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Interesting Blog from Dr. John M
Posted by LarryG
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Re: Interesting Blog from Dr. John M August 28, 2014 06:30PM |
Hi Tsco,
Please do not overly worry about 'extreme fibrosis' as a long term consequence of skilled AFIB ablation itself. There have been quite a few very solid studies on this question showing an overall net improvement in atrial function as a result of ablation even at 5 years later, and there in NO good evidence to the contrary longer term, in spite of what some speculative alarmist would have us believe.
Dr John said a couple of irresponsible points, in my view, in what was otherwise a very good article with much we can all agree on in terms of adopting a better diet and nutrient repletion program and well as reduce stress, improve moderate exercise fitness and avoid alcohol at most two drinks or more a day to make a real significant improvement in many folks in terms of reduced AFIB Burden. That is all common sense.
However, when Dr John, with what feels like a newly converted acolyte's zeal about life style and weight lose and BP reduction etc, goes way overboard in stating that this study shows 'AFIB is optional' and can certainly be avoided if one just tries hard enough, that is an overstatement of by any measure, and you will be hard pressed to find anyone, more than many of us here at afibbers.org, that are more dedicated and positive about the benefits for minimizing AFIB in many cases and improving overall health by these same core principle's of life style and dietary improvements that we preach tirelessly here since the start of this forum over 14 years ago.
However, it is just a gross exaggeration and oversimplification that undermines the varacity of the several very good points Dr John otherwise made in his article to state that AFIB is now 'optional' if everyone could only work hard enough at it'. Look at how many very fit and health conscious afibbers have none-the-less had to get an expert ablation like myself and so many others here as well, to ultimately stem the tide of arrhythmia which, if left poorly addressed, is THE biggest source by far of widespread indiscriminate fibrosis and scarring and often in areas that really do impact contractile functioning long term.
I totally agree with Dr J that teaching patients to take care of themselves and helping them find the tools to learn how ought to the the foundation of every initial exam where its clear the person needs those changes to their lives, and in most all areas of medicine dealing with chronic diseases of aging, but to make like its an almost defacto cure all or only cause of AFIB thus making it 'optional', only waters down the credibility of his appeal in my view.
Even in the small Australian study, in another case of exaggerated hyperbole, he calls this study "the most significant breakthrough information in decades in cardiology and indeed medicine, when it's hardly new or novel at all. Looking at the study, it noted that 14 of 75 participants in the control group had to get ablations while 10 out of 75 people in the weight loss and myriad life style modifications had to have ablations in spite of all the relative, and in some cases temporary improvements they got from all of their heroic efforts. That is still a good improvement in any event and about what one would expect, but that is a far cry short of making 'AFIB optional'.
And it is this loose use of language at times that make some of Dr Johns articles occasionally seem mixed reading to me, I so often want to slap a big 'high five' to his palm when reading some of his good points, and yet then he often throws a big dose of ice water on that whole feeling with statements like that, which only confuse and, in some cases, add totally unnecessary fear and vacillation into patients who may not know better.
That is what he did as well by his dropping in the off the cuff speculation about 'what is going to happen in 20 years with all the AFIB scars' comment without also counterbalancing that speculation with the honest truth that so far, with some 16 years now of AFIB ablation history on the books, we have yet to see these dire consequences in left atrial function appear in the vast majority of ablation patients. That is the truth.
There have also been a number of very well designed and investigated studies showing a longer term improvement in left atrial function as compared to pre ablation functioning which, itself, causes more wide spread and less targeted scarring and fibrosis as well as electrical remodeling degradation due to ongoing AFIB ITSELF.
Some factions of well meaning cardios, and a smaller number of EPs that were too reticent for their patients good in my view, have been making this claim from the very beginning of AFIB ablation history, and which now borders on fear mongering based on what we have seen over the last decade and a half. Early on, these factions of cardiologist said, 'the jury is out on ablations and lets see how peoples hearts fare in 5 years time etc etc'. Well, its now 16 years with a large body of evidence and the overall results land strongly on the side of a net overall benefit for the patient in terms of atrial function and improved quality of life.
Even so, now the nay sayers, including some part time ablationists that should know better, or should at least be more careful in how they word things, like Dr John in this case throwing more fuel on that fire just to try to make the good point that its always a good idea to do everything you can to reduce your AFIB burden as much as is possible with good life style, dietary and exercise choices which I gladly salute him for reinforcing.
Perhaps Dr John is mostly only speaking to the other EPs and Cardios as his expected audience who he may rightly feel, in many cases, might still need to get the basic message that so many of us patients instinctively know already for a very long time .. that you very much can make a real impact on reducing overall incidence of AFIB and in many cases reduce AF burden considerably in a good number of those who already have AFIB.
However, in my view, such comments like the 'AF is now optional' breakthrough only undermine their own credibility to a degree with careless statements like that, or "what are these AFIB scars going to do to us in 20 to 30 years" without even beginning to place all that in a deeper and more accurate context of reality and what we now do know about AFIB ablation in the here and now of 2014.
If you are having serious and significant enough longer duration episodes and to be qualified for an ablation, your odds of avoiding some, so far, totally speculative very long term undefined risk from these scars changing their character in the late elderly heart, you are much better off stopping the long term scarring from the AFIB first and foremost rather than worry yourself into even more stress endives episodes about a very unlikely consequence that has no currently defendable mechanism for appearing in 30 years based on what we know now. And remember, a large majority of AFIB ablation patients have been over 50 when they got their ablations during this 16 year period of AF ablations and a large number in their 70s and even late 80s in age. And yet, we still don't see hordes of cardiomyopathy directly from ablation scars showing up anywhere yet.
Ironically, those that listen to this reticent philosophy are the very ones that are most apt to wind up having and needing 4 to 6 or more ablations along the way, and likely all of them with a piece meal method with only doing a few burns and get out and hope for the best approach if they don't find a better option. It is those with many more procedures on the books that stand much greater odds of added fibrosis and scarring in any event. Certainly beyond those who go to a more knowledgable and skilled EP who can typically get even the most challenging jobs done and over with for the long term with one, two or at most three procedures.
I just hope Tsco you do not worry too much about all this and 'what if' kind of speculations about the distant future. We might all have an asteroid fall on our heads in 30 years too or Yellowstone volcano might blow as well. The point being that if you suffer from on-going arrhythmia, you are not avoiding a bigger fibrosis and scar issue way down the road by avoiding an ablation on that basis. Just the opposite in fact., your odds of insuring a far great likelihood of extensive fibrosis and scarring spread potentially all over the left and right atriums only increases the longer your life with unresolved or poorly resolved AFIb/Flutter goes on.
As the old Indian Hindu saying goes: 'it often takes a small targeted thorn to remove a much larger problematic and potentially dangerous thorn'. And yet in the case of an expert ablation process needed to quieten AFIB long term, those intentional carefully targeted scars are almost all done in areas of the LA that have very little direct impact on atrial contractility and thus atrial function.
There have been some overzealous EPs carpet bombing the whole LA in wide swaths that rarely but occasionally have impared LA function to a degree that show up right away, but that is not at all the result of highly skilled appropriately extensive ablation technique by top EPs who know what they are doing.
Not to mention, the extreme stress on one's life experience over the next 30 years by enduring such episodes of unresolved AFIB solely to avoid the remote possibility of some unknown mechanism leading to unexpected consequences from ablation related scars. Most AFIB ablation lesions take place in tissue that is morphologically and embryologically identical to the Pulmonary vein muscle sleeve and has very little to no role in atrial contraction to begin with, further undermining the speculative guesses about what 'might' in a long shot happen some several decades from now when a good many of us will likely be pushing up daisies in any event.
Im really hoping you are done already now as it is Tsco. And Im sorry too you have had to endure a number of right atrial flutter and tachycardia ablations before your first, and so far only, AFIB ablation this past February. Your case has been a challenging one for sure and your initial more targeted right atrial flutter/tachycardia ablations happened at a time long enough ago when they were all just starting to gather all the data to learn what they have learned now in the last couple years, that its best to start and end with a PVAI, rather than go first through the the right atrial targeted ablations first in such cases as yours. And then any touch ups in the left atrium that might be needed to button down the whole process can finish things off for good.
In closing, I really do enjoy reading Dr John as a doc and overall journalist, he is a very good communicator and as you said Tsco a very nice guy no doubt. But its these occasional literary reaches he offers often in the midst of very solid points otherwise, that make me wince at times. Even though I often agree with his overall premise. Im sure I would enjoy speaking to him over some spritzer (non alcohol
and I can imagine he could well be a good bedside manner doc too.
Cheers!
Shannon
Edited 4 time(s). Last edit at 08/30/2014 12:23PM by Shannon.
Please do not overly worry about 'extreme fibrosis' as a long term consequence of skilled AFIB ablation itself. There have been quite a few very solid studies on this question showing an overall net improvement in atrial function as a result of ablation even at 5 years later, and there in NO good evidence to the contrary longer term, in spite of what some speculative alarmist would have us believe.
Dr John said a couple of irresponsible points, in my view, in what was otherwise a very good article with much we can all agree on in terms of adopting a better diet and nutrient repletion program and well as reduce stress, improve moderate exercise fitness and avoid alcohol at most two drinks or more a day to make a real significant improvement in many folks in terms of reduced AFIB Burden. That is all common sense.
However, when Dr John, with what feels like a newly converted acolyte's zeal about life style and weight lose and BP reduction etc, goes way overboard in stating that this study shows 'AFIB is optional' and can certainly be avoided if one just tries hard enough, that is an overstatement of by any measure, and you will be hard pressed to find anyone, more than many of us here at afibbers.org, that are more dedicated and positive about the benefits for minimizing AFIB in many cases and improving overall health by these same core principle's of life style and dietary improvements that we preach tirelessly here since the start of this forum over 14 years ago.
However, it is just a gross exaggeration and oversimplification that undermines the varacity of the several very good points Dr John otherwise made in his article to state that AFIB is now 'optional' if everyone could only work hard enough at it'. Look at how many very fit and health conscious afibbers have none-the-less had to get an expert ablation like myself and so many others here as well, to ultimately stem the tide of arrhythmia which, if left poorly addressed, is THE biggest source by far of widespread indiscriminate fibrosis and scarring and often in areas that really do impact contractile functioning long term.
I totally agree with Dr J that teaching patients to take care of themselves and helping them find the tools to learn how ought to the the foundation of every initial exam where its clear the person needs those changes to their lives, and in most all areas of medicine dealing with chronic diseases of aging, but to make like its an almost defacto cure all or only cause of AFIB thus making it 'optional', only waters down the credibility of his appeal in my view.
Even in the small Australian study, in another case of exaggerated hyperbole, he calls this study "the most significant breakthrough information in decades in cardiology and indeed medicine, when it's hardly new or novel at all. Looking at the study, it noted that 14 of 75 participants in the control group had to get ablations while 10 out of 75 people in the weight loss and myriad life style modifications had to have ablations in spite of all the relative, and in some cases temporary improvements they got from all of their heroic efforts. That is still a good improvement in any event and about what one would expect, but that is a far cry short of making 'AFIB optional'.
And it is this loose use of language at times that make some of Dr Johns articles occasionally seem mixed reading to me, I so often want to slap a big 'high five' to his palm when reading some of his good points, and yet then he often throws a big dose of ice water on that whole feeling with statements like that, which only confuse and, in some cases, add totally unnecessary fear and vacillation into patients who may not know better.
That is what he did as well by his dropping in the off the cuff speculation about 'what is going to happen in 20 years with all the AFIB scars' comment without also counterbalancing that speculation with the honest truth that so far, with some 16 years now of AFIB ablation history on the books, we have yet to see these dire consequences in left atrial function appear in the vast majority of ablation patients. That is the truth.
There have also been a number of very well designed and investigated studies showing a longer term improvement in left atrial function as compared to pre ablation functioning which, itself, causes more wide spread and less targeted scarring and fibrosis as well as electrical remodeling degradation due to ongoing AFIB ITSELF.
Some factions of well meaning cardios, and a smaller number of EPs that were too reticent for their patients good in my view, have been making this claim from the very beginning of AFIB ablation history, and which now borders on fear mongering based on what we have seen over the last decade and a half. Early on, these factions of cardiologist said, 'the jury is out on ablations and lets see how peoples hearts fare in 5 years time etc etc'. Well, its now 16 years with a large body of evidence and the overall results land strongly on the side of a net overall benefit for the patient in terms of atrial function and improved quality of life.
Even so, now the nay sayers, including some part time ablationists that should know better, or should at least be more careful in how they word things, like Dr John in this case throwing more fuel on that fire just to try to make the good point that its always a good idea to do everything you can to reduce your AFIB burden as much as is possible with good life style, dietary and exercise choices which I gladly salute him for reinforcing.
Perhaps Dr John is mostly only speaking to the other EPs and Cardios as his expected audience who he may rightly feel, in many cases, might still need to get the basic message that so many of us patients instinctively know already for a very long time .. that you very much can make a real impact on reducing overall incidence of AFIB and in many cases reduce AF burden considerably in a good number of those who already have AFIB.
However, in my view, such comments like the 'AF is now optional' breakthrough only undermine their own credibility to a degree with careless statements like that, or "what are these AFIB scars going to do to us in 20 to 30 years" without even beginning to place all that in a deeper and more accurate context of reality and what we now do know about AFIB ablation in the here and now of 2014.
If you are having serious and significant enough longer duration episodes and to be qualified for an ablation, your odds of avoiding some, so far, totally speculative very long term undefined risk from these scars changing their character in the late elderly heart, you are much better off stopping the long term scarring from the AFIB first and foremost rather than worry yourself into even more stress endives episodes about a very unlikely consequence that has no currently defendable mechanism for appearing in 30 years based on what we know now. And remember, a large majority of AFIB ablation patients have been over 50 when they got their ablations during this 16 year period of AF ablations and a large number in their 70s and even late 80s in age. And yet, we still don't see hordes of cardiomyopathy directly from ablation scars showing up anywhere yet.
Ironically, those that listen to this reticent philosophy are the very ones that are most apt to wind up having and needing 4 to 6 or more ablations along the way, and likely all of them with a piece meal method with only doing a few burns and get out and hope for the best approach if they don't find a better option. It is those with many more procedures on the books that stand much greater odds of added fibrosis and scarring in any event. Certainly beyond those who go to a more knowledgable and skilled EP who can typically get even the most challenging jobs done and over with for the long term with one, two or at most three procedures.
I just hope Tsco you do not worry too much about all this and 'what if' kind of speculations about the distant future. We might all have an asteroid fall on our heads in 30 years too or Yellowstone volcano might blow as well. The point being that if you suffer from on-going arrhythmia, you are not avoiding a bigger fibrosis and scar issue way down the road by avoiding an ablation on that basis. Just the opposite in fact., your odds of insuring a far great likelihood of extensive fibrosis and scarring spread potentially all over the left and right atriums only increases the longer your life with unresolved or poorly resolved AFIb/Flutter goes on.
As the old Indian Hindu saying goes: 'it often takes a small targeted thorn to remove a much larger problematic and potentially dangerous thorn'. And yet in the case of an expert ablation process needed to quieten AFIB long term, those intentional carefully targeted scars are almost all done in areas of the LA that have very little direct impact on atrial contractility and thus atrial function.
There have been some overzealous EPs carpet bombing the whole LA in wide swaths that rarely but occasionally have impared LA function to a degree that show up right away, but that is not at all the result of highly skilled appropriately extensive ablation technique by top EPs who know what they are doing.
Not to mention, the extreme stress on one's life experience over the next 30 years by enduring such episodes of unresolved AFIB solely to avoid the remote possibility of some unknown mechanism leading to unexpected consequences from ablation related scars. Most AFIB ablation lesions take place in tissue that is morphologically and embryologically identical to the Pulmonary vein muscle sleeve and has very little to no role in atrial contraction to begin with, further undermining the speculative guesses about what 'might' in a long shot happen some several decades from now when a good many of us will likely be pushing up daisies in any event.
Im really hoping you are done already now as it is Tsco. And Im sorry too you have had to endure a number of right atrial flutter and tachycardia ablations before your first, and so far only, AFIB ablation this past February. Your case has been a challenging one for sure and your initial more targeted right atrial flutter/tachycardia ablations happened at a time long enough ago when they were all just starting to gather all the data to learn what they have learned now in the last couple years, that its best to start and end with a PVAI, rather than go first through the the right atrial targeted ablations first in such cases as yours. And then any touch ups in the left atrium that might be needed to button down the whole process can finish things off for good.
In closing, I really do enjoy reading Dr John as a doc and overall journalist, he is a very good communicator and as you said Tsco a very nice guy no doubt. But its these occasional literary reaches he offers often in the midst of very solid points otherwise, that make me wince at times. Even though I often agree with his overall premise. Im sure I would enjoy speaking to him over some spritzer (non alcohol
and I can imagine he could well be a good bedside manner doc too.
Cheers!
Shannon
Edited 4 time(s). Last edit at 08/30/2014 12:23PM by Shannon.
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