Impact of timing on AF ablation success/failure

This is data from the Intermountain hospital group covering a wide area around Salt Lake City.

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Article in Press
Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes☆
T. Jared Bunch, MDemail address, Heidi T. May, PhD, Tami L. Bair, RN, David L Johnson, PAC, J. Peter Weiss, MD, Brian G. Crandall, MD, Jeffrey S. Osborn, MD, Jeffrey L. Anderson, MD, J. Brent Muhlestein, MD, Donald L. Lappe, MD, John D. Day, MD
published online 22 May 2013.
Accepted Manuscript

Abstract PDF
Abstract
Background
Many patients who develop atrial fibrillation (AF) will experience a worsening of their arrhythmia over time. The optimal time to proceed with catheter ablation during the disease course is unknown. Further, it is unknown if delays in treatment will negatively influence outcomes.

Methods
A total of 4,535 consecutive patients who underwent an AF ablation procedure that had long-term established care within an integrated health care system were evaluated. Recursive partitioning was used to determine categories associated with changes in risk from the time of first AF diagnosis to first AF ablation: 1:30-180(n=1,152), 2:181-545(n=856), 3:546-1825(n=1,326), 4:>1825(n=1,201) days). Outcomes evaluated include 1 year AF recurrence, stroke, heart failure hospitalization, and death.

Results
With increasing time to treatment, surprisingly patients were older (1: 63.7±11.1, 2: 62.6±11.8, 3: 66.4±10.2, 4: 67.6±9.7, p<0.0001) and had more hypertension (1:53.0%, 2:59.0%, 3:53.8%, 4:39.0%, p<0.0001). For each strata of time increase, there was a direct increase of 1 year AF recurrence (1:19.4%, 2: 23.4%, 3:24.9%, 4:24.0%, p-trend = 0.02). After adjustment, clinically significant differences in risk of recurrent AF were found when compared to the 30-180 day time category: 181-545: odd ratio(OR)=1.23, p=0.08; 546-1825: OR=1.27, p=0.02; and >1825: OR=1.25, p=0.05. No differences were observed for 1 year stroke among the groups. Death (1:2.1%, 2:3.9%, 3:5.7%, 4:4.4%, p-trend=0.001) and heart failure hospitalization (1:2.6%, 2:4.1%, 3:5.4%, 4:4.4%, p-trend=0.009) rates at 1 year were higher in the most delayed groups.

Conclusions
Delays in treatment with catheter ablation impact procedural success rates independent of temporal changes to the AF subtype at ablation.

Keywords: catheter ablation, arrhythmia, atrial fibrillation, stroke, heart failure, outcomes, death

That's all greek to me. Can anyone decipher it?

Link to the above, please. Can't find it in PubMed.

"With increasing time to treatment, surprisingly patients were older"
This is a surprise? Sarcasm?

PeggyM

Anyway. these patients were not lone afibbers i bet.

PeggyM

It may be that in some cases, sooner is better for ablations but based on my history, waiting didn’t seem to interfere with the success of the procedure once I gave in to it eight turbulent years after the onset.

I recently wrote the following to an afibber who asked for my history:

..." My AF history – 8 years of escalating events starting with one event in 18 months (age 59), then 2 a year, then 3-4 a year and in years 7 and 8 increasing until every day or every other day… often lasting 24 – 27 hours… NSR for 4 hours and then back in AF for another 24. Because I had been mislead in the past about the need for other surgical procedures rather than addressing the core cause, I was determined not to make another mistake. Reluctantly, I consulted for an ablation thinking I was progressing to “permanent” and had no quality of life at that point. My only other health issue was longstanding hypothyroidism which never seemed to be fully addressed in spite of the test numbers being “normal.”

I was given an ablation date 6 months out and since I never, ever wanted an ablation, I decided to do everything possible as a last ditch effort to avoid the ablation. These heroics included homeopathy, acupuncture, chiropractic and increasing doses of the core AF supplements including proteolytic enzymes. Nothing seemed to make much of a difference until I had the chiropractic adjustment for the stomach/diaphragm area. Then everything changed. This was apparently an irritated vagus nerve which, once out of the line of fire, calmed down and was no longer a trigger. I was also doing heroics with magnesium, potassium and taurine.

In a matter of weeks, I went from daily AF to zero events, but was still on 150 mg flecainide BID. My next goal was to wean slowly off Flec and did so for two months by shaving off portions of the pills until virtually nothing remained but a crumb. I then had a significant rebound which required only 50 mg to maintain NSR until the ablation date. I was tempted to delay the date to give weaning off more time but my insurance situation was not solid so rather than risk that complication, I had the Natale ablation in 11/03.

At 103 days post ablation, I had AF breakthrough which was electro-cardioverted. No other AF until year 4 when I had two breakthroughs which were easily converted back to NSR with the PIP protocol. Then, more AF biannually 6 – 9 months apart in years 4, 5, and 6.

Hindsight reflection on those breakthrough years led me to realize that I had become lax in making sure I had the daily core nutrients in place without fail… so I shored up those and added d-Ribose, more carnitine, Ubiquinol form of CoQ10 in substantial doses and focused on pH and alkalinity faithfully. I became a student of energy medicine techniques and practiced grounding or Earthing as a way to replace missing electrons that helped optimize cellular voltage.

Then, last summer, Lyme disease was diagnosed in year 9 post-ablation (now age 76) and with aggressive treatment, all hell broke loose and I had dramatic, turbulent AF… 9 events in 16 days and 1 electrocardioversion. A nightmare of a situation. Back on heart meds for 3 months. I saw three EPs (another long story) all of whom thought I’d need the second ablation since mine was done “so long ago” with the older technique.

I stopped the aggressive Lyme treatment and focused on calming my heart once again with extra emphasis on pH and voltage. And once again, I weaned off heart drugs and maintain NSR. At the last EP visit, I was down to 50 mg flecainide daily and he said… “Well, it’s not the drug.. that amount is virtually nothing. Your heart is doing it all by itself…it’s rock solid and the ECG looks perfect. When do you want to see me again… I said how about 6 months?” That was December, 2012.

My personal observation is AF is a result of a waning supply of critical nutrients and balances plus interferences that keep the heart energy (voltage) from being optimal. Inflammation is a huge contributor as is acidic tissue pH and the subsequent low-voltage factor which has been discussed frequently in other threads. In my case, when imbalances become dominant, I get AF. Others may manifest in different chronic ailments or diseases such as hypertension, cancer and neurodegenerative diseases. Since more afibbers are diagnosed at earlier ages, the nutrient deficiencies and environmental influences are coming into play more frequently than in previous years... indicating once again getting to the core causes is an important consideration. AF is the canary in the coal mine that systemic imbalances interferring with appropriate neurological conduction are present. "

Jackie

Jackie, WOW, thanks for your story. I will do a good search on what I am doing because of it ....ron

Delaying and procrastinating while waiting for some future
or natural cure may not be the logical and best decision.....
And I almost paid dearly for it with a TIA!



Edited 1 time(s). Last edit at 05/26/2013 04:14PM by McHale.

Frequently, you can't get the whole story from the abstract of a journal article. You need to read the entire article.

It's hard to tell what the import of this is.

Jackie - I've known your story, but not the more recent events you've just described. Thank you for sharing all of that. I plan to keep this for my "files", so I can follow your guidelines if I end up in a similiar situation. As you know, I've been on again, off again, on the ablation decision. But I have had more breakthroughs lately - all tolerable - the longest one lasting 14 hours, most last just 1-3 hours..so I am rethinking that it might be wise to seek our Dr. Natale.

I am still curious as to just what the chiropractor did. I mentioned this adjustment to 2 different chiropractors, and neither seemed to know quite what I meant...and neither did I, really. Just tried to tell them what I thought you meant. Can you please clarify that procedure for us?

Sorry to hear you've had some recent problems, but glad you have also been able to beat this beast back down.

You are an amazing role model and weath of information for us all. Thank you for being on here to help the rest of us. ~ Barb

Barb,
Don't wait too long as the line is starting to go out the door down Amsterdam ave..............



Edited 1 time(s). Last edit at 05/27/2013 08:02AM by McHale.

Barb,

This link will show you a Chiropractor doing this adjustment on a patient and how to do it on yourself.

One thing I would suggest is that you may find it easier to do while lying down. Total relaxation of the abdomen can be quite difficult in the seated position.

Sam

<www.youtube.com/watch?v=8lurmmWObB8>

Sorry, that link doesn't seem to take us to the video. Enter Maneuver for Hiatal Hernia Type Symptoms in Google and you should get it.

Chiropractic was one of the first avenues my doctor took me down. The Chiro she is associated with is specially trained in neuro chiropractic from a school in California and is one of only a few with her speciality in Canada. While she was going through the assessment and adjustments she had lots of consultation with her teachers and mentors. At the end of the day she determined there was nothing she could do to help my afib. It was worth a try.

In my original Calming My Heart (12/04) report about my initial chiro treatments, I wrote:

...." I began NET treatments (Neuro Emotional Technique) which includes Applied Kinesiology, with Dr. Jordan the first of July '03 (having wasted far too much valuable time with the other approaches) and saw him twice a week for about six weeks.

Various conditions were discovered and addressed through NET wherein locked emotional responses called Neuro Emotional Complexes (emotional reality) are detected with reflex responses or patterns…much like the Pavlov-dog response. Negative emotional responses (either conscious or unconscious) can manifest as symptoms and the result is ill health and imbalance. Neuropeptides carry emotions throughout the body. NET seeks to normalize neurological imbalances using physical corrections and removes the blocks to the body’s natural healing process.

One very significant finding was a displaced diaphragm that was causing hiccoughs that set off afib immediately. Once the diaphragm was repositioned and it held in that position (about five treatments), I no longer triggered afib in that manner. Hiccoughs are a spasm of the diaphragm and, attributed to magnesium deficiency.

Concomitant with that, Erling Waller, who had previously attempted to get me to understand the importance of magnesium deficiency by sending me very convincing evidence on the subject, began again to hammer away at intractable magnesium deficiency. All the while I thought I was taking enough magnesium…400 mg. a day plus that from my food. I continued to read the data.

Finally, I had a revelation based on a posting from Carol on the BB saying she increased her magnesium up to 800 or 1,000 mg daily and had stopped her afib. I tried increasing gradually while I was getting the emotional energy work from Dr. Jordan. After the first session, I went 5 days without an event. This was a record. Then, I went a week, then 13 days and by the end of August… breakthrough arrhythmia was not a common occurrence. If it happened, it was short…sometimes 2 hours or less. Previously, I was always afibbing for around or over 20 hours. The record was 39 hours before converting on my own.

In my case, Erling was right about magnesium deficiency. My magnesium glycinate dosage was at 800 mg. daily. I also made a conscious effort to use only unsoftened water for drinking and cooking. While I have a well with hard water and a separate spigot in another area for unsoftened water, I admit to frequently being lazy and just using what was handy. After reading that water softened with sodium (either well water or municipal water) removes magnesium and calcium, I resolved not to use the water produced from our in-house softening system and to take 100% advantage of our naturally occurring spring water. " Complete report: [www.afibbers.org]

Since 2004, I’ve refined my daily protocols considerably and drink the Waller Water as my only source of water because I'm diligently focused on tissue alkalinity and how that impacts heart energy.

Additonally, my current chiropractic treatments( which are hugely different from previous) now focus on balancing the ANS through a spinal alignment technique (subluxation) which is a highly-specialized area of chiropractic treatment evaluated by Subluxation Station scan technique called Insight™ Millennium that detects areas of nerve disturbance. The focus is to make sure that neither the sympathetic or parasympathetic nervous system varies too much past the central or normal-range area and uses the Directional Non-Force Technique ™ that measures electrical current of muscles as it relates to spinal alignment. When an abnormal position or movement of the vertebrae disturbs communication within the Central Nervous System, a disturbance occurs in the body.

I believe the founder of this system is located in Toronto. He teaches workshop classes in the US and my DC is now one of his instructors. The technique is not at all similar to any chiropractic treatment I’ve ever experienced … and I’ve experimented with a lot of chiropractic over the last 20+ years.

Hopefully, someday, this technique will become commonly available in all chiropractic settings. It's an amazing development. My DC (Dr. S) often shares success stories and a recent one involved a six-week old infant who had been crying non-stop from birth... not much sleep in that family. The parents were referred and drove a couple hours; arrived with the crying infant.... and after the treatment/adjustment which is about 15 minutes, the child stopped crying, smiled and slept all the way home. Dr. S. showed me before and after photos from her cell phone camera...and said, often the trip down and out of the birth canal is tortuous and when there is subluxation, situations such as this child can be the result. The pediatricians were unable to help.

Jackie


www.subluxation.com

Wow - thanks all for your replies. I have one big toe heading in that direction, McHale! I am anxiously waiting to hear from you after you have your ablation - did you say it's THIS Wednesday? If so, that was quick! Please get back to us before and after so we can cheer you on and be there to support you in your recovery.
Thanks for the link, Sam - I will look at that tomorrow (starting to fall asleep..bedtime now)..but thank you.I'm definitely a "visual person", so this should help.
I know we all have different results and different experiences in our Afib journeys, but I do appreciate hearing them all. Thank you Jackie for clarifying your chiropractic experience. Also a good reminder on the magnesium.

Good night all ~ Barb

McHale, Best of luck to you. Keeep up posted on the details. Dennis

RonB - sorry for all the technical jargon and symbols and no glossary to go with them. For starters, the first group of numbers are Days, N= number of people in the group and P= probability that something is NOT random. Let me know what other questions you have. I like the study because it is the same group of ablation specialists and they have a very good reputation so the study applies if you live around Salt Lake City and belong to the Intermountain healthcare system. If you live elsewhere and have numerous choices of EP specialist, then the other important factor is who you choose to do the ablation.

The link is below. Full article is available for members or pay-for-view,

[www.heartrhythmjournal.com]

Researcher,
Thanks for all your help in helping me make my decision!



Edited 1 time(s). Last edit at 06/01/2013 12:02PM by McHale.

The groups studied above may have had other heart health risk factors and may not be representative of lone afibbers. Quite a bit of hypertension is reported in the abstract.

researcher, can you copy and paste relevant selections from the paper?

No doubt. These were consecutive patients. There was no screening for other health issues, interrelated or not. I think I am limited to 300 words so I will try my best to cut and paste discussion(s). I visit Utah a lot and I would say in general that the population there have relatively healthy habits and get their exercise.

Sorry for not getting back to you sooner. PM me your email address and I will send paper. The entire discussion is germain so I find it hard to pick and choose what to cut and paste.

McHale, Great to hear that you are doing great post procedure and that it went like a breeze. Hopefully, the results continue long term for you.

Article made it to the current issue of Heart Rhythm Journal as featured article with editorial comments.