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Ablation Decision Time
Posted by Bill B
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Bill B
Ablation Decision Time October 30, 2003 12:20PM |
Hello All,
I finally had my visit to Yale. I guess its decision time. The folks at Yale were very attentive. They spent 90 minutes with me. They answered every question and seemed in no rush to be rid of me. Because I have been spending about 50 percent of the time out of NSR since July, I had been concerned about ablation success. So were they. We discussed four options:
First, Dr. Clancy said I wouldnt like this, but I could go on Amiodarone for six months BEFORE I had the ablations (flutter and fib). He was concerned about remodeling, and that ablating the pulmonary veins would be insufficient if the atrium itself was out of sync. He said the Amiodarone was the best drug to get you into NSR, and only caused problems with extended use. Id be off it before that happened. He was right. I didnt like that option much.
Second, since I had better luck maintaining NSR when I was in FIB only, I asked if it would be a good idea to ablate the flutter first, go on flecanide, which put me in flutter before, for the six months and then ablate the fib. He thought that was a good plan. He also agreed there was a chance (a very slim one) the flutter ablation would fix the fib.
Third, they typically do focal point ablations, not PVI. The third option was a flutter ablation and a focal point ablation. I know that evidence on ablation techniques is mixed. I think Dr. Wharton does focal point ablations with great success. But I am not crazy about the idea. PVI seems to make more sense to me, and would mean a lot less time on the table. Dr. Clancy claimed a 70 percent success rate after the first ablation. He doubted the rates of others. In any case, he said, you can skew your numbers up by rejecting folks who were unlikely to be success stories.
Four, they are gearing up to do PVI ablations. I would be one of the first. I said I didnt like the sound of that. Dr. Clancy said it was not a great leap from focal to PVI. He made a convincing case that PVI was easier than focal point, and both used the same equipment. BTW, I got the feeling they were moving toward PVI ablations not because they thought they were better than focal point ablations, but because patients wanted them.
My other option here is to go to NYU and get the flutter and PVI ablations. Dr. Chinitz has done 100s (including Sammys). I met with him on October 10 and feel comfortable he would do a good job.
A factor for Yale is that it is my regular hospital, and both my EP and my cardiologist are affiliated with Yale. I DO feel aftercare would be better with Yale.
I have two primary issues to toss around:
One I accept the fact my atrium may need some positive remodeling (his term). Assuming the amiodarone worked (not a certainty, I fear), I wonder if there is an advantage to doing the remodeling before the procedure and not after it, by staying on the Norpace or going back to the flecanide.
Two - Is it NOT a great leap to go from focal point to PVI? Should I be worried they may be learning on my heart? Or is PVI, in fact, much easier than focal?
If Yale told me they had done 200 PVI ablations, I probably would have made appointment right then and there. Dr. Clancy seems like a good guy and he works with my regular doctors. But they havent done any PVIs. It makes things complicated.
I know a lot of you have done much research on ablations. Please offer your opinions. Thanks.
BillB
48;A;2000
I finally had my visit to Yale. I guess its decision time. The folks at Yale were very attentive. They spent 90 minutes with me. They answered every question and seemed in no rush to be rid of me. Because I have been spending about 50 percent of the time out of NSR since July, I had been concerned about ablation success. So were they. We discussed four options:
First, Dr. Clancy said I wouldnt like this, but I could go on Amiodarone for six months BEFORE I had the ablations (flutter and fib). He was concerned about remodeling, and that ablating the pulmonary veins would be insufficient if the atrium itself was out of sync. He said the Amiodarone was the best drug to get you into NSR, and only caused problems with extended use. Id be off it before that happened. He was right. I didnt like that option much.
Second, since I had better luck maintaining NSR when I was in FIB only, I asked if it would be a good idea to ablate the flutter first, go on flecanide, which put me in flutter before, for the six months and then ablate the fib. He thought that was a good plan. He also agreed there was a chance (a very slim one) the flutter ablation would fix the fib.
Third, they typically do focal point ablations, not PVI. The third option was a flutter ablation and a focal point ablation. I know that evidence on ablation techniques is mixed. I think Dr. Wharton does focal point ablations with great success. But I am not crazy about the idea. PVI seems to make more sense to me, and would mean a lot less time on the table. Dr. Clancy claimed a 70 percent success rate after the first ablation. He doubted the rates of others. In any case, he said, you can skew your numbers up by rejecting folks who were unlikely to be success stories.
Four, they are gearing up to do PVI ablations. I would be one of the first. I said I didnt like the sound of that. Dr. Clancy said it was not a great leap from focal to PVI. He made a convincing case that PVI was easier than focal point, and both used the same equipment. BTW, I got the feeling they were moving toward PVI ablations not because they thought they were better than focal point ablations, but because patients wanted them.
My other option here is to go to NYU and get the flutter and PVI ablations. Dr. Chinitz has done 100s (including Sammys). I met with him on October 10 and feel comfortable he would do a good job.
A factor for Yale is that it is my regular hospital, and both my EP and my cardiologist are affiliated with Yale. I DO feel aftercare would be better with Yale.
I have two primary issues to toss around:
One I accept the fact my atrium may need some positive remodeling (his term). Assuming the amiodarone worked (not a certainty, I fear), I wonder if there is an advantage to doing the remodeling before the procedure and not after it, by staying on the Norpace or going back to the flecanide.
Two - Is it NOT a great leap to go from focal point to PVI? Should I be worried they may be learning on my heart? Or is PVI, in fact, much easier than focal?
If Yale told me they had done 200 PVI ablations, I probably would have made appointment right then and there. Dr. Clancy seems like a good guy and he works with my regular doctors. But they havent done any PVIs. It makes things complicated.
I know a lot of you have done much research on ablations. Please offer your opinions. Thanks.
BillB
48;A;2000
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JRBabb
Re: Ablation Decision Time October 30, 2003 05:54PM |
Having just gone through the Ablation, and the focal pt. ablation, which my doctor uses along with a very concise mapping, I this point 1 week, 1 day, no afib, pacs at all.
But I am on all meds., Flecanide, topral and cardizem, which he indicated was needed for me. (He did 79 burns in the left atrial).
On the positive side also, meds. will be reduced ove the next 6 to 8 weeks.
48, afib for 30 years.
babb
But I am on all meds., Flecanide, topral and cardizem, which he indicated was needed for me. (He did 79 burns in the left atrial).
On the positive side also, meds. will be reduced ove the next 6 to 8 weeks.
48, afib for 30 years.
babb
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Re: Ablation Decision Time October 31, 2003 09:19AM |
Registered: 8 years ago Posts: 18,890 |
Bill B - I have a copy (courtesy of Lorraine) of a July 2003 Special Issue of the Cleveland Clinic Journal of Medicine - with the feature being "Managing Atrial Fibrillation: Focus on Nonpharmacologic Strategies"
Here is what it says about Amiodorone:
Actions: Amiodarone (A) was developed as an antianginal drug but was later found to have antiarrhythmic properties and was introduced in 1986. It is generally categorized as a class III antiarrhythmic, though it has properties of all four classes. "A" has a unique pharmacokineticts. It is highly lipid-soluble, and because a long time is rquired for adequate loading to saturate body lipids, drug levels build up slowly with repeated doses. Plus, the very large lipid stores act as a massive drug reservior when treatment is stopped, resulting in a very long elimination half-life (about 50 days.)
Safety: "A" is associated with a variety of adverse effects, including pulmonary fibrosis, corneal microdeposits, skin photosensitivity, gray-blue skin discoloration and reversible liver enzyme abnormalities. Central nervous system side effects ar relatively common and include anxiety, tremor,headaches, and peripheral neuropathy. Hypothyroidism also is relatively common. Although QT prolongation occcurs often, torsades des pointes is uncommon.
Role: Other than dofetilide, A is the only antiarrhythmic that has been found safe and effective in patients with moderate to severe left ventricular dysfunction. LIke dofetilide, A is a first-line agent for patients with AF and structural heart disease. It is also useful for patients with renal disease. Because of its potential for organ toxicity, we generally reserve amiodarone as a second- or third-line agent for other types of patients with AF.
Summary of drugs: For patients with AF and structurally normal hearts, the class IC agents, flecanide and propafenone, are first-line choices for maintaining sinus rhythm. Sotalol and dofetilide are also effective for this patient population. Because of its potential for organ toxicity, amiodarone should be reserved as a third-line option for these patients.
For patients with coronary artery disease and a left ventricular ejection fraction of 40% or greater, sotalol and dofetilide are the first-line agents. For patients with an ejection fraction less than 40%, dofetilide and "A" are the drugs of choice.
Because the Class IA agents are not as well tolerated as the Class IC and III drugs, they should be reserved as third-line agents for patients with AF.
Although many patients can be managed withdrug therapy alone, many others continue tohave symptoms related to AF despite optimal drug therapy. For these altter patients, nonpharmacologic therapies - the focus ofthe rest of this article - should be considered.
Bill - the rest of the article discusses ablation techniques and other subsections on management of afib.
If you would like a copy, I can arrange to send you that if you email me privately with your address.
I don't know if reading the article will help or just give you more consternation about what to do. The article on PVI is by some of the EP's at CCF including Dr. Natale.
On the Amiodorone issue, I'd just want to know for the short period of time you may be on it, what the consequences may be - based on reports and experience. It could be that it makes good sense to get the heart calmed down prior to ablation - enough so to give it every chance of success. It is my understanding based on many articles that the less irritated the heart cells are before ablation, the better the sucess. So if that's what it takes to keep you in NRS for a few months prior, then it could be a good choice. I'm only speculating.
Good luck with your decision. It's a dilemma for sure, but it sounds as if you have some good people there working with you so rely on them to do some thorough research for you...with copies of studies that you can examine.
Excuse any typing errors I may have missed. I'm on the fly these days!
Take care. Jackie
Here is what it says about Amiodorone:
Actions: Amiodarone (A) was developed as an antianginal drug but was later found to have antiarrhythmic properties and was introduced in 1986. It is generally categorized as a class III antiarrhythmic, though it has properties of all four classes. "A" has a unique pharmacokineticts. It is highly lipid-soluble, and because a long time is rquired for adequate loading to saturate body lipids, drug levels build up slowly with repeated doses. Plus, the very large lipid stores act as a massive drug reservior when treatment is stopped, resulting in a very long elimination half-life (about 50 days.)
Safety: "A" is associated with a variety of adverse effects, including pulmonary fibrosis, corneal microdeposits, skin photosensitivity, gray-blue skin discoloration and reversible liver enzyme abnormalities. Central nervous system side effects ar relatively common and include anxiety, tremor,headaches, and peripheral neuropathy. Hypothyroidism also is relatively common. Although QT prolongation occcurs often, torsades des pointes is uncommon.
Role: Other than dofetilide, A is the only antiarrhythmic that has been found safe and effective in patients with moderate to severe left ventricular dysfunction. LIke dofetilide, A is a first-line agent for patients with AF and structural heart disease. It is also useful for patients with renal disease. Because of its potential for organ toxicity, we generally reserve amiodarone as a second- or third-line agent for other types of patients with AF.
Summary of drugs: For patients with AF and structurally normal hearts, the class IC agents, flecanide and propafenone, are first-line choices for maintaining sinus rhythm. Sotalol and dofetilide are also effective for this patient population. Because of its potential for organ toxicity, amiodarone should be reserved as a third-line option for these patients.
For patients with coronary artery disease and a left ventricular ejection fraction of 40% or greater, sotalol and dofetilide are the first-line agents. For patients with an ejection fraction less than 40%, dofetilide and "A" are the drugs of choice.
Because the Class IA agents are not as well tolerated as the Class IC and III drugs, they should be reserved as third-line agents for patients with AF.
Although many patients can be managed withdrug therapy alone, many others continue tohave symptoms related to AF despite optimal drug therapy. For these altter patients, nonpharmacologic therapies - the focus ofthe rest of this article - should be considered.
Bill - the rest of the article discusses ablation techniques and other subsections on management of afib.
If you would like a copy, I can arrange to send you that if you email me privately with your address.
I don't know if reading the article will help or just give you more consternation about what to do. The article on PVI is by some of the EP's at CCF including Dr. Natale.
On the Amiodorone issue, I'd just want to know for the short period of time you may be on it, what the consequences may be - based on reports and experience. It could be that it makes good sense to get the heart calmed down prior to ablation - enough so to give it every chance of success. It is my understanding based on many articles that the less irritated the heart cells are before ablation, the better the sucess. So if that's what it takes to keep you in NRS for a few months prior, then it could be a good choice. I'm only speculating.
Good luck with your decision. It's a dilemma for sure, but it sounds as if you have some good people there working with you so rely on them to do some thorough research for you...with copies of studies that you can examine.
Excuse any typing errors I may have missed. I'm on the fly these days!
Take care. Jackie
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Re: Ablation Decision Time October 31, 2003 09:48AM |
Registered: 8 years ago Posts: 18,890 |
Bill - I just typed a lengthy report to you and I could have just gone online - I found the entire article at this address:
[www.ccjm.org]
Lots of current and informative stuff here. Happy researching.
Jackie
[www.ccjm.org]
Lots of current and informative stuff here. Happy researching.
Jackie
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Sammy
Re: Ablation Decision Time October 31, 2003 10:27AM |
Bill,I can understand your confusion about which way to turn at this point.I know we`ve spoken one to one already but if can add my 2 cents worth... I personally would have a hard time knowing that I was the first of ANY procedure.Even if focal point is similar it still would scare me...As far as Amiodarone goes,any research I did into that drug scared me silly.I remember my doctor writing out the prescrip and after I read about what it can do to your eyes etc. I ripped up the paper.I know that all meds have side effects but that one seems a little more extreme...I did tell you that the post procedure after care from NYU was lacking and it`s absolutely true but,for me anyway I`m convinced that I have been cured under the hands of Dr. Chinitz..I think that unless you`re comfortable making more of your own decisions post op, NYU is a reasonable choice.I`m not trying to convince you to go there and I have nothing to gain by recommending anyone to them but at about 10 weeks post procedure I have my life back(not without some setbacks along the way.) At least you`re not in permanent AF... 50% of the time might give you a better shot than someone who is always in flutter or fib...Living closer to Yale and having it as your regular hospital is comforting due to the fact that you`ll be 75? miles away if you go to NYU...So,I wish you the best in your decision even if I made it more confusing........It aint easy trying to decide these things my brother...
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Bill B
Re: Ablation Decision Time October 31, 2003 01:19PM |
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Yypo
Re: Ablation Decision Time October 31, 2003 01:56PM |
Focal-point ablations are passe. Your practitioner's skepticism about Pappone"s and Natale's published results (do your homework) sound like old-fashioned rationalization for not having embraced the newer more effective technique.
The real success rate of focal-point is much closer to 50% than 70%.
If I were you, I would go to the CCF for a second opinion. Don't let theprospect of an airline trip intimidate you from making the optimal choice.
The real success rate of focal-point is much closer to 50% than 70%.
If I were you, I would go to the CCF for a second opinion. Don't let theprospect of an airline trip intimidate you from making the optimal choice.
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Newman
Re: Ablation Decision Time October 31, 2003 03:33PM |
Bill B.,
If you want the best chance to cure your AFIB with one ablation, you need to do the following:
(1) Have a PVI. 90% of the bad signals come from the pulmonary veins. A properly performed PVI will probably cure you. An ablation without a PVI will probably fail. The best results today are coming from the centers that do PVIs. Most EPs that do the PVIs also do some mapping during the ablation, and ablate other problem areas as well. So you get the best of both worlds.
(2) Go to an EP that has done hundreds of PVIs. Much experience is crucial in success. Don't be a guinea pig unless you are a masochist and love hospitals.
(3) Do not have an ablation unless the EP uses an ICE (Intra Cardiac Echocardiogram). This is like a television camera in the heart, and it has improved success rates greatly. It allows for precision.
(4) Go to South Africa if necessary to find the best center and EP. Selecting a center and an EP because of proximity to where you live is, to put it bluntly, stupid. Do you want to get cured or not?
(5) Get a second opinion from someone who has done a lot of PVIs.
(6) Get that second opinion at the Cleveland Clinic.
You can take these suggestions to the bank!
Newman
If you want the best chance to cure your AFIB with one ablation, you need to do the following:
(1) Have a PVI. 90% of the bad signals come from the pulmonary veins. A properly performed PVI will probably cure you. An ablation without a PVI will probably fail. The best results today are coming from the centers that do PVIs. Most EPs that do the PVIs also do some mapping during the ablation, and ablate other problem areas as well. So you get the best of both worlds.
(2) Go to an EP that has done hundreds of PVIs. Much experience is crucial in success. Don't be a guinea pig unless you are a masochist and love hospitals.
(3) Do not have an ablation unless the EP uses an ICE (Intra Cardiac Echocardiogram). This is like a television camera in the heart, and it has improved success rates greatly. It allows for precision.
(4) Go to South Africa if necessary to find the best center and EP. Selecting a center and an EP because of proximity to where you live is, to put it bluntly, stupid. Do you want to get cured or not?
(5) Get a second opinion from someone who has done a lot of PVIs.
(6) Get that second opinion at the Cleveland Clinic.
You can take these suggestions to the bank!
Newman
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Re: Ablation Decision Time November 01, 2003 05:02AM |
Registered: 8 years ago Posts: 18,890 |
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