Cryoablation Procedure

My Dr. recommended the cryoablation procedure for Atrial Fibrillation. Can anyone tell me roughly how long a procedure it is, how long recovery is (until you feel 80% to 90%), how long in hospital and generally how it went? I had an ablation 3 yrs ago for atrial flutter. Worked ok for the flutter but had atrial fib too. Now the fib is much more active. Thx

Allen

My Ep Dr. said that about a third of all Ablations worldwide are now Cryo. It is especially popular in Europe. Good success is being reported.

Cryo balloon has definitely taken off in the past couple of years. For labs that have average skills, the success rate are about the same for RF and Cryo for PAROXYSMAL AF or around 70% successful rate at the 12 month mark. Cryo balloon is not appropriate for persistent AF as it is designed for PVI only. The big advantage is that cryo procedures saves time and there is lower risk of perforation balanced by high risk of phrenic nerve injury. Atrial-esophageal fistula risk is about the same between RF and cryo. Recovery from either RF and cryo is suppose to be similar. In the Natale persistent AF ablation video thread, there is a link to a cryo procedure done at Natale's Austin center performed by Javier Sanchez.

Hi Allen,

And welcome, indeed Cryo has made some real progress in the last few years, but the best suggestion is always choose the very best. most experienced and most widely recognized as a top tier ablationist you can possibly partner with, regardless if you have to travel to the next city, state or across the US to hook up with such an elite level operator. And then let the technology used be entirely up to him or her to decide in your case.

That is a FAR better stance and viewpoint rather than to get overly enamored by a given technology such a Cryo, FIRM, RF ablation or whatever and wind up very possibly getting a more modest to even risky talent behind such tools .. perhaps even someone depending on such tools to bail out a less than highly experienced and successful ablation history and resume' . As researcher noted, Cryo's main attraction is as a bit simpler process for doing a straight forward PVI and saving a bit of time in the process, which are very appealing particularly to less experienced EPs who many take 6 to 8 hours struggling to do with a rock star can smoothly, and efficiently completes in 2 to 3 hours total with full RF ablation technology and mapping including doing not just a PVAI but a full extended ablation address all non-PV triggers as well.

However, Cryo too has some limitations and should your case require more than a garden variety PVI to do the trick, you may well have to settle for, at best, a decent PVI as a starting point via Cryo alone, and venture elsewhere for any more extended non-PV ablation work that may well be needed. there is a Cryo focal based point by point catheter too but its not the tool of choice for focal ablation.

I always prefer to go to someone from the outset that I have every confidence can handle with consummate skill whatever surprised my heart might throw their way once they are inside there, and someone who can easily adapt to any changing landscape beyond, say, a predicted simple paroxysmal case prior to the procedure getting under way.

Interestingly, I really don't know of many (any really) of the truly elite level EPs in the world that who are world famous for addressing all types and degrees of difficulty, that ever use Cryo as a main tool in such a broad-based practice. They may use it in select patients or for just for some PVI portions or an ablation, etc. But the vast majority of the top volume operators use RF tech at this stage of our ablation evolution.

And for what looks surely to be a pretty slam dunk paroxysmal case, the odds are much higher that Cryo could work well too, just as can RF in experienced hands. ... Thus I would strongly recommend to look first and foremost for the best pair of hands and most experienced ablationist behind those hands, and go from there and not give two hoots to the wind which tools he or she may choose as best in their opinion for your case.

This is your heart and you always want to put its care in the best possible hands you can arrange for yourself not only for the obvious increased odds of success, but also with much increased odds of a very safe process and thus granting real peace of mind leading up to the procedure and beyond knowing that you truly did everything in your power to stack those odds clearly in your favor and did not compromise only for the same of convenience of a local doctor as a prime priority. Doing so can work out okay in many cases.

However, making goign to a local area EP a prime consideration can be a very risky and even dangerous prospect too if that person does not also belong on the highly experienced and widely known as a consistently successful ablationist over many years list, and with at least 1,500 ablations under their belt, as my admittedly rather strict cut off number to even make the short list for consideration.

Best wishes,

Shannon

PS ... Please be sure to also take advantage of all of our tools for improving life style risk factors and insuring better diet and key nutrient repletion that can very much help many people with gaining better control over AFIB or flutter.



Edited 1 time(s). Last edit at 08/06/2015 12:43PM by Shannon.

Does anyone have any stats on who has done a large Number of Cryo's? Or who are the top Cryo Dr's in the country. My Doctor did 70 of them, Apaches did 25. Also does it make that much difference how many RF Ablations a Dr. has done, if they are now performing a Cryo on you?

Did Natale really do 8000 RF Ablations? and how many Cryos has he done?
How much money does he make from doing an Ablation?

As Shannon wrote, the elites stay with RF because it offers more flexibility in terms of where they can go and also power titration. If you saw Natale's persistent AF ablation video, then you would have heard him tell the audience what his thinking was with regards to going after everything in the index ablation vs waiting to see how a less aggressive approach (that still terminated the AF) holds out. You just don't have that flexibility with Cryo and in top hands like Natale, RF gives him the better outcome. It probably cost him more hourly wages to use RF as Cryo would have cut an hour out of the procedure. So in answer to your question, centers can treat a higher volume of paroxysmal cases and EPs make more money with Cryo. If you look at a HMO like Kaiser California that do high volumes (where EPs get a salary), they are at 40% cryo and come back with stereotaxis RF if the index ablation doesn't work. My parents had Kaiser and they watch every penny and they manage to do well for the patients based upon our experience.



Edited 4 time(s). Last edit at 08/05/2015 01:52PM by researcher.

If your triggers are outside the pulmonary veins, cryo is of little benefit correct? You're still going to have afib.

Quote
Researcher
You just don't have that flexibility with Cryo and in top hands like Natale, RF gives him the better outcome. It probably cost him more hourly wages to use RF as Cryo would have cut an hour out of the procedure. So in answer to your question, centers can treat a higher volume of paroxysmal cases and EPs make more money with Cryo.

Researcher makes a very good point - follow the money. Not only is cryo faster, but it requires less skill, so it can be done by an EP with less experience (read: lower salary).

It's amazing how little the surgeons get, out of the total bill - often the OR (or EP lab, in this case) is the majority of the cost. I was reading a medical school forum where the MD's were discussing how there is no longer big money to be made in cardiology, due to the changes in reimbursements by insurance. Most cardiology patients are older, and thus often depend on Medicare. The Medicare reimbursement has been going down over the past decade or so. If one wants to make big $ as an MD, cosmetic surgery is the way to go.

Another (non-fiscal) factor is that EP's are concerned about long-term orthopedic issues (due to lead protective gear) as well as long-term (decades of career) fluroscopy (X-ray) exposure. Another reason why they'd want to do ablations quicker. As in cryo.

Hi Researcher,

Good summary of Natale's long standing persistent and regular persistent approach as he narrated in the video.

Many EPs less sure and experienced ... And yes he has at least 8,000 right and left atrial ablations since he began helping to pioneer focal AFIB approaches and worked in concert with the Bordeaux team as they developed and published the blueprint for PVI ablation with their seminal paper describing how more than 85 % of paroxysmal AFIB triggering was found to be from the pulmonary veins which launched the entire catheter ablation for AFIB world. Natale has been at the forefront of innovation in this field ever since pioneering many techniques, tools and methodologies such as the uninterrupted preiprocedural anti coagulation method that is now the standard method after recent large multi-center international randomized controlled trials have definitively proven this method of continuous unbroken OAC foopr several weeks at a minimum prior to ablation as well as unbroken all the way through to the ablation itself with either Warfarin, Xeralto or Eliquis (but not Pradaxa) and then combed with using IV full weight heparin just BEFORE using a double transeptal puncture to allow both the ablation catheter and lasso mapping Cather to be inserted one time across the septal wall within the sheath and avoid possible multiple transfers of catheters in and out from the RA to the LA which increases risk of micro emboli and micro bubble formation and dislodge meant into the LA when only one sheath is used and two catheters have to be exchanges a few times (not a good idea at all!) .

Next they discovered that insuring that the ACT time is maintained from 300sec to 350sec starting again just before LA access is established helps not only reduces stroke and TIA risk compared with using interrupted and bridged warfarin with enoparin (low molecular weight heparin which has different properties and actions than does either Warfarin, and NOAC or full IV heparin), and then switching back to warfarin only after the procedure has been found to even more dramatically increase risk of Peri-procedural SCI creation by a significant margin over using the now much preferred Continous unbroken procedural anticoagulation for most every procedure involving left atrial access across the septal wall.

Please note: Apache and Anti AFIB who inquired about this after Apache posted that rather marginal study from down under on neuro-cognitive impact of these SCI caused during an ablation I've not had the time to address the onslaught of one paper after another here but this one must be addressed as I will later after returning home from Phoenix where my wife is getting her biopsy as I type this on my IPhone.

But hearin lies your answers ... Right up front you can toss a large percentage of that Aussue studies number of cognitive impact with the longer AFIB ablations compared to the shorter SVT ablations used as controls, not only because of the different time components under anesthesia for each group, but far more importantly because they used a broken INTERRUPTED anticoagulation protocol for the AFIB A
Ablation procedures too like with those right sided only shorter SVT ablations that didn't always include LA access.

A number of far more robust multi center studies by top tier groups in this field Thomas Deneke, Gaita, Natale, Pierre Jais etc etc have underscored now the large superiority of unbroken peri procedural anticoagulation in sharply reducing AFIB ablation related SCI creation which is obvious a key important goal that all the heavy weights have been working on non stop since the first indication of this phenomenon was first noted over 10 years ago and really caught everyone's attention about 6 years ago.

Combining properly used irrigated catheters. Unbroken periprocedural Anti-coagulation with assured ACT times in the LA above 300sec up to 350sec from just before LAaccess until protamine partial reversal of the IV heparin bolus is applied only AFTER all instrumentation is removed from the LA and the Continous warfarin, Eliquis or Xeralto is maintained unbroken as before the rate of SCI creation drops to the range of 1 to 2 ..3 max tiny white SCI lesions noted the first DE-MRI 24 to 48 hours post ablation and which almost always resolve and disappear after 48 hours to the point where it is not common to detect much, if any, Flare weighted MRI evidence of glial scar remnants which would indicate some possible lingered brain cell injury.

In contrast with interrupted anticoagulation schemes and/or when singke sheath and multiple Cathyer transfer in and out of the LA is used and/or when ACT is not maintained above 300 secs ... All bets are off as the rate of SCI generation jumps to from around 12 up to close to 70 such SCI lesions noted on early DE MRI in typical patients and with a significantly greater number potentially remaining visible days and months later on FLARE MRI as glial scar remnants...

Not surprisingly this Aussie study Apache dug up used an interrupted anticoagulation scheme... It wasn't entirely clear if each AFIB ablation patient had been on warfarin before the procedure or not and then had it interrupted for the 4 to 5 days that is typical with interrupted schemes during which they switch to enoxaparin up
until Transeptal puncture at which time typically the IV Heparin is infused often at high 10,000 to 13,000 unit doses and after the procedure enoxaparin is used again to bridge back to warfarin in light of the slow uptake rate of warfarin of around 5 days for INR to stabilize again.... That is a Lot of variability in anticoagulation status over this key period of time and what contributes to the excess generation of SCI and thus by logic and inference the Modest increase in subtle post procedure cognitive function decline that appears mostly temporary and a good part of which was also acknowledged to be from early anesthesia recovery effect for the first large 24% number vs 13% for the later period of either 30 or 90 days I can't recall at the moment.

The single most important thing for you and others to grasp, Apache, is that leading centers are already greatly reducing the degree of potential SCI creation during an ablation. We are not at zero yet, and may never be, but great consolation is there when you realize that the very procedures Dr Natale uses (since he is the doc you were asking about) have very low rates of SCI in their carefully screened patient pool ... If you ever really do decide to get an ablation and decide that perhaps he gives you a good balance of odds stacked in your favor you could request to be apart of any ingoing study of SCI as they have done quite a few so far, and then will get pre and post DeMRI and FLARE MRI to
Determine how much SCI burden you already have accumulated from the years of ongoing AFIB which is ... BY FAR ... The single greatest generator of These micro brain lesions and that continues to accumulate indefinitely the longer even subclinical asymptiomatic AFIB continues!!

The relative small SCI burden even from
The worst catheters and most out of date interrupted anticoagulation
Schemes still pales in comparison to the much larger burden over time from
Ongoing living without consistently stable NSR!!

When that fact sinks in, you will
Quickly realize the importance not only of partnering with an EP who has been at the forefront of SCI reduction research from its first recognition, but from the reality that any successful ablation process will be the single biggest weapon you can employ to reduce your long term SCI and thus early dementia likelihood related to ongoing paroxysmal or persistent AFIB/Flutter!

It's like the old Indian proverb about how it often takes a small thorn to remove a much larger thorn and then you cast them both aside and get on with your life.

Cheers!
Shannon

PS George or Jackie, can either of you please copy and past this reply into the thread Apache started related to the study about the neuro-cognitive impact of ablations. Magdalena and I won't be home until tomorrow and I wanted to get this info out about this important topic.

Also, for those who don't read THe AFIB Report , I have covered this key issue three times in the last year and a half and will be featuring the largest and most comprehensive and up today's international Multi center review of the subject in the Next issue (Aug/Sept) of The AFIB Report once again.

Many thanks
Shannon

is this guy Natale really that damn good.......?

Damn right he is!
God Bless the Man,
McHale