Ablation with an enlarged atrium

I am about to have my third ablation here in Australia...in approximately 2 weeks time
In the information pack that I just received from my cardiologist - it says "In difficult cases particularly patients with left atrial enlargement or other associated cardiac conditions (which are then listed) left atrial substrate ablation comprising linear ablation or ablation targeting fractionated atrial signals may be required. When left atrial substrate ablation is undertaken there is a 10% to 20% risk of the patient developing left atrial flutter in the longer term. If this happens, it may be more symptomatic than AF and almost always requires an additional ablation procedure or alternatively a pacemaker followed by ablation of the atrioventricular node"
My left atrium is around 4.7cm. (I am female) I guess I fall into this category. I would really not like to end up with a pacemaker and am feeling rather anxious about the procedure.
Does anyone on the Forum have a similar story to mine? Any comments would be most appreciated.

My understanding is that flutter is actually one of the simplest problems to eliminate with ablation, so I'm quite surprised your info pack has the disclaimer about possibly needing a pacemaker.

The old "cauterize the SA node and install a pacemaker" is very old school thinking, and is extremely rare these days.

Thank you for your reply Apache. I find your comments very interesting.......the only thing is that I don't think it is the SA node - it is the AV Node. Would you know if it is 'old school thinking' to cauterize the AV node as well? I am encouraged by the fact that a flutter ablation is a simpler procedure

spekkles Wrote:
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> Would you know if it is 'old school thinking' to cauterize the AV node as well?

The procedure was an AV node ablation, which requires a pacemaker afterwards. It is not used much these days, and for good reason.

There are docs in Australia who've been trained by the Bordeaux group, they would be my preference. Or I would contact them and ask their suggestion for someone near you.

Quote
Hans Larsen
If you are considering going to Australia for a procedure I would recommend either Dr. Prash Sanders at Royal Adelaide Hospital or Dr. Rukshen Weerasooriya at Royal Perth Hospital. They both trained with Pr. Haissaguerre in Bordeaux

<[www.afibbers.org]

George - thank you for your reply.
I am, in fact, going to Prof Rukshen Weerasooriya. He did train in Bordeaux and in fact, Pr Pierre Jais (who works with Pr. Haissaguerre) - has spent the last year working with Rukshen ...on a year's sabbatical... in Perth. Rukshen has done over 2000 ablations.
I am a bit perplexed, I must admit.

I'm assuming your cardiologist is someone besides Prof Rukshen. Perhaps Rukshen had nothing to do with the information packet.

Hi Speckles,

The easy flutter ablation apache is referring too is typical right sided CTI-FLutter or Cavo-Tricuspid-Isthmus flutter. This is a rather simple ablation that any half-way decent EP should be able to perform with very high success rates at 98% as it's all laid out with a predicted anatomical only pattern in the right atria that requires no transeptal puncture.

The type of flutter that occurs as a result of some extended ablation, is much different and more challenging to ablate unless the EP has been well trained and has a lot of experience tracking down and zapping these "Atypical Left Atrial Flutters". These atypical left flutters can very successfully be eliminated by experienced persistent AFIB ablationists, as I, and many other's here on this forum, are direct examples of.

Also, it is the A-V node ablation, that has been the standard fall back offered by lesser experienced EPs ... not an SA node ablation ( thank heavens!) ... when they are not able to treat the patient with more advanced disease successfully with their own often average skills with a catheter inside the left atrium. A-V node ablation are, alas, still offered when a given EPs toolkit is empty and he has nothing more to offer the patient.

By contrast, Dr Natale has never once had to resort to doing an A-V node on any of his patients in now over 8,000 cases and over 75% of these being among the most challenging kind of ablation cases with persistent and true many year LSPAF cases. He as reduced an increasing number of folks who found our forum asking for guidance after they had been told there only last choice was an A-V node ablation with permanent Pacer installed. Dr Natale as successfully fixed all of these patients so fara

At 47mm diameter for your LA size that is that is still considered moderately enlarged range but moving toward more significant. Typically severely enlarged LAs are set at 50mm and above and is where some EPs get cold feet in doing any ablation on such people. But again this is not a barrier to highly skilled persistent ablation experts.

Elite EPs who focus most of their work on persistent and LSPAF cases do many cases at 50mm and above, though more extensive work is usually required as indicated by the sheet you got from your EPs office.

Even at 45mm and above and not infrequently at 42-43 there can still be some non-PV triggers active irrespective of LA diameter, and that are located beyond the PVI and posterior wall isolation anatomical ablation phases.

You did not describe the details of what was done in each ablation, but I suspect there were a good deal of reconnections of previous work found from one ablation to the next.

In any event, carefully screen for the EP ablationist in your accessible area who focuses a majority of their caseload on persistent and long standing persistent AFIB, if such an EP exists in Australia. Ideally, as someone with 3 prior ablations you really want to exercise as much discrimination in who you partner with to finally finish up this business hopefully once and for all. Seek out someone in your case with minimum of 3,000 AFIB ablations or more (or as close as you can realistically come to that overall level of experience) and confirm what percentage of his or her cases are persistent and/or LSPAF cases if you can at all confirm such stats.

Make sure your next EP is very comfortable doing more extended ablation beyond the PVI and Posterior walls alone. This is a must in order to up your odds for real progress after 3 procedures which likely did not venture much beyond the standard anatomical source targets.

In Australia, you might find fewer EPs who even consider ablation for LSPAF cases, but in any event try to find someone who does at least as many persistent AFIB ablation as they do paroxysmal cases to increase your odds of hooking up with an EP now who should be able to bring this all home for you, hopefully in just one more if any of the three prior ablations lesions were done reasonably transmural and durable.

Once reason for still need work done after 3 could also possibly be due to migration of your more active triggers now to the more frontier areas where AFIB/Flutter tends to spread too over time and with progression of the condition .. for example the coronary sinus and left atrial appendage. Without an ablationist who is skilled at ablating these structures when he or she works on more challenging cases.

Your EP who has been working with Pierre Jais the last year in Perth sounds like a potentially promising option. If you'd like speak more about your option and send me you number I can try to call you by Skype at a time that works for both of us during the day.

Best wishes speckles,
Shannon



Edited 1 time(s). Last edit at 08/20/2016 02:50AM by Shannon.

Shannon,

Which dimension is used when referring to left atrial enlargement? This got me looking back at my cardiac MRI report. It says:

LA measurements
Roof to floor: 6.6 cm
Left to right: 4.7 cm
Ant to post: 4.1 cm

And, elsewhere:

LA DIMENSIONS (LV SYSTOLE)
---------------------------------
DIAMETER: 4.5 cm

The report calls this "moderately enlarged". The EP report indicated electrical activity in the right and left superior pulmonary veins only. Nothing elsewhere. Notably, I have 3 right-sided PV's, but that occurs in about 20% of the population as I understand it.

Shannon, thank you so much for your extensive reply. I have emailed a few questions to my EP and am just awaiting for him to reply. I would like to Skype with you - but let me just wait until I hear back from him. I'll contact you when he has replied.
Shannon - just one thing. I have had 2 ablation....I am going for my third one. I really appreciate this Shannon...thank you.

Spekkles, let me know when you want to talk and PM me your cell number and time zone.

Cheers!
Shannon

Wolfpack,

Your TTE measure you want to know is LA diameter and yours is 45mm which is moderately enlarged but not seriously so. The longer you stay in unbroken NSR the more that number will drop back toward normal levels. The degree of reverse remodeling and recovery of smaller LA size can be limited by degree of atrial fibrosis present. A lot of long term fibrotic changes and only partial reverse remodeling is likely but any degree of recovery is a bonus!

Shannon

Shannon,

Thanks for clearing that up.

The cardiac MRI (delayed enhancement) reported 0% scarring. Of course, that was BEFORE someone stuck a catheter in there!

Hi Clay,

Good question which brings up the issue of using a DeMRI for pre-screening prior to AFIB ablation. Certainly, a preliminary DeMRI as you apparently have had is good to see that is shows both atria with essentially zero fibrosis/scarring on MRI which is very likely a good sign you don't have much, if any, atrial fibrosis to speak of. But DeMRI is still quite controversial as a method for accurately detecting atrial scar.

This, as opposed to Venticular scar detection where the muscular ventricular walls are very thick and thus ideally suited for DeMRI scar detection. However, many MRI experts counter that the atrial tissue is too thin for DEMRI to accurately distinquish between true fibrotic scar and imagining artifacts. It does give a rough indication of presence of scar. However, trying to assign things as fine-tuned as 1% variations in scar many MRI experts say is just not possible with current tech inspite of what one center who has been pushing requiring DeMRI with a proprietary algorithm as a necessary pre-screening tool prior to any AFIB ablation to screen people with too much scar away from ablation and offer them only medical management of their AFIB.

I strongly disagree with that approach even when assuming for the sake of the debate over its true utility that DeMRI screening of atrial scar is just as accurate as its promoters imply.

The developing group for this concept at Univ. of Utah ( not to be confused with Intermountain Med Center AFIB group) created the controversial Utah IV system. It's not the active gradations between the four Utah fibrosis burden classification stages that is controversial, but rather the interprtation and recommended actions recommended for these Utah stages that have come under considerable critical scrutiny, especially controversial is their Use of Utah IV stage not as a referral tool to direct these more advanced fibrotic patients to only top volume persistent AFIB ablation centers and their highly experienced ablationists. Instead Utah IV is interpreted to be an exclusion tool to deny patients with significant fibrosis from ever having the chance from benefitting from even an expert ablation process see the Utah system become codified as official ablation guidelines and possibly adopted by insurance companies to deny advanced patients anything than being shuffled off to the ice flow with the elderly Eskimos parked on a lifetime of rate control and OAC drugs with nearly zero chance of ever seeing long term NSR again.

Alas, the premise of this extreme Utah IV Implication as a clear denial of ablation tool, simply because statistically more advanced afibbers are much less likely to be one and done at 1 year following a SINGLE standard PVI, and also based on the fact that the group of studies used to derive this draconian ablation qualification model, don't seem show more than very modest gains on average by going to these same mostly moderately experienced EPs over and over again who, for the most part, are limited to just repeating the same minimal anatomical-only ablation protocol whenever these advanced afibbers require any follow up ablations.

This in dramatic contrast to including real world RCT results of combining an advanced Non-PV trigger detection/-ablation protocol to an extended PVAI index procedure, including when often needed in such advanced afibbers one to two max additional limited touch up procedures in order to acheive a very high percentage of long term freedom from all atrial arrhythmia.

I really got steamed when I first read that Utah classification system and it was clear that it was being proposed as a way to make a largely redundant and expensive DeMRI scan (rough average of $5,000 added to an already expensive procedure), as a prerequisite before anyone could qualify for an AFIB ablation!!

We're the Utah IV stage classification to become a requirement to qualify AFIB ablation patients, it would prevent folks like me and so many others on our site who are now enjoying long term freedom from all AT, or at least greatly reduced AT burden, from ever being offered an expert ablation based on the assumption that since folks like me with more advanced AFIB are likely to need more than one simple PVI to get long term freedom so why bother as it's more cost savings to just stash us all medical management and 'get used to your gradually progressive AFIB except in more rare cases that can make some hardware with dedicated lifestyle risk reduction too without ablation)

Keep in mind, that every single ablation using an EAM (electro-anatomical mapping system like Carto-3 or Insite) automatically will detect the degree of atrial fibrosis and scarring at the beginning of each ablation with a universally accepted gold standard accuracy at measuring atrial fibrosis/scarring in any event. And all without having to burden the whole cost structure with another $5,000 or more when incidental expenses are factored in to do a preliminary non-invasive DeMRI a few days before any ablation.

The only possible advantage of screening every patient in this way is to be able to steer those with more advanced disease to more experieced persistent AFIB ablationists and insure that the majority of zeros doing ablations on the side while primarily keeping their doors open doing ECVs, TEEs, pacers, ICDs, CRTs and some CTI flutter or SVT right sided only rather simple and quick ablations ... Basically doing the whole gamut of EP procedures, but who do not command come close enough in volume of AFIB ablation
to really advance their skill and craft much beyond decent proficiently with an anatomical-only AFIB ablation protocol.

Would not all that time and money needed to do an MRI that every EP will get an even more valid answer about the degree of fibrotic scarring any patient has from their EAM mapping before they start the actual ablation lesions in every ablation in any event be sufficient? And would not all those resources be better spent to better train a greater number of EPs in how to safely and with greater efficacy perform the more advance 'expert ablation protocols' so that far more can actually treat most every patient that might come through their doors, and not be embarrassed by suddenly finding themselves over their heads too often when a case that seemed like it might well fall within their comfort zone suddenly turns out to be more complex than a simple cookie cutter 'get in, circle the veins, and get out' anatomical ablation they were hoping for??

And it's a total travesty to suggest using UTAH IV as the 'go/no go' ultimate screening tool for cutting every advanced Afibber off from their chance at real freedom, or at least a dramatic reduction in AFIB burden, by a one, two or three step expert ablation process in the hands of a highly skilled advanced ablationist.

Utah IV, if any utility whatsoever, should be used to immediately refer said patients with that degree of atrial structural changes to the most highly experieced Advanced ablstion EP and center in their region who does a majority of such cases as their prime workload every day.

But why bother with the up front MRI in any event, as most EPs have a pretty good idea just in their own screening process already who are likely going to be the advanced cases and discriminating between those who have high odds of getting good outcomes with the more basic anatomical-only approach. Doing this kind of extra DeMRI screening would mostly be a windfall for the MRI companies funding much of this research, as well as the developing/promoting centers getting large good notoriety and increased flow of grants to continue trying to increase MRI's use in catheter ablation.

Don't get me wrong, I'm all for the research and it's all good to try to press the edge of what we know, but when we start having to create scenarios and justifications for adopting such a largely redundant process that already exists in our standard ablation process, when there are more sensible and effective means of gathering the same information and insights already built into the cost of every ablation, then trying to manufacture such a need starts looking a bit like an effort to fit a square peg into a round hole for the purpose of shoe-horning a role in the AFIB space for MRI tech (which no doubt the MRI makers are all excited about as would be the center and leaders of the effort that are hoping to see MRI scanning florish in this area where it has had limited utility up until now. And these days many of the docs helping develop new tech also wind up gaining big windfalls from large stock options, sale of patentable ideas and bonuses ... and nothing wrong with that for their hard work for sure.

But we first have to ask, just what utility is use of an existing tech like MRI in a new way going to provide a NET new benefit to both doctors and patients alike? And is there any potential for abuse of the technology even if the misuse, as in this case in my opinion, is mostly from creating an inappropriate use of Utsh stage IV as an ablation exclusion tool.

There are times when a DeMRI for atria visualization may well be warranted, but adopting this proposed Utah DeMRi fibrosis classification system as a standard screening tool for all ablations, seems the very definition of a red herring to me. And also apparently to a lot of EPs and hospital cost screeners as well as evident by the limited broad scale adoption of DeMRI screening before all AFIB ablations now even after the last four years of studies mostly originating from one overseeing center that processes all the properitary Algorithmically-adjusted DeMRI data in-house, even when the MRIs themselves were done in other centers as well.

At the very least, if they would redefine Utah stage IV to mean only that such patients should be referred to expert persistent Ablation centers, rather than excluding these patients from ever benefiting from an advanced ablation process, that would be a good start in the right direction in my view and I would have far less objection than I do now to the current language used in the Utah clasification system.

Myself and so many others on our website and forum have benefited so greatly from an advanced expert ablation processes of from 1 to 3 procedures, but who would easily be listed in Utah class III or IV and thus strongly discouraged from ever having an ablation at all! That is what makes me as steamed as a poached egg about this Utah system as originally defined.

It appears that since the first two Utah stages, and even the third Utah stage to a degree, are clearly redundant to EAM mapping, it thus would be hard to justify the investment of new MRI resources dedicated just for AF ablation prescreening, so the interpretation of Utah IV as an actual ablation exclusion tool would serve to really save the hospital a fair larger amount of money from simply denying these patients even referral to more advanced top volume centers who specialize in successful treatment of these cases every day.

The logic of the current inappropriate (in my view) Utah IV interpretation is based on the observation from looking at studies of mostly PVI-only experience that not only is such a single limited index ablation procedure not enough for high degree of long term success in more advanced patients, but that just repeating the same basic PVI-only or PVI plus posterior wall isolation-only follow-up procedures when recurrences occur over and over, only buys a little bit of added success long term. So why not use Utah IV to deny this group a chance at freedom from AT (all atrial tachyarrhythmia) and save at least most of advanced patients and doctors the frustration and time needed to redo the same exact expensive repeat procedure repeatedly, only to gain incrementally just a little improvement on average in the bargain?

The problem here is the skill of the EPs and/or the scope and effectiveness of the ablation procedures offered in the referenced studies used to build a case for Utah IV. And that it does not account for what is really possible in elite level persistent Ablatuon centers like Natale's groups, Bordeaux, Univ of Penn and others.

Finally, keep in mind, too, next time someone tells you you need a preliminary added DeMRI scan of your LA and RA before getting an AFIB ablation, that all they will learn will already be clearly seen in the beginning of your ablation anyway, and just by choosing the most experienced EP who does mostly advanced cases to begin with this whole debate instantly goes away!and you don't have to worry about possibly getting stuck with either a greenhorn or just a moderately experienced ablation EP who has yet to master Non-PV trigger detection and ablation beyond just the anatomical only PVI plus posterior wall isolation at best.

Roughly 9% of persistent and LSPAF cases ONLY have active drivers of their AFIB/AFlutter coming from their LAA and no where else in either atria. And since LAA tissue harbors almost zero fibrosis to begin with and no amont of MRI prescreening will confirm that you can get by with an anatomical-only ablationist. To a much lesser degree, the same is true for even basic paroxysmal cases who occasionly have Non-PV drivers in the coronary sinus and LAA as well as in the PVs and posterior wall, essentially guaranteeing such patients endless repeat ablations required unless, and until, they wise up and partner with a highly experienced advanced ablationist who does most only advanced non-PV trigger-based procedures in their daily practice.

Just some food for thought when considering if undergoing a DeMRI is a necessary step at all. Certainly, for those here who have already gotten the mantra about choosing the very best and most experienced ablatiomost they can possibly arrange for themselves, there is no need at all for such an added procedure at DeMRI and an hour slid heat first in most Tesla 2or 3 machine in those rather snug torpedoe tubes many of these high powered magnet MRI machines still have.

Be well,
Shannon

Wow, I had no idea about the MRI stuff! In my case it was done the day before the ablation, so I thought it was simply part of the anatomical mapping procedure.

Here's another thumb's down for the Utah MRI.

I got a cardiac MRI for Utah classification and not only was it not useful, it was completely unusable because of artifacts in the crucial series used for the classification. Not motion artifact, artifact caused by the MRI techs not dialing in the sequence correctly. The EP apologized profusely and said that the techs were being retrained. Still billed my insurance for $6000. They just submitted it as a regular cardiac MRI. Grrr.

Hi Wolfpack,

Regarding added ablation lesion scars, the large majority of ablation lesions are laid down in atrial tissue not involved in contractile function of the heart. Hence, such deliberate lesions have a good deal less significance on mechanical function of the atria, not always the case with AFIB-induced fibrotic scarring which gets distributed randomly in various regions of the heart, some of which can impact mechanical function.

The intentional AFIB lesions scars are carefully laid down to address AFIB activation areas while minimizing any impact of cardiac function.

Shannon