List of the top 5 Electrophysiogist in the United States

We all know our sweet Dr. Natale is #1 but who would be considered #2/3/4/5

That's an excellent question but one that takes a lot of careful consideration to answer in a way that's objective, fair, and based on evidence rather than opinion. I've talked with Shannon about producing such a list and he agrees it's a worthy goal, but it's not an easy task. The one thing I'm sure of is it shouldn't be done by popularity poll. It should be based on verifiable outcomes, peer recognition, training, and education, but verifiable outcomes (the most important measure) is very hard to come by for individual doctors. Natale is unique in that regard that we do know approximately how many ablations he's done and he has published his results. Very few other EPs have done so.

That information would virtually be unobtainable in Melbourne Australia.
I know of one allegedly top EP working in a top hospital who did 3 ablations in 18months to get a result - so far so good. This EP doesn't inspire me with a lot of confidence.
Last visit to my EP i mentioned that and he told me data on success rate of EPs is not available to his knowledge. However, he knows a number he would be happy to do a procedure on him. He ruled himself out (he is quite young) as having not enough experience to do it by himself. He also recommended that i see his boss who trained him.

Plus, one would have to define what is a "successful ablation", then Doctors would have to have accurate follow up data on their ablation patients. Then there would have to be a system in place to collect the data.

The same issue(s) apply to all medical procedures when looking for the best available Dr.

Bottom line - it isn't going to happen. We all struggle to find the best doctors for whatever care we need, and the best way is usually knowing enough folks in the medical field to ask who they would go to, to have a particular procedure done. I have been lucky in that regard since my wife was in hospital management and administration for most of her career.

I'm on Dr Natale radar waiting for him to review my records with a recommendation wether the ablat now or wait. Only thing that worries me is Dr. Natale is 58 and imagine well deserved retirement is within the next 10yrs.

At least list of high volume RFA operators would be great.

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Kleinkp
At least list of high volume RFA operators would be great.

That might be a more achievable objective and it would definitely be of value.

The more ablations a Dr. does, the better he/she should be. BUT, doing too many back to back because of high demand may lead to rushed/botched ablations. Same with any surgery, so looking at the total number done alone is not a full proof measure of the quality of the surgery. Just a skeptic/realist.

Alot of EP I look into in my region are predominantly CBA operators. It's been highly recommended that I do not want CBA.

Excuse my ignorance - what does CBA stand for?

Shortening up cryoballoon ablation.

Thank you!
Any particular reason why you don't want CBA? The reason i'm asking is because my EP refered me to his 'boss' who does cryo but i don't know if it is with a balloon until i see him in December.
Got a previous impression that it is the operator rather than the method used???

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Joe
Thank you!
Any particular reason why you don't want CBA? The reason i'm asking is because my EP refered me to his 'boss' who does cryo but i don't know if it is with a balloon until i see him in December.
Got a previous impression that it is the operator rather than the method used???

Cryo is always done with a balloon. It's more of a cookie cutter, one-size-fits-all procedure that's much less dependent on operator skill than RF ablation. It isolates only the pulmonary veins, so if that's the sole source of your afib, it can be very successful. If you have sources outside the PVs, it won't be successful.

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Carey

Cryo is always done with a balloon. It's more of a cookie cutter, one-size-fits-all procedure that's much less dependent on operator skill than RF ablation. It isolates only the pulmonary veins, so if that's the sole source of your afib, it can be very successful. If you have sources outside the PVs, it won't be successful.

What determines where in the atrium the ablation will take place? How is it determined to isolate only pulmonary veins?

THANKS!



Edited 1 time(s). Last edit at 11/20/2018 02:22PM by Kleinkp.

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Kleinkp
What determines where in the atrium the ablation will take place? How is it determined to isolate only pulmonary veins?

It takes place where the pulmonary veins enter the left atrium, which is on the roof of the atrium. The balloon freezes a circle around the PVs thereby creating lesions that turn into scars and electrically isolating them.

The pulmonary veins have been found to be the most common source of afib signals, so that's they they are isolated. Doing only the PVs will stop about 65% of paroxysmal afib and about 40% of persistent. Cryo is totally inappropriate for persistent.

Thank you, Carey! Gives me a basis to ask a very important question to the EP and i might as well ask it here -
How do they establish the source of the stray electrical impulses prior to actually going in with a catheter and therefor be in a position to choose if cryo or RF is the best way to do the job?

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Joe
How do they establish the source of the stray electrical impulses prior to actually going in with a catheter and therefor be in a position to choose if cryo or RF is the best way to do the job?

They don't, because it's not possible. The only way to map the electrical activity inside the heart is to be inside the heart with the mapping catheter. At that point you've chosen your EP and he or she has chosen the tool.

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Carey

What determines where in the atrium the ablation will take place? How is it determined to isolate only pulmonary veins?


It takes place where the pulmonary veins enter the left atrium, which is on the roof of the atrium. The balloon freezes a circle around the PVs thereby creating lesions that turn into scars and electrically isolating them.

The pulmonary veins have been found to be the most common source of afib signals, so that's they they are isolated. Doing only the PVs will stop about 65% of paroxysmal afib and about 40% of persistent. Cryo is totally inappropriate for persistent.

RF for paroxysmal what can make it more effective then the ballon?

Thanks!

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Kleinkp

RF for paroxysmal what can make it more effective then the ballon?

Thanks!

It’s always going to come down to operator skill. An expert with a balloon could easily outperform a greenhorn with RF. That being said, take a moment to think about the tools and how they work. The balloon inflates, gets cold, and makes a big lesion all at once. If this lesion is both continuous and transmural then great. If it has “holes” in it then maybe not so great. And that’s all assuming that the only source of ectopy are the pulmonary veins. The RF catheter has a finer point to it and delivers a very focused heat. I’ve said before it’s basically a soldering iron. About 40W of power in a pencil tip. The operator can makes “dots” (or lines in the case of Natale), and he or she can go back and re-do spots that may need it. Burns can be made elsewhere in the left atrium as required. It’s a much finer and more precise tool. Of course, it can also do more damage in the hands of a poorly skilled operator. It can burn a hole through the heart. It can “weld” the esophagus to the heart and precipitate an almost always fatal complication of atrioesophageal fistula in the days or weeks following an ablation.

OPERATOR SKILL MATTERS. There’s just no overstating this.

In my opinion, RF in the hands of a highly skilled operator will outperform cryo. Everyone is, of course, entitled to form their own opinions.

I would assume Dr Natale only does RF ablations - no cryo.

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wolfpack
OPERATOR SKILL MATTERS. There’s just no overstating this.

In my opinion, RF in the hands of a highly skilled operator will outperform cryo.

What he said.

Cryo is a reasonable approach if it's your first ablation, you're paroxysmal, and your EP isn't highly experienced. It gives you roughly a 65% chance of success. If it's not your first ablation, if you're persistent, or if your EP isn't highly experienced, then you need RF ablation from an expert and shouldn't even consider cryo.

Thank you Wolfpack, that's what i was afraid of the answer is. It's a bummer the source can't be established prior to inserting a catheter. It is what it is at this stage

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Carey

OPERATOR SKILL MATTERS. There’s just no overstating this.

In my opinion, RF in the hands of a highly skilled operator will outperform cryo.

What he said.

Cryo is a reasonable approach if it's your first ablation, you're paroxysmal, and your EP isn't highly experienced. It gives you roughly a 65% chance of success. If it's not your first ablation, if you're persistent, or if your EP isn't highly experienced, then you need RF ablation from an expert and shouldn't even consider cryo.

My first EP did RF back in 2009. I had almost 10 years of relief from it. He used Cryo the second time around and if the issies would have just been reconnection or missed areas it would not have been an issue. However, it was less thatn 3 months before I was back into persistant afib which was worse than where I started.

An EP entering your heart doing Cryo is tying his hands. If your triggers lie beyond the Pulminary Veins, as was the case for me, there is nothing he can really do unless he pulls and reneters with the RF Catheter. that is assuming he has the skills to address triggers that lie beyond the pulminary veins.

When the operator is in your heart can he/she tell if triggers are beyond PVs?

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Kleinkp
When the operator is in your heart can he/she tell if triggers are beyond PVs?

Yes. And if they're good at what they do they'll be able to locate the precise locations and ablate them.

Moved!



Edited 1 time(s). Last edit at 11/23/2018 02:55PM by Kleinkp.

The TOP Ep is the one that cures you.