Post second Bordeaux ablation

For a bit of history I have had afib for over five years, starting with a few events per year and increasing over time until I had a rapid increase of events this year to daily or multi events per day. I was always self terminating within 24 hours. I had sinus bradycardia - a very low resting heart beat - and as a result, and contrary to what some cardiologists will say, I was not a good candidate for antiarythmic drugs, and so refused them.

My second ablation two days ago in Bordeaux was markedly easier than the first one. The first ablation was on June 3rd, five weeks ago. Within seven days I had my first attack and returned to the ER at Bordeuax so I could have it recorded and it was also converted with flecanide after three hours. A week later I had another, and then they came at three day intervals with a duration of up to ten hours for a total of six events within the five week period.

During this time I stayed in France and in contact with Pr. Jais (professor is one level up from doctor). As we were getting ready to depart for the airport for our return trip home on July 1, Pr. Jais made a decision that I should come in for a second ablation.

During the time leading up to the ablation, I continued to second guess myself as to whether it was necessary.

I also beat myself up over what I could have done differently. Travelling and eating in restaurants is not the best for your system at any time, especially when recovering from heart surgery.

On Monday we checked back in to the Hopital Haut Levesque in Pessac, just outside of Bordeaux. The condition of the hospital grounds and hallways was no less shocking the second time around. In my world of commercial real estate this is called "deferred maintenance". The wall paper is pealing to say the least. However once a person penetrates that cloak you find a beehive of concerned and professional care givers. The nurses in the ward swarmed me with tests and comfort. Once in the operating theatre and Pr. Jais took over I felt that I was in the hands of the best.

The food situation however is beyond pathetic. This time we did bring a bag of our own food. All we could do when they delivered the meals was laugh, because the only other option is to cry. As my dear and supportive wife says, they get much better food in prison.

At Haut Levesque the procedure is done under a local anaesthesia for the puncture and under a partial anaesthesia for the operation, which means I was awake enough to watch the proceedings and hear what was going on. Pr. Jais filled me in on the details immediately after the proceedure while still on the table. He found this second ablation to be absolutely necessary. One vein required extensive ablating and two others required two burns each.

In discussing my condition with him later, and of course continuing to beat myself up for not treating my recovery more carefully, he said there was nothing I could have done that would have prevented this. That it is impossible at the time of the original ablation to see this type of reconnection.

He has hope that the ablation is now complete, and has asked me to have a holter with a duration of at least a week in one months time. If there is no further afib I can eliminate the Xeralto at that time.

My own challenge will be to eliminate the Nexium. While I have been using it the past two weeks I have had no indigestion issues or the ensuing afib, so it has been effective. Such drugs are a double edged sword and I hope to find a way to a peaceful GI without them.

Right now I am early, early in the recovery after surgery. We have a train to take to the beach where I plan to move very little for the next four or five days until we fly home.

I feel no pain whatsoever in the heart region. This is so different from the first ablation where I experienced noticeable discomfort for at least three weeks.

I am feeling strain in the groin area of the insertions and it has me a bit concerned. I hope it is ok and will be moving very slow.

The condition of the hospital here would make it hard for me to give a wholehearted recommendation. As time passes of course we will eventually have EPs throughout Canada who are highly experienced. At this time I would have had no control over which doctor would have done the proceedure in Alberta and they would have had much less than 1000 procedures under their belt. In fact it could have been a beginner. So if I had to make my decision again today I would still choose Bordeaux.

The initial cost was about $15000 for the first procedure.

The second procedure cost about $6000 including a second fee to the doctors,

Extra days of hospital stay are around $4000 as they have just increased fees as of July 1st.

I'm not sure how that stacks up for a foreigner going to Dr. Natale. If the fees are about the same, I would hesitate to go to Bordeaux because of the extra travel time, but more than that, I fear their blatant lack of building maintenance is spilling over into their equipment.

Today I have a content feeling of well being. I hope it continues and the beast is put to bed. I would not hesitate to go for another ablation if it rears its ugly head again.

I am committed to watching my lifestyle carefully, to continue monitoring my potassium and supplementing with magnesium and other supplements. Booze and coffee are pretty much a distant memory in my life, as is excessive exercise.

If anyone is on their way to Bordeaux they can send me a PM and can fill you in on hotel and travel details. Linda would be happy to communicate her experience as a spouse and advocate on this journey.

RonB

Good news Ron, and thanks for all the good detail and insights from your experience, now things can settle in and you'll be feeling good before you know it..

Reconnected PVs can do it for sure, and it is true as Prof Jais said that its nearly impossible to predict who will have reconnected PVs during the initial ablation as all the PVs are confirmed to be disconnected before they finish the PVI.

While all EPs, even among the best like Prof Jais, have some percentage of PV reconnections with all the incredibly variable PV anatomy they encounter from one person to the next, the most elite operators tend to have dramatically less PV reconnects found whenever a touch up is needed.

This is especially true for those Docs who seem to have 'the touch' inherently in addition to all the expertise that doing thousands of these will grant in terms of fine tuned muscle memory and learned dexterity improvements over time.

Those relatively rare top guns who are blessed with that kind of innate talent with a catheter that is only refined and brought out more with accumulated vast experience, tend to have far lower percentage of PV reconnects on repeat ablation than otherwise very experienced ablationists who simply lack that degree of natural 'feel' . In other words, while many can become very proficient at doing ablations with knowledge and practice, there is a level of skill that just cannot easily be taught or acquired in the absence of the 'gift' part of the equation.

Much of the improvement in catheter and technique development has been geared toward minimizing this gulf between the natural super stars and the majority of very good EPs who simply may not have been so fortunate in the 'maestro' genetic roulette department.

Having that 'just right' instinctive touch when an EP is controlling by feel and tactile feedback as much as with technical feedback from EP mapping, in real time, as they move the catheter tip from one spot to another along these parts of a continuously variable left atrial wall thickness ... In a beating heart no less... and know instinctively how much pressure to maintain and for just how long at each spot and do so with real consistency is as much art as it is technical know how.

The efforts that are starting to bear some fruit with contact force catheter development will hopefully improve this efficiency and the transmurality of ablation burns that a far greater number of otherwise excellent EPs can start to achieve on a consistent basis. But until that technology is refined and ready for prime time, there will always be a special premium placed on doing everything one can for going to the best ablationist one can find .. in truth there will likely always be a strong incentive for chosing the best you can for yourself as the people with innate talent will also further benefit from continued improvements in catheter and imaging methods. And yet, even still, there will be some percentage of reconnected PVs just from the complex nature of the beast, regardless of who does the work...

Looking at the Univ of Penn studies and a few orher groups as well, they find around 95% of those needing reablation have reconnected PVs. In contrast, the really top guns with 'the touch' tend to have dramatically less PV reconnects and more often find new sources as the main reason for needing followup ablation.

Time to take it easy and enjoy resting at the beach in France these last days you are in Europe. I bet you will be thrilled to get back home to your own biome as well! Have a safe uneventful journey Ron.

Shannon



Edited 2 time(s). Last edit at 07/10/2013 02:52PM by Shannon.

Wishing you the best, Ron.

Shannon, please say Steven Hao, who did my procedure, is among those elite ablationists!

______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.

Ron - I am relieved to read your report and learn all went well for you in spite of your misgivings about the hospital environment there. You are much more tolerant than I would be in a foreign country and out of my comfort zone including my budget.

Relax and enjoy a leisurely recovery. Glad that is behind you. and you'll be able to get back to your regular, healthy eating and lifestyle.
Best to you,
Jackie

Ron,

I hear you on the one limitation of Bordeaux... besides the long travel ... that being the facilities. As a state run entity, I'm afraid a lot of cutbacks like that have been happening all over France and Europe for that matter. While the EPs are great and the support staff are courteous and well trained as well, I can imagine they don't get all the goodies they might wish for. Have often wondered if their not using ICE imaging as well was a cost decision, since a very capable EP can certainly do a fine ablation without the extra benefits of what ICE can bring in an ablation? But it does offer some real advantages.

In any event, for 15,000 Euros including the room costs, that is a bargain no matter what the currency and so something has got to give at some point and I guess the facility maintenance is the place they chose to absorb the hit on their budget?

Once you are on the table though, you are in good hands there, for sure.

Shannon



Edited 1 time(s). Last edit at 07/10/2013 02:17PM by Shannon.

Hi Iatrogenia,

I've heard good things about Dr Hao, and know he has trained with the best in Dr Natale. But I dont have a running list of all those who by consensus are deemed to have got 'the touch', so to speak. The only one's that I have heard about consistently in that light are, foremost, Dr Natale, who several EPs who have worked with him have told me personally how amazed they were at that aspect of his talent and that being what really sets him apart. But, also I heard a number of times similar stories about Drs Schwiekart and Pinksi as well. And of course, Prof's Haissaguerre and Jais too in Bordeaux from all reports. Dr. Boersma in Holland is also highly respected for his skill with a catheter as well.

I know from my own experience in meeting with Prof. Haissguerre in 2008 as well as Dr. Natale so many times since then, that they both share that something special in terms of a quiet calm demeanor and supreme confidence, and also understated humility, that only comes from really knowing your stuff and having the 'right stuff' as well.

No doubt there are a good deal more out there with real talent, in addition to all that they have learned, that I am simply not aware of. Dr Reddy in NYC too is an up and coming EP in this field. Also, I know Drs. Gallinghouse and Burkhardt as well as Luigi DiBiase .. all three out of Austin and also trained with Natale, are very highly regarded. Chinitz too in NYC has a good rep for quality ablations and Callan at Penn.

But where any of these men fall on the true 'maestro meter' with the bar set by Natale, Haissaguerre and Jais I simply could not say.

The main thing is that you are doing well Iatrogenia and Dr Hao may very well have exceptional innate skills in addition to the strong experience he has developed in his own right as well as under the guidance of Dr Natale over the years.

Just keep in mind, this is a challenging profession and it is a PROCESS!! Do not at all be discouraged if you might have to do another touch up at some point to lock things down for the long term. That frequently happens, even with the top guns. The advantage with going to the best is that they are fully capable of dealing with whatever might arise in one's ablation and give the best chance for the fastest path for you to long term NSR, whatever that might require in any individuals case.

A guy like Natale, for example, is far more likely to get you to the finish line with the minimal number of ablations needed than a man with much less experience and less innate talent with a catheter. But that in no way means it still might not take two procedures, and more rarely even a third procedure, for final touch up to be done for the long haul. But it does mean your odds of needing a 3rd, 4th, 5th or 6th procedure .. ad infinitum ... are dramatically less with a true elite ablationist on your team. Equally important, your odds of having a real screw up are almost nil with a true top gun.

The complexity of AFIB and all the factors that can complicate one's picture, including all the other aspects of one's health, or lack there of, that one brings to the ablation table just make it impossible for everyone to expect to be 'one and done', no matter who does the procedure.

If you have anything beyond the most basic case of paroxysmal AFIB with little to now scarring present in the left atrium, the best mental perspective is to assume two ablations will be needed and then just enjoy the big bonus if you turn out to be 'one and done'. That is the most realistic and best approach for how to walk through this 'process' with the calmest mind and appreciation for what each step does mean as moving you that much closer to the goal.

Shannon



Edited 3 time(s). Last edit at 07/10/2013 02:56PM by Shannon.

Iatrogenia,

Dr. Hao has an excellent success rate. You can find a listing of "elite" ablation EP's in my 2008 Ablation/Maze survey [afibbers.org].

They can only have gotten better since then.

Hans

Thanks, Hans.

The CPMC group is now claiming a one-year success rate of 78% for the first procedure, greater than 90% for the second should it be needed.

Dr. Hao told me his yearly reversion rates are in the low single digits, much less than the 7% per year reported in the literature.

______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.

Those are solid believable numbers out of CPMC Iatrogenia and consistent with the elite center that they are. You need not worry at all as you chose well. just relax in thatcknowledge as time goes by, even if at some point a little more work is on the menu to finish tieing up any loose ends . Dr Hao is plenty capable of addressing anything that comes up, if anything at all ever does in the future.

I'm always very suspicious when people quote 90% success with first ablations. Almost invariably the numbers have been jiggered a bit in one way or another so that the EP can attempt to justify such optimistic claims with a straight face.

Shannon

Thank you, Shannon. Very much relieved by the info you posted above.

Now, back to RonB -- wishing you all the best.

______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.

Ron - very happy to hear your good news. I'm sure this was quite stressful being in a foreign country and able to leave, but then not sure if you should, etc. But it sounds like a good decision was made and you are now on the road to recovery and calm, consistent NSR.

Happy for you ~ Barb

Hi Ron, I hope all continues to go well. I was sort of happy to hear that your af after the first ablation was not you fault and that it was a mechanical reconnection and not coquille ST Jacques. Sounds like you made a wise decision. Best of luck. Dennis

Good news Ron! Let's hope the 2nd time is a charm and that you continue in NSR. Sounds like you had quite an experience and it will be good to get home again. Best of luck.

Jim