Esophageal Fistula - low probability, high consequence complication of AF ablation

With the recent question and discussions regarding extended fever post ablation, I decided with Shannon's concurrence that it would be good idea to provide a more detailed look at this very dangerous complication. Approximately chronological links to a selection of papers are provided, some on my Google drive. The review is not exhaustive as there are a lot more papers in the literature than provided here but it provides a breath to help readers understand the problem, the symptoms, current protocols to minimize the risk and continued caution that is still required during the post ablation recovery period. I will break up the post to bite size pieces.

Introduction - the problem

The esophagus is anatomically adjacent to the posterior wall of the left atria. Too deep heat energy penetration will cause esophageal thermal injury. The precursor to esophageal fistula. Also, with the introduction and advance in irrigated catheter technology in the late 1990's - early 2000's, cooler catheter tip-tissue contact temperatures allowed for increased RF depth of penetration. The frequency of occurrence and subsequent fistula formation is unknown because observations were anecdotal and understanding of observed widely varying symptoms was lacking. In 2003-04, 3 teams of expert ablationists (d'Avila et al and Pappone and Morady et al) published index papers for this complication and reported their observations and findings of their initial encounters with this complication. The Pappone- Morady et al paper is available here - [circ.ahajournals.org]

Of particular interest in Pappone-Morady paper are the power and temperature settings used with the solid (non-irrigated) catheters. The max settings for case 1 was 60 C and 100 W and 55 C and 70 W for case 2. Non-irrigated catheters required much higher limits to achieve transmurality compare to irrigated catheters. There is also technique dependence in that if a catheter is dragged along an ablation line instead of maintaining an unchanging contact point for a fixed temperature end point would impact operator setting preferences.

The Cleveland Clinic headed up by Natale followed up the index reports with their own survey reported by Cummings et al.
The link to the CCF paper is here - [drive.google.com]

The problem can be clearly visualize in the MRI scan showing the position of the esophagus with relation to the heart. The CCF survey also showed that the complication occurred at all experience levels.

Pathology, statistics and symptoms

The unfortunate case of a patient turning down early surgical intervention offer some insight into how the complication appears to settle only to accelerate beyond control. Serial CT images were taken starting at day 10 through day 41 post ablation so the case gave the EP community an unusual lengthy look at how the complication progresses. The paper is here -
. [drive.google.com]

Hindricks and his team was the first to warn about the risk soon after the release of the Thermocool irrigated catheter in Europe. His team has probably done the most (in terms of number patients in various trials) detailed research on temperature measurements and endoscopic measurements. He observed in the following study that the frequency of occurrence of thermal lesions jumped if the luminal esophagus temperature exceeded 41 C. Temperature probes in this Hindricks et al study was guided by real time 3D CT so that thermocouples positions were adjacent to the catheter tip-tissue contact. Although none of the 185 consecutive patients developed fistula, 15% had thermal lesions.
[www.nature.com]

Other teams found results consistent with those of Hindricks. D'Avila et al looked at placment of temperature probes and using a max 2 C increase or an absolute 39 C to be a useful guideline for shutting off RF energy. D'Avila observed that even after the RF energy is turned off, luminal esophagus temperature continues to rise about 1.5 C such that his 39 C shut-off corresponds to 40.5 C max esophageal temperature which is for practical purposes, the same as Hindricks measurements.
[circep.ahajournals.org]

Manual compared to robotics

In the discussions so far, the studies addressed manual catheter ablation. Procedures assisted by robotics (both cable robotics and magnetic robotics) also is subject to esophageal lesions. Kuck et al investigated the difference between magnetic and manual ablation in a small trial and reported their results here -
[www.heartrhythmjournal.com]
50 total patients were split between manual and magnetics. Endoscopy (EGD) were performed on all patients post ablation. Of those in the magnetic group, 9 had lesions and 2 of the 9 had tissue loss. Of those in the manual group, 11 had lesions and 1 had tissue loss. Luminal esophageal temperature distributions were 43.7 +/- 3.7 C in the magnetic group and 45.4 +/- 3.5 C in the manual group. Even though the Kuck et al trial exceeded the temperature guidelines provided by Hindricks and D'Avila et al, none of the Kuck et al patients progressed to fistula. However, the overall 40% incidence of lesions is much higher than the 15% seen in the Hindricks et al data.

There has not been a comparative study on esophageal lesions with cable-robotics and manual. There is one interesting paper by the Pittsburgh group on their experience on one patient where they were able to repair a fistula that connected to the pericardium. In the Pittsburgh report, the procedure was done according to the latest guidelines with thermal probes, ICE imaging to insure good placement and peak LET temperature limit at 39 C. Yet the procedure still resulted in fistula. They saw air in the pericardium and ran a endoscope into the pericardial space. They were able to see "Punched out linear ablation lesions surrounding the antra were clearly visualized with corresponding direct imprints on the parietal pericardium - Figure 2). This is the only study of a surviving patient where doctors were able to directly see the lesion epicardially soon after ablation and it vividly illustrates the complication.
The complete paper is here - [drive.google.com]

The other available anecdotal cable-robotics data is from the FDA adverse report database (MAUDE) where manufacturers report incidents. Since MAUDE reporting is USA facilities based, subject to doctors discretion and manufacturer screening, it is at best incomplete and lacks procedural details. With those cautionary comments in mind, several MAUDE AEF reports resulting in deaths were filed by doctors using the Hansen sensei cable-robotics system clustered in 2011. 5 deaths due to AEF reports were filed in 2011. The system according to company reports are being used in about 2000 AF ablations world wide each year so it is uncertain what the incidence is exactly as USA procedures are not broken out. Also, only a small fraction of thermal lesions result in complete AEF so it is difficult to really tell what is going on.
MAUDE searches are availalbe here - [www.accessdata.fda.gov]

Current procedural guidelines

Nakagawa and Jackman et al looked at the temperature measurement shortcomings in their canine studies. They reviewed at different energy sources including Cryo and high-intensity ultrasound. In fact, the deep penetration of high-intensity ultrasound energy and resultant esphogeal damage made that type of device untenable. They showed that single thermocouple probes lack sufficient accuracy and that multiple thermocouples and careful placement are needed. Pre procedure CT, MRI and TEE all help to define important anatomical spacing in 3D and important. Canine studies also confirm the usefulness of post procedure PPI intake helps in healing the esophagus compared to controls. All AF procedures have incorporated the guidelines to various degrees in since the Hindricks and D'Avila reports. (I highlighted the PPI intake for Nancy (Windstar) sake since she is questioning why she has to do that in a recent post.)
[circep.ahajournals.org]



So is Everything Cool and we don't need to worry now?
Hindricks et al decided to see how things are going now that all the latest guidelines are followed. In 425 consecutive patients, his group ran endoscopes (EGD) through the entire upper intestinal tract.(the paper was recently accepted for journal - abstract here [www.heartrhythmjournal.com])

I paste here the results verbatim
===================================
Pathological gastrointestinal findings were observed in 328 patients (77%) and included: gastral erosions (22 %), esophageal erythema (21 %), gastroparesis (17 %), hiatal hernia (16 %), reflux esophagitis (12 %), thermal esophageal lesion (11 %) and suspected Barrett’s esophagus (5 %). Biopsies were extracted in 70 patients, showing gastritis (84 %), Helicobacter pylori colonization (17 %) and mucosa-associated lymphoid tissue (17 %), esophagitis (9%), and Barrett’s esophagus (4%). Further diagnostic work-up or treatment was initiated in 105 (25%) patients.
===================================

Alll those guidelines and we are still at 11% thermal lesions, down from 15%. Whoopeedoo. Granted, I am fairly certain that not all thermal lesions are equal and that the current crop is probably a lot less likely to progress to full fistula compare to 10 years ago. Also of note is the 17% gastroparesis. What Randy is feeling now is not uncommon. (i highlight this for Randy - see his post)..

Hindricks also made many insightful comments in an editorial about temperature, contact force and power levels. I think the one sentence summary is that EPs are doing everything they can to minimize the risk but it will still exist to various degrees. This editorial comment was written in 2010. His 2013 results above is consistent with the thoughts he expressed in 2010.
[europace.oxfordjournals.org]


Conclusion

If you are having post ablation fever for more than a few days, let your EP know what's going on. If you are having a fever, along with a hard time swallowing and stomach problems, don't wait to call your EP. Above all else, when the EP tells you to take PPI post ablation, know that he is telling you to do that in your best interest.

====================================



Edited 9 time(s). Last edit at 02/19/2014 12:48AM by researcher.

Consolidated into post 1



Edited 4 time(s). Last edit at 02/18/2014 02:39PM by researcher.

Researcher:

Dr. Fred Morady M.D of the University of Michigan, Ann Arbor, had a patient, who was a doctor, die after he performed an ablation, so I guess he knows first hand of what he is talking about. I live in Michigan, my doctor has a small private practice and also goes to U. of M.

Liz

Thank you, Researcher, for your endeavors. Very important to relate the experience and skill of the EP to this adverse occurrence.

About the time the papers you reference were published.. in '04...I attended the Afib Summit here in Cleveland sponsored by Cleveland Clinic. They spent a good deal of time talking about the esophageal fistula problem and demonstrated via video clips about how to detect when too much energy (heat) was being delivered to the tissue being ablated. The use of the ICE monitoring (Intracardiac echocardiography) equipment was being used in the more advanced centers and demonstrations were shown via video as to how that equipment allows the EP to visualize the results of the energy delivered as evidenced by microbubbles coming from the burned areas.

At that time, emphasis was on knowing that the tissue keeps on heating even when the energy or burn activity is stopped and that was the cautionary note of the day... stop the energy before the bubbles indicate the heat level and that would help prevent the esophageal fistula injury.

Since the back of the heart wall rests right on top of the esophagus, it was easy to see how there could easily be damage from overheating the heart tissue.

The water-cooled catheters were not discussed so I presume they were either not used or used only very experimentally as compared to current practice. However, the emphasis was that EP centers that don't use the ICE monitor as an assist run the risk of overheating and the esophageal trauma...and death if there is a fistula. This would be especially true when the EP is less experienced.

This is important information, so I'm glad you are presenting your report.

Jackie

Researcher, thanks for the post. The Gilcrease & Stein article is interesting. Fortunately, as you noted, esophageal fistula is rare with an incidence of 1% or less. What caught my attention though is the observation that esophageal injury short of a fistula, such as esophageal ulcers (some asymptomatic) may be more common post-ablation with an incidence approaching 30% or more. Good news there too, evidently, as the authors state that most of these ulcers heal with minimal symptoms and no sequelae. Which brings me to my own experience post-ablation. I did have some mild abdominal pain, various locations, starting day 9 or earlier, and a couple instances of acid reflux with regurgitation starting day 13 (with clear food triggers) which have not recurred since. Have had mild heartburn after some meals and briefly as soon as I lay down at night. I've had some of these symptoms in the distant past but clearly there is an exacerbation post-ablation. One final new symptom for past few days is drinking water right after a meal I notice some right upper quadrant discomfort until the liquid passes further down. Except for this latter symptom, the reflux symptoms seem to be abating. I'm now at day 24 post-ablation and otherwise doing quite well. Just wondering if the symptoms I mentioned could be due to esophageal irritation or mild resolving ulcer from the procedure.

Randy, yes only a small fraction of the lesions turn into complete fistula. Most resolve quickly within a couple of weeks. Difficulty with swallowing afterwards is common indication but it is minor by itself. An extended fever is worrisome especially if combined with swallowing pain. I am about 1/3 to halfway through the write-up.

note - writeup completed 2/18/14 midnight GMT



Edited 1 time(s). Last edit at 02/19/2014 01:02AM by researcher.

Hi Randy,

Keep in mind that not all GI symptoms post ablation are related solely to esophageal irritation or mild to moderate ulceration. While its possible for some mild irritation to be there its unlikely that esophageal irritation from the catheter is responsible for any new symptoms at this point. As researcher said, in the absence of any later onset fevers its extremely unlikely to be anything remotely close to a significant ulceration much less hinting at a possible fistula.

As noted before, to my knowledge out of 9,000 or there about and constantly increasing number of AFIB ablations in Dr Natale's quiver, I have never heard of an Atrio-esophageal fistula happening to one of his patients, and I don't know of any from any of his trained colleagues as well, though I know less about all of their full track records than I do of Dr Natale himself.

GI issues can also be from close brushes with the phrenic nerve that fall far far short of phrenic nerve palsy or paralysis, but some minor transient irritation of that nerve area can happen during SVC (superior vena cava) isolation or even at points ablated near and around some aspects of the longish Coronary Sinus tract when that is ablated or isolated and could potentially have some mild lingering effects on digestive motility for a bit. Also, some people have GI issues for a bit after an ablation from the excess water load from the irrigated catheters used, which can dump a good deal of water into the body during a longer ablation. However, the latest generation Thermocool catheter puts out about 50% less volume of water for the same cooling effect as the original FDA approved Thermocool that Natale started using on a trial basis in the summer of 2008 (I was something like the 15th patient to have the original Thermocool used in my index ablation the third week of Aug 2008) and that was finally FDA approved in January 2009 I believe.

In any event, these are all 'Exhibit A' reasons for choosing a top gun highly experienced EP, as the most serious consequences like a fistula are extremely extremely unlikely to ever happen with these EPs at the helm and are far less than the 1.0% Randy mentions above. It's closer to 0.05% these days overall, and that is in spite of the fact that nearly 80% of all ablations over the ten years from 2000 through 2010 in the US were, shockingly, done by EPs doing less than 25 ablations a year in small to mid-size hospitals doing less than 50 total AFIB ablations a year, which is nuts if you ask me! If you look at just this group though I imagine the vast majority of what few fistulas do occur do so from this cohort of EPs, a good number of whom probably should never be doing ablations to begin with.

Its important to know about this issue though, and many thanks to researcher for his effort to post about this most dire potential consequence of AFIB ablation. But mostly its good to know just as a final motivation for not compromising on choosing an experienced EP. Once you make a good choice from among a good number of skilled EPs across the country, worries or even passing thoughts about an esophageal fistula need not at all keep you up at nights prior to your ablation and you can rest assured that this will not happen to you with a skilled EP at a top center.

Don't even dare consider going with anyone who does less than 100 to 150 ablations a year, at the barest minimum! And even that low a number, would have to be an EP that has a very solid reputation for skill and success over a good number of years and is not just a 'newbie' getting his or her feet wet. Keep in mind that the most ablations even the busiest EP like Dr N can do in a year is around 500 to 525 tops, when they are really flying and are mostly located in one spot. Natale now averages around 475 a year, down slightly from his peak the last few at Cleveland Clinic of around 500 to 525 a year, and during the first couple of years bouncing between St Davids and CPMC, but that is because not only now does he have more very well trained proteges in both CPMC and Austin as well as in Ohio, NYC in Barrett and Danik and Penski in Florida to spread the load too, as well as Verma in Canada, but because he travels to and from San Fran and Austin and perhaps NYC before long again as well. Also, he attends quite a few big conferences around the world as a key speaker and is very involved in helping research and develop new ablation tools and gear as a consultant and beta-tester for top equipment makers as well. How he fits it all in as it is remains a genuine mystery of the universe in my book.

Bottomline, it's vital for people to know, as researcher has taken the time to spell out, that any one who has a lingering fever especially one that goes above 101F degrees and continues, with or without noticeable esophageal or heartburn like symptoms, as an immediate signal to get thee quicky to your EP or local Cardio for a thorough echocardiogram and possible CT or MRI scan of the esophageal/atrial area. Though your EP would be the one to guide when and if you might need such a scan, which is extremely unlikely to begin with.

This is not at all meant to scare people away from a modern ablation in a good center with a skilled EP, its just one of those good to know in a pinch facts that will almost surely never happen to you.

Shannon



Edited 1 time(s). Last edit at 02/17/2014 04:20PM by Shannon.

Yes, I believe the incidence of esophageal fistula at CPMC, where Dr. Natale and protegees practice, is zero.

______________
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.

Hi Shannon - you mentioned Dr Verma in Canada, and this is the first that I have heard that there could be a top tier ablationist EP IN Canada. Do you know much about Dr Verma and his track record? I have been successfully ablated, but am keeping my eye open just in case, as I would not want to take the trip back to Bordeaux if there is an alternative where Medicare would covert he expense.
Thanks, Ron

Hi Ron,

I know Atul Verma is very well thought of and Dr Natale told me when I asked him who he would recommend for ablation in Canada if the person could not come see him in the US and he said Dr Verma without a moments hesitation.

I also know Verma worked with Natale when Dr N was running the Cleveland Clinic AFIB department as director. And that Dr Verma authored a number of key research papers under Natale's group there including a seminal study on the relationship between fibrosis and likelihood of needing more than one ablation as seen via Electro-anatomic voltage mapping which Dr Verma was the lead author on in 2005 with Nassir Marrouche also as a co-author as was Natale as well. This was the very first paper that made the connection with Left atrial scar and progressive severity of structural remodeling and more advanced AFIB.

Marrouche left CC in 2008 for Utah just after Natale moved to Austin and continued his explorations into fibrosis /scar with MRI imaging.

In any event, I don't know how many ablations Dr Verma has done or how many persistent but Dr N seems to have real confidence in him as the man he would trust most in Canada at least, which says a lot in my book.

Shannon



Edited 1 time(s). Last edit at 02/18/2014 08:22AM by Shannon.

Randy, i am mostly done with post number 1 now. Sorry for the delay. Near the bottom I highlighted something just for you.

Researcher, got it. Thanks you very much!

The signs and symptoms of gastroparesis seem to pretty much summarize my current status. My symptoms are on the mild side (I think) in that I have no chronic or morning nausea, or vomiting, but definitely some heartburn, abdominal discomfort, feeling full quickly, a little bloating, no real appetite but I eat anyway. The idea of delayed gastric emptying, with food staying in the stomach for a longer time than normal, really nails what I've been experiencing. I knew something was going on but wasn't sure what.

If I do have some gastroparesis, does that suggest possible thermal injury to some adjacent vagal nerves affecting stomach contractions I wonder. I know it wasn't the main reason for your post, Researcher, but it has been very helpful to me. Next step is for me to research further diagnosis and treatment. Thanks again.

As you noted Randy, its rather mild. It will get better just give it a little time. This is way far away from a fistula and nothing to fret about too much. I had some of those symptoms after the initial big ablation. It will settle down soon.

Take care
Shannon

Randy, I would consider gastroparesis as a second order complication that should resolve over time without worrying about the esophagus as you haven't had swallowing pain or fever. If it doesn't get better over time, you may want to ask your EP if running an EGD should be considered. Are you still on PPI?

Thanks, Shannon and Researcher. Had low grade fever only up to day 6, no swallowing pain at any point. Was not prescribed or advised to take any post-procedure PPIs. I won't worry, will just monitor and back off size/fat of my meals a little temporarily. Guess I can't completely rule out that my current symptoms could be exacerbation of some pre-existing GI stuff too, who knows (though gastroparesis seems to describe well). Should there be lingering concern about gastroparesis, I read that clinically, it is solely defined on the emptying time of the stomach, not on other symptoms, and scans can assess that.

Also, thanks to Jackie's tutelage, one of the top items already on my post-ablation to-do list has been to get a comprehensive digestive stool analysis for a thorough gut check, I'm moving forward on that and it should be revealing.

Above all, heart remains in NSR and after being so sick this past fall with daily AF for months, life is good again.

What is the mechanism behind gastroparesis as a complication of ablation?

I am wondering if this is what I had -- I had post-procedure anorexia, no appetite and difficulty eating. Took perhaps 4-5 months to go away, but my gut is still touchy.

______________
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.

Iatrogenia, the suspect is vagus nerve injury. Linked abstract below talks about this. Hindricks et al will probably have the last word as his group has the most expertize in looking at this.
[www.ncbi.nlm.nih.gov]

Is Dr Hao aware of your problem and if so what are his suggestions?



Edited 1 time(s). Last edit at 02/20/2014 10:00AM by researcher.

Iatogenia and Randy, More info here on possible solution to your issue. Same author as post above.

[drive.google.com]

Researcher, I really appreciate you making the Kuwahara & Takahashi resource available. Is it an article just now in press? Good to see it reiterated that most problems with gastric hypomotility resolve within the first few months post-ablation. I've got plenty of time left since I'm not quite at the one month point yet.

Randy, both papers were out last year. Took them 2-3 years to gather the data so they started soon after temperature guidelines came out.

Hi Randy,

Yes based on your description I wouldn't worry at all about it, as it will just fade away until you realize you haven't thought about it for a while and that will be it. Having a vagal nerve injury severe enough to require anything close to a surgical fix is essentially as remote a likelihood as having a fistula. Yes, it can very rarely happen and is more likely, by far, even though still very rare, in less experience hands. But almost never happens to that degree in highly skilled hands.

AFIB ablation is quite an invasive procedure required to really fix a terrible condition to live with. But recommending 'avoiding the posterior wall' is tantamount to condemning a huge number of afibbers to only a partially successful ablation, at best, with guaranteed continued breakthroughs that will only increase over time.

The skilled EP has to balance the risks/benefits while always striving for perfection, yet knowing that some degree of tissue irritation is going to happen and the goal is to make that a minor issue at most, and one that is self-resolving over a modest period of time in exchange for far more solid and reliable ablation results The vast majority never even notice any GI symptoms. Those of us that do have a few symptoms of vagal or even minor phrenic irritation, its almost always a transient issue that passes with the wind ... no pun intended :-).

Shannon

I guess I didn't have this, I had no "nausea, bloating, and abdominal pain." Dr. Hao's office were no help when I told them I was having difficulty eating.

Another doctor told me post-op anorexia was not unknown. I gather this is what affected me.

______________
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.

Shannon and Randy, Most definitely, the way to manage the stomach problems post ablation is conservatively. As Kuwahara stated near the bottom of his editorial. Fasting first (length of fasting depends on severity) followed by the gradual introduction of low-fat and low-fiber food. Upper GI antibiotics may help. And time. I think for the vast majority, the relatively short term stomach related complications is minor cost compare to the major benefit of converting to long term NSR.

Thanks Shannon and Researcher. I have no regrets about my ablation with Dr. Natale and know it was done with the highest degree of expertise. Any surgical procedure carries collateral risks and issues. I would not have wanted the posterior wall to be excluded from my ablation. I don't mind dealing with issues such as tissue irritation while in joyous NSR, and expect them to resolve with time. Short of fasting, I tried cutting back on portion size and amount of fat with each meal and got immediate positive results in the past 48 hours. I appreciate the various articles as they've helped me understand what's going on with my situation and broadened my knowledge of this area generally, so thanks again.

So guys, at the end of the day, what's the safest approach? Cryo? Presumably irrigated catheters over non-irrigated (I'm figuring all the top centres use these now)??

I look in here now and again and the breadth of knowledge is both astounding and more than a little confusing!

What would be really cool for folks like me with a little knowledge (sometimes a dangerous thing!) would be a routinely updated resume of all of the top tier ablation centres and a summary of their approach in terms of type of ablation, wattages used, irrigated or non-irrigated catheters, mapping methods, whether or not they instigate AF to check for non-PV foci during the procedure etc etc.

I mean I find myself wondering where best - once the time comes around for an ablation - to actually go for a procedure, safety/success rate etc out of Schilling, Ernst, Bordeaux etc. I don't know whether compiling such a updatable summary is readily/easily do-able, and I guess it's asking a lot of someone/some folks to give of their time and expertise to so do. I'm only really raising the idea as a possibility… what do you think? Maybe this is a dumb/naive idea… I won't be offended if that's the case… as I said, just an idea! I suppose in the final analysis the centres with the highest success rates and the lowest complication rates are the way to go and maybe my idea as aforementioned is just overkill and maybe even a bit confusing itself! I suppose in my case it's a case of wanting a little knowledge to assist with the decision process but not too much!

Best to all,

Mike F

Hi MikeJ

Thanks for the idea. And its one I've been formulating how to best to structure and maintain updates on for some time now. Also so I can have a thorough boiler plate set of responses to frequent questions so that the regulars here don't have to reinvent the wheel each time a common and key question gets asked any of us can then just point to such a guidelines post and save a lot of time.

One of the perks of going to a number of these EP conferences I'm attending this year, including in particular the one this coming week in Austin at EP-Live is the ability to gain a front row seat for learning and actually watching a wide array of ablation procedures first hand while the experts who use those techniques explain all the nuances and
reasons why behind each aspect of the procedures. 13 separate live and recorded procedures are going to be taught covering much of the current state of the art in ablation technology and process. Including a live long standing persistent AFIB ablation of our relative new friend Smackman by Dr Natale this Thursday and a recorded video of Dr Gery Tomassoni doing a classic PVAI plus using the Topera FIRM mapping as well to hunt down stray non-PV rotors or foci in new member Tsco which will be shown as well.

In any event, I hear you about trying to make a roadmap better accessible for people to access and that's on my rather lengthy to-do list that I've noticed has recently taken on an exponential growth rate . It should help a lot in giving even better feedback to our community here when We can get that put together.

Shannon

RE Iatrogenia's "Another doctor told me post-op anorexia was not unknown."

Sigh. That's the same as saying, it happens. We don't understand why. So no problem.

Hopefully, some day soon. AF ablation specialists and and internal medicine groups work better together to take better care of patients post ablation. Anorexia as a complication lasting more than a few weeks should not be acceptable and ignored. See Kuwahara's discussion regarding Lo et al's finding on AF ablation impairment of gastric myoelectricity. Send your EPs and doctors the citations as they may not be up to date.

Here is the link to the Lo et al paper.
[drive.google.com]



Edited 1 time(s). Last edit at 02/24/2014 02:40PM by researcher.

Mike F, should have answered earlier, sorry for the delay. Irrigated RF is still the way to go. Just make sure that LET guidelines are followed which means they have to be properly equipped for the procedure. Cryo has its own set of issues and it can also cause esophageal thermal injury. See the Nakagawa reference from above. The major issue with cryo is high rate of phrenic nerve injury. Most of those resolve but a couple percent of them don't and that would be devastating. Also, you can't do focal ablation with a balloon. It is most used for AVNRT ablation.

Mike F

As a data point Dr Sabine Ernst stated that she had zero Atrio-esphageal fistulas in her 14 years of ablation. She did warn of it though and said she avoided the back wall unless absolutely necessary and even then reduced wattage to I think ~25W to mitigate the risk.

Phil.

Shannon, Researcher and PhilS,

Great info and many thanks - much appreciated.

Best regards,

Mike