Clinical Trial on Vagally Induced AF - New Ablation Strategy

Just back from the Royal Brompton Hospital having had a pre-ablation consultation with Dr Sabine Ernst. I really can't speak highly enough of this woman - she gave almost an hour of her time to explain the options I had, risks and probabilities.

What I wasn't expecting was an invitation to take part on a current clinical trial. I will try my best to explain this, but if you want to hear how she describes it, view this presentation she made in Qatar: [www.youtube.com]

The first thing she said that impressed me was that she believes in vagally-induced AF (of the type I and many others on here experience, but have a heck of a time convincing cardiologists over) and wants to understand 'what triggers the trigger?' i.e. why can we have all kinds of PACs, and not go into AF, and yet at other times, we do. The second thing that impressed me was why she'd set up this trial (which is involving a centre in Oklahoma and in a number of other countries). She said that, despite technological advances, 'one and done' success rates have remained around 75% - and she wants to see that ratio go up, by doing something different.

So, the trial will do the normal PVA isolation, but in addition, a number of ganglionated plexi spots will be burnt. When I asked how many, she said that between 1-9 were showing up across the trial, the median number being 5. I don't claim to fully understand the 3-D mapping process, sympathetic innervation, D-SPECT,that identifies these autonomic nervous system hot-spots, but it seems to be having very promising early results - Dr Ernst said that, the people with vagally-induced paroxysmal or persistent AF (requirements to take part in the trial) treated in this way had so far yielded 90% 'one and done'. Early days of course.

So, she will either ablate me using their current methods or I can join the trial, and have a little bit more done.

The thing that resonated with me (also seen in the video) is her concern around long term impact of making too many burns, and the impact this may have, later in life, on the heart's elasticity. Since the bottom end of my heart has cardiomyopathy, thus slightly compromising my diastolic function, my instinct is to be included in the trial. Dr Ernst was very honest about the pros and cons:
Pros:
1. I can pretty much pick my time for ablation (beginning of December is my preferred time)
2. The after-care will be very good and prolonged

Cons;
1. History may show that , fewer burns were needed
2. There's a bit of radioactive dye needs to be injected for the mapping to work

Given all the above, I'm inclined to opt in.

But, I'd very much appreciated your thoughts!

I'm interested in hearing about this too. One of my fears of getting my ablation done soon (I'm 36) is how my heart will last over time, post ablation. I'd be hoping to stick around another 50+ years from now, and I don't know what studies have been done on hearts that have been ablated, over time.

-Eric

I asked Dr Barret about that (doctor who did my ablation coming up for 2 years ago) - he said ablation improves heart function. I guess I'd look at it another way. How long will your heart last with an AF burden?



Edited 1 time(s). Last edit at 08/20/2014 11:10PM by afhound99.

While there's no doubt that a heart in NSR will perform better than a heart in AF, the procedure leaves scar tissue, and the choice - assuming a successful outcome - would be to minimise that, surely?

To be honest, I think the interesting part of this trial is not how many burns to make, but the idea of identifying where vagally-induced AF appears, outside the pulmonary veins, has merit, because, as Sabine says in the presentation, why else does AF reappear in people who have had PVs completely isolated?

I don't pretend to understand all of the science behind it (perhaps Shannon can make it simpler for us all) but I'd be interested to see if people would put themselves forward for this kind of trial?

And does anyone know about the Oklahoma Centre (and Dr Jackman) Dr Ernst mentions?

"And does anyone know about the Oklahoma Centre (and Dr Jackman) Dr Ernst mentions?"

David, both have been the subject of many posts over the years. Search function will turn them up. Search the previous forum as well as this one.

All the best to you.

PeggyM



Edited 2 time(s). Last edit at 08/21/2014 11:56AM by Shannon.

Excellent, thanks Peggie. Didn't know that.

I responded to your other thread David on experience with Dr. E.

She mentioned the trial to me in Nov 2013 and I read a few research papers on GP ablation and also what GPs actually do in the heart. What doesn't seem to be clear is how GP regulates the heart and what other functions they perform. DR Ernst said they they were monitoring GP patients for barometric function etc to check for adverse reactions but I had a feeling this was pioneering territory.

In balance given I had waiting a number of years for the standard ablation to mature as my afib was vagal and proxysmal so not a major burden I felt that I did not want to go with this approach for my first ablation given its relatively immaturity and lack of patient data. My view is that if the one and done does not happen then I would look at this for the second approach which she was fine with.

That said it was a tricky decision and everyone has their own specific reasons why they would go either way.

Phil

Phil, The idea of GP triggers have been around at least 10yrs. Jackman's group did beating heart (open) experiments on dogs originally to see what was happening with electrical and chemical stimulation to force AF and mapping the hearts. That led to the discovery of the role of GP. When the GP were ablated, it was nearly impossible to reinitiate AF. Since around 2006-7, Jackman started to do GP ablation trials on humans. The difficulty has always been trying to figure out how to map GP with available tools without open surgery. Looks like there are now tools to do it. I may have some of the hardcopy slides from the Jackman-Po work laying around my office as I attended one of his talks a long time ago. I will post if found.



Edited 2 time(s). Last edit at 08/21/2014 10:57AM by researcher.

Hi David the jury is still out in GP ablation. The Oklahoma group she is referring too is Sonny Jackman's group who has basically single handedly been leading the charge about this concept though with mostly lukewarm interest from the bulk of the EP community based on some rather equivocal results in the body of what testing and investigation that has been done so far.

It is certainly a worthwhile project Dr Ernst is investigating though and I'm glad she is offering the standard PVAI as part of the procedure, and not just winging it at this point with doing only a GP-only ablation. I would be far less excited in your shoes to try one of those and no doubt she realizes the same thing.

So what they will be looking for is consistent added improvement over a standard run of the mill PVA with the added ablation lesion spots.

One big question mark that has arisen in similar previous studies is that it's very common to get a better long term result when also ablating some degree of non-PV triggers as CAFE real time focal points, or other anatomical structures that show triggering. The LA surface is very small overall and by the time you do a full PVAI there are not large areas remaining to be ablated except in the outer peripheral regions of he LA.

Often times whether it's technically an internal spot corresponding to an external fat pad on the outer surface of the atria that contains a GP that is zapped, or a spot right next to it or an overlapping CAFE or rotor perhaps and then some improvement is noted with ablation of that area, it's still been very hard to tell if it was actually ablating the GP , or was it the CAFE or the rotor mechanisms that once fully zapped did the trick??

I know Dr Natale's group also has done quite a lot of investigation into GP ablation and they have also found similar ambivalent results so far in pegging the improvements that are typically see in a more extensive ablation to just the GP theory and not being equally plausibly due to addressing the other mechanisms as well.

Often times, especially when a group of relatively typical Ablationists are involved in such a study they can still get quite variable results in terms of consistently solid transmural burns and thus not so durable isolation of the PVs leading to multiple reconnected PVs and often multiple ablations just to get that first job done right to begin with. Often times it appears that simply adding one, two, three or more strategic burns in the close vacinity to the PV as turn and posterior wall can suddenly terminate AFIB that was in full gear after yet another reconnected PV so in effect its not uncommon for some of these added non-PV lesions, once ablated too, wind up providing they final step needed to acheive a durable PV isolation. Even though those spots were not necessarily in the traditional spots of the typical PVAI anatomical ablation lesion pattern.

Often time these extra spots can and do fall over Ganglionated Plexi area, so was it really the GP itself that was the mechanism for terminating that arrhythmia or was it the now confirmed solid transmural PV isolation as a result of that additional burn(s) that was the mechanism of termination as a result of an additional lesion(s) in that proximal area near the PVAntrum or posterior wall that was the relevant factor??

These are the kinds of conudrums that have so far left GP ablation theory on the back burner. The results of targeting just specifically GPs so far just haven't been a that great or reproducible especially outside of the center supporting the theory.

I think its a good idea though in your case because whether or not is an actual zapping a GP or just a key added lesion in an area known to be the hotbed of AFIB triggers, your odds of getting a more solid ablation, particularly for those with longer term AFIB histories is much greater when not limited only to a straight PVAI.

Hopefully, Dr Ernst will learn some interesting and no doubt useful insights during this research as well and that can only be helpful for everyone, even if at the end if the day it turns out that it's no so much the GP mechanism itself that was important, but that those key areas around which GPs are typically found is just a highly active trigger source for mostly possibly for other 'reasons' beyond it being just the GP itself that was zapped.

The PVAI ablation itself pioneered and refined over the years by Natale and his group has wide area lesions sets surrounding the PV Antrums that inherently bisect a few GPs as it is. Sonny Jackman recognizes that and heralds Natale's inherent addressing of some key GP regions as one reason for his great track record of success, but Andrea and other EPs are not convinced that the GP zapping he does deserves near that much credit from their own studies.

He does say they do have some bearing on the issue for sure, but perhaps not so cut and dried as the theory would paint and it's perhaps a more nuanced array of contributing factors that result in such consistently high success rates that Natale and other top EPs achieve. Going after GPs alone as ablation targets is far more risky for failure though, but I see no real harm and quite possibly some real gain by trying Dr Ernst combined PVAI plus GP study

Does she include posterior wall isolation or ablation in her standard procedure? That would be good if so, then adding in a few GP areas as extra targets if you are still not converted to NSR after she finishes the standard part of the procedure is certainly worth the try in my view.

Shannon



Edited 2 time(s). Last edit at 08/22/2014 10:43AM by Shannon.

Peggy,
Dr Jackman has been a long time pioneering AFIB and arrhythmia researcher and has made some key contributions particularly in the earlier days of ablation development with helping to design tools and procedures etc.

While he technically does do some ablations still, that is not considered his main long suit and at this stage he is mostly a respected leader, educator and lion within the AFIB community but not someone doing many hundreds of ablations a year by any means.

His research and stimulating ideas for investigation are his main focus these days at Oklahoma.

Cheers!
Shannon



PeggyM Wrote:
-------------------------------------------------------
> "And does anyone know about the Oklahoma Centre
> (and Dr Jackman) Dr Ernst mentions?"
>
> David, both have been the subject of many posts
> over the years. Search function will turn them
> up. Search the previous forum as well as this
> one.
>
> All the best to you.
>
> PeggyM

David, the trial seems like a great opportunity. I would go for it.

Jim

From what Dr Barrett told me, while there is deliberate scarring around the PVs the tissue that is scarred was not contributing to heart function, so it doesn't matter was my takeaway..

Thoughts from Jackman regarding CFAE and GP as of 2 years ago.

[circep.ahajournals.org]

Shannon,
What you've said rings true - I wish I could do her explanation more justice. I was at the very edge of my understanding for much of our consultation, as she perhaps assumed I knew rather more than I actually did (I get that a lot). I don't know if you had a chance to look at the video of her presentation, but a lot of it is in there. Here's some other things I've picked up from a note she left me:
1. She mentioned that previously she'd probably taken out some GP in doing the PVA, which may have accounted for some of the 'one and done' successes she'd had - same thing as you said, just from a different direction. And yes, the jury is still out - I guess that's why they call it a trial. Except the video does share a slide from Oklahoma showing impressive results, and, as I say, her anecdotal evidence so far is a 90% success rate
2. Her notes have MIGB: image of sympathetic innervation; D-SPECT - I presume this is how they get the accurate positioning of these tiny things
3. You're right about covering a lot of my LA - as it's only 2.5 cm squared, it wouldn;t take much to cover it
4. She mentioned CAFE, but I'm afraid I was lost at that point!
5. Another paper I read seemed to suggest that successful Paroxysmal AF ablations tend to correlate to the number of GPs they discover. Don't quite know why that should be, but perhaps I should be less concerned about the 'downside' she mentioned (that by the end of the study they may discover that they didn't need to zap all of the GPs)
6. She mentioned Natale's approach (and she's worked with him and has a great deal of respect for him) but she was firm that, in my case, I wouldn't want to add to the stiffness at the apex of my heart - caused through the HCM - by doing more burns than is absolutely necessary. She clearly feels we may be underestimating the amount of atrial 'kick' we might be losing, which may affect us all in our 80s!

One last question I've uncovered through an afternoon spent researching the role of GPs: There's a Dr. Prystowsky who apparently questioned the connection between the GP and the GI system, wondering if it could have an impact on gastric function. Given that I have a hiatal hernia and what might be termed a 'nervous stomach', I wouldn't want to be aggravating that!

Thanks for your comments, and that of others, I think I'm inclined to go for it - it looks as though, statistically, the odds will be a little more in my favour.

Researcher,
I understood about one sentence in every three, but it seems to confirm that I should join this trial, given the highly-vagal nature of my AF and the longer-term picture! Thanks for uncovering it. Dr Jackman seems to be right on the cutting edge.

David, I don't see much downside to it as long as it is done in combination with PVI. As noted by Jackman, PVI sites coincide with a lot GP locations (fat pads) so it is being done anyway in conventional PVI ablation already. Outside of the PVs, GP ablation has a lot of similarities with current practices that use isoproterenol challenge to locate triggers outside of PVs. Jackman and Po in fact used isoproterenol in an iterative process as the chemical trigger for AF in their original GP studies.

Hello everyone,
I'm scheduled to have an ablation with Dr. Natale in December in San Diego.
From what I read in this discussion so far, it appears that it may be good to include GP ablation as well if necessary.

My question is: Would Dr. Natale's ablation for me in December include some of the GP's area?

Shannon or anyone who had ablation with Dr. Natale or anyone knows the answer?

Thank you.

Duke

One reason I like my GP in Lexington KY is that he uses some caution and consideration in his work. I may think differently if my Afib starts again but for now after my Feb. this year ablation I am somewhat pleased.
The plan was go in ablate the PV's and any other aberant spots or areas that show up. PV's are almost always a given.

Many of the big name guys do just that, they go in and ablate ALL of the typical problem areas (in general). The success rates for these docs are much better than other great EPs. BUT we may need to consider the long term outcome of agressively ablating lots of healthy heart tissue unecessarily (concerns mentioned in another thread), what about all the scarring in your heart 30 years from now ??? A problem? NO ONE KNOWS YET!

My guy went in found nothing in the pulmonary veins so this time they were not ablated. I was disappointed finding that out but hindsite maybe it is good to not be so overzealous. Need be we can go back later I suppose.

Maybe I am going to be all the better??? Who Knows. I like the idea of having specific targeted areas as discussed for this study vs ablating all the more general trouble areas.

Duke, you are going to get GPs ablated as an inherent part of the Natale PVAI that you are in the cue for so no worries either way ... But keep in mind that Ganglionated Plexi ablation is still a very iffy procedure and Sabine Ernset only has her hunches and hopes at this point, which is fine, but does not really know yet how it will pan out. Hence the trial she is doing to try to find out if it really pans out in the long run.

It s possible too at the end of the day she might discover that it wasn't so much that an area with a GP being ablated helped because of the GP itself, and she might find it was some other influence, or combination of influences, in those regions that has helped? It's just another attempt to try to describe why doing more ablation besides just a PVI so often confers better results than PVI alone.

My point being don't get too far ahead of the train here and by assuming you need to have your GPs specifically ablated to have success. It just so happens you will have a GP ablation as well as part of the extended PVAI, so your are covered either way, but know too that those who pioneered and refined that technique are quite skeptical that the GP ablation part itself has a significant bearing on the outcome.

Getting excellent results from more extensive ablation beyond the PVs is something other elite EPs have worked out quite well already for years. Up to now GP ablation is basically a nice sounding theory that has proven quite frustrating in practice to draw real and consistent cause and effect connection between ablated GPs and consistent improvement in outcomes ... A fact that is often a red flag that said theory may be incorrect or at lesst not complete and in need of modification.

Hopefully, some of the research Dr Ernst is working on now in conjunction with Oklahoma, might at least add to the knowledge base on GP, but so far it still a quite speculative idea as an ablation strategy. It has shown little capability for working as a stand alone target so don't dare agree to a GP-only ablation which I understand Dr Ernst is not even offering which is reassuring.

Frankly, the key to improved ablations seems to be greater skill in delivering more consistently transmural PVAI lesions along with using real time electrophysiology and not just addressing anatomical targets alone with little to no regard paid to any real time triggers discovered by doing actual EP mapping work outside the PVs, as, alas, so very many ablationist still do not do.

Most techniques addressing non-PV triggers, whether they call those extra PV sources CAFEs, GPs, focal triggers, or rotors .. Its more about just branching out beyond the PVI alone and particularly for more challenging cases, as long as that extra work, including expert EP mapping analysis is performed with real skill ,... most of these approaches will then improve outcomes significantly, if for no other reason as they go after other real time targets that would otherwise be missed in just a straight PVI or regular run of the mill form of a PVAI (as opposed to the extended PVAI method refined by Natale and his groups).

Speaking of which, you can search back looking for paper with first author Atul Verma on identifying a good number of GPs commonly ablated inherently in Natale's extended pulmonary vein antral isolation approach protocol, and yet those ablated GPs were still a cause of recurrence at times. That led to more investigation on ganglia by Natale's large research group, as well as by other centers, with not such exciting results and findings from those studies. I know Dr N is not a big fan of ganglia ablation theory. But if it will encourage more EPs to branch out beyond PVI alone it's probably worthwhile even if it turns out more of a case of a blind squirrel finding some nuts anyway just from the extra effort. regardless, with skill hands doing a few extra burns around those highly arrhytmogenic areas of the LA, it should only increase Davids odds of a good outcome and hopefully will lessen the total number of burns and ablations he will need to be done with this business for good!

In any event Duke, since you are in cue with Natale for his modern cutting edge extended PVAI procedure. You WILL be having a good number of GPs bisected by ablation lesions as it is so you get to kill two birds with one stone and won't miss out regardless of the real role GPs might play in the whole equation.

As far as the big fear of making one burn too many that the Europeans in particular have been indoctrinated in as a philosophy, Dr Barrett is very much right and is well supported by extensive studies showing that the histological and morphological nature of these areas in the LA that are included in an extended PVAI are all embryologically the exact same tissue as the Pulmonary vein muscle sleeves and has very little to no contribution at all in atrial contractility. Those followed up long term after having such extended PVAIs have almost universally shown improvement in atrial and overall cardiac function .. not a diminishment ... as a result of a successful PVAI based ablation process.

As I've said many times the better motto should be ' not one burn too few' to get the job thoroughly and successfully done for long term unbroken NSR, rather than the seemingly appealing sounding mantra of the more reticent Euros saying 'minimize the number of burns at all cost' which in practice, ironically almost invariably sucks the patient and EP on an even longer duration process of piece meal ablations that no one can recognize while in the early midst of such a journey.

Some EPs ( Im not referring to Dr Ernst here as I think she is more forward thinking and is truly trying to find what will work best for her) get so wedded to their philosophy that it seems they lose track of whether it's really working worth a darn? Many simply lack the research money and team large enough to really follow up long term to learn either way what is going on.

Everyone would love the idea of a one burn and we are done for life ablation, but its dangerous and can be highly frustrating and very draining for such patients that have to endure the end result of a good number of more reticent, though no doubt well-meaning 'piecemeal' ablation, often just to get to first base.

Better yet, in my book, is more experienced and confident EPs who take a bigger picture view in which getting the job done as efficienty and safely as possible while also achieving durable success in the fewest possible procedures make very good sense. In my experience, and in listening to and studying the results of the more reticent crowd, these folks tend to wind up having to do even more rather haphazard and often repeated burns.. often with repeated reconnections which can occur when you see cases of 4, 5 or even 6 ablations that it not infrequenly takes to put the genie reasonably back in the bottle with this so called 'conservative' and 'cautious' approach and philosophy.

Whenever, and if ever, we can get this all done with elite level long term success with just a small handful of lesions then that would be wonderful, but again we have to be careful too about trying too hard to squeeze a square leg into a round hole too just because we loose sight of the big picture and become too enamored with an elegant sounding theory. , that we wind up always doing one or more burns too few to get the job done, and all in the name of doing the least possible ablation they can get away with even when they aren't 'getting away with it' all that successfully as it is.

Nevertheless, Im glad to see Dr Ernst and more and more EU EPs gradually at least venturing beyond just PVAI or PVI-alone ablation and Dr Ernst in particular seems to be very dedicated to better understanding, and as a young EP in her early 40s I believe, these kind of studies are sure to continue broadening her experience base and make her an even better physician for all her efforts.

Plus David, compared to going to an regular NHS EP , there is no question in my mind that you will be in better hands with Dr Ernst. Just look at it as the total package of the ablation and her skill that is what you are going for and if in the process your case can help her learn more about the role of GPs in the whole process, one way or the other, that is great!

Best wishes Shannon



Edited 2 time(s). Last edit at 08/22/2014 03:39AM by Shannon.

Shannon,
I don't think Duke was suggesting he ask Dr Natale to do only GP ablation. He said 'as well'. FWIW, I would not be interested in a trial that wasn't including PV isolation. But, as we've seen with even the best EPs doing more burns isn't a guarantee that it'll be one and done.

Dr Ernst advised me to think of me process as a two-procedure thing. If the second one isn't needed, that's a bonus. And that's the mindset I will adopt.

I'd also like to draw the distinction between myself and others who post on here. My hypertrophic cardiomyopathy means there's a degree of stiffness in the apex of my heart. Most people here don't seem to have HCM. In my case, therefore, it's important not to risk further damage to the heart's ability to 'kick' when I'm in my 80s (IF the burns lead to a diminution of atrial kick over time - which no-one can say for certain is probable or not). If I didn't have HCM I might be considering more of an extensive set of burns.

Only time will tell and, as Shannon says, doing the GPs gets Ernst/Jackman and Co, closer to Natale/Bordeaux anyway!

Thanks David, yes I didnt think Duke was going for an only GP ablation ( and I edited some of the above post to make that more clear), but I also wanted to urge him and others not to jump the gun too quickly in assuming that ablating GPs automatically is an effective thing and should alway be done. in your case I think its a good idea as noted above, it will only insure you will get more than just a straight PVI and with your many years of paroxysmal history ( if I heard you correctly on the phone) then I think this could be a good thing for you.

And I realize too Dr Ernst is not doing only GP ablations now in any event. The point is its all very interesting and worthwhile to investigate but I want to caution against jumping on the GP bandwagon quite yet based on the rather large amount of prior work on the subject with so far rather equivocal results. Mind you, that doesnt at all mean that something more can't be learned now, but I just dont want people to get overly excited about the procedure itself to the point where they are demanding it be a main feature of their ablation by EPs with an already very good track record and who are already addressing much of those same areas, but perhaps under a different rationale, such as under guidance of direct mapping of active triggers, perhaps during Isoproterenol challenge, and uncover activity in a general area where GP are typically found. Or as in the case of EP s trained doing the extended PVAI of the Natale protocol where the nature of the lesion set used to isolated the PVs and parts of the posterior wall also bisect and zap GPs in those areas,

We simply need a lot more hard evidence than we have now, which is what Dr Ernst is busy trying to test with her trial, before getting too excited about demanding or seeking out a GP-centered ablation procedure. We simply don't know yet, if ablating the actual GP is what causes the generally superior results from doing more extensive nonPV ablation work that is often located in the same highly arrhythmo-genic areas that many EPs already address, and the bulk of what evidence we do have so far shows more of a mixed bag at this point on that question.

If her study shows it is very well structured, as Im sure it will be with Dr Ernst, and the end result shows it to be a very compelling consistent positive outcome with she the procedure she is doing, and if it produces as good or even better results than that of other approaches that already have found good success when ablating in those same areas perhaps as well as addressing other nonPV triggers, then that would certainly rekindle the GP debate again no doubt.

I am always more for chosing an EP based on the track record and experience of the man or women doing the procedure, rather than put too much emphasis on the tools, process or theories they use, especially when the theory is still quite experimental and with mixed signals about whether the target of the theory is really the main driver of success or perhaps just an associated bystander (see the unbridled enthusiasm generated by the buzz over CAFE ablation, the rotors are everything mantra and other such promising sounding ideas that don't turn out to he quite the panacea many had expected when further experience reconfirms the complex and more nuanced nature of AFIB.

Nevertheless, in this regard David you are no doubt in good hands with Dr E and I strongly recommended you seek her out as one of the best EPs I know of in the UK. She is a bright and up and coming contributor to EP and is sure to put her own stamp on the field.

I also wholeheartedly agree with Dr Ernst recommendation to expect two procedures and consider it a bonus when one and done as well. The second one is generally easier than the first, all things considered, should you even need a touch up.

Anyway, I look foward to getting your report when its all over and you are in NSR!

Shannon



Edited 2 time(s). Last edit at 08/22/2014 10:07AM by Shannon.

Hello David - I'm so pleased that your consult with Dr. Sabine went so well. I've always contended as you mentioned that it can't be good for the heart to sustain a large number of burn areas by repeated ablations and I totally agree with you that choosing and elite EP with lots of hands on experience and successes makes the most sense.

I certainly wish you well in December.

Jackie

Shannon,
Absolutely agree with you re getting overly excited about GP ablations. That's why they call it a 'trial', I guess. People shouldn't assume this is the way to go until the papers are published and peer-reviewed!

Jackie,
How fantastic to hear from you again! I trust you're on the road to recovery - hopefully, you will have no more scar tissue following this latest adventure. You were one of the early ablation trailblazers - the rest of us are just standing on your shoulders.

Thank you Shannon and David for your input.

David, you are correct that I meant to ask if GP is part of the PVI ablation with Dr. Natale as well.
Shannon, thank you for clearing things up like always. I guess Dr. Natale would include the GP ablation as well if he sees that it's necessary, as part of his ablation procedure once he's in there.

And Jackie, I'm so happy to read from you again. I wish you a speedy recovery and endless NSR.

Duke

You are welcome David and Duke,

And yes Duke, with the extended PVAI ablation that Dr Natale and all members of his group perform, the ablation of a number of GPs is inherent in the procedure itself. but that is more incidental to the pathway of the circular lesion sets around the PVs and the posterior left atrial wall which bisect these GPs during an extended PVAI, rather than as a specific target intended just to hit the GPs.

On top of that, they always do real-time electrophysiology to determine if there are any other trouble spots that, if so, and such non-PV triggers are ignored, will lead to a quick return to the table for more work in a follow up procedure.

Many EPs and protocols when doing a PVAI or PVI will not do much real time EP work at all to speak of while they are in there, and its strictly a 'get in and get out' anatomical procedure in which once bi-directional PV isolation and exit block is confirmed, that is the end of the procedure.

Alas, many less experienced EPs are not all that skilled at doing extensive real time EP sleuthing in any event, and thus not all EPs are equal at recognizing, and then knowing what to do with, many non PV triggers ... assuming they are even looking for them to begin with. Hence, yet again another major reason to go for the best you can arrange for yourself and don't settle for the most convenient EP nearest one's bus line, just because a local cardio of GP is referring you to such an EP.

Shannon



Edited 2 time(s). Last edit at 08/23/2014 06:09PM by Shannon.

BTW - that's a great video explaining current state of play!