Study finds ablation more effective for PAF than drugs

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Quote

Paroxysmal atrial fibrillation (Afib) recurred significantly less often in patients initially treated with radiofrequency ablation (RFA) instead of medication, results of a randomized trial showed.

Patients who received anti-arrhythmic drugs as first-line therapy had a recurrence rate of 72.1% compared with 54.5% in patients treated with RFA at 2 years. Patients treated with RFA had fewer symptomatic recurrences of Afib and better quality of life.

Primary source: Journal of the American Medical Association
Source reference: Morillo CA, et al "Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2). A randomized trial" JAMA 2014; 311: 692-699.

Additional source: Journal of the American Medical Association
Source reference: Calkins H "Has the time come to recommend catheter ablation of atrial fibrillation as first-line therapy?" JAMA 2014; 311: 679-680.

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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.

Well now isn't this strange, this was in your article:

Serious adverse events occurred in 9% of the RFA group and 6% of the drug therapy group. There were no reports of deaths or strokes in either group.

I would certainly try the magnesium, potassium supplement route before going right for the ablation. I will add however that I think it would also depend on the severity of ones AF episodes.

There was a poster here that had an ablation which went wrong, she didn't die but had a lot of serious health problems, I have also read of a doctor who had an ablation and died. There have been a few posters that have had success with diet, supplements, I understand that they are few, but I would certainly give it a go before an ablation.

Liz

I concur with Liz. Interesting, my recollection is that Dr C was reported to be the EP in charge when one of our posters was severely injured. I recall the issue being described that a fellow did the job of threading the catheters and tore a valve while Dr C was out of the room. Hence the suggestion to always ask whose hands will actually be at the controls!

The story about Pam Walter's ablation procedure injury is in the book, Collateral Damage...

Here's a preview:

Preview CHAPTER ONE:

“A Mitral Valve, Flapping in the Breeze, Prolapsed into the Atrium …”

JOHNS HOPKINS MEDICINE has a long tradition of prioritizing patients, and striving for the bottom rung are the anonymous poor. If, for example, you catch a bullet on a Baltimore street corner, or your mother presents you at the ER as a feverish welfare child, then it’s open season for the med students, well meaning as they may be. They can practice on you because if their actions result in an adverse outcome—which is to say that if you are mangled or killed—nobody will question said outcome, precisely because… you are a nobody.

At the other end of the spectrum are wealthy and prominent patients, who get treated by doctors who have already learned what not to do from the mistakes inflicted upon the lower classes.

My wife landed somewhere in the middle. We got snookered by all the hype from US News into thinking that she was going to be treated by the best doctor at “The Best Hospital in America.”Hugh Calkins performs an ablation procedure at Johns Hopkins Hugh Calkins, MD was to maneuver tiny wires around in my wife’s heart and burn scar tissue in the wall of the atrium to stop atrial fibrillation.

The job required someone with a cool head and a keen eye, and Hugh Grosvenor Calkins, MD, FACC, FAHA, FHRS, Professor of Medicine, Director of the Electrophysiology Lab at Johns Hopkins University School of Medicine—and graduate of Harvard Medical School—assured us that he had done plenty of these procedures, and, he said, “experience counts.” So we knew we were in the best of hands. What we didn’t know is that Professor Calkins—according to what he later told colleagues—follows the practice at most teaching hospitals wherein “the attending shows up to be there during the burn.”

Continue: [collateral-damage.net]

It's not my article, it's a report of a recent study. You can evaluate it according to your own biases.

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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,

I appreciate your posting the articles. I actually agree that ablation can be a first line treatment as many AA meds do not have stellar records, IF you are able to go to one of the top centers for an ablation. In Dr. C's editorial you cite, in a med vs. ablation study he writes about, he notes there were major complications in 9% of the ablations, including 6% with tamponade. This is certainly non-trivial and those stats are not particularly inviting.

Gelorge

Liz,

That serious adverse event rate of 9% was derived from a quite small group of patients at obviously a not very experienced center and marginal EPs as well on average to get that bad of results... In the much larger study of 80,000 ablation patients across the US over ten years they noted a major difference between complication rates with more experienced EPs and centers compared to the 80% of those 80,000 who had been ablated... Believe it or not ... By EPs doing less than 25 ablations a year at small centers doing under 50 ablations total a year...Stunning to read!

Those 80% who just went to whomever their local GP or Cardio referred them too , no questions asked, and got stuck often times with a very inexperienced ablationist had around a 6% complication rate experience overall, including minor groin he aromas in that list of adverse effects, while people who went to top volume centers and top tier ablationist had vanishingly lower overall complications, especially very few serious complications.

That is the take home message Liz. If and when you need an ablation, choose wisely as we always preach around here.

And I wholeheartedly agree with you too, that starting with a good nutrient/ mineral repletion effort and trigger avoidance is the very best first step for most folks . And should be adopted as a life long habit in any event.

However, one has to be careful of procrastinating too long if and when too much activity starts up again or continues in spite of a strong effort at natural control of the beast.

In addition to ongoing structural remodeling changes that will continue taking place as one bargains with themselves to rationalize avoiding an expert ablation even when it's clear they need one with ongoing AFIB too often, a new study recently published found that the combination of a less favorable LAA morphology of shape combined with living with AFIB led to finding on average 23 SCIs (Silent Cerebral Ischemia) white spots in the brains of 84.8 % of all AFIBbers tested out of around 286 people with active AF awaiting a first ablation!!

This is before any ablation was done so this increase in silent TIAs or silent mini strokes is directly related to living too long with Poorly controlled AFIB and exacerbated further by having in particular the three least favorable LAA shapes.. But just having AFIB even with the most friendly 'chicken wing' LAA shape brings with it some increase in SCIs.

Now there is debate on long term significance of SCI but many feel it predisposes to early dementia and there is fear that having too many of these largely asymptomatic white spots on the brain does leads to bigger stroke risk.

So there is a not so fine line between wanting to continue postponing an ablation that is clearly needed, when and if more conservative efforts are not working so well any longer, and the mistaken belief that there is no added risks or downside from continued procrastination in the face of clear evidence if things are not working so well trying to manage the beast on one's own solely.

The main thing when, and if, the time comes to consider an ablation, is that the person should strive for the most experienced operator they can get to greatly improve their odds for an effective and very safe ablation ... and make double sure that ONLY the EP you signed on the dotted line for will be handing the catheter inside your heart. There are many thousands of uninformed patients for trainee EPs to learn from without anyone here feeling the slightest bit of pause or reservation in insisting in a very nice way that your chosen EP be the one who actually does your ablation .. as George noted.

Shannon



Edited 3 time(s). Last edit at 02/21/2014 05:49PM by Shannon.

Shannon,

I did not mean to imply the 9% rate was typical. I think it speaks loudly about his attitude that Dr. C would choose a study with a 9% (and 6% tamponade) rate to cite in his editorial suggesting that afib be a first line treatment. My recollection of Pam's description of dealing with him after his fellow ripped her valve was basically "too bad, so sad." Without taking ownership that his team had significantly degraded her life. It makes your point "then the person should strive for the most experienced operator they can get to greatly improve their odds for an effective and very safe ablation." Though Dr. C could be considered a very experienced operator.

Cheers,

George

Thanks George,

Ive amended my last paragraph above with the qualifier to confirm that who you choose as your EP is actually going to be your ablationist and no pinch hitter joins in the fun once your are in dreamland!

here is my amendment I included in my post above

.......and make double sure that ONLY the EP you signed on the dotted line for will be handing the catheter inside your heart. There are many thousands of uninformed patients for trainee EPs to learn from without anyone here feeling the slightest bit of pause or reservation in insisting in a very nice way that your chosen EP be the one who actually does your ablation .. as George noted.

Shannon

Shannon:

The theme that runs through this site is pick the best doctor in the country to do your ablation, what if that isn't possible for a lot of people, their insurance doesn't allow for them to go out of network so they would have to pick up the cost and they don't have the money, would you still advise them to go for the ablation in their network with a doctor that doesn't have too much experience?

Liz

Hi Liz

That's a very good and fair question. My sense is to try to set the standard of excellence high here with the full understanding that many will not be able to go to a Natale, Jais or Callans etc. for the reasons you mentioned and no doubt other reasons as well. But at least give a blueprint for people of what the very best looks like, and thus we do try to convey these top EPs own insights and approaches toward addressing AFIB. Hopefully, this will give people a better map with which to best evaluate those EPs that are within their reach in order to make the very best choice they can in each given circumstance. The fact is too, there are quite a few very good and even excellent ablationists around the country and Europe too as it is, and particularly for relatively straight-forward paroxysmal AFIB ablations, so its far from hopeless.

But the more folks can understand the principles, techniques and vision of docs like Drs Natale, Haissaguerre/Jais or Callans at Penn, for example, and that other long established elites share, the better their chance of recognizing those characteristics in the EPs that may be much less well known but still very good doctors and who are dedicated to excellence in their field during their interviews with them.

It's my hope that our community will feel better armed and equipped to ask the insightful questions and discuss their options in a way too that will earn the respect of their chosen EP and help in cementing a good proactive partnership together toward solving this thing.

But I would urge everyone also not to fear walking away from doing an ablation with an EP who is clearly undertrained and with too little real world ablation experience. There are plenty of unknowing guinea pigs out there to more than keep the new EPs busy while they cut their teeth, without anyone from our site having to feel it necessary to offer themselves up as a learning experiment for the EP.

It is a big step for sure, but for those with the means, time and ability to travel its rather easy, just chose one of the top five to ten or so and have at it!

For those who have to really hunt in their own areas it can be a more challenging process, but there are enough very qualified paroxysmal AF ablationists spread fairly wide across the US now I feel, that most people who have to decide under the restrictions you mention should be able to find a safe, caring and competent ablationist not too awfully far from where they live. I wish it was all free of course, but alas don't have any great answers for the financial inequities and insurance problems so many people have to face that's a tough one for sure.

At least we try to offer a well-rounded array of options here for addressing this beast and if an ablation just isn't feasible, for so many we encourage them to learn all they can about heart healthy supplements, dietary, stress management and weight loss, hypertension control and effective sleep apnea treatment as the best foundation for everyone to do the most we can for ourselves, outside of a good ablation process while trying to save or find a way that an ablation might fit it at some point if you really need one.

For those with difficult persistent AF cases, I definitely do strongly recommend not sparing any effort or expense to go see one of the very best EPs with as much persistent AF ablation success as they can find, while also staying dedicated to the nutritional plan, good diet and life-style programs noted above for life ... These are the honest realities Im afraid and while it certainly isn't fair, neither is this condition and we all have to make the best of the hands we've been dealt.

Hope that clarifies how I see all this. One project among a number I hope to get to as time allows in the coming months and over the next year or so, is to start a good reference list of high quality Ablationists in each region of the country. It will take a good while and must be done as fairly and thoroughly as possible so it doesn't just become an open ended list where every EP who has done a few ablations tries to get listed, or it just becomes a list like from a phone book you see on some other AF support sites that has very limited value and can just as easily inadvertently encourage people to go very inexperienced or downright dangerous EPs simply because they were listed next in line in the area. The standards have to remain pretty high and yet also be as inclusive as necessary so as not to cut too many very well qualified EPs off the list as well, so it will take some real time and effort.

Also I hope to gradually modify aspects of the website down the road a bit to offer a more flexible format and design based on HTML5 and CSS3 design tools and coding that support video and audio coding easily as well. This will allow us to expand the tools for sharing this knowledge for all of us, but this first year for me behind the wheel here will mostly be just trying to keep it rolling alone steadily while I get up to speed as well in many ways. Anyway, food for thought.

Take care Liz,
Shannonr



Edited 2 time(s). Last edit at 03/03/2014 05:44AM by Shannon.

Shannon:

That is a great idea, to be able to find very good Ablationists throughout the nation. Looks like lots of things coming down the pike, looking forward to it.

Many thanks
Liz

What I find significant here is that ablation is moving inexorably towards being acknowledged as a first-line treatment for certain types of afib.

______________
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.

Besides the SCI, here's more to worry about once you cross into more persistent afib
AFIB is not a benign condition even when rate controlled. MI and end stage renal disease are just 2 complications that have only just now been realized. The inflammation from constant AFIB leads to so much more disease as discussed by Dr Reddy.

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McHale