Definition of "aggressive" when it comes to an ablation procedure

I've seen the word "aggressive" in this forum as it relates to describing this Doctor or that Doctor performing an ablation. Also, I seen the word used when describing the Doctors who have had the highest success rates as being "aggressive." Would someone please define the word aggressive in this context? Also, I've read in this forum that the Doctors who are more aggressive also have patients with more complications. It would be helpful to know what kind of complications. Thank you.

I would like to add my name to this request to. As someone who is considering ablation with Dr. Natale who has been described on this board as slightly more "aggressive" it is of interest to me too. Does aggressive describe thorough, or overdoing it, or somewhere in between?

I have always equalled agressive with burning deeper and longer.

After I had ablation No 2 in Bordeaux in which AF returned only an hour before leaving the hospital I was sat on the bed talking to Dr Haissaguerre about the AF returning. I asked what he had done and then I said why did you not do your full 5 step approach as I had travelled to France for a no-nonesense full slash and burn so it would be totally impossible for me to get AF again. Dr Haissaguerre said they only burn as little as possible rather than overdo the burning. I had ablation No 3 three days later for free.

Barry G.

One adverse event that may be associated with ablations in general (and overly-aggressive ablations, in particular) is that they have the potential to affect the ability of the atrium to contract (i.e., the mechanical function of the atria).

Dr. John Mandrola has several posts at his blog regarding this potential down-side of ablations. Here's a quote from one of his posts [www.drjohnm.org] :

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Dr Thomas Arentz (Germany) went over the issue of brain lesions after AF ablation. He mostly talked about PVAC, which as we know was associated with an excess of brain lesions. In the end, the significance of non-symptomatic brain lesions is unknown. Interestingly, he pointed out that other well accepted heart procedures, like coronary angiograms, are associated with brain lesions as well. He also showed a beautiful MRI image of a non-contracting left atrium in a patient who had multiple extensive left atrial ablations, which highlights the idea that aggressive ablation strategies have downsides.

In this same post, Dr. Mandrola also expresses his concerns about atrial contractability issues that might be associated with surgical ablations.

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As an AF ablationist, I am conflicted about surgical ablation. That said, however, though the upfront risks are greater with surgery, the success rates are encouraging. Worries about surgical ablation beyond the immediate risks include how well the atrium will contract. Remember, regular electrical rhythm is good, but you also want the atria to transport blood to the ventricle. Medical people call this the mechanical function of the atria.



Edited 3 time(s). Last edit at 04/04/2012 12:14PM by Buster.

Here's another quote from Dr. Mandrola's blog [www.drjohnm.org] :

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The second limitation stems from the fact that the researchers could not tease out the specific technique used to ablate AF. They knew a patient had AF ablation, but they could not tell whether (or what) additional ablation was done. Additional ablation beyond the standard PVI lesion set may be an important risk factor for complications and paradoxically, some believe, may actually lower the success rate. The best way to do AF ablation remains both unknown and hotly debated among leaders in the field. Questions like, when should right atrial flutter lines be made, should the SVC be isolated, should one look for extra-pulmonary triggers with adrenaline infusions, or in more advanced cases of AF, should additional lines be made, all remain unresolved.

Edited 1 time(s). Last edit at 04/04/2012 11:57AM by Buster.

Barry G. Wrote:
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> I have always equalled agressive with burning
> deeper and longer.

I always thought an "aggressive ablation" meant one that had many more burns than usual, i.e. a more extensive lesion set. I guess we really do need a definition here.

Bister

Buster,

Actually, there is no evidence that a successful ablation is associated with post-procedure impairment of left atrial function - quite the contrary.

[www.afibbers.com]

[www.afibbers.com]

Also, while Dr. Mandrola may have an interesting blog he is hardly one of the "heavyweights" as far as EPs dealing with afib are concerned. A MEDLINE search (of 21 million articles) turned up exactly one where Dr. Mandrola was listed as one of 87 coauthors. As far as ablation-related brain injury is concerned again a search of 21 million articles turned up only one dealing with ablation-associated brain damage (cerebral microembolism), so whether the danger is significant or not is obviously not a main-stream subject.

Hans

Hans,

Do you have any references to studies that have compared the effects on the mechanical function of the atria of vanilla PVI ablations versus aggressive ablations?

Buster

I've had 5 ablations and do regular hill\mountain?? hiking here in Hong Kong with a few guys in their mid 30s.

I have found that as long as I keep stopping now and again to pretend I am admiriing the view they can all keep up with me ;-)

There may be some merit in the brain lesions though as they all think I'm mad!!!!

Barry G. 62 going on 22.