Ablate or Wait?

Hi everyone! My situation: 63 year old female, in very good health overall (low b.p., low cholesterol, normal A1C, normal weight, eating right and exercising regularly, no alcohol, limited caffeine). I had one 30-hour incident of AF 1.5 years ago while on vacation, after a kidney stone (one and only), dehydration, and a couple of opioid pain killers were administered in the E.R. (No AF in the ER until AFTER I was given painkillers!) The backdrop was a very stressful period at work and recently diagnosed sleep apnea, which is now being treated.

This AF incident left me with frequent but brief bursts of atrial tachycardia (5-10 per day, most lasting 5 seconds or less), and some inappropriate sinus tachycardia (mostly during upper body exercise), so I stayed on metoprolol. My EP was not particularly concerned and suggested that I might not see any AF again for years. That held true until a couple of weeks ago when (with no trigger that I can identify) I caught a brief (about 2 minute) run of AF on my Kardia Mobile, which was confirmed by my EP. I have an appointment with her in a couple of weeks to discuss next steps.

So while I will of course listen to my EP's advice, I'm also seeking input from those of you with much experience than I have. I am not interested in taking anti-arrhythmic drugs. My inclination is to just nip this in the bud and have the ablation. I've been following forums and attending conferences (virtually), and from what I gather, ablation is now a first-line treatment, very safe, and tends to be easier and more effective if done early.

I imagine it sounds like I'm jumping the gun. I wonder that myself. But what would be the advantage to waiting? New mapping or ablation techniques may be developed, I suppose. But I'm not getting any younger, and I worry about the effects of being under anesthesia as I get older. (I saw what it did to an older family member!) Having this hanging over my head has been difficult psychologically--as you are all familiar with, I'm sure! I want it gone and out of my life, and it seems that ablation is my best shot at that, especially since I've already addressed all the lifestyle factors that I know of. Of course, with such infrequent episodes, you might well ask how I will know if the ablation was successful? I guess I might not know on the AF for awhile, but if my AT could be ablated I would definitely be able to see whether that worked or not. I wonder also if the AT may set off the AF (or lead to it, if it continues to increase in frequency), so ablating it might also head off AF?

I am also debating, if I choose to go ahead with it, where to have it done. I like my EP very much. Although I don't know if she is considered among the "elite" she has decades of experience and I trust her. I think I am a fairly simple case that might not require the best of the best? But...she doesn't do PFA (yet?), and I would like to take advantage of the higher safety profile that it offers. I am in a geographic area where I could fairly easily travel to Johns Hopkins (Hugh Calkins?) or possibly even Cleveland Clinic (any recommendations?). I know Natale is considered the best, but he does not take my insurance. I also know that I have time to reach a decision, and that is comforting. I would appreciate any thoughts. Am I missing or misunderstanding something? What would you do in my situation? Thank you in advance for any responses.

Your story is very typical. It's a progressive disorder, for some taking decades to get bad enough that it adversely impacts well-being. For me, and for many others, you go a year, maybe three, and you're looking for relief from an electrophysiologist.

Drugs work. Really well in many case. Then......................they don't. Another drug? Or.....an electrophysiologist....a really GOOD one, might mean years before you have another run of AF again. It seems that many ablations can provide several years of relief, and then they fail. But many stem AF for the rest of their owner's lives.

There are several cardinal rules about AF: AF begets AF. The longer you wait, the more complicated and intractable the disorder becomes.

So, before you're really behind the 8 ball, at least consult with a great EP now, get on his/her good books, and have an ablation waiting for you within a coupla weeks...if possible. Two months at most.

PFA isn't all it's cracked up to be. I believe it obviates a TEE, but that's about it according to the literature. If you're a simple PVI, great, why not. If you're more involved, and you WILL be in six/sight years, it will take more than PFA (as it is currently licensed and designed) to help you.

My 2 cents.

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Nancy9
I am in a geographic area where I could fairly easily travel to Johns Hopkins (Hugh Calkins?)

Years ago a member here got an ablation by Dr. C. I've not read the details in many years, but my recollection is that the doc was out of the room when a Fellow threaded the catheter. It ripped a valve and was life altering in a negative way for the patient.

One of a number of threads on the topic is here. The patient's husband wrote a book on the ordeal. The way the problem was handled after the fact was part of the issue.

One of the lessons is that in many teaching hospitals, "your" EP is not the one with their hands on the catheters. I know that in Natale's case, he does the procedure.

Wow, that is certainly sobering. I guess “Are you the person who will actually be doing the procedure?” needs to be asked in the consult.

Since Natale is not a possibility (due to not accepting my insurance), is there anyone you can recommend in the DC area? Or at Cleveland Cliniic, which I’ve heard is excellent?

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gloaming
So, before you're really behind the 8 ball, at least consult with a great EP now, get on his/her good books, and have an ablation waiting for you within a coupla weeks...if possible. Two months at most.

Who would you consider to be a great EP outside of Natale? Preferably in the DC/Baltimore/Cleveland area? I know to ask how many ablations the EP has done and their success rate (and how the define it), and to look at the Heart Rhythm Society’s list of Fellows, but was hoping not to just pick a name out of a hat. It’s not so easy to figure out who else is in the top tier with Natale. Any suggestions would be welcome!

In my case here in Alberta Canada my EP was slated to do my ablation and then an opening came up sooner by a fellow EP. I researched and asked both of them how many ablations they had done and would they be the one doing the procedure and not a student. Both EP's had 16 years experience and do about 100 ablations a year so that was 1600 ablations each.

I went with the earlier appointment and was very happy with the decision as I am now in NSR since June 11th this year so 5 months of blissfull NSR. Before the ablation I went into to AFib every night for 1/1/2 hours for over a year.

Ask questions of the EP they should be glad to answer.
Calvin

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calvin
In my case here in Alberta Canada my EP was slated to do my ablation and then an opening came up sooner by a fellow EP. I researched and asked both of them how many ablations they had done and would they be the one doing the procedure and not a student. Both EP's had 16 years experience and do about 100 ablations a year so that was 1600 ablations each.

I went with the earlier appointment and was very happy with the decision as I am now in NSR since June 11th this year so 5 months of blissfull NSR. Before the ablation I went into to AFib every night for 1/1/2 hours for over a year.

Ask questions of the EP they should be glad to answer.
Calvin

Thank you!

Pasquale Santangeli at Cleveland Clinic. He trained with Natale and has comparable skills.

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Carey
Pasquale Santangeli at Cleveland Clinic. He trained with Natale and has comparable skills.

Thank you--that's very helpful!

It is manifestly unethical for a professional to not seek your signed agreement to have someone other than the person consulted and who agreed to the intervention perform that intervention. It's so smarmy that the college ought to have been informed about that case.

It's pretty standard in teaching hospitals that fellows will likely do at least some of your procedure (that includes actual surgery). They can do that because fellows are already licensed MDs who have completed their residency, so they can do almost anything legally. The real fault in that case was the attending leaving the fellow unsupervised. You can't claim to be teaching someone if you're not in the room. I don't know what the legal outcome was but I imagine it was very expensive.

I ran across a couple of articles that may be of interest to others trying to decide whether to wait on their ablation--recognizing that it's a very personal decision and everyone's circumstances are a little different.


Diagnosis-to-Ablation Time and Recurrence of Atrial Fibrillation Following Catheter Ablation: A Systematic Review and Meta-Analysis of Observational Studies
[www.ahajournals.org]


Outcomes Just as Good With Delayed vs Early AF Ablation
[www.tctmd.com]

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Nancy9
Outcomes Just as Good With Delayed vs Early AF Ablation

I know you didn't write the headline, but that wouldn't be my take on the article at all. I'm not surprised that delaying ablation for a year doesn't increase mortality, but when you consider quality of life and afib recurrence it becomes a different story. If you read the first study linked in the article, you see that for every year of delay recurrence increased by 20%. Damn, that's huge. Frankly, I think that ought to be the headline.

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Carey

Outcomes Just as Good With Delayed vs Early AF Ablation


I know you didn't write the headline, but that wouldn't be my take on the article at all. I'm not surprised that delaying ablation for a year doesn't increase mortality, but when you consider quality of life and afib recurrence it becomes a different story. If you read the first study linked in the article, you see that for every year of delay recurrence increased by 20%. Damn, that's huge. Frankly, I think that ought to be the headline.

Agree. I posted them both because of their differences in point of view, for others to evaluate. I’m wondering if that 20% “rule” applies in the absence of actual afib episodes? I’m assuming that few to no episodes means little disease progression and more frequent episodes means greater progression? Or are there changes happening in the heart kind of behind the scenes irrespective of the number and duration of afib episodes?

Well, there's the old "afib begets afib" thing so more frequent episodes probably does mean greater progression.