Beware of keen but inexperienced EPs!

Today I had my annual checkup at King's College Hospital in London. I have been in nsr since my ablation and touch up in Bordeaux 11½ years ago but I get huge numbers of ectopics.

I usually see a Consultant EP that I work very well with but he has moved to another hospital so I saw a new one, young and keen. During the discussion I told him that if ever AF recurred I would want to be referred back to Bordeaux. To my astonishment he said "I wouldn't do that, I would do the ablation myself".

I though this was rather arrogant - it's my decision, not his, so I asked him how many he had done. He avoided the question and told me that the department now does 6 a week. So I asked again how many he had done. He answered "A hundred". So in my eyes he is a novice, keen to get his numbers up. The final blow came when he told me that it wasn't his practice to do annual checkups so he wouldn't be seeing me again. End of the line, I am cast adrift from good advice.

I am so glad that I have the information from this forum. Without it I wouldn't have known the questions to ask and the answers to expect. I would never let this man near my heart, and he confirmed my decision to go to Bordeaux if ever I need more treatment.

Beware!!

Gill

Sounds like my dentist trying to break into Endodontics

Gill,
what kind of ectopics you have pacs , pvcs ?
Are you free from sleep apnea which might contribute to afib and ectopics ?
[www.afibbers.org]

Ben

Ben

AF recurred three days after my first ablation so Professor Haissaguerre did an immediate touch up. He suspected that one of the veins might have reconnected but that was not the case. There was an extremely toxic focus in the coronary sinus which was extremely difficult to find and ablate, and he said that he wasn't sure that he had been able to get all of it. I suspect this is what is causing the ectopics.

They are atrial, and used to be very uncomfortable, but taking magnesium, potassium and taurine dampens them down so that I hardly feel them.

Gill

Hi Gill,

Contrast your experience with that of David Price with Sabine Ernst!

Wow, quite amazing.

George

Be glad and count your lucky stars this new fangled EP said he won't be seeing you again Gill!

Its stunning the level of misinformation there exists among some doctors ... this is why we always urge a high level of discrimination when choosing and ablationist or even just an EP to listen too. You can easily get a can of worms if you are not vigilant and rather demanding ... all of which you can be while being perfectly courteous and kind even to the clueless EPs out there one might run across.

Just thank them for their time and run for the hills!

Shannon



Edited 1 time(s). Last edit at 08/29/2014 03:57PM by Shannon.

Shannon

He also told me that Bordeaux's long term success rates for persistent AF were not good, and that I had been very lucky. I asked him which piece of research he was referring to and he just said "Bordeaux's own publications".

From what I have read this is certainly not the case. What is your view?

Gill

Hi Gill,

First of all, this rather misinformed 'newbie' doesn't even have a track record with persistent AFIB with only 100 total ablations under his belt .. if that many. At least in the US, EPs usually aren't asked, nor do they seek, to address persistent AFIB, at least solo, until they get further along the learning curve. He is just talking out of his hat kind of like a puffer fish who puffs up his body to make him look a lot bigger and meaner than he really is to other big fish.

Bordeaux does more persistent ablations in a day than this fellows medical center does ablations of all kinds of AFIB in a week and they have the best published track record in Europe for those kind of cases.

Your mention, Gill, of the heavy ectopics you still get and it's possible relationship to a not yet completely isolated coronary sinus (CS), and that idea could very well have merit. I'm not sure how long ago Prof Haissaguerre noted your particularly toxic and difficult to quiet down CS, but in more recent years, Bordeaux too has gradually been doing more LAA ablation work and even some LAA isolation from what I have heard, which is often an entirely necessary step to achieve full CS isolation too, and a quiet heart in more challenging cases.

The CS and LAA are very closely related and just as in my case of LAA isolation, my ablation report read: "LAA isolation was completed to the distal CS". Meaning the CS and LAA often have to be isolated as a 'two-fer' and its often not possible to get a fully satisfactory result until both structures are isolated. And it works both ways, not infrequently while isolating the CS suddenly the LAA becomes isolated, and vice versa, so closely the electrophysiology of these two structures are inter-connected.

I'm glad to see Bordeaux doing more LAA work now too as otherwise it can take quite a few more procedures to get the most difficult jobs to quiet down. Professor Haissaguerre at the last Boston AFIB conference in Orlando last January said that they have confirmed that the three most arrhythmia-genic sources of AFIB are the PVs, posterior wall of the LA and the LAA. It thus only stands to reason that completely ignoring one of the 'big three' as, alas, so many EPs still do, will leave a big hole in one's track record for successfully addressing challenging cases.

Of course, not all persistent cases have significant LAA involvement, but a good many do and that likelihood only increases with age and as well as with the intensity and duration of AFIB burden.

This is something too that Dr Natale has found over the years and why he has focused so much on perfecting the LAA/CS isolation protocol as, not unlike Bordeaux, Natale sees so many more challenging cases than do most centers and the vast majority of more typical EPs addressing just one local area of population. These relatively few elite EPs that get such a huge load of tough cases referred to them from all over the world will, by definition, see a much larger percentage of folks needing to have their LAA and CS isolated for true success to be achieved.

I suspect if you were to have to return Bordeaux any time in the future, Gill (knock on wood), after all the work you have had over the years, that they would indeed very likely focus on shutting down triggering from both the LAA and CS, just as would Dr Natale if, theoretically, you were in the US and were go to him with a history such as yours.

Also too, while the need for LAA isolation increases with both duration and degree of AFIB and also with advancing age, it is even more commonly required in females over males for a given age, particularly as we get older.

Best wishes,
Shannon



Edited 1 time(s). Last edit at 08/23/2014 11:00PM by Shannon.

Shannon

>>I'm not sure how long ago Prof Haissaguerre noted your particularly toxic and difficult to quiet down CS<<

It was in January 2003. He said that he isolated the pulmonary veins, did the roof line, and the line from the LIV to the mitral annulus. He said after the first ablation that he had done everything that it was possible to do. So I think he did not attempt to isolate the coronary sinus, just ablated the focus he found there during the second ablation.

I have always suspected that, as he said at the time, he wasn't able to get all of it, and that that is the cause of the many atrial ectopics that I get.

At times I get little runs of tachycardia as well, but nothing that bothers me - the magnesium/potassium/taurine combination dampens the ectopics so I hardly feel them. If things stay the same I am content, but if anything changes for the worse I will contact Bordeaux. I now have an AliveCor and will take readings if the ectopics get to be bothersome or if I suspect there is any AF.

Gill

Gill,
As George mentioned, I have had a very different consultation with Sabine Ernst and the staff from the Royal Brompton Hospital. But, prior to my decision to go for ablation, I had good treatment at the Heart Hospital. Both hospitals are in London and I live in Leeds. Under the NHS you have the right to be treated wherever you choose.

Given the arrogance of the EP you saw, I would seriously consider switching hospitals!