in line for a second ablation...a few questions about approach

I'm a basically healthy 65 year old with non-paroxsymal lone atrial flutter. In 2006, I went into a-fib. After a period of time on drugs (they eventually failed) and then an electro-cardioversion (immediate fail) I went in for a catheter ablation in 07. Good success and 7 years of NSR. But a year ago I reverted into a-flutter. Tried another electro cardioversion which stuck for a nice 7 months, but that failed in August 2015 and now I'm in line for a second catheter ablation. My question. My cardiologist is Dr Girish Narayan who has a more conservative approach than some. He feels that the jury is still out on the left atrial appendage and does not isolate it. Dr Andrea Natale did the first ablation and he represents the more aggressive wing of opinion. My questions: First, has anyone had good or bad experiences with Dr Girish Narayan (Palo Alto Medical Foundation) and does anyone have good reasons to prefer the conservative vs aggressive approach to a second go at an ablation for flutter for a patient w my profiel? When I seek additional surgical opinions, whoever I ask tends to suggest that they, personally, are the best option. I'm wondering how much surgical ego is involved in this area.... and how much science.

Hello Cass - I have no knowledge of Dr. Narayan, but I will comment that it's been well known that some flutter ablations can be difficult. Back when you had your 2006 procedure, I don't recall that they were ablating in the trouble areas closer to the Left Atrial Appendage. That's changed now and they are doing successful flutter ablations in the LAA area which often does lead to more aggressive treatments involving LAA isolation. Dr. Natale has pioneered that area very successfully as has been reported here for a number of years.

My first Natale ablation for afib in 2003, lasted for 11 years, but then flutter cropped up and became a nightmare as nothing worked to keep it under control. So, Dr. Natale did the second ablation in the summer of 2014 which did involved isolating the LAA (as we had expected). A few errant signals prompted a third, short procedure last April 2015. It's certainly a welcome relief not to have the surprise visits of either afib or aflutter. Obviously, I'm most grateful to Dr. Natale for his persistence in perfecting this LAA area technique.

As far as ego is concerned, Dr. Natale has no need as his experience in sheer volume or numbers of safe and successful ablations speaks for itself. We have seen posts here where people have gone to less experienced EPs for 5 and six ablations and are still struggling.

Circulation published a study report titled: Left Atrial Appendage: An Underrecognized Trigger Site of Atrial Fibrillation in 2010. [circ.ahajournals.org] I have the complete study in a pdf if you would like to read... just send me a PM. Shannon has posted on the proceedings of the organized group that meets to discuss the LAA...and my mind at the moment is just blank about the name or I'd look up those posts for you. Sorry. I'm sure he'll chime in.

Best to you,
Jackie

Hi Cass,

Sounds like you had seven great years free of AFIB after your first Natale ablation which is a very good outcome. I highly suggest you stick with the most experienced operator you can which is your original ablationist by a huge margin.

It is not at all uncommon for a late developing Atrial flutter triggers years after a successful PVAI or PVI, with perhaps a few other non-PV trigger areas beyond the PVAI addressed too in the index ablation. In such a case, the substrate progression very often like yours, Cass, will have extended to the left Atrial Appendage and/or Coronary Sinus by that time in the progression of the disease in these fringe areas of the LA and RA that were not previously addressed in the index or subsequent follow up ablation in the first few years around that index ablation.

This is VERY important to Grok so to speak. Especially for a woman and especially for women over the age of 60 to 70 years old who had a solid and successful early ablation and then many years later from 6 to 12 years typically of near total quiet NSR, then suddenly a flutter appears.

It is often not from around previously ablated lesions that these late flutters arise, but from all the triggers in more remote area away from the PVI and posterior wall areas, like the LAA and CS, that AFIB structural and electrical remodeling can progress too even when the PVAI and other initial work is holding up fine and will not retrigger long term.

If you go to a self-professed 'conservative' ablationist, the odds of him or her even recognizing such triggers, much less knowing how to successfully ablate them at this stage of the game, are not that high I'm afraid.

And it's better to move past the misleading idea that Natale is too 'agressive', largely fostered by his more reticent and misinformed competitors. Dr Natale, and those he has trained, do a more extensive PVAI than most minimal PVI procedures for sure as the core of each standard and more advanced ablations, but every one of his burns in any given patient are guided individually, after the extended PVAI portion with includes the wide areaPV antrum isolation and isolation of the posterior wall and in many cases isolatiob of the Superior vena cava (SVC) too.

After that, he then targets only those active non-PV triggers in a given person as dictated by the degree of progression of the disease shown in each case. He does not perform a fixed 'same size fits all' extended ablation in all patients as some erroneous imagine... Not even close! In otherwords, he is fully capable of detecting and going after any active triggers a patient has thay are triggering AFIB/Flutter, and which will almost certainly cause more problems either soon after or within a year after an index ablation if not properly addressed.

But he does not go in willy nilly doing full extended ablations in every patient, by any means. It's very individualized.

And yet, because his case load is over 75% persistent and Long standing persistent AFIB ... the most difficult cases of all ... he has a much larger number of cases which required more extensive work in order to put the genie back in the bottle for the long term over a one to generally two and more rarely three ablation process with the last two being true touch up procedures in the vast majority of cases. This is why to an infomed eye it might seem like he is 'more aggressive', but in reality Natale tends to have the least number of total overall burns required to really get an expert ablation process done solidly for the long term of anyone I know of.

A key factor in your decision Cass, is that women who have had a successful first ablation and then go on after many years of NSR to later manifest flutter or tachycardia, have such a high odds if having an active LAA and/or CS found during the follow up ablaton ... Dr Natale told me that for women over 70 yrs old when they come back for a very late occuring flutter after years of NSR following a much earlier solid index ablation or two, it is not quite at 100% but is not far from that almost total number as well!

As such, if you go back now to Dr Natale, as I highly recommend, and all your have is one or two PV spots that have reconnected and are active again, then that is all he will touch up, just as any other EP would do if that was all that was found causing your flutter ( thoiugh PV triggers more often connected to AFIB abd not as often left atrial flutter.

But if Dr Natale finds that the LAA or CS is a significant source of your recurrance of what now is left Atrial flutter, then if you had not gone back to him or to another highly experienced EP who understands and can successful ablate or isolated these more advanced ablation targets like the LAA or CS .. then you will very likely be out of luck and could well get stuck on the multiple repeat merrygo around trying to get this flutter addressed all teh while possibly working with an ablationist who is not very experienced in both detecting these LAA and CS triggers nor successfully isolating them/b

The fact that your local EP said he does not address the LAA for a case like yours after having had an excellent run from an index Natale ablation, and being a women these many years later, the odds are very high indeed you wull need a much more experienced operator to be sure they are even detecting the right sources of this flutter and taking care of it for the long term.

In any event, that would be my strong advice. You already started with undoubtedly one of the very best in the world and who did a very fine job for you already in the first go around, The follow ups are even more demanding of a highly experienced ablationists, so I would not stray from your original strong choice and discrimination used and compromising now based on a dubious concept that you only need a 'conservative follow up' so a less experienced EP should be good enough.

You could get a good outcome with him or someone in his experience level.. but the odds of that versus going with the guy who bought you 7 years so far, is far less from the outset before hand than going with the proven commodity who knows your heart already and can easily reset your NSR for the long term with a true touch up ablation.

I trust you will make the best decision for yourself Cass, and if you wish to talk more about it send me your cell and I will try to call back when I can.

Cheers!
Shannon



Edited 3 time(s). Last edit at 11/22/2015 12:27AM by Shannon.

Shannon, I was truly impressed with your reply to Cassie . I was an active71 year old woman who did aerobics, dance, etc who was diagnosed with afib 5 months ago. I am on xerelto, multaq and metropolis which at this point seem to be keeping the afib pretty much in check but I don't want to live on meds the rest of my life. I have no other heart disease. I had one opinion from NYU dr chinitz and am about to make an appointment with dr Natal because I've read some great things about this man. I am so scared of what is happening to me, but I know no one can make this decision but me. I live in New Jersey. I want to get back to living again. Any advice and input u can give me will be much appreciated. Regards Vickie

Hi Vickie,
You'll get good advice from Dr Natale but I might add, since it's happening in 10 days, that the annual afib symposium is going to be in Orlando this year and Dr Natale, along with many others, will be presenting. It's a conference designed for patients as well as providers and many of the leading lights of the field will be there. Go to afsymposium.com for all the details. It starts on the 14th of Jan. Good luck! Cass