Have Bordeuax proceedures advanced these last 10 years.

It looks like I will be re-visiting the forum at least for the short term after being away for the last 9 years or so apart from dropping in when ordering supplements via Shannon's contact with iHerb. I would like to get up to speed on if RF ablation procedures and success rates in general have improved to any significant degree over those last 9 years, especially at the Bordeaux hospital. I ask because when I had my third ablation, 2009, in Bordeaux by Professor (Madam) Hocini - fourth overall - she said the ablation was very tough but had gone well in the end. She then added that the procedure had advanced dramatically in the last 5 years. She then 'said' she cringes (actually using facial expression) when she remembers what they did during the procedure 5 years previously. The question I put is, would she cringe today if she thinks back to procedures carried out 10 years ago.

One of our regular poster's, Gill, had her ablation in Bordeaux around 2004 during the ablation cringe period and is still ticking along nicely though with some PACs/PVCs which she has learnt to ignore.

Cheers,
Barry G.

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Barry G.
The question I put is, would she cringe today if she thinks back to procedures carried out 10 years ago.

Probably. Heck, I cringe at things I did 10 years ago in my job and I don't stick wires in hearts. And 10 years from now she'll cringe at things she's doing now. But I guess that's how progress works, right?

Hi Carey, I agree that's how progress happens however if ablation techniques and current equipment's are still based on RF catheters then things may well have stopped moving forward to a large degree from 10 years ago hence my question. It would appear if the skill of the ablator is still paramount then does that mean techniques/equipments along with success rates have not move forward as they rapidly did between 2004 and 2009.

When I was in Bordeaux for the first of four ablations there in say 2008 I met an English Doctor learning the trade from Profs, Haissagurre, Jais and Hocini and when I asked him if he would be as good as Prof. Jais one day he said he would never be in his class. He likened Prof. Jais to Ronaldo - the best footballer in the world at the time - saying no matter how much he himself trained at football/soccer he would never be in the same league as Ronaldo, a good analogy I thought. So if new techniques and equipment's have not made the English guy rise to the standard of Prof Jais after 10 years it seems to me things have not moved forward as fast as they did 2004 to 2009. As I mentioned in my post over 10years ago the new robotic ablation machine that was going to revolutionise ablations is still probably in the box and never seen the light of day in the basement of the Bordeaux Hospital.

Cheers,
Barry G.

Good to hear from you Barry. Where are you these days?

There has been a consistent stream of improvements in the field over the last 5 to 10 years, both in terms of technology and, most importantly, with advances in the procedural steps and design via various refinements in technique.

The issue still remains that not all operators are equally up to speed nor equally skilled and experienced with these recent advances, obviously, so the onus is still on the patient making a very discriminating choice as to whom one will intrust their hearts care too. Our motto of not compromising based mostly on convenience in selecting an ablation EP and being willing to travel for up to 5 days or more to partner with a genuinely elite level ablation EP, and is still the single best advice we can give when your AFIB journey has progressed to the point where starting an expert ablation process is your best option to finically but all atrial arrhythmia in the rear view mirror for the long haul.

And finally, don't be overly concerned with this or that technology advance. Pick first the most experienced and consistently successful ablation EP you can arrange for yourself and let them choose the best tools currently available for your particular case and manifestation of AFIB/Flutter/Tachycardia.

Cheers!
Shannon

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Barry G.
it seems to me things have not moved forward as fast as they did 2004 to 2009. As I mentioned in my post over 10years ago the new robotic ablation machine that was going to revolutionise ablations is still probably in the box and never seen the light of day in the basement of the Bordeaux Hospital.

Oh, I think you're very wrong about that. I would say it's quite the opposite, that ablation technology is moving faster now than ever before. I also don't think Bordeaux is a good example to look at. I would say they have not moved forward as much as others and are depending more on prior reputation than advancement now.

Hi, Carey. I'm surprised by this statement about Bordeaux. Would you elaborate, please ?

Barry, the Stereotaxis robotic system has made real advances over the last ten years, mostly it has found a home in VT ablation where it is even more suited than AFIB ablation.

But some EPs like using it in AFIB ablation too. One advantage for the EP is less fluoroscopy exposure than even with wearing lead vests and skirts. However it is not as suited for tracking down and ablation of non-PV triggers, as is increasingly common now in the more advanced AFIB/AFlutter ablation procedures.

A number of very promising new catheters are on the scene now too and these are mostly based around the new HPSD ablation protocol that is quickly becoming the preferred new approach where much higher power (‘HP’) is combined with much shorter duration (‘SD’) burns to deliver more consistent and uniform lesion transmurailty as well as more uniform lesion diameter as well as depth.

In several more years, we will have a new energy source that will almost surely supplant RF, CRYO and Laser ... in other words supplant all thermal ablation energy sources in favor of Electroporation using Pulse Field Ablation based on the oldest form of electrical energy in Direct Current (DC). The DC energy is delivered in short micro-pulse bursts of DC and short enough to avoid any collateral tissue damage and which inherently will only ‘ablate’ cardiomyocyte cells that are uniquely sensitive to Electroporation while entirely sparing damage to all other cells of the body!

There is still some more development required before PFA is truly ready for prime time deployment in EP-Labs everywhere, and it will likely take a good three years minimum, and quite likely longer, before the field largely switches over to Electroporation-based ablation. So don’t go holding your breath if any of you need an ablation or touch up soon.

Plus, the main advantage of PFA (Pulse Field Ablation) is significantly improved safety. When this new energy source is truly ready for prime time it should essentially eliminate the possibility of the dreaded Atrio-Esophageal Fistula entirely and in one fell swoop! Also, PV Stenosis, Phrenic Nerve Palsy and any other collateral tissue damage will be avoided outside of the cardiomyocytes that, in essence, house our pacing cells and that require ablation to free us from all atrial arrhythmia.

It’s simply the luck of nature that these cardiac pacing cells that are the prime target for cardiac ablations are so uniquely sensitive to being destroyed through creation of micro-pores in the cardio-myocyte cells leading to their loss of cellular structure and function and hence acheiving ablation/isolation of those cells while leaving
all other tissues in and around the heart unaffected!

Assuming this all works out, as the latest research surely implies it will, then we will no doubt see a day in the not too distant future when new afibbers will be ablated as one of the first steps in their treatment due to the improved inherent safety.

Now before any of you get too hot and bothered over wanting to postpone a pending ablation .... Don’t do that! We still need to let this tech mature and fully confirm the very promising preliminary results we have just now seen at HRS 2019.

Plus, AFIB ablation is very safe already, as is, and especially so in highly experienced hands. And I assume all of our readers know well enough now to choose only a highly experienced operator to begin with, so while it will be a very nice thing when all ablations are based on a well-vetted and mature electroporation energy source, we do not know how long that future day will be in manifesting as every day ablation technology.

In the meantime, if you are in need of stopping a miserable arrhythmia scenario, do NOT procrastinate only to get some minor practical increase in safety when, if you make an expert choice up front, you will already benefit from a roughly similar level of over all safety. And to postpone for still uncertain future promises could well allow much more advanced atrial disease, perhaps progressing to persistent or LSPAF in the interim, making the actual ablation process more complex and possibly requiring additional steps.

Keep in mind too, PFA ablation will not improve ablation efficacy by much, certainly not over an already elite ablationist. And it will not allow you to get great results by going to a less experienced EP that is using PFA. Indeed, the less experienced EP will be no more likely to deliver true freedom from all AT than they would be with RF or CRYO. PFA is no substitute for knowing where and how to ablate, but it should promise an amazingly safe invasive cardiac procedure even in modestly experienced hands.

It will be a super step forward for the field when, and if, PFA fully realizes its great potential and early profound promise of eliminating these typically very rare, but potentially devastating complications when they do occur, most often in inexperienced hands.

In summary, there are a lot of very exciting advances being made in EP in recent years Barry, and I’ve barely scratched the surface here!

Shannon



Edited 1 time(s). Last edit at 06/09/2019 02:43PM by Shannon.

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Shannon
Good to hear from you Barry. Where are you these days?

Shannon,

Barry mentioned in a recent post that he's in the Hong Kong area, as he has been previously.

George

Thanks George, I recall now Barry is in Hong Kong. He should do well with Dr. Hocini if he needs a touch up.

And PS, I’ve just finished a rough edit on my post above. Due to my ongoing problems with both hands/thumbs, these days I’m not able to type out messages very well and thus now resort often to using dictation, most often done in my car (otherwise known as my rolling office). And obviously, I have yet to master accurate dictation, not even close! I find my struggles with the spell checking in dictation even more unreliable than the challenging results I achieved with typing.

As such, I hope all readers to my posts will take the first reading of any new post of mine with a grain of salt and patience. I will make every effort by the evening of the first day, or by the next day after an evening dictation I have posted, to go back and properly proof read and at least improve legibility of said posts to hopefully a workable degree :-).

Thanks and Cheers!
Shannon

Hi again Carey thanks for your response. As my original post explains I am well behind the curve after being out of the arrythmias world for best part of ten years hence my original question. My whole recollection of being in that world was that there were three AFib centers in the world that were miles ahead of the rest i.e. Natalie in San Francisco and possibly a clinic in Huston Texas?, the Team in Bordeuax and a guy in Milan we never hear about.

Your post "I also don't think Bordeaux is a good example to look at. I would say they have not moved forward as much as others and are depending more on prior reputation than advancement now." would suggest that at least one of those top hospitals and technique/equipment has not moved forward to any great degree as I suggested, you may very well be correct on that score.

All good info for this 'newbie'.

Cheers.
Barry G.

Hi George, you are correct I live in Hong Kong these last 10 years, originally from Oldham, Manchester, England. I first found out I had Afib when I was living in Macau 2006, just an hours ferry ride from Hong Kong. As I recollect from 10 years back you live in Colorado, or at least you go skiing there, Jackie is from the Rust Belt near the Great Lakes, Gill from England, possibly Manchester and goes scuba diving, Peggy from toward the east side of the US, Pennsilvania? etc etc. Strange that I can remember that kind of info but can't remember what I had for dinner last night ;-)

Cheers,
Barry G.

Hi Shannon thanks for your post, a question if I may but no problem if you are snowed under with other requests. As I have just tipped my toe back into the AF pond I am just checking which way to go to get back out of it again. I am now convinced I am in Atrial Flutter and waiting for the hospital to contact me to attend a meeting with the hospitals top cardio. From that point I would expect to go on warfarin for minimum 3 weeks before having a cardio conversion. Should the cardio conversion be successful I would hope that puts the arrhythmias away for a while however should it not be successful - it failed twice in India years ago - I then have to move onto an ablation even though my resting heart rate at the moment is a solid 80BPM, up from 56BPM almost a week ago. I truly hate this condition - I am lucky that its not much higher at the moment - with a vengeance but have to put a brave face on it to keep my wife calm.

My question would be as follows... As always I look on the dark side of things with arrhythmias and prepare for the worst and I am usually correct, however should I need an ablation for this Flutter and with all the improvements made in the last 10 years would it be a safe bet to have an ablation in the local hospital EP department if they should offer the service. 10 years ago they offered to carry out an ablation for serious Afib but I refused and went to Bordeaux and all the cost involved in actual three visits. Reading on the internet it seems that there is a school of thought that the very simple and very safe ablation of Flutter is now the first line of attack for this arrhythmia.

The thought of the costs and upheaval of attending Bordeaux for ablation of Flutter might be considered overkill however if I remember correctly in many cases stopping Flutter can well start up Afib which thankfully is not showing up at the moment. To travel to France to stop the Flutter only for Afib to raise its head a few months later would seem false economy. It may be the case that Bordeaux would not just carry out an ablation for Flutter for a paying customer travelling across the world but would to the local population of that area of France.

I know I go on a bit but I am sure the questions I ask and the experience answers in reply are good information for the many newbies that attend this forum looking for their own way out of this club.

Cheers,
Barry G.



Edited 1 time(s). Last edit at 06/10/2019 12:29AM by Barry G..

Hi Shannon, what a very informative and uplifting post for all of us regarding the future of eliminating these arrhythmias.

Your post has certainly filled the lack of information gap I have been had these last 10 years even though the benefits of the advances are still a few years down the line.

Thanks again.
Barry G.

My philosophy on ablation has always been to delay it as long as possible if it isnt breaking your threshold for tolerating afib. Of course I have been told my many that the older you are, ablation is less successful. Ill take my chances with science getting better with age.

Hi hwkmn05.
Many years ago there was plenty of discussion on this forum regarding whether to go for ablation early or wait until the procedure and success rates improved. Once I was under no illusion of having Afib I decided to give myself 12 months trying to find whatever was triggering this curse and then go for ablation if things did not improve. I used to say at the time there is afib and there is AFIB, I had AFIB and at the 10 month mark in desperation I went at 1 weeks notice to Escorts Hospital, New Delhi, India, I asked no questions and I wouldn't have cared if Mickey Mouse turned up to carry out the procedure. It was the start of a 4 year ablation struggle with this affliction.

As a mechanical guy AF affected me psychologically as much if not more than physically as I knew and could feel my heart was flopping, twisting and contorting unnaturally every second of every minute of every hour of every day that I was having an attack. The attacks were lasting up to 48 hours before stopping and then starting up again within 12 hours. A human being in Afib is much the same as a missing firing car though the affects are not as visible but no doubt damages will be occurring.

As you point out and was the case made by many others back in the day maybe delay an ablation if your Afib tolerance is easily managed. I was in the opposite camp of having an ablation before the heart damaged itself permanently and although it was a long hard very frustrating and expensive struggle I do not regret taking that route for one minute. I got my life back. :-)

Cheers, Barry G.

Hi Barry, sorry to hear you're having AFlutter issues at present.

A couple of points in response to the above post/s by Shannon.

As a recent (Aug 18) Bordeaux Jais ablatee, I can contribute as follows.

Re Shannon's paragraph: "A number of very promising new catheters are on the scene now too and these are mostly based around the new HPSD ablation protocol that is quickly becoming the preferred new approach where much higher power (‘HP’) is combined with much shorter duration (‘SD’) burns to deliver more consistent and uniform lesion transmurailty as well as more uniform lesion diameter as well as depth. "
Prof Jais did use the latest Smart Touch catheter with Carto system and he did use high power (45W) for short duration (7-20 seconds), so he's definitely up to speed on that front. But I wouldn't expect anything else really.

Re PEF - also as per Shannon's above post, I can assure you that Prof Jais is absolutely at the forefront of this area of research and spoke most enthusiastically about it to me for 10 minutes last year. (See: [www.ncbi.nlm.nih.gov] where Prof Jais is the 3rd-mentioned co-author.)

Trying as hard as I can to set aside my own obvious prejudice, I'd say that Bordeaux are still right up there amongst the best centres in Europe if not the world and Jais and Hocini definitely right up there in the top 10 EPs for AF ablation in the world.

And before you ask, other than a couple of fairly bad few-hour-long episodes of ectopics (including bigeminy - really unpleasant) in the blanking period, I'm doing OK. I do feel some leaps and jumps now and again that do occasionally remind me of AF trying to start up but thus far at least it thankfully does not. If and when it does, I'll be straight back to Bordeaux for some more intervention. I do so hope that that doesn't happen until PEF becomes available but obviously only time will tell.

Wishing you the very best for whatever you decide to do. Please keep us posted.

Mike F.

Hi Mike, good to hear you are doing well apart from a few slight upsets with the PACs and Bidegimies etc. After ablation No5 I had two worrying times with these excessive arrhythmias in the first 6 to 8 months each lasting say about 10 days. I was sure AF would break out under the pressure but it didn't and over time I stopped being on full alert for signs of arrhythmias for the first time in almost 5 years. I have said it countless times on this forum that Proffessor Jais told me I was possibly one of the 3 most difficult cases he had ever come across and he had done over 4000 ablations (2010) and if not in the most difficult 3 then certainly in the most difficult 10. I mention his statement for no other reason than to let people know if I can come through it all most others have got a far great chance of getting through as well.

Very re-assuring to hear Bordeaux is keeping pace with the lastest technology in the ablation field as well has having world class EPs in both Professor Jais and Professor Hocini who have both carried out ablations on me. I remember Ms Hocini in the final stage of her ablation struggle with me leaning back in her chair, blowing out heavily and saying "I think I will have to get Professor Jais" my hopes sank there and then. She then had one more go for about 10 minutes and said "got it" and she did as I have never had AFib again these last 10 years.

It would appear that PEF is going to be a great leap forward in the ablation field and hopefully so but probably not available on the NHS - I believe you are from the UK, Manchester? - for many years unfortunately.

Hope all goes well for you and should you ever need to go back to Bordeuax the PEF is up and running ;-)

Cheers,
Barry G.

Thanks for your reassuring post, Mike.

My pleasure Pompon - hope you're doing OK.
Cheers,
Mike F.

I will admit to hearing they have little regret, from my ablated friends IRL and virtual. That certainly is encouraging. If this rotten condition is close to the point of diminishing return while damaging our hearts, the choice is a no brainer. Being very selective with EPs seems to be key.

Hi Barry

I’m not in Manchester but in London, having lived for many years in various countries - Russia, South Africa, Australia and Ukraine among them. Been to Hong Kong many times but never lived there.

You were right about the scuba diving but sadly, two years ago at age 79, I did my final dive in Mexico. Once in the water diving is effortless but getting to remote places in the world lugging bags of heavy equipment was getting to be too hard.

I have never forgotten your telling me about my 'cringe' ablation! (It was in January 2003 btw, not 2004.) At that time all the EPs I saw in London advised against ablation, saying it was experimental and dangerous but I ignored their advice! I still can hardly believe how long it has lasted - I’m half way through my 17th year of normal rhythm. Still seems like some kind of miracle.

I do hope you get your flutter sorted soon. Please keep us posted here - if you end up in Bordeaux again it would be good to know if things there have changed much.

Gill



Edited 2 time(s). Last edit at 06/13/2019 01:46PM by Gill.

Hi Gill, good to hear you are still doing well even though you have decided to hang up your scuba gear. No doubt you can still travel to those exotic places in the sun if you so wish.

I fully understand an afibber ignoring advice not to go the ablation route especially a person with an adventuristic nature and if I am correct the procedure had been being carried in Bordeaux since 1997 so already 6 years progress down the line. Very important to have such successful ablations such as yours on the forum

Gill, just an add on below for any adventuristic newbie reading this if you don't mind.

Looking back to my first ablation, which was in New Delhi India, I also, like Gill above, probably ignored advice (though in my case mainly from this forum to only go to a top EP). After 10 months I had just had enough of AFIB and would give anything to be rid of it. Bordeaux would be considered expensive to most but in my position the 8 or 9 months waiting period was the main problem, I just could not wait that long. I then read an article of this English guy going to India for his ablation which was successful at a price of around USD6000max. peanuts against the costs in the US and well down on the costs of Bordeaux. So there on the spot I rang Escorts hospital in India and got to the main man organising patients entry for ALL heart conditions. After the initial pleasantries the guy says "So when do you want to come" and I said "Well, as soon as its convenient for you". The immediate reply was "So when do YOU want to come". Scratching my head I paused and said tongue in cheek "Its Monday morning here at work so I would like to have an ablation next Monday" and his reply was "OK see you then, I will now hand you over to our administration. Staring at the wall I thought, what have I just done??????. It may have turned out to be two weeks later before I arrived at the hospital has I had to apply for a Visa and buy an air ticket.

Just a word or two about the English guy above. As I recollect he travelled to India with his brother or cousin who also had Atrial Fibrillation. On arrival they were both subjected to the elephants trunk 'camera' pushed down the throat which must be carried out before any ablation and unfortunately the brother/cousin was found to have some issue that cancelled any possibility of an ablation during that trip. This does appear to suggest the hospital were not just a money grabbing machine and took safety seriously. As I have mentioned many times the hospital, staff and equipment there was fantastic and 12 years down the line no doubt things will have only got better. NOTE: When I was there the top docs were Indian guys who had left the UK National Health Service for better money and conditions!!!!!!

Cheers, Barry G.



Edited 2 time(s). Last edit at 06/13/2019 12:08AM by Barry G..

Scanning through many of these posts, I am seeing that some people don’t feel the need to get ablation if your symptoms aren’t so bothersome and are controlled with medicine. I think that would be me, but I am on the list to get ablation. I do look forward to getting off the anti-arrhythmic & blood thinner, but other than that my afib is not heavy duty by any means. I was surprised to see people talking this way about ablation though and also waiting for further improvements before seeking it.

Quote
Madeline
Scanning through many of these posts, I am seeing that some people don’t feel the need to get ablation if your symptoms aren’t so bothersome and are controlled with medicine. I think that would be me, but I am on the list to get ablation. I do look forward to getting off the anti-arrhythmic & blood thinner, but other than that my afib is not heavy duty by any means. I was surprised to see people talking this way about ablation though and also waiting for further improvements before seeking it.

It quite depends on your situation. If your afib is longstanding persistent (meaning out of rhythm) or still paroxysmal, but progressing, the longer you wait, the more difficult a successful ablation becomes. Also you really need to be very selective about your ablationist and choose the very best you are able to access. If your afib burden is low because of an anti arrythmic med, lifestyle interventions or just good luck, then waiting is not as big of a deal. It also depends on your choices. People in afib 24x7 who have a well controlled afib rate (< 100 BPM) are comfortably asymptomatic and anticoagulated can live well. There are quite a few who choose this path.

George