Reversal of common medical practice for ablations?

I found the following review fascinating in general and, in my case (recently having an extensive ablation for persistent AF) rather startling.
The specific contraindication exemplified for ablations (beyond PVIs) is certain to be controversial in this forum! I'd appreciate full commentary.

[www.medscape.com]

The specific "medical reversal" described reads:


Here are four highlights from the reversals identified in cardiology:
......
Ablation beyond pulmonary vein isolation (PVI) for atrial fibrillation (AF) ablation: In the STAR AF 2 trial, extra ablation outside the basic PVI lesion set did not reduce the rate of recurrent AF in patients with persistent AF.[12] I was among those duped by key opinion leaders who promoted the idea that advanced forms of AF require more ablation. Before de-adopting the practice, I spent years doing repeat procedures for arrhythmias created by the extra lesions. If only I had been a medical conservative[13] earlier in my career.

sigh... Mandrola.... As far as I can tell, he's an EP who thinks the only treatment for afib that has any value is lifelong amiodarone.

The STAR AF trial was very limited in the lesion sets it looked at. Mandrola is -- as usual -- greatly exaggerating its importance. Instead of looking at the approaches that don't work someday he might want to look at the ones that do, as proven thousands of times by his EP peers with greater ablation skills.

Mandrola becomes more and more of a disappointment to me and I have been following him for years. Have even had email correspondence with him. He seems more interested these days in self promotion than furthering his craft. Which leads me to believe he has reached his limits as an EP.



Edited 2 time(s). Last edit at 07/21/2019 03:34PM by rocketritch.

So we are supposed to have one view on this broad which is "ablations are great when done by Natalie and some others". Even Dr. Natalie has to do more than one ablation for a patient. On this board some have had 3 done by him. There are some tragic stories about some ablations outcomes, which we usually don't read about them on here. I recall a few years ago a doctor had an ablation at U of M hospital in Ann Arbor by the top guy there and unfortunately he died.

I just would like to hear about other things that some do for their AF that doesn't always include ablations without it being squashed by Carey.

Liz

The problem with all these arguments is no 2 cases are the same. My flutter/fib was definitly coming from outside PVI, it took 3 failed ablations with another "top guy" to go to Natale and get my life back on the 4th try.

I was in congestive heart failure at age 40, and getting ready to file for disability and spend my life doped up on beta blockers on the couch.

So while I like to hear about anything and everything guys like Mandrola telling people what to do is dangerous. My life was effectively over until a proper ablation was done. He can have an opinion but he morphed into Dr. Doom of ablations maybe because he sucked at performing them, maybe other reasons all together. The fact I and others are mentioning his name is most likely what he is after so well done Doc M.

And he can spare me the i've had afib so I understand BS, 30 seconds of afib is not permanent and I question if he is even being truthful and certainly misleading.

Him or anyone here should realize that while ablations may not be perfect, performed by the right person they are simply the best hope at taming this crappy condition. I am all ears for a better option but thus far it does not exist. And random horror stories can be found on even the commonest procedures so to use them as fear mongering and potentially keep someone from getting there life back is irresponsible at best.

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Elizabeth
So we are supposed to have one view on this broad which is "ablations are great when done by Natalie and some others". Even Dr. Natalie has to do more than one ablation for a patient. On this board some have had 3 done by him. There are some tragic stories about some ablations outcomes, which we usually don't read about them on here. I recall a few years ago a doctor had an ablation at U of M hospital in Ann Arbor by the top guy there and unfortunately he died.

I just would like to hear about other things that some do for their AF that doesn't always include ablations without it being squashed by Carey.

There is no single view on this forum, I don't believe ablation is right for everyone, and I don't think Natale and a few others are the only EPs who can do them. I would appreciate if you avoided completely distorting and misrepresenting my words and views.

And I'm going to tell you this just once: personal attacks on me or anyone else as you engaged in above won't be tolerated here. If your have such disdain for me or someone else on this forum, I recommend you take it up with an administrator. That would be me or Shannon. Your choice.

Now, if you actually have something to say about Mandrola's article, please say it. Just leave the hostility at the door.

Liz,

Your comment vastly crosses the line! Don't do it again!!!

George

I know that some of you have been members of this forum for over a decade, but that doesnt mean you know more than others or have any more authority over anything other than your opinion, which you're free to share. Carey is right, stick to the article and findings argued by Mandrola, then state your opinion and let others challenge it, plain and simple. Remember that none of us are medically trained EP's so you can openly disagree with methods or the idea of ablation but back it with some research data at least, without naming names or personal attacks which, add no value whatsoever and give any new members the wrong idea of what this forum is about.

I returned here following a close to 10 year hiatus due to what would be considered a successful ablation in 2009.

From what I remember the topics are quite similar to back then. Afib ablation has come a long way since then and continues to progress. The natural approach seems to have stayed the same. Not that that is a bad thing there just haven't been any huge gains in natural or alternative remedies that work for everyone.

When I was first diagnosed I was able to minimize it with excersize, supliments and avoiding what I had found to be trigger's. But as a progressive disease that only worked for so long. Then came the choice of meds or ablation. My EP and I at the time decided that ablation was the best course of action for me.

Close to 10 years later it became persistent once again so my EP recommended a second ablation since the first was a considerable success. He did find some cracks in his original PVI work and another flutter circuit. And when he challenged my heart on the table nothing showed up but 3 months later I was right back where I started because my issues lay beyond the PVI.

Unfortunately that EP was not savvy beyond PVI ablation and was referring me to go the route of convergent ablation. However, when I mentioned I had been in contact with Dr Natale he was excited and offered his assistants in any way he could.

As you probably already know my first ablation in Austin did not completely rid me of my afib first time around. But it did greatly reduced my burden. I also believe that the other health issues I was experiencing at the time also contributed to the first procedure not working to it's fullest.

I base this on the fact that once those issues were resolved the afib I was experiencing at the same time also went away.

Also, during my first ablation with in Austin, I had an organic afib episode on the table that originated in my LAA Which shows there are times that one must go beyond PVI to fully address the issue.



Edited 2 time(s). Last edit at 07/21/2019 03:39PM by rocketritch.

George:

What?

Liz

Hi, everyone.
I'm not here for a long time, but I can understand what some may feel about names often written on this forum.
I don't doubt Dr Natale is a great EP, maybe the best in the World (who knows, actually ?), but reading many posts here often make me think he's the only guy able to ablate successfully. It's somewhat puzzling for those who can't afford a trip to Austin.
Here in EU, we're usually very cautious about names we write in our posts. Common use is to only give our Dr's name in private messages.
I don't want to offense, I'm just talking about things I feel while reading all those posts where Dr Natale's name appear. Maybe the fact I'm french speaking makes me understand things differently than I should, but It's sometimes disconcerting.

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Pompon
Here in EU, we're usually very cautious about names we write in our posts. Common use is to only give our Dr's name in private messages

I’m curious about this caution. If someone is looking for an excellent EP in a certain geographical region, it would seem that the best way to help them would be to post the names of EPs whom members have knowledge of or experience with. That way everyone reading the forum can benefit and members can search the forum for an EP’s name to read about others’ experiences with him or her. What is the reason for caution in sharing an EP’s name?

Not much longer in the EU ☺️ but here's a new report with names of all the EPs in UK and number of ablations they did for 2016. You can see the ones that are doing like 3-4 a week.


[bhrs.com]



Edited 1 time(s). Last edit at 07/21/2019 03:06PM by Brian_og.

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Daisy

What is the reason for caution in sharing an EP’s name?

I don't know exactly, but I understand it may be considered as advertisement, and usually forbidden. Here, our health insurance system is different, and it's likely the reason for only giving names privately.

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Carey
sigh... Mandrola.... As far as I can tell, he's an EP who thinks the only treatment for afib that has any value is lifelong amiodarone.

What is the evidence for this statement about Mandrola?.

From what I have read his primary treatment is lifestyle changes, followed by drug therapy, followed by ablation. Also, as far as amiodarone, the only reference I can find is a JACC 2019 study where where he demonstrates the significant increase in adverse effects with amiodarone, which is hardly a recommendation of it.

My take on him is that he is evolving to a more data-driven approach and is less enamored with the latest innovations in pharmaceuticals and procedures which don't meet a certain rigorous standard. It appears he actually reads and understands studies and attempts to explain them to laymen, which is a valuable thing. He is definitely an outlier in broaching the idea of sham studies of ablation, but he has a point if not a solution. He is without doubt much better informed than these cardiologists turned nutritional epidemiologists like Gundry who has no footprint in peer-reviewed literature and obvious commercial interests.

So I don't agree with characterizing and dismissing his viewpoint in this way.

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safib
My take on him is that he is evolving to a more data-driven approach and is less enamored with the latest innovations in pharmaceuticals and procedures which don't meet a certain rigorous standard. It appears he actually reads and understands studies and attempts to explain them to laymen, which is a valuable thing. He is definitely an outlier in broaching the idea of sham studies of ablation, but he has a point if not a solution. He is without doubt much better informed than these cardiologists turned nutritional epidemiologists like Gundry who has no footprint in peer-reviewed literature and obvious commercial interests.

I see this as an accurate assessment of the current John. However, he comes off at times as the sole voice in an ocean of ideas.

The disservice here is that there are many who take and follow his advice or perceptions which could and I am sure does lead people away from options that could truly help.