by his fellow players recently) this is DR. Natale....75% of the ablations he does are complicated cases that others have failed over and over on.....like in her case. A. Natale was made for this lady.....she needs to go to austin.....hell even if he was in chile....Go.
Tell her to go to UTUBE 2015 AF Patient Conference Catheter Ablation Panel and not only witness his incred. insight into the procedure itself and the post procedure stats. that backup everything he says but the 2nd to none respect he gets and deserves from the best EP`s who came from all over the world that are in that hall with him.
After 4 ablations she is running out of heart tissue to ablate.....she should have done this before....like i am doing (just got approved by Dr. Natale himself today for later this year) after just 1 failed cryo ablation up here in Canada...i could get another 1 up here for FREE but i am going to pay 40K= about 55K can. dollars for the 1400 mile trip to austin, hotel ect. to go see Da Vinci himself. Tell her about me and other int. patients....he is not the Best in the world for no reason....as i am living proof voting with my bank account and she needs to beat me there.

I have been trying to get her to go to Dr. Natale but I think she thinks any very good EP could do this...(even though apparently at least 1 has tried 4 times or she's had 4 different ones...not sure)....

I will see what else I can say or do, if anything. It's her choice. I did take a quick look at the video on YouTube, vanlith, but it talks about pulmonary vein isolation ablation, and I think she may be well past that....she surely needs a LAA isolation at this point.

Thank you for your suggestions ~ Barb

Or maybe not. LAA Isolation isn’t something anyone can figure out beforehand. It’s possible that the 4 PVIs weren’t transmural or their are other areas of ectopy which may include the coronary sinus or posterior wall. Failed PVI does not immediately mean LAA isolation. What it does mean is the patient needs to be seen by a more experienced ablationist.

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wolfpack
It’s possible that the 4 PVIs weren’t transmural

That right there is the most likely explanation. It explains a huge percentage of failed ablations, including three of mine.

So since I suspect I'm heading there...

How do you decide who is great ablation PE and who isn't.
Clearly the Dr. Natale so frequently mentioned here has a great reputation, but I'm sure for many of us that is not an option.
I'm seeing a local hot shot EP... but I suspect there is a chance that being an academic expert type does not necessarily make him the best ablationist. Then again, perhaps he is.

What is the best way for me to research this? What questions should I be asking?

My August appt got moved up until next Tuesday... so I am working on my question list.
I'm 98% sure he'll recommend ablation, so I'd like to make sure he's up for the task, not just good at writing papers about it.

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bolimasa
How do you decide who is great ablation PE and who isn't.

It's the same as choosing a surgeon -- volume. You want the EP who's done thousands of ablations, not hundreds. The first thing you do is simply ask them. Any EP should have a pretty good estimate of how many he does every year and for how many years.

One way to get a good estimate is this site. Although it's derived from Medicare data, it includes non-Medicare patients as well. Just enter the EP's last name, wait for the list of choices to come up, then select the right one and click Search. Scroll down to the details, and what you're looking for is "Destruction of tissue of right or left upper heart chamber via catheter for treatment of abnormal heart rhythm". Look at the rankings for that procedure and what you want to see is an EP who is in the top 25% or so.

That data isn't perfect. It undercounts sometimes because credit for the procedure may be assigned to the center director, or an assistant EP, or various other reasons. So treat it like a statistical sample rather than a raw count. For comparison purposes, it says Natale did 101 in 2015, but that's almost certainly an undercount. So judge other EPs accordingly. But all in all, it provides the most accurate, objective count of how many procedures an EP actually does.

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Carey

How do you decide who is great ablation PE and who isn't.


It's the same as choosing a surgeon -- volume. You want the EP who's done thousands of ablations, not hundreds. The first thing you do is simply ask them. Any EP should have a pretty good estimate of how many he does every year and for how many years.

One way to get a good estimate is this site. Although it's derived from Medicare data, it includes non-Medicare patients as well. Just enter the EP's last name, wait for the list of choices to come up, then select the right one and click Search. Scroll down to the details, and what you're looking for is "Destruction of tissue of right or left upper heart chamber via catheter for treatment of abnormal heart rhythm". Look at the rankings for that procedure and what you want to see is an EP who is in the top 25% or so.

That data isn't perfect. It undercounts sometimes because credit for the procedure may be assigned to the center director, or an assistant EP, or various other reasons. So treat it like a statistical sample rather than a raw count. For comparison purposes, it says Natale did 101 in 2015, but that's almost certainly an undercount. So judge other EPs accordingly. But all in all, it provides the most accurate, objective count of how many procedures an EP actually does.

Oh, thanks for that! He's in the top 20%, so that's great. (thought only 42, not 101)
I guess what I really need to know now is his success rate!
Of course that's probably hard since I imagine some cases are easier than others.
I have no idea if my situation is easy or not. I'll be interested to see what the 'research team' thinks of my MRI (which was pretty normal according ti the standard MRI report) Hopefully they will tell me something about that on Tuesday.

If the MRI was of the delayed enhancement variety then it may have been done to look for fibrosis which, unfortunately, is used by some centers as an exclusion protocol for AF ablation. If in your case that was done and didn't show anything then I don't suspect you'll hear much about it at all. The MRI also estimates the dimensions of each heart chamber. LA anterior to posterior is the big one here - > 45mm will start to "scare away" EPs. It also can look for evidence of thrombus and estimate LV systolic function (ejection fraction). Those are all good questions to ask, especially if you have the report in hand.

I had the DE-MRI done on the day prior to my ablation. I never heard a word about it afterwards. I downloaded the report and it was Shannon, I think, who was kind enough to decipher it for me well after the fact.

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wolfpack
If the MRI was of the delayed enhancement variety then it may have been done to look for fibrosis which, unfortunately, is used by some centers as an exclusion protocol for AF ablation. If in your case that was done and didn't show anything then I don't suspect you'll hear much about it at all. The MRI also estimates the dimensions of each heart chamber. LA anterior to posterior is the big one here - > 45mm will start to "scare away" EPs. It also can look for evidence of thrombus and estimate LV systolic function (ejection fraction). Those are all good questions to ask, especially if you have the report in hand.

I had the DE-MRI done on the day prior to my ablation. I never heard a word about it afterwards. I downloaded the report and it was Shannon, I think, who was kind enough to decipher it for me well after the fact.

Exclusion meaning too much fibrosis no ablation?
I hope this means I'm good:
Delayed gadolinium enhancement:
Left ventricle: No delayed enhancement.
Left atrium: None

The short version of my results:
1. MRI pulmonary angiogram for planning treatment of atrial fibrillation
2. Normal pulmonary vein anatomy with four separate pulmonary vein ostia. There is proximal branching of the right superior and right inferior pulmonary veins is incidentally noted.
3. Normal left ventricular size and systolic function. Estimated LVEF is 55-60%
4. Right ventricle is qualitatively normal in size and systolic function.
5. No significant valvular abnormalities.
6. Normal atrial size

I sort of had fun and wasted a quite a bit of time trying to self interpret the actual MRI images.... not that I could interpret much but it was interesting to try to pick through the anatomical features. Google is your friend (yeah, I'm a little nerdy)

Yes, excess fibrosis or a very large left atrium will, like I said, "scare away" some practitioners. They are indicators that a PVI-only ablation probably won't work.

Yours looks pretty vanilla to my layperson's eyes. Ask them, though. Your insurance probably paid a pretty penny for it, so get your money's worth!

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wolfpack
Yes, excess fibrosis or a very large left atrium will, like I said, "scare away" some practitioners. They are indicators that a PVI-only ablation probably won't work.

Yours looks pretty vanilla to my layperson's eyes. Ask them, though. Your insurance probably paid a pretty penny for it, so get your money's worth!

Vanilla to me too... all my tests have have been pretty darn vanilla... except my ECG's which are totally wacky.
I have been battling blood pressure issues... other than that and my anxiety filled head I feel pretty darn healthy... and gobsmacked how this can just come out of the blue.

Next week I get a brain MRI... mostly unrelated to this problem, but I have been sporadically hearing a pulse in my left ear for the last year and half. I eventually saw an ENT and he said it's extremely rare to really be anything, but said I could get an MRI if I wanted to. I never bothered, but my GP suggested that now that I'm on blood thinners I should get it done, just in case. I am so sick of doctors appointments and tests... I really want to go back to my physician avoiding self.

Well talking about numbers....when i talked to Shannon in june about my upcoming trip to Austin to see Dr. Natale and what a conversation that was...about 90 minutes long....what a great guy with incred. insight on the subject for a non EP and i was on the edge of my seat the whole time as NOBODY knows Natale better than him and as a whole world wide afib EP vs EP better than Shannon Dickson and Shannon says Dr. Natale has performed over 11 thousand procedures with the vast vast majority mostly last resort type cases......so he has seen everything that can be seen many times over including tons of LAA iso's ect......who in the world has done as many as him....Shannon said he does 4 a day sometimes so if someone ???? this guys track record in any way shape or form from any angle from his success or freq. of ablations performed then they better start ???? the likes of Babe Ruth...Wayne Gretzky....M. Jordan ect......maybe in the future there may be a better afib ablationist but to this point and including NOW nobody has been or is CURRENTLY better and 2nd place is a bit of a squint in the rear view mirror.



Edited 2 time(s). Last edit at 07/13/2018 05:07PM by vanlith.

Awhile back some one mentioned Dr Mansour from MGH as a Dr who did a fair number of ablations.

Do you have the contact information on doctor Natale? I am in nj and had an abliation 4 months ago. Not sure if it worked. Have a monitor on now for two weeks. This afib is a life changer. Knocked me down hard. Thank you.

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Carey


One way to get a good estimate is this site. Although it's derived from Medicare data, it includes non-Medicare patients as well. Just enter the EP's last name, wait for the list of choices to come up, then select the right one and click Search. Scroll down to the details, and what you're looking for is "Destruction of tissue of right or left upper heart chamber via catheter for treatment of abnormal heart rhythm". Look at the rankings for that procedure and what you want to see is an EP who is in the top 25% or so.

.

Thank you Carey for the site, very informative. Does it just go to 2015? Do you know of any other sites that have more recent data?