Sabine Ernst presentation

Thinking about Robo 11's decision between Sabine Ernst in the UK and the Bordeaux team, I came across this presentation by Dr. Ernst. I thought it was worth sharing. <[www.youtube.com]

George

Interesting, no mention of diet being a trigger.

That is a good post George, a very good presentation, and also an honest one about the downside of making burns on the Atria.

What is the downside of "making burns on the Atria"? I'd watch but it's 25 minutes ..

They've found that some of the lines people were putting in to mimic a Maze procedure were diminishing atrial contractivity.

Thanks..

The 1st 7:30 of the video covers this area, then it moves on to more recent advances that she talks about incorporating into the procedure.

All-

I talked with Shannon about the this video clip last evening. Not to diminish the good intentions of Dr. Sabine... just wait until Shannon is free from his immediate obligations and he'll provide important and current insight.

Put all your thoughts or conclusions on hold until he can elaborate on several erroneous and misleading statements.

Jackie

Sabine Ernst is a very well meaning and caring physician and a smart physician and I would have no qualms about recommending her for paroxysmal ablation case, perhaps even foremost among UK EPs I am aware of, but after hearing several of the comments on this video posted above which I saw first several weeks ago, I can no longer offer the same degree of enthusiasm as a persistent or more long standing complex paroxysmal ablationist as I would the very seasoned experts such at Professors Jais and Haissaguerre in Bordeaux.

She makes a similar statements popular in certain EU centers, in lumping together in what I feel is too broad of an association , a few of the most extreme and quite rare unwanted consequences and outcomes that typically only show up in very occasional cases of persistent AFIB patients most often after having gone to EPs who are either under-experienced and/or wedded to a reticent piece meal step at a time ablation philosophy process. As a result, these patients who inadvertently find themselves in the middle of such a piece meal strategy, and infrequently wind up requiring 5, 6 or more ablations, and particularly when the first half or more of those are done by under-skilled EP's who may lack the kind of experience necessary to do the kind of more extended procedure most often successful in such cases, typically it is from this group that these quite rare outcomes such as 'stiff LA syndrome', pulmonary hypertension or a functional loss of 'atrial kick' (the later a more minor issue than the first two) can arise.

These relatively rare complications tend to happen from such a compilation of undergoing too many procedures often too by multiple different EPs over time as the disappointed patient switches from one to another after repeated failures. This kind of ad hoc process with a ton of duplication and repeatedly re-covering ones tracks all over again often using different strategies and all overlapping the same areas can result in gradually covering almost all of the LA and much of RA with what eventually results in a kind of carpet bombing effect.

This scenario is 'Exhibit A' in why a persistent or long duration persistent and even some highly symptomatic paroxysmal patients's best decision and effort is to start and finish their choice for ablationist with only the most experienced and successful ablationists you can arrange for yourself. Choosing those whose primary practice entails persistent AFIB ablation every day and who take a broad view of the process beginning with a targeted deliberate step-wise process that is not at all an indiscriminate torching of everything in sight. At least such patients should do whatever is within their means and power that they can, if at all they can afford to travel and as is so oftenis required, to reach such elite level persistent AFIB ablationists for the best chance at an excellent long term result in a minimum of procedures and with excellent safety and very low risk of significant complications.

Patients of top tier elite ablationist such as Pierre Jais or Michel Haissaguerre at Bordeaux and Andrea Natale and select members of his group as well as David Callans at Penn, DJ Lakkireddy at University of Kansas, and a number of others (apologies to all the other qualified ablationists not mentioned here) in the US and elsewhere, do not experience these kind of unwanted complications as anything close to a common outcome. Unfortunately, in the opening section of the video above I feel the scope of those few complications were paintd with much too broad a brush by Dr. Ernst in her comments. Such complications are exceedingly rare from the top level and most experienced persistent operators, especially when the patient begins their ablation process with them and is not just arriving at their door for a final shot at repair and resolution after more than a handful of prior mix-mash ablations that were unsuccessful.

Natale's group, as well as Bordeaux, has done very extensive investigation and follow up research over the last decade into the long term outcomes of ablation work beyond the pulmonary veins, when called for, and these issues that are made to sound like some major disaster in the talk are not at all common occurrences in cases of expertly performed more extended ablation protocols addressing specific targets, as needed and found during real time Electrophysiology discovery.

Again, its worth emphasizing that this is especially true in patients who went to these top flight elite ablationists from the outset of their ablation process, in which event, typically a large majority of even very challenging cases are routinely rendered functionally cured in one, two or at most a relatively rare three procedures being required for long term freedom from all arrhythmia and off all AAR drugs. And with the second and third ablation, when they are required, almost invariably being minor touch up procedures requiring only a small handful or less of new lesions in very targeted areas and rarely requiring extensive redo work on previously ablated areas that have reconnected .. at least with the true maestros in the field.

These statements on this issue were carbon copy repeats of scare tactics applied far too generally to any work beyond PVI-only ablation that I have heard from some others with that outlook and that you hear on occasion at conferences and from certain other European centers or EPs as justification for why sticking to a strict PVI-only approach is the prudent thing to do. Even though, ironically, so often this strategy is what eventually winds up causing a persistent patient to have to undergo far more procedures and increases the nevertheless still small risks for those very complications like pulmonary hypertension and stiff LA syndrome where the LA isn't pumping much at all ... and which is the common state of affairs in persistent AFIB to begin with.

The casual dismissal of all CAFE approaches too, implying they all cause too much random destruction of myocardium and thus lead to these problems, is similarly misleading and does not even distinguish between a broadly empirical CAFE strategy in which all CAFES discovered at <120ms are ablated, from the much more targeted approach that advanced top level ablationist use to help address only those CAFEs demonstrating repeatable ectopy triggering.

Keep in mind, though, this talk was intended for an audience of EPs and it's perfectly appropriate to discuss these rare findings for sure. But it's important too to keep them in the context supported by the evidence and not run wild with speculations that fly in the face of existing evidence and the long term experience seen so far without some solid evidence of one's own to support those broad concerns beyond just one's hunch or projections about the future that are not supported by what is now known.

You hear these kind of comments at every conference expressed from certain groups of EPs almost invariably those with very little to no first had experience venturing much beyond a basic PVI and is part of the healthy debate within those walls, but unless you are there at those conferences too, you don't get to hear four or five of the following presenters, and often very renowned EPs, get up and refute or reframe the comments of the first presenter in a manner that gives more balance and real world context.

Again I think Dr Ernst is a fine and caring physician and is Up and coming in her still blossoming career, and that she has inherited the typical 'less is more' philosophy that is always appealing sounding at first blush is not surprising... wouldn't we all love to be able to cure challenging persistent AFIB with one or two burns ... coming from her European training where such a perspective is common.

It's clear too, though, that she recognizes PVI alone is not sufficient in many cases with her main focus now exploring the possible contribution of Ganglionated Plexi or GP ablation as an adjunct to PVI. Hopefully Dr Ernst's research there will lead to her finding an adaptation of extra PV ablation targets that work well too and when she can show solid evidence of that, I will be more than happy to recommend her again for more complex ablations beyond more straight forward paroxysmal cases.

I'm sure she would be a fine follow up EP in the UK though Mark after your procedure with Dr Jais or Haissgeurre in Bordeaux, but I strongly urge you to make the effort to go to get yourself to those tried and true ablationist in Bordeaux with such a potentially challenging case as yours certainly appears to be from all of your history. In the EU, ablation registries list very few EPs that are doing persistent AF ablation and far fewer still with long standing AFIB. But Bordeaux is one oasis there that really does have a good long term track record for just these kinds of challenging cases.

Also, please don't worry about some catastrophe happening in Bordeaux during your ablation that might require some emergency open heart surgery you can't afford. The odds of that are so vanishing remote you are more likely to buy the farm on the fllight over, or on your drive to the Royal Bromptom for a local ablation than you are to wake up in Bordeaux with a cracked chest. Don't make such an important decision based on such an unlikely and extremely remote ,'what if'.

You want an EP to start and finish your ablation process in a case like yours, who will know when to stop once they are confident they have quelled your AFIB to the best of their ability both during the procedure and for the long term, but also one that knows how to extend the procedure in a deliberate and careful step by step manner, when that becomes necessary, to achieve that goal while keeping the big picture and your hearts health in mind as any top elite level ablationist will do.

Shannon



Edited 6 time(s). Last edit at 09/27/2014 09:33AM by Shannon.

"Sabine Ernst is a very well meaning and caring physician and a smart lady and I would have no qualms about recommending her for a straight forward paroxysmal ablation cas"

She's scary IMO but then so is the NHS

Hi Afhound99,

I do have to admit to being a bit disappointed in hearing some aspects of her talk at Qatar as noted above. But I dont doubt she is sincere and has a genuine interest in her patients and in learning to do the best for them. She is still an up and coming ablationist building her practice too and discovering what will work for her and I have hopes that her viewpoints will expand with more experience and research .. perhaps her current focus on GP ablation will open some of those doors to more extended ablation targets beyond just a PVI, even if she finds the GP centered ablation targets are some what of a variable mixed bag as so many others have found previously, but if she and Sonny Jackman can offer some added insights into how to target GPs as parts of an extended process beyond the PVI for persistent and complex paroxysmal cases then that will be great. The very skimpy evidence shown so far is a long way from demonstrating any kind of lasting repeatable and long term net positive impact, but Im all for the continued research there and see where it goes.

Alas, a recent RCT study that was released at Barcelona ESC recently and it has several key structural problems in the very set up of the trial, in my view, the purpose of which was reportedly to compare PVI-only to PVI+ CAFEs and PVI+Linear Lines as two well known more extended procedures beyond just PVI alone for persistent AFIB to see which method was really superior.

Unfortunately, they used a very odd and skewed allocation ratio arbitrarily allocating the 590 some odd persistent patients to a 1:4:4 allotment ratio with only 64 patients being assigned to the PVI-only group and 4 times that number to both the PVI +CAFEs (254) and PVI+ lines (250) groups, instead of dividing all three groups 'Even Steven' right down the middle three ways which is what they should have done if a common sense comparison of the three methods was truly desired. This is a good example of how numbers can sometimes result in a skewed outcome and interpretation, even though inadvertently and with well-meaning intention.

The implied rationale for using such a screw-ball allotment ratio was 'because we all expected the two extended groups to do better based on the fact that the prequel study they did a couple years ago did do better, and in prior studies extended ablation has consistently shown an advantage for persistent patients' ... so from this very weak rationale for messing with an even allocation, they automatically stacked the deck anyway in favor of the PVI-only group based on an up front assumption and bias of superiority for the more extensive methods, and thus they wind up taking a stab at what 'might' be a good guess as to the proper weighting to use! That is a real stretch fraught with possible built in inherent errors from the outset baked into the results.

Talk about skewing the game with loaded dice! If there was some other end point target other than a direct comparison of which of the three methods were really best, then just 'maybe' they would have slightly thicker ice to skate that odd ratio of assignment for each group out onto, based on such a preconceived assumption. But the main goal of this study was a straight-up comparison of the three methods to see which one had the best results inherently and what their respective risk burdens were... you don't stack the deck in such a case unless one is so focused on the minutia during set up of such a study and so intent on accounting for every little variable that they wind up over analyzing the issue and going way overboard as here, and thus missing the forest for all the trees.

The designers of this study then compounded that error, in my view, by recruiting a large multinational group of EPs from 48 mostly small to modest sized centers in most small to modest size countries ( which on the surface sounds reasonable if your main aim is to want to see the end result from these procedures in more typical ablationists hands that the average local afibber might run into in these moistly small countries, and if you are not looking for a clear example of the best possible state of the art examples of all three methods to determine which method is inherently superior when done with consummate skill). In addition, outside of the Southlake group in Canada and Dr Macles group, there were not a large number of centers and EPs recruited for these trial ablations who are renowned for a large track record of dedicated persistent AFIB ablation experience and prowess, and thus a minority fraction of the whole group of EPs doing all three classes of persistent AFIB ablations were what we would call 'highly skilled' previously in doing these more extended segments of a persistent AFIB ablation beyond just the PVI alone.

There were none of the bigger high volume world-renowned elite level persistent AFIb ablation centers or EPs recruited to perform the most challenging extended ablation methods in the two PVI+CAFE AND PVI+LINES groups. And yet, both of those extended techniques require real added skills beyond those implied in the PVI-only group that all the EPs were at least familiar with, even though with varying degrees of skill at doing the PVI alone as well.

But at least in the PVI portion of each group that was a common denominator in terms of general familiarity level among all three groups and the majority of ablationists in this cohort of EPs selected were, by definition, much more comfortable on the whole doing the PVI portion of the ablations required, than were those who were being asked to, in more than a few cases, stretch their skills and experience level to also include discovering and ablating a predefined and prescribed technique for CAFEs and Linear Lines in addition to the PVI, some of whom were doing the more extended segments for the first times.

Little wonder then that the study showed no real statistical difference for any of the three methods of PVI-alone, PVI + CAFEs or PVI + Linear Lines, yet with a slight straight numerical edge to the PVI-only group ... A result which flies in the face of a number of other previous studies, including the actual prequel stage study of this very same STAR AF I trial done a few years ago in which a smaller, yet on the whole more experienced, group of EPs with collectively a greater experience level in performing these more extended persistent ablations addressing substrate targets beyond the PVI alone, which achieved just the opposite results showing that the more extended persistent ablations beyond just the PVI alone showed a significant advantage over PVI-alone in persistent AFIB ablation which is entirely in agreement with multiple other prior studies showing the very same outcome.... and also what has been clinically found to be true time and again in real world results.

In any event, it's too bad the authors of this study in their zeal to pronounce the results a major advance in our understanding went more than a bit over the top, such that they recommend now immediate abandoning of extra PV ablation and only doing PVI alone, even for persistent AFIB, simply based on the results of this one questionable study, which is another clear example of how the bright glare of being in the spot light can overshadow good common sense and a careful analysis of what these results might really suggest ... even by very smart and well-meaning physicians.

It's unfortunate, too, that one of the key members and spokesman of the trial who was one of the more experienced ablationists with extensive ablation work as well in this STAR AF II study, did not bother to even attempt to explain why this result flies so entirely in the face of not only their very own prior STAR AF I study, which was done to demonstrate the process and baseline for the study, and which even though had a smaller overall number of ablations done, still showed the very opposite results with a statistically solid advantage of the more extended approach to persistent AFIB, that has also been confirmed by most of the well done previous studies on this topic, and also confirmed by the first STAR AF I study results as noted.

Any careful analysis of this scenario and the study structure would instantly poke some holes in these results, and at least demand more confirmation before suggesting even thinking of changing guidelines.

However, one problem that may really be hard, I can imagine, for the authors to to acknowledge and admit is that they claim this was a 'highly experience group' of EPs used to do all the persistent AFIB ablations and yet they had 48 some odd small to modest size centers used in 12 mostly smaller-sized countries (China, Canada, UK and Germany being the few bigger countries with one or more centers involved).

The majority of the the EPs involved are not from centers renowned for large numbers of persistent AFIB ablations, thus its unreasonable to expect a majority of the operators in this study to be 'highly skilled' at doing non-PV ablations during their own daily practice before joining this trial. And yet, it's no secret that AFIB ablation is a very skill and experience dependent procedure, and even though much effort is being made to make it less so with new mapping technologies and contact force catheters etc, nevertheless for all the advances so far, there is still a very steep and drawn out learning curve in this very demanding procedure, all the more so with substrate ablation beyond the PVI alone.

Why on earth did they not use say the top five to ten persistent AFIB centers in the world as their source of ablationists since, by definition, they are all experts in paroxysmal PVI ablation as well? And then allow each expert to employ, and describe in detail, the exact methodology they used for the more extended non-PV ablations that they have found most successful at the cutting edge of this field.

Then they would have had a true multi-center study using genuine experts in ALL facets of the protocols being performed, and showing real world examples of the results from best practices for each method, while eliminating the major issue of operator experience as even a question mark, especially with more challenging cases beyond the anatomical-only PVI-only portion of the procedure.

In short, what they are assuming, perhaps inadvertently, in this study is that any modestly experienced paroxysmal AFIB ablationist is fully capable of achieving the same kind of results in persistent AFIB cases as can the famous Bordeaux team, or the very few Dr Natales' of the world and some of his top protege's like Drs Lakkireddy, Pinski, Burkhardt, Gibson etc and Dr. Callans and Marchlinski at U Penn etc., and quite a few others so who are well known experts in these more extended procedures that many of these operators in this study were apparently not overly familiar with doing in their daily practices, and some not at all, prior to this study. Assuming, I suppose, they the overall results should equal that of the very best in the world simply because they gave them a cookie-cutter recipe to follow step by step for the extra-PV ablation work.

That implied assumption doesn't make much sense to me.

When looking at the centers used, in the study and the EPs there is obviously a broad mix of experience and talents, and yet it is simply stretching the mark and being a bit too generous in my view when insisting the majority of these operators where 'highly experienced' with persistent AFIB cases prior to this study. Admittedly, I hold a very high standard for persistent AFIB ablation from my own, and so many others here, direct experiences over many years.

A relatively smaller number of the EPs in this study do have a solid body of experience in such extended ablation work previously, but the majority were, by no means, 'highly experienced' extensive persistent AFIB ablationists in their daily practice with large numbers of such cases under their belts. At least not with my criteria for being 'highly experienced' in such challenging cases.

But even looking beyond the issue of operator experience per se, the limitation of a fixed CAFE and Linear lines protocol that had to be repeated exactly if any

Regardless, actual results reported in this study were quite mediocre in any event and yet a few have been trumpeting the study as proof, at last, of their 'less is more' mantra when it really shows just the opposite when honestly looking at all the variables and built in 'gotchas' in the study design.

After two procedures allowed and still 11% on AAR drugs at the 18 month mark with no more AF/Flutter or AT (atrialtachycardia) only 60% of the PVI-only group met that end point.. this includes all those who needed a second ablation and those requiring still ongoing anti-arrhythmics! Freedom from all arrhythmias at 18 months for the PVI +CAFE group was 50% with 12% still on AAR drugs and 48% for the same conditions for the PVI +Linear Lines group with 12% on AAR drugs at 18 months. Those results are nothing to write home about.

Those are not very impressive results at all, even if fairly typical for less than the top persistent AF centers including the more elite level high volume operations who do a lot more of this kind of work. But for the most experienced persistent ablationists, given two procedures for those who need a touch up in the first year, the best operators achieve in the 80% to 85% and off all AAR drugs at 1 year for even long standing persistent AFIB and a bit higher for straight persistent AFIB when accounting for the second touch up procedure when needed.

Just look at the many anecdotal reports over the years here on our site from Bordeaux and Dr Natale as reflected in the overwhelmingly positive long term outcomes from those patients just coming through our site alone who have gone to France or to Dr Natale, or selected proteges of his groups over the years, for complex ablations and who have frequented our forum for so long. These major centers have a wealth of experience and long term results over the years demonstrating the constantly evolving positive long term outcome from venturing beyond just the PVI alone when dealing with persistent AFIB.

All efforts to make those non-PV targets more effective and efficient as Dr Ernst was discussing, and that all the top persistent EPs are constantly pressing the envelope forward on, are very welcomed and these efforts are ongoing developments from Texas to France to the UK a like, and many points in between.

What this study really does, in my view, is serve is a solid confirmation of what he have preached here for years, that when it comes to persistent and more challenging long standing persistent cases there is little substitute for choosing the most experienced ablationist you can find.

In closing, though, i want to reiterate that I feel Dr Ernst is a solid EP with a very bright future in the field. This is a very challenging field and there are many new developments and discoveries yet to be made and so I applaud her dedication to the this work and appreciate many of her insights on other key issues in this field.

Yet in light of my strong support for her as a local alternative for UK patients based mostly on the input from a couple of EPs, and from reading her excellent book I purchased on 'Cardiac Anatomy for Electrophysiologist' , I now must temper that enthusiasm a bit after hearing her viewpoints on the specific topics mentioned in the beginning of this threads video clip George posted from the otherwise very interesting Qatar talk.

Primarily its just the too broad of a brush used to paint those concerns about the specific complications in what amounts to a fairly small number of ablation patients, most of whom had too many overlapping ablations over time, and the exaggerated implication that these kind of complications are found commonly in more extensive ablation process is where I have my disagreement. Hopefully that will change in the future and that I will find good reason to once again support a more open ended approval for the whole gamut of ablations done there. I will try to seek her out at the upcoming large conference in the beginning of the year and get a more nuanced impression of her views on this controversy.

Regardless though, I feel certain that Dr Ernst would be an excellent follow up EP in the UK as it is, or for doing paroxysmal ablation which I trust she is very capable and skilled at performing. She may well still be my number one choice for persistent AF in the UK if there is no way circumstances would allow a British patient to travel to Bordeaux for ablation. However, when UK patients do have the option and ability to go to Professors Jais or Haissaguerre for persistent or challenging ablation cases, that would be my strong preference and recommendation still at this time.

This reply was dictated last night into the big sized new iPhone 6 I picked up last week, and did so just before bed (BTW, this new Iphone works great with AliveCor app too), but I simply wont have time to address this issue much more until after Oct 8th to 9th, give or take a day or two, after which I will have the latest AFIB Report finished and out to press.

Shannon

Shannon, thanks for all of that. I've kinda got Ernst penned in for myself in my own mind as and when I require an ablation. Thankfully I'm a straightforward paroxysmal nocturnal LAFr and, as such, should be in good hands.

Mike F (UK)

You are welcome Mike,

I was reluctant to even bring any of this up at first, but decided to share my two cents once it became a topic. My hesitation to try to convey all of the above was because its a subject that is rather complex and requires following a lot of different trails and avenues along the way to appreciate how this kind of split in viewpoints among otherwise very intelligent physicians has occurred.

And when I heard what I felt was simply going too far with the projections about a few rather rare complications, with the kind of comments that you mostly hear only from certain factions of EPs who typically don't really have much personal experience in doing these more extended protocols to begin with, and rarely, if ever, get to see first hand during careful follow up the real world results of these more extended ablation protocols beyond the PVI alone that the top docs who specialize in these procedures see every day in their practices.

As such, I just could not stay silent and let what I see as a skewed perspective based on little more than a guess or hunch really that reinforces the preconceived philosophy of those who are preaching these dire warnings and implying they are the result of even expert persistent AFIB ablation beyond the PVI alone, which is simply not true in any way shape or form, go on without a contrasting rebuttal. The idea that such complications are or will be a common outcome from even expert persistent ablations that include work beyond the PVI is not at all supported by the majority of current persistent AFIB literature over time.

As noted above, those issues raised in the Qatar talk video occur quite rarely, and when they do they are most typically seen in those having been stuck on the merry-go round or far too many piece meal ablations being required and still not a satisfactory result.

One of the top EPs in the world shared with me recently a story of a man who came to him after having had 6 previous ablations and he was still rocking and rolling with a combination of AFIB/Flutter and when he went in to start repairing the situation, he discovered that all 4 PVs were fully active and not one of them remained electrically isolated and disconnected from communication with the left atrium!!! And he had gone to 3 different EPs, each doing two a piece before he would move on to someone else in his neighborhood who he hoped might have better luck and all in the Los Angeles area with a couple of them at rather well known medical centers! How that is even possible that after 6 ablations all 4 PVs would still be connected reflects truly mind-boggling.

Not only were all four PVs not isolated even though each ablation he had was simply a repeat PV Isolation ablation with no real venturing beyond the PVs as each of these EPs apparently only felt comfortable sticking with this anatomical only PVI method when this fellow had multiple active targets firing from the posterior wall, LA septum, SVC and coronary sinus (CS). so even had they dont a perfect PVI only the first time they still would not have addressed his full problem.

As it was, even after 6 ablations this man had undergone before he finally, and gratefully, made his way to this expert maestros' table, the expert EP had to first do an effective PVI once and for all before going on to address the other non-PV triggers and finally end the man's battle with the beast.

Thankfully, and luckily, this man has shown no signs of excess stiff LA or pulmonary hypertension as of the one year follow up in spite of this last one being his 7th, and so far still solid procedure. However, this is the kind of scenario where the risks of those kind of complications increases for sure and obviously this man would have been so much better served had he been fortunate enough to find this site early on, or have had a wise and well-connected cardiologist or primary EP refer him to a real expert and not just put him on the merry-go-round of most convenient local ablationists.

Fortunately, these kind of extreme stories are becoming less common as ablation technology and experience continue to progress, But it is still not rare enough as indicated by that large survey of 93,800 ablations done in the US from 2000 through 2010 that showed >81% of them were done by mostly what amount to chronically inexperienced ablationist doing less than 25 ablations a year and small low volume centers doing less than 50 procedures per year which is too low a number to maintain much less build on one's innate manual muscle memory that is so key toward becoming a more proficient AFIB ablation EP.

That finding still floors me every time I think about it! And it shows how many people will just blindly follow whoever their local physician refers them too for an invasive procedure on their heart without hardly a second thought or any real investigation into the qualifications and experience level of their ablationist ... amazing really.

And it is from these kind of marginal results, largely from this majority of under-experienced ablationist data pool, that those front line cardiologist and EPs who are still so reluctant to recommend ablation, even when it makes good sense, have derived their real world but very skewed impressions from. In a good number of regions, the frontline referral physicians really have seen a very mixed bag of results from ablations in their patients and its entirely understandable why they are so reticent to recommend it except as a last resort. But unfortunately , they simply have not seen the bigger picture, and the vastly better picture, when directing their patients only to highly experienced EPs at top high volume centers for a much brighter outcome for the lions share of their patients.

I feel confident Dr Ernst will do a bang up job for you with your paroxysmal case Mike, and she is at the top of my list among those UK EPs I am familar with, for heading such a procedure. The fact that she is dedicated to the Ganglionated Plexi GPablation research beyond just hte PVI alone, is comforting too in that her ability and understanding of when that adjunctive approach might well make the difference, beyond the PVI she will do at the outset, gives her a better chance for success too should she discover some significant triggers after the PVI is complete around some of these GP locations and ablate them too.

You may well have a small to normal size LA diameter as it is, and if so, your odds of having a successful outcome even from just one procedure are very high indeed. The same is true for basic persistent cases ( as opposed to long standing persistent cases) in that careful patient selection in choosing only those with normal to smaller LA diameters and without too long a persistent history, can really up the odds of a PVI alone working well in such cases too.

What you get with a highly experienced group such as Dr Natale or Bordeaux, as the two most elite examples I know of, are EPs who will do only what is needed in your case, whatever it presents and nothing more, while also being fully capable and alert to address any non-PV sources when they are proven to show a high probability for current and future triggering of more mischief. With an EP like that, you truly get the real 'less is more' end result at the end of the shortest possible ablation process your heart will demand whether that is one, two or on the outside three procedures rarely for the most challenging cases .. and whatever it takes to get the job done safely and with the best state of the art odds now available.

Cheers!
Shannon



Edited 2 time(s). Last edit at 09/29/2014 09:43AM by Shannon.

Well, since I have an ablation scheduled with Dr Ernst, I feel like I've got to defend her against some of the things being said about her and in the case of the AfHound99, the things being said about the National Health Service.

I give talks for a living. If every comment I made was pored over, and extrapolated as her comments in the talk have been here, I'd be horrified. Way too much inference, I think. Second, unlike most people who are commenting upon her, I've actually had a consultation with her, and found her to be an exemplary professional. She absolutely believes that diet plays a big part in many people's AF - towards the end of that talk, she points to her dedication in finding out 'what triggers the trigger?' She's pioneered the use of magnet-guided catheters, and despite her relative youth, has developed a fine reputation.

She actually believes that 'more is more, not less' but up to a point. As Shannon points out, her new approach is to do more burns than simply the PVs. I'm going to be treated as part of a clinical trial - because she- and the other EPs running the trial -need empirical data that informs the cost-benefit trade-off of doing more burns. I think she should be applauded for this - she's not in any particular US vs Europe camp on this (besides it's too simplistic to separate approaches on geographical grounds). In my case, she recommended the additional GP burns for me as a good option, because to do more might add to the stiffness that I've already got through my Hypertrophic Cardiomyopathy. Although the trial is still in progress, her anecdotal view was that she believes this approach - which is using cutting-edge nuclear imaging to find the trigger hot-spots - is realising 90% 'first and done' rates. Even something less than this is highly desirable for me.

For UK patients, I find it hard to accept that no UK ablationists should be trusted with the procedure. As good as the Bordeaux and Natale professional are there are simply not enough of them to fix the people in this world who need fixing. Besides, as Sabine Ernst said to me, we've been living with only incremental improvements in 1st time ablations for a long time now - she is trying to do something different using the latest technology, and cooperating with skilled practitioners and researchers from around the globe. I'm grateful people like Dr Ernst are looking to make breakthroughs in success rates, and I'm more than happy to put myself in her hands (after Shannon's recommendation, for which many thanks!) Even the best treatments have occasional complications (as Shannon found out dramatically after his Natale treatment) There are no guarantees no matter how good the professional.

As for the NHS: for UK patients, it is impossible to be treated in Bordeaux without paying for it yourself. For my Dr Ernst process with absolute cutting-edge facilities, I pay nothing. I had successful prostate cancer treatment at Europe's largest, newest oncology centre, here in my home town of Leeds. I know the mainstream US media became fixated on scare stories during the Obamacare Bill hysteria, but most were simply not true. Waiting lists? Well, I had my first consultation with Dr Ernst in September - I'll be treated within 12 weeks of that date. The wait-time for cancer treatment is even shorter. I'm not sure too many privatised systems can beat that.

We're pretty cynical about our politicians in this country - with good reason - and have little faith in most of our institutions, but repeated polls show exceptionally high support for the maintenance of a National Health Service free to anyone living in the UK, regardless of their income or insurance. I, for one, am very proud of that.

Hi David, I'm sure you will do splendidly with Dr Ernst. And as I noted previously she remains my top choice in the UK. I also applaud her investigations into non PV triggers and GP ablatiion as its will very likely lead her into more productive and yet targeted extended ablation methods beyond just the PVI to the benefit of her more challenging patients going forward.

It's certainly true too that one's comments in any given talk can take on a more rigid or all inclusive connotation than one intended, for sure, and after hearing just a few of her comments about her projected fears of pulmonary HT and stiff left atrium syndrome as associated with too many repeat ablations, I felt the need to bring those rare complications down to a more reasonable real world degree of concern and not at all as a common consequence of more expertly applied more extensive ablation. Knowing that the comments in her talk likely don't reflect the full breadth of her insights on the issue, I noted too that I look forward to meeting her soon, hopefully at Orlando AFIB conference if she attends this January, and hopefully have the chance to discuss her views further with her.

I was speaking with Dr Natale yesterday here at Scripps La Jolla after my 3DTEE about the mistaken impressions in some circles, especially some EU centers on more extended beyond PVI alone work and he said that very few Europeans even attempt long standing persistent Ablation (most EU EPs. and many in the US too, will typically just park a long-standing persistent case on a cocktail of drugs and anticoagulants and never even attempt to get them out of AFI and that many of what are classified as regular persistent AF in the EU are really what we would classify here as more progressive paroxysmal cases. As such, it is noit always an apples to apples comparison when some of these international studies from many small to modest size centers are discussion their persistent cases compared to the generally more challenging levels that qualify as persistent AFIB among more elite high volume centers that specialize in these more difficult cases and thus very naturally see a far larger percentage of their total case load being these more advanced cases often referred to them from all over the world.

This relative lack of in depth experience with these more challenging cases, combined then with what is largely just assuming that more extended ablation won't work, has left the majority of EPs in some circles with little to no true first hand experience in doing more extended cases properly and successfully so far, and yet it is clear that Sabine really is exploring beyond the PVI which is much to her credit, particularly when that goes a bit against the common view over their.

Just one little anecdote she shared on the stiff LA issue, which is almost never seen in expert persistent ablation results, except occasionally in people who finally make their way at last to such experienced persistent ablationist, after having had too many piecemeal repeat ablations which continue to avoid the real remaining triggers, is that you can eliminate the risk of stiff LA not only by proper targeting of these added areas of ablation but with, for example, posterior wall ablation and other similar areas, using a diagonal angled approach with the ablation catheter right next to the mapping catheter and dragging it across the areas of the posterior wall to reduce the amplitude of triggering. With this approach you simply will not typically see the stiffening of LA contraction at all.

This important nuance in technique that would never be learned if an EP never expanded their horizons, and continued only with a near perpendicular catheter tip angle to the posterior wall tissue and pressing straight down into the tissue which, when addressing the posterior wall, could potentially impact mechanical function to some degree and also make complications like the dreaded esophageal fistula more of a risk as well ... are a complication Dr Natale, as a prime example, has thankfully never experienced in the many thousands of challenging cases he has successfully ablated.

It's these kind of details in understanding and experience that make all the difference in the world between a maestro level operator and those less experienced EPs who often were mentored in a center where they rarely, if ever, did more challenging cases and did not benefit from such cutting edge instruction. Quite naturally they would not have a direct first person feel and understanding of what such procedure can achieve and thus are much more prone to being influences by others many of whom are just as in the dark about the outcome of these methods, when properly applied, really are.

While I wanted to clarify those few comments in her video talk that I wish had been worded a bit differently, I also trust my efforts to emphasize my respect for Dr Ernst were clearly conveyed as well. I do feel she is a bright and capable EP and likely the best option in the UK and at her age is only going to get even better, and for your case too David, she is no doubt a fine choice. I've also heard from others what a kind and caring doctor Dr Ernst is which is always a big plus.

You are right too David, even with the very best, unexpected things can happen in any medical procedure, yet in my Lariat leak case the stroke had nothing to do with any operator error in installation of the Lariat which Dr's Burkhardt and Natale had achieved in perfect fashion as demonstrated on two subsequent TEEs where it remained perfectly sealed. In addition, at the time prior to me undergoing the Lariat Dr Natale had gone out of his way to emphasize all the possible known risks from this then very new procedure, and repeatedly told me that there was much we didn't yet know, but that so far complications are more in the frail and elderly and it was clear I met all the criteria for it as a potential long term benefit in my case which remain true today as well.

Once I had the suprise late leak and stroke, it was Dr Natale who not only insisted I fly to Austin the next day, after inmmediately putting me on Eliquis, but it was he that also discovered the leak even on a 2D TEE done in Austin at the time when the highly experience TEE cardio there felt there was no leak. It was simply not clear on 2DTEE . But Dr N felt sure he saw a suspicious indication of an LAA leak and then urged me to come to Scripps for both advanced MRI as well as 3DTEE for a second expert opinion which did clearly reveal the leak so that I could get it fixed.

Had Dr Natale not stuck with his conviction that he saw what he felt was a evidence of a leak in my LAA and had he not sent me to Scripps, I would definitely still be at real risk for another stroke, if not already have had one by now. That is what choosing an EP with such immense experience buys you, someone who will go against the grain and override a written analysis of a scan, and a decision which spared me from no doubt more dire consequences.

Yesterday, I got the great news that the Amplatzer plug is still perfectly sealing my LAA, as we expected, but it is super to confirm that nonetheless! Dr Natale's group is going to do a paper on my case to highlight the need for more frequent first year TEE testing for Lariat patients and to emphasize the until now unknown requirement to use only 3DTEE in order to discover and repair such leaks when, and if, they occur. Austin now has and is using 3DTEE to screen all Lariat patients as is.

Best wishes David in December
Shannon



Edited 1 time(s). Last edit at 10/04/2014 03:53PM by Shannon.

Shannon,
That's great to hear that there's no longer a hole in the bucket! And I can think of no better subject for an academic paper - perhaps he might just out-source it to you to write

Shannon,

Glad to hear your plug still seals your LAA and that you are doing well. Does this mean you are free from having 3DTEEs too or will you have to have more until the year is up?
Best wishes for continued good health.

Betty

Hi Betty and David, thanks for the kind best wishes. Well, it's a big step toward freedom from all the 3DTEEs but not quite yet...I have to return in 4 months which will be just over 6 months from my ADOII plug procedure at Scripps. Dr Price wants me to get another 3DTEE then in early February to make sure everything is well sealed over and the device is basically embedded by that time in my own endothelial lining covering both the outer disc of the device facing the inside of my LA and the tiny deployment female screw extending out very slightly into the left atrium from the center top of that metal mesh disc. That small screw could but with a very remote possibility be a perch upon which a small thrombus could form so long as metal screw is still exposed to the direct LA blood flow.

It takes a full six months to be sure full endothelial encapsulation takes place, and as such, although I can stop the Eliquis in under 3 weeks now on Oct 25 which marks three months since my LAA leak was plugged, Dr Price also wants me then to continue on for three more months taking both one 75mg Clopidegrel (Plavix) plus an 81mg baby aspirin until the next 3DTEE at Scripps in February. The Plavix plus baby aspirin is simply for anti-platelet aggregation effect while there is potentially still any amount of the metal disc or screw exposed directly to prevent any possible little embolic bubbles forming. Once that TEE reconfirms all is well, as again it is fully expected to, I can then drop the Plavix once and for all and go back to my normal natural supplemental blood thinning agents like Cardiokinase, Omega 3, Pycnogenol etc that have either or both anti-platelet aggregation function as well as endothelial growth and repair support.

So, while the saga is not quite over yet, a big milestone was crossed this past week toward hearing the Fat Lady sing for real before too much longer! Dr Price was really thrilled by how what he called 'perfectly' my plug was seated within the 5mm diameter hole causing the leak back too and from the LA and LAA. A complete leak seal as well, so that is really good news.

I'm very grateful too that Dr Natale had the insight and vision to detect that leak in the original 2DTEE in Austin right after the stroke. All but probably a tiny handful of EPs would have accepted the finding of the highly experience TEE expert cardiologist who felt that the 2DTEE did not show a leak, while Dr an even the next day said he felt certain he say evidence of a leak. I could so very easily have been sent home with being told there was no Lariat leak and having no idea where the stroke came from and likely would have had another and quite possibly much more damaging stroke already as well! I've been counting my lucky stars lately.

Shannon

Take care, Shannon



Edited 3 time(s). Last edit at 10/05/2014 01:05PM by Shannon.

I used to give scientific talks too and I think too much is being read into what Ernst said in the video. She reviewed Middle East ablation procedures, likely King Faud hospital, and made some comments with regard to how procedures are being done there in comparison to the latest standard of care. It takes skill and experience to go beyond PVI. The main caution is disconnection of the Bachmann bundle. New mapping tools and methods are giving new insights into what's happening during AF. There is still a lack of understanding of how AF starts.

...and that's why I'm happy to support the clinical trial looking into 'what triggers the trigger'!

Shannon and David,
Many thanks for the very interesting and informative discussion and all the best to you David with your upcoming procedure with Prof. Ernst and looking forward to reading all about it in due course.
Cheers,
Mike F.