does having a non-Natale prior ablation limit options?

In many areas of problem-solving (eg, working on computer problems, or fixing cars, just to name a few), it is often a lot harder to "fix" the original problem if a non-elite operator has tried fixing it first.

Is this also true with ablations?

In other words, is it ever the case that someone goes to a non-Natale EP for an ablation, then (when it isn't 100% successful), sees the light and goes to Dr. Natale. Only to be told, "Sorry son, if you'd come to me first I could've fixed you up. But the EP who did your first ablation has burned some areas which prevent me from doing a proper job. It would be too dangerous to ablate any more tissue in your case."

To be less abstract, consider the following made-up example. Let's say the first EP did PVI, and laid down a large amount of lesions in and around the PV's. Yet Natale discovers (during mapping) that the patient's PV's still conduct. Is it ever the case that Natale might decline to do the PVAI, because the prior EP's extensive (albeit ineffective) lesion set has burned so much tissue... that to burn even a little bit more tissue (to do a proper PVAI).... would compromise the structure of the heart (cause stenosis, or perforation, or some other unpleasant outcome) and leave the patient in a worse state?

-Ted

Ted,

What you say might be true in some cases. In my case I had two ablations before I learned about Dr. Natale. When I talked about this with him his reaction was that it could take two more ablations because it would be like starting over. All of what you fear might be true, but Dr. Natale didn't raise any of your concerns with me

Nick.

It's always preferable to start with the very best and most experienced EP you can to minimize the total amount of work needed to complete a fully successful expert ablation process.

Dr Natale often has to do repair work, so to speak when another EP had been in there first, it doesn't help either if, and when, the index EP didn't have a very steady consistent hand that bounced off the LA wall a lot with the heart beats, and was using a very different procedural approach, but I can't recall any that he has not been able to help sort them out to a better state than there were, though the odds of needing an extra ablation or two more than you would have likely required had you gone to him, or any other top level ablationist, with a fresh heart are significantly higher, no doubt. Nevertheless, choosing an ablationist of his experience and track record with such a case after having had multiple prior less than satisfactory ablation outcomes is even more paramount, and not resorting to just winging it again with a local EP likely referred by your local Cardio or GP.

I met a guy in Dr Natale's waiting room in San Fran once many years ago when I would fly back and forth from Amsterdam where I was living for a four year period to my long time (38yr) home in Hawaii to reset my Dutch visa priveledges every 6 months, and so would make it a point to stop in to see Dr Natale during a two day stop over in SF on these long round trips.

This guy had had a whopping 8 ablation AFIB ablations starting in 1998 with what he called 'a cowboy in Berkeley' that must have just read Bordeaux's seminal article defining the PVs as the prime source of AF triggers that had just been published that same year and which launched the whole PVI ablation jugger-naught. Perhaps that doc was he had recently penciled it all out on a coffee cup napkin and found this guy as a willing sacrifice to his learning experimentation and went for it. In any event both the EP and patient were pretty adventurous and intrepid it seems.

The description of the hellish state this man had gone through via a handful of rather greenhorn ablationist ( by definition at that early history) during those early years of this field had left him in what he termed a near 'cardiac cripple' (his term used) state in which he could no longer drive and needed a friend or a taxi to go places.

Two years before I saw him, which was in late 2009, he had finally been referred to Natale to see if he could lessen his extreme swings from moderate speed AFIB/Flutter to super high speed well over 200bpm runs. He was there in the waiting room on the day of my follow up appointment, just for his own one year follow up appointment after having had two additional procedures making 8 total, with those final two done by Dr Natale in which Dr N had said to him it would take at least two to rework the unusual mess that had been made inside his heart be the early attempts at ablation, in order to get him to NSR.

Just as predicted, he had been in constant NSR for 14 months when I ran into this guy and was totally overjoyed to have life back, was driving and walking SF hills again even though he did have some EF compromise from the earlier procedures, he had regained a very functional degree of his life and he was only in his early 50's at the time I saw him.

And he was there in the waiting room with his new girlfriend so things were definitely making a big turn around in his life at the time and hopefully have continued to do so.

This man represents the single greatest amount of ablation work done of anyone I have met, or talked too, and he was speaking in the same glowing terms so often heard here from people who have chosen to put this EP in charge of their hearts long term health, whether or not they started out with him or found him only after needing a repair job from a prior ablationist(s) attempt(s). And this is just one of so very many similar stories to one degree or another in our archives conveying and reinforcing the very same message.

And it most certainly can save a lot of guesswork and added ablation work to start with the best possible choice up front.

Shannon



Edited 2 time(s). Last edit at 08/25/2015 12:30PM by Shannon.

I think obviously we all want to be in the best hands. However, there are many good EP's. a good EP is not going in and burning every flippin spot they might suspect and without evidence. (I hope NO EP is doing that). So it is not a matter of some mad hatter in there burning the hell outta stuff and scarring everything and ruining the inside of your heart. A good doctor is cautious.

I think there is a risk of future problems no matter who is doing the ablation. That includes everyone.

Hi Shannon,

While I'm very happy at the pleasant final outcome of your 8-ablation friend... I am a bit surprised that it seems that when one was "burned imperfectly", the situation can (in most cases, if I'm reading your replies correctly) be fixed by doing more burning (correctly this time). Burning is a one-way street -- there is no way to undo a burn. So it seems counter-intuitive that a poorly laid down burn can (in most cases) be fixed by burning correctly. I'd have thought that at some point the incorrectly burned tissue would need to be fixed (via graft). Or just written off as an unfixable case.

What am I missing here?

Cheers,
-Ted

True enough Tsco,

There are a good number of very good EPs out there in various parts of the country and ANY EP can, and will have some degree of complications along the way. Though it's very much true too that the odds of higher success rates and much lower risk of complications increase directly in proportion to the increase in hands on experience level of said EPs, though that risk level is never zero, obviously even for the very best maestros. This is an invasive cardiac procedure after all.

But all prospective AFIB patients also need to be aware, too, that they can't automatically just assume anyone with an EP fellowship certificate and a friendly referral by a local cardio or clinical EP are all roughly on the same par when it comes to doing actual AFIB ablations. All of us here who had the where-withall and instinct to seek out a forum such as our own here might find that a very obvious understanding and step any reasonable person would take when considering something like an ablation, but there is strong evidence we are in the minority .. surprisingly so!

A fact, alas, that has certainly not gotten through to the vast majority of all AFIB patients to-date. Not with the large Desmukhs meta-analysis of all 91,800+ Medicare patients that were ablated over the decade from 2,000 to 2010, in which >81% of them were ablated by EPs doing less than 25 procedures a year at small centers doing less than 50 total ablations a year, in which those patients had accounted for a much higher proportion of the generally higher complication rates in this survey compared to many prior ablation outcome studies that tended to be conducted at larger much more experienced centers that reflected both the higher success rates and much lower risk rates accordingly that can and should be the norm when better informed patients take the time to become more discriminating in their chose of who to entrust their hearts too.

Even in the low volume less than 25 procedures a year, not every patient was injured and no doubt quite a few had decent outcomes too, but the added risk one assumes when going to such a doc is substantially higher than when making a more informed decision ... and the more challenging the case the more this factor is underscored.

Which is a truism that we have anecdotally confirmed here too from all of our long experience following folks who have come through our forum and from Hans' surveys.

The story I recounted above of the guy with 8 ablations reflected his experience where the majority of his first 6 ablations, prior to his final two with Natale, had been done in the very early years of anyone attempting AFIB related ablations, and it was his terms and descriptions I passed on above of finding first a 'true cowboy' who was very confident in his own ability and inspired him to be a guinea pig that he later regretted.

Certainly this fellows story is more an extreme example of excessive ablations and yet even his case was one that was still reasonably repaired and NSR restored when he finally made it into the right hands. But for sure, the details are not so indicative of the kind of issue most folks will face now.

The one point of real caution that is still implied in that story, though, is that the way forward can be harder and a bit longer for those who have bounced through a handful of different EPs doing different types of ablations over time .. again underscoring the wisdom of partnering with a top level operator from the beginning whenever possible.

Preferably an EP doing almost nothing else but AFIB ablations and one who is very busy doing so... The problem that can come from two many less experienced ablations being done on a given person, is there can be so much repeat ablation over the same areas over and over, if each EP is just recreating their entire own process and not trying to build on the still good parts of the prior procedures that are holding well, this scenarios which, unfortuately in not that uncommon still, can lead to markedly greater degrees of total ablation burden on the heart by the time the person has carved out a workable level of success for them.

This typically happens when each EP expects their magic will do the final trick for this person and then proceeds to do an entire all new ablation without dovetailing it at all with the still good parts of past efforts.

The better, more experienced docs will take that into account typically as you noted Tsco, while less experienced operators will tend to just repeat an entire PVI and then since almost by definition such docs are less comfortable doing a lot of real time EP analysis and decision making and if they address any non-PV targets at all in they typical patient case loads, the majority of these folks do still follow their own process for doing so. That is what can make a big difference from, say, one person having 4 or 5 ablations with near full repeat jobs being done each ablation by several different EPs who normally only do PVI/PVAI only procedures, compared to someone with the same number even of total ablations done by an EP more flexible and comfortable addressing just the active triggers as they are found each time when the patient presents to them to try to restore NSR finally.

In reality the later type of EP tends not to require 4 to 5 ablations to seal the deal, but even the best have some exceptions.

While nearly all the docs we talk about here on our forum fall into that more experienced and more reliable category, there is a surprising large number of practicing ablationist out there who still stick with the 'repeat the whole PVI' approach on any new follow up ablation whether they did the index ablation on the patients or they came to them after some less than successful procedures elsewhere.

Shannon



Edited 3 time(s). Last edit at 08/20/2015 10:42AM by Shannon.