EP visit and Medicare

My yearly pilgrimage to the EP happened this week. I was actually interested in discussing ablation because I will be on Medicare next summer and not certain I would get to choose the carver and a low co pay my current insurance allows. His remark was because ablation at their hospital was 65% for Paroxysmal and less than 50% for Permanent, I should consider using AADs as a PIP for as long as possible, (used once in 15 months). Are these honest stats with all types and ages, or just bad EPs? If I later chose ablation, would medicare have some strict guidelines for choosing the EP or even allowing without a med protocol first?

Those stats aren't good. You don't want an ablation there.

I don't think Medicare is going to be a problem for any future ablation. But I'll let others chime in. I'm just a 44-year old kid with no experience there!

I agree with wolfpack. Those are miserably bad stats. Medicare won't dictate who you can choose, so don't choose them.

Get the best supplemental plan along with your medicare, and you won't pay anything.

WP, Carey and JP, thanks for that info. When I questioned his stats he expressed that I would be a very "simple" case and most likely in the 90% success rate range. No thanks, Austin's pretty in the fall I believe.

I'd like to know how he knows you would be a very simple case before he has you in the lab. For all he knows you have ectopic sources in places extremely difficult to ablate or that require unusual skills (the LAA, for example). I've been quoted that 90% number before -- several times -- and each time I got the 10% results. The one guy who didn't quote me odds and didn't tell me he was "extremely confident" was the guy who actually fixed the problem. And yes, he's in Austin.

Possibly due to the low occurrence and long periods of time in NSR. Their rates were overall for patients as old as 95. Who knows, But that is still quite a statement without scoping or lab evidence. And if the first one failed I would be told most need a second one anyway. Wont be studying that plan at this point.

I have had frank discussions with 4-5 Cardiologists/EP's. As far as I can tell the usual stats given for successful Ablation are exaggerated. This happens in general in Medical procedures. Maybe the 65/50 Stat is is just an honest one.
The success rate depends upon the thoroughness of the follow-up, and how far out the go in the post-Ablation monitoring period.

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The Anti-Fib
Maybe the 65/50 Stat is is just an honest one.

It is an honest one for average EPs but it's not accurate for top EPs. They get well above that.

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Carey

Maybe the 65/50 Stat is is just an honest one.

It is an honest one for average EPs but it's not accurate for top EPs. They get well above that.

I don't have direct knowledge of this, but I do not disagree. I know Shannon's knowledge on Ablationism is unsurpassed for someone who is not actually a Dr. and this is also his assertion.

Which is a sad commentary on the disease management association. If only a handful of EPs have the highest success rates, that leaves the general afib population in a crap shoot for any chance at a normal life. No matter, I would be going to the Tom Brady of EPs for my money.

It comes from the fact that the majority of EP fellowships just teach PVI and, in any cases, using cryobaloons because it's easier to train the operators on. If you start with those limitations, you get the 60% number.

It's often said by accident investigators that one has to ask 7 questions to get to a root cause. Never accept the first answer, but rather let it lead you to the next question. So, when we say "ablation", perhaps the next question is "what kind?", followed by "how?" or "where?", etc., until one gets the whole picture of what exactly a provider is proposing to do. That's really the beauty of this forum. It allows us to do that outside the confines of a 15-minute office visit in a busy and noisy facility.

If the odds are proven to be greater with RF vs PVI, then I am left with only one conclusion. I ll just bite my tongue for now and go sit in the corner for cussing out loud.

PVI means "pulmonary vein isolation". PVI is accomplished either with RF (radiofrequency) catheters or with cryobaloons. RF is superior to cryo, in my opinion. RF is also able to ablate other areas of the left atrium whereas cryo cannot.

Over the years, Shannon has referenced the Desmukhs dtudy: <[www.afibbers.org]

"The Desmukhs data for those who may not be familiar is from the large review of all Medicare cases from 2000 to 2010 that included all 93,801 U.S. Medicare ablation patients durung that period, and the overall significant increase in most complications noted in that study reflect the fact that >81% of all of these patients were ablated by greenhorn EPs doing less than 25 procedures a year and at small low volume centers or hospitals doing under 50 total AFIB ablations a year !!

And Desmukhs emphasizes our core message so often reinforced strongly on our forum and newsletter urging those needing an ablation to be very discriminating in who they choose as the complication rates broken down by upper 19% or so of higher volume operators show progressively much lower such complications, especially the really serious adverse events, with the greater the experience of the operator ... no surprise there. "

As a point of reference, I believe Natale has done over 11,000 ablations. Ten or so years ago, there was a Cleveland Clinic study (I'm doing this from memory) where they sorted by EP volume. I think the cut point for high volume was 350 or 400 afib ablations/year. The team in Bordeaux is also in this category.

All of those "success" rates are meaningless, unless "success" is defined. Plus there must be universal agreement on the definition and it must be used as an established standard that all EP's go by.

I don't know, but I doubt that when one Dr. says 50% and another says 80% that they are using the same definition of success. I can't even venture to guess what an appropriate definition of "success" would be.

Be skeptical!!!!!

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Ken
All of those "success" rates are meaningless, unless "success" is defined.

That's an excellent point. I've seen many instance of EPs labeling ablations successful when the patient still needed antiarrhythmic drugs to remain in normal rhythm. I've even seen that done in published studies. It's a complete lie, of course. If you need AADs to remain in rhythm then your ablation was a failure. Saying anything else is just putting lipstick on a pig. Now, maybe your afib burden is lower, and that's great, but that's not "success." That's partial success or symptom reduction.

The definition of success that honest EPs use is freedom from all atrial arrhythmias without AADs from the end of the blanking period to one year.

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I doubt that when one Dr. says 50% and another says 80% that they are using the same definition of success.

Possibly, but I know of EPs who legitimately get numbers that different. My first EP is probably about 50% and Natale is better than 80%.

Find an expert EP who has done many ablations with a high rate of success...using Dr. Natale in Austin as an example. There are other top rated EP in other areas of the country.....Cleveland Clinic ....Salt Lake City, etc. It pays to completely check out the EP who will be doing your ablation. What is considered a successful ablation varyies with different EP.s. I agree with Carey's definition of what can be considered a sucessful ablation.

Cary said: "The definition of success that honest EPs use is freedom from all atrial arrhythmias without AADs from the end of the blanking period to one year".
If that was the recognized standard world wide, there probably wouldn't be many ablations. I am 11 years and 10 months afib free. I would call mine a success. If I was back in afib after one year - I would call that a significant failure.

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Ken
If that was the recognized standard world wide, there probably wouldn't be many ablations. I am 11 years and 10 months afib free. I would call mine a success. If I was back in afib after one year - I would call that a significant failure.

It is the recognized standard among top EPs, and frankly I think fewer ablations would be a good thing. Too many EPs are doing ablations who have insufficient training and experience. I firmly believe ablations should be treated like other advanced surgical procedures and should only be done at large centers with volumes sufficient to train new EPs adequately and maintain skill levels. It is not the cookie-cutter procedure that many EPs think it is.

From:

[www.everydayhealth.com][/url]

"Moderate success rates average around 50 percent overall. “Research shows that with medication there’s a good 40 to 60 percent maintenance of normal rhythm at one year,” says Saliba. “And that’s acceptable to some patients.”"

Only one source, but if this was/is true, there wouldn't be many ablations. I don't disagree with your statement about "fewer ablations", but knowing were to go is a challenge, even with what is posted on this web site. Natale is not the only guy in town, and I wonder how many have had a "one and done" ablation with Natale? Done meaning 5 years plus.

For example, I can't find any stats on my Doctor, plus he is never mentioned on this site except by me. I think there are some great EP surgeons out there, but finding them is a real challenge.