Welcome to the Afibber’s Forum
Serving Afibbers worldwide since 1999
Moderated by Shannon and Carey
 |
 |
 |
 |
 |
 |
Home
>
AFIBBERS FORUM
>
Topic
A "Touch Up" sounds so simple and non-invasive.
Posted by Chuck Connors
|
A "Touch Up" sounds so simple and non-invasive. April 11, 2015 04:13AM |
Registered: 12 years ago Posts: 107 |
I'm having a difficult time understanding why some people refer to a 2nd or 3rd ablation as a "touch up". It's as if you had your engine (heart) overhauled during the 1st ablation and now need to go back just for a "touch up" (change the spark plugs or oil). The reality, as I understand it, is that a 2nd or 3rd ablation requires all of the preparation, intensity, duration, medical attention, personnel, expense and follow-on care as the 1st ablation. Why would one want to minimize what's really involved by simply referring to it as a touch up? Am I missing something here? Thank you for shedding some light on this. -Chuck-
|
Re: A "Touch Up" sounds so simple and non-invasive. April 11, 2015 07:10AM |
Admin Registered: 11 years ago Posts: 2,779 |
Hi Chuck, good question.
When I, and others, refer to a touch up, it is not to minimize the obvious disappointment in needing to go one more round, but to underscore too the very real and major difference in selecting the best possible ablationist you can to guide your ablation process to begin with to insure the least number of procedures your condition of AFIB might require to finally be rid of it for the long haul.
As such the term 'touch up' is especially to indicate a follow up ablation as part of a process with an elite level EP in which the ground work was largely laid successfully so, in the first index ablation and any follow ups that might be needed ( and which tend to not exceed two or and occasionaly three procedures with the most experienced EPs but very rarely any more than that) and in which each touch up truly entails a limited amount of burning and further work in the left and/or right atriums.
The point being that say looking at Dr Natale for example, very rarely will any follow up or touch up to one of his index ablations will require any at all or more than one to two true reconnected lesion repair of anything he already ablated in the first ablation. This is a huge difference from the more typical EP most of whose ablations are of a simpler nature to begin with and often limited to an anatomical PVI or PVAI alone and which almost invariably when the typical average EP and even many very good ones, have rework to do, it entails a good deal of repeat ablation over the very same areas and lesions they tried to fully address in the first ablation.
You will not find this to be the case in the vast majority of Dr. Natale's patients where the lions share of any further work is typically found to be new trigger sources not yet mature enough during the index ablation to rise above the considerable 'noise floor' of the un-ablated, yet highly fibrillating heart. Even after drug challenge with isoproterenol at the end of the index ablation, it is not uncommon that latent signals are still too dormant either due to not being mature enough such that they are sufficiently suppressed due to the general anesthesia used during the first procedure to discover during them during that initial drug challenge. As such, these undetectable triggers wont make themselves known while still on the table during round one, and only are discovered in the next follow up touch up or even third ablation at times to get every last one.
Or course, even mediocre EPs have a good number of these undetectable triggers appear too after their own index ablations, but so often these new triggers in their follow up cases are to often masked to some degree or just not addressed at all by EPs who most often just repeat entirely the entire PVI or PVAI as their main strategy when going in for round two or three, four or five etc etc.
This is the big difference between a true touch up procedure as part of an 'expert ablation process' as compared to a more typical reload and fire again approach in which far too many EPs are not skilled enough to consistently preform a fully transmural PVI over PVAI anatomical only ablation, and much less are the majority of EPs skilled enough to even seek out non-PV triggers that require real time EP work outside their ablation comfort zone and that are not around these PVI/PVAI anatomical well-defined structures.
As such, embarking on an ablation journey with progressively lesser experienced EPs is signing up for an indefinite process often including quite a few full repetitions of nearly the entire first ablation over and over in hopes of finally getting a fully transmural PVI which will then typically work longer term only for those with the most basic paroxysmal cases and/or to a less degree of success with those who are early persistent cases who still have small left atrial diameters. These class of ablation process are much closer to what you question above Chuck when you presume its bascially the same amount of work, stress and intensity as the first ablation which is much closer to the true case with many less experienced operators compared to the most experienced top tier ablationists in which follow up tend to be limited to true touch up level work.
If you are like many on our board with more extensive atrial disease or condition of remodeling, the majority of EPs doing ablations will not be able to offer you much help beyond this anatomical approach that too often requires too many repeats of too much of the work that already should have been successfully sealed off and done.
Yes, the preparation and often travel back to the center and being on OAC drugs etc is similar. Though more often now we carefully ferret out who will likely need a 'touch up' in the first 3 to 6 months or so when the person is more likely to still be on an OAC drug anyway and with the newer OACs starting and stopping them are not as onerous as with Coumadin.
No one wants to have a follow up or touch up by any name you choose to call it, but make no mistake, there is a major difference between making the best choice for yourself up front to minimize not only the total number of ablations each person might require to end the affliction for then long term, but also too insure that the huge majority of the work is over with and done correctly and holds tight for many years to come from the first ablation, and thus any more work that is needed is generally truly of a limited 'touch up' nature.
If you read the ablation reports of Dr Natale patients for his index procedures versus his follow up work with him as I have done many times, you see the stark contrast in how few burns are typically needed in any touch up with him, versus looking at both index and follow up ablation reports from many other EPs and the much larger amount of work most often required in these follow up ablations by more typical operators, and how many of them include substantial redo of the primary anatomical PVI/PVAI lesion sets.
This is why the impact on you, as a patient, in spite of the obvious hassle and temporary disappointment in having to go back for a follow up to begin with is so largely lessened and assuaged with a Natale or Bordeaux follow up touch up, as two examples, with the patients invariably having a much easier time of it in round two and even three when needed, compared to the index ablation.
Less burn time equals much faster recover typically, and with the well trained staffs and you having been through it all before at least once, are all mitigating factors for sure during any follow up with a true expert ablationist and their staffs doing mop up duty as the finishing touches on what we all emphasize here is an 'ablation process'.
For as long as I can remember, that has been our mantra here repeated often to new ablation prospects going into their first procedure. That it is good psychology and a the best approach to consider you will need two ablations, and possibly a third with the first being a big one and the other one or two more like touch ups and much less work done to complete your AFIB journey successfully.
And if, instead, you get done in one which a good number do, especially among those with more garden variety paroxysmal cases to begin with, then consider it a big bonus!
That is the honest truth of our collective experience and the vast majority of us who have gone through their whole process while keeping the long view firmly in mind, even during the middle of the process when it occasionally can be tough to keep that larger perspective in view, this big majority of us will reaffirm how worth it all the whole process has been when making a good choice on who to guide your process long term.
It really is much more like the car tune up analogy you use above. With a highly skilled EP the first one is the major overhaul and any touch ups are generally mostly just that and fine tuning the engine and dealign with new little leaks that were not apparent during the first one of even that may, in part have appears only after a given lesion set was laid down in round one to stop the AFIB which may have unpredictably set up a focal tachycardia or flutter circuit that now needs addressing as well.. this is what is most typically seen in Natale touch ups, that and those remnent low level triggers that were suppressed by the anesthesia or high noise flow of the index ablation.
I hope this run down clarifies for you Chuck the big difference I am pointing out. A touch up is generally not as intense or nearly as involved as is an index procedure either for the EP or the patient when the EP you started out with and who handles the rest is a really good one.
Even the waiting in bed six hours to move your legs tends to go faster the next time around and the pain or discomfort is almost always a good deal less. or certainly not more that round one. And rarely is the recovery any where near as long as the index ablation due to the huge reduction in actual burns made in true touch up procedures. Thus',the term 'touch up' is just about the best one for describing what typically happens when your index ablation was an excellent procedure by a very experienced operator.
We all bring to the table a unique puzzle to solve that the EP must deal with what ever we present to him or her, and not surprisingly our group attracts a large number of more seasoned Afibbers who tend to have longer term AFIB, or worse cases, than is found at some of the more boards with more general superficial coverage of these topics. As such, we tend to see a more complex mix of cases reported here, and yet we also see a very high level of happy campers long term in spite of the lousy nature of this condition that requires us to have to go through this gauntlet to get rid of it for good in any event.
Shannon
Edited 1 time(s). Last edit at 04/11/2015 07:29AM by Shannon.
When I, and others, refer to a touch up, it is not to minimize the obvious disappointment in needing to go one more round, but to underscore too the very real and major difference in selecting the best possible ablationist you can to guide your ablation process to begin with to insure the least number of procedures your condition of AFIB might require to finally be rid of it for the long haul.
As such the term 'touch up' is especially to indicate a follow up ablation as part of a process with an elite level EP in which the ground work was largely laid successfully so, in the first index ablation and any follow ups that might be needed ( and which tend to not exceed two or and occasionaly three procedures with the most experienced EPs but very rarely any more than that) and in which each touch up truly entails a limited amount of burning and further work in the left and/or right atriums.
The point being that say looking at Dr Natale for example, very rarely will any follow up or touch up to one of his index ablations will require any at all or more than one to two true reconnected lesion repair of anything he already ablated in the first ablation. This is a huge difference from the more typical EP most of whose ablations are of a simpler nature to begin with and often limited to an anatomical PVI or PVAI alone and which almost invariably when the typical average EP and even many very good ones, have rework to do, it entails a good deal of repeat ablation over the very same areas and lesions they tried to fully address in the first ablation.
You will not find this to be the case in the vast majority of Dr. Natale's patients where the lions share of any further work is typically found to be new trigger sources not yet mature enough during the index ablation to rise above the considerable 'noise floor' of the un-ablated, yet highly fibrillating heart. Even after drug challenge with isoproterenol at the end of the index ablation, it is not uncommon that latent signals are still too dormant either due to not being mature enough such that they are sufficiently suppressed due to the general anesthesia used during the first procedure to discover during them during that initial drug challenge. As such, these undetectable triggers wont make themselves known while still on the table during round one, and only are discovered in the next follow up touch up or even third ablation at times to get every last one.
Or course, even mediocre EPs have a good number of these undetectable triggers appear too after their own index ablations, but so often these new triggers in their follow up cases are to often masked to some degree or just not addressed at all by EPs who most often just repeat entirely the entire PVI or PVAI as their main strategy when going in for round two or three, four or five etc etc.
This is the big difference between a true touch up procedure as part of an 'expert ablation process' as compared to a more typical reload and fire again approach in which far too many EPs are not skilled enough to consistently preform a fully transmural PVI over PVAI anatomical only ablation, and much less are the majority of EPs skilled enough to even seek out non-PV triggers that require real time EP work outside their ablation comfort zone and that are not around these PVI/PVAI anatomical well-defined structures.
As such, embarking on an ablation journey with progressively lesser experienced EPs is signing up for an indefinite process often including quite a few full repetitions of nearly the entire first ablation over and over in hopes of finally getting a fully transmural PVI which will then typically work longer term only for those with the most basic paroxysmal cases and/or to a less degree of success with those who are early persistent cases who still have small left atrial diameters. These class of ablation process are much closer to what you question above Chuck when you presume its bascially the same amount of work, stress and intensity as the first ablation which is much closer to the true case with many less experienced operators compared to the most experienced top tier ablationists in which follow up tend to be limited to true touch up level work.
If you are like many on our board with more extensive atrial disease or condition of remodeling, the majority of EPs doing ablations will not be able to offer you much help beyond this anatomical approach that too often requires too many repeats of too much of the work that already should have been successfully sealed off and done.
Yes, the preparation and often travel back to the center and being on OAC drugs etc is similar. Though more often now we carefully ferret out who will likely need a 'touch up' in the first 3 to 6 months or so when the person is more likely to still be on an OAC drug anyway and with the newer OACs starting and stopping them are not as onerous as with Coumadin.
No one wants to have a follow up or touch up by any name you choose to call it, but make no mistake, there is a major difference between making the best choice for yourself up front to minimize not only the total number of ablations each person might require to end the affliction for then long term, but also too insure that the huge majority of the work is over with and done correctly and holds tight for many years to come from the first ablation, and thus any more work that is needed is generally truly of a limited 'touch up' nature.
If you read the ablation reports of Dr Natale patients for his index procedures versus his follow up work with him as I have done many times, you see the stark contrast in how few burns are typically needed in any touch up with him, versus looking at both index and follow up ablation reports from many other EPs and the much larger amount of work most often required in these follow up ablations by more typical operators, and how many of them include substantial redo of the primary anatomical PVI/PVAI lesion sets.
This is why the impact on you, as a patient, in spite of the obvious hassle and temporary disappointment in having to go back for a follow up to begin with is so largely lessened and assuaged with a Natale or Bordeaux follow up touch up, as two examples, with the patients invariably having a much easier time of it in round two and even three when needed, compared to the index ablation.
Less burn time equals much faster recover typically, and with the well trained staffs and you having been through it all before at least once, are all mitigating factors for sure during any follow up with a true expert ablationist and their staffs doing mop up duty as the finishing touches on what we all emphasize here is an 'ablation process'.
For as long as I can remember, that has been our mantra here repeated often to new ablation prospects going into their first procedure. That it is good psychology and a the best approach to consider you will need two ablations, and possibly a third with the first being a big one and the other one or two more like touch ups and much less work done to complete your AFIB journey successfully.
And if, instead, you get done in one which a good number do, especially among those with more garden variety paroxysmal cases to begin with, then consider it a big bonus!
That is the honest truth of our collective experience and the vast majority of us who have gone through their whole process while keeping the long view firmly in mind, even during the middle of the process when it occasionally can be tough to keep that larger perspective in view, this big majority of us will reaffirm how worth it all the whole process has been when making a good choice on who to guide your process long term.
It really is much more like the car tune up analogy you use above. With a highly skilled EP the first one is the major overhaul and any touch ups are generally mostly just that and fine tuning the engine and dealign with new little leaks that were not apparent during the first one of even that may, in part have appears only after a given lesion set was laid down in round one to stop the AFIB which may have unpredictably set up a focal tachycardia or flutter circuit that now needs addressing as well.. this is what is most typically seen in Natale touch ups, that and those remnent low level triggers that were suppressed by the anesthesia or high noise flow of the index ablation.
I hope this run down clarifies for you Chuck the big difference I am pointing out. A touch up is generally not as intense or nearly as involved as is an index procedure either for the EP or the patient when the EP you started out with and who handles the rest is a really good one.
Even the waiting in bed six hours to move your legs tends to go faster the next time around and the pain or discomfort is almost always a good deal less. or certainly not more that round one. And rarely is the recovery any where near as long as the index ablation due to the huge reduction in actual burns made in true touch up procedures. Thus',the term 'touch up' is just about the best one for describing what typically happens when your index ablation was an excellent procedure by a very experienced operator.
We all bring to the table a unique puzzle to solve that the EP must deal with what ever we present to him or her, and not surprisingly our group attracts a large number of more seasoned Afibbers who tend to have longer term AFIB, or worse cases, than is found at some of the more boards with more general superficial coverage of these topics. As such, we tend to see a more complex mix of cases reported here, and yet we also see a very high level of happy campers long term in spite of the lousy nature of this condition that requires us to have to go through this gauntlet to get rid of it for good in any event.
Shannon
Edited 1 time(s). Last edit at 04/11/2015 07:29AM by Shannon.
|
Re: A "Touch Up" sounds so simple and non-invasive. April 11, 2015 10:14AM |
Registered: 12 years ago Posts: 486 |
Chuck
When I had my ablation by Prof. Haissaguerre in Bordeaux in 2003 AF recurred after 48 hours. Because I had travelled a long way, rather than waiting to see if it settled he did an immediate second ablation and told me that there was a highly toxic focus in the coronary sinus which was extremely difficult to find and ablate. He had thought there might be a gap in one of the lines but that was not the case.
I was not anaesthetised and well remember him saying "Did you see that?" to his colleagues sitting at computer screens. The didn't see it for several minutes, then finally one of them did. I think a less experienced and skilled doctor would not have found it, and I wouldn't be having all these years of normal rhythm.
Gill
When I had my ablation by Prof. Haissaguerre in Bordeaux in 2003 AF recurred after 48 hours. Because I had travelled a long way, rather than waiting to see if it settled he did an immediate second ablation and told me that there was a highly toxic focus in the coronary sinus which was extremely difficult to find and ablate. He had thought there might be a gap in one of the lines but that was not the case.
I was not anaesthetised and well remember him saying "Did you see that?" to his colleagues sitting at computer screens. The didn't see it for several minutes, then finally one of them did. I think a less experienced and skilled doctor would not have found it, and I wouldn't be having all these years of normal rhythm.
Gill
|
Re: A "Touch Up" sounds so simple and non-invasive. April 11, 2015 02:56PM |
Registered: 9 years ago Posts: 34 |
Thank you Chuck and Shannon,
I had a left atrial appendage ablation in November by Dr. Natale at Scripps. I am now scheduled for a "touch up" on May 28 because I went into flutter after the blanking period when I stopped taking Tikosyn. I have been aware of, and thought of, a touch up as another ablation and the prospect is not welcome, but unavoidable. Your words help. Since it'll be the maestro doing it, I'll think of it more positively now.
Nick
I had a left atrial appendage ablation in November by Dr. Natale at Scripps. I am now scheduled for a "touch up" on May 28 because I went into flutter after the blanking period when I stopped taking Tikosyn. I have been aware of, and thought of, a touch up as another ablation and the prospect is not welcome, but unavoidable. Your words help. Since it'll be the maestro doing it, I'll think of it more positively now.
Nick
|
Re: A "Touch Up" sounds so simple and non-invasive. April 11, 2015 03:55PM |
Registered: 6 years ago Posts: 18,882 |
Nick - as you may have just read, I've just returned from my 'touch up' procedure after LAA isolation last August and I can totally relate to your thoughts. The procedure was 'easy' enough as well as short, but it is still invasive and most likely because I'm older, the bounce-back isn't as rapid as my initial 2003 PVAI but I'm only 8 days post-ablation so I keep telling myself to be patient, relax and take it easy. Invasive procedures with all that entails and, for me, the chemicals of the anesthesia and so forth always take a toll no matter what the focus but I was most anxious to get this behind me as quickly as possible so I can move on.
I tell myself ~ c'est la vie and remind myself to be grateful this is not a cancer surgery or something not manageable by surgery such as my two (younger) friends with late stage Alzheimer's and two others, bedridden with an unknown muscle weakness disorder.
While I wish the third procedure wasn't needed, I am most grateful to have had the skill and expertise of Dr. Natale's magic hands to manage what wouldn't even be addressed by all but a very few elite EPs.
I'll be thinking of you on May 28 and hope your procedure is as short and straight forward as mine was.
Best to you and speedy recovery,
Jackie
I tell myself ~ c'est la vie and remind myself to be grateful this is not a cancer surgery or something not manageable by surgery such as my two (younger) friends with late stage Alzheimer's and two others, bedridden with an unknown muscle weakness disorder.
While I wish the third procedure wasn't needed, I am most grateful to have had the skill and expertise of Dr. Natale's magic hands to manage what wouldn't even be addressed by all but a very few elite EPs.
I'll be thinking of you on May 28 and hope your procedure is as short and straight forward as mine was.
Best to you and speedy recovery,
Jackie
|
Re: A "Touch Up" sounds so simple and non-invasive. April 11, 2015 04:14PM |
Admin Registered: 11 years ago Posts: 2,779 |
Glad to hear it helps Nick,
It really should, regardless of the fact that its obviously a hassle and not what any of us would chose to do for our spring vacation, as Jackie put it. But as you noted, you are in truly the best possible expert hands and just as you no doubt had an overall positive experience in the index ablation with Dr Natale, you can expect an even easier ride through the whole thing and most definitely the recovery tend to be remarkably easy and quick. Again as you might expect from the minimal amount of work actually done on you which typically consist of the three catheter venous access punctures, two transeptal punctures and a very small number of burns after 2 to 5 burns is often all such a true touch up takes and its not uncommon to experience no heart discomfort whatsoever after such an LAA touch up.
You might have a bruise or two from the venous access puncture in the groin but usually that is about it for recovery and why we label these a true touch up.
More and more top EPs are staring to do LAA isolation and have noted a significant increase in their overall success rates as a result, and opening up a whole class of patients who can truly benefit the most from ablation who previously were more or less doomed to an unknown series of more extensive repeat ablations and/or maze procedures to address an intractable AFIB simple because its remaining origins lay in the LAA/CS structure that so many EPs shy away from and often don't even consider for ablation ... and rightly so if they feel uncomfortable about what and how to do it.
Dr. Rodney Horton in Austin who is a highly experienced EP with 5,000 + ablations under his belt and a close colleague of Dr Natale does them as does DJ Lakkireddy in Kansas City and Doug Gibson at Scripps La Jolla. I spoke with Dr Gibson about it when he happened to pass through the procedure room just when I was about to take the proposal ride to sleep before getting my last 3D-TEE two months ago in La Jolla and he mentioned to me how adding LAA isolation that Dr Natale mentored him in doing had significantly boosted his overall results with these challenging cases.
Shannon
It really should, regardless of the fact that its obviously a hassle and not what any of us would chose to do for our spring vacation, as Jackie put it. But as you noted, you are in truly the best possible expert hands and just as you no doubt had an overall positive experience in the index ablation with Dr Natale, you can expect an even easier ride through the whole thing and most definitely the recovery tend to be remarkably easy and quick. Again as you might expect from the minimal amount of work actually done on you which typically consist of the three catheter venous access punctures, two transeptal punctures and a very small number of burns after 2 to 5 burns is often all such a true touch up takes and its not uncommon to experience no heart discomfort whatsoever after such an LAA touch up.
You might have a bruise or two from the venous access puncture in the groin but usually that is about it for recovery and why we label these a true touch up.
More and more top EPs are staring to do LAA isolation and have noted a significant increase in their overall success rates as a result, and opening up a whole class of patients who can truly benefit the most from ablation who previously were more or less doomed to an unknown series of more extensive repeat ablations and/or maze procedures to address an intractable AFIB simple because its remaining origins lay in the LAA/CS structure that so many EPs shy away from and often don't even consider for ablation ... and rightly so if they feel uncomfortable about what and how to do it.
Dr. Rodney Horton in Austin who is a highly experienced EP with 5,000 + ablations under his belt and a close colleague of Dr Natale does them as does DJ Lakkireddy in Kansas City and Doug Gibson at Scripps La Jolla. I spoke with Dr Gibson about it when he happened to pass through the procedure room just when I was about to take the proposal ride to sleep before getting my last 3D-TEE two months ago in La Jolla and he mentioned to me how adding LAA isolation that Dr Natale mentored him in doing had significantly boosted his overall results with these challenging cases.
Shannon
Sorry, only registered users may post in this forum.