2 types of ablation

Hi all.
Had a 1st hospital visit today to talk to the ep about my Afib. He offered an ablation to me. Said it’s a 12 month waiting list.
He spoke about the 2 types. Freezing or the heat type.
I’m wondering which is the safest and gives the best results ?

Radio frequency (RF) ablation is the "heat type." It uses the same type of electrical energy that microwave ovens use to burn tissue and create a scar. The other type is cryo ablation. It uses a super-cold balloon to burn tissue and create a scar. Either way, the objective is scars in specific places.

RF in the hands of a highly experienced EP is vastly superior. In the hands of a less experienced EP, cryo is probably more effective because it doesn't take a lot of skill, but still has limitations that RF doesn't.

In a nutshell, cryo produces a single burn pattern encircling the pulmonary veins, which is the most common source of AF. If your AF has sources elsewhere, as many do, cryo will not resolve your AF. Basically, it's kind of a blunt instrument whose only advantage is that it takes less skill and experience.

RF can produce burns anywhere, so AF originating from almost any source can be addressed. However, it really does require much more experience to be highly effective.

With ablations, experience is absolutely everything. I don't care what lofty degrees or titles your EP has or what schools they went to; if they haven't done many hundreds or thousands of AF ablations, find someone who has.

I read of the effectiveness of both types of ablation. The RF ablation is stated as being about 70% or so effective. That is why often there needs to be more interventions. The second is cryoablation. What I've read, it is supposed to be about 90% effective. But check it out. Search: cryoablation for Afib.

No, that's not correct. I think you misread something or the source wasn't reliable. If cryoablations had a 90% success rate and RF 70%, no one would be doing RF ablations. I don't have time to find good numbers right now, but in general RF has higher success rates than cryo and comparable complication rates.

But the thing to remember is that numbers like this are broad averages and they include the best, most highly experienced EPs who've done thousands of procedures along with the EPs who just did their first procedure yesterday and won't do another one for a month. The thing is, experience is everything with ablations, so broad averages really don't predict much about your experience. I guarantee that an EP highly experienced with RF ablations can outperform any EP using cryo, especially with persistent AF and difficult cases where cryo is almost useless.

So my advice would be to find the best EP you can and let them choose the appropriate technology to use.

I have a trusted EP who does (before covid19) a few ablations possibly a month being generous with that number. I asked the questions Carey recommended-how many ablations have you performed? What is your success rate? What do you recommend (my question) if the first ablation is not successful? My EP reply to that for me (I’m a complex case and any advice is usually out of the norm) if the first ablation fails then get a BB to stabilize my hr and live a life of AF. His advice was not new. Many told me there is nothing wrong with living with AF. I just disagree if one is symptomatic and it affects one’s quality of life.

I ended up asking him if he was the right EP for me? He then said I should get a Natale ablation—many here have. Dr. N is an elite EP with the experience of tens of thousands of ablations. My local EP said it was up to me...then that week I talked to Carey and found out Dr. Natale travels to California one week a month. Best decision I’ve made. You should seek an experienced operator. Post what state you live in and ask for recommendations of a skilled experienced EP. It may be worth it to drive a bit. Skill outweighs geographic convenience as another option and get the best your insurance will cover.

I turned down another Ep earlier who wanted Cyro and had the RF technique. He didn’t have much experience.



Edited 2 time(s). Last edit at 01/07/2021 10:59PM by susan.d.

Cheers all. I went to Coventry hospital. England
My ep appointment was with dr panikker He was really helpful. I asked who would be doing my ablation and he said anyone of 5 people
Just depends who’s on shift I suppose. That didn’t fill me with with hope



Edited 1 time(s). Last edit at 01/09/2021 05:10PM by Lenlec.

Sorry, didn't realize you were in the UK, but don't let the way they assign cases get you down. If they rotate like that consistently then most of them probably have a similar amount of experience. You can go private, of course, or even go to Bordeaux or Austin, but as I'm sure we all know that's not cheap.

If this is your first ablation and your AF is paroxysmal, a cryo ablation even by a relatively inexperienced EP has very good odds of succeeding -- somewhere in the neighborhood of 75%. And if it doesn't fully succeed, a touch-up procedure using RF has something on the order of a 90% success rate.

So go into this knowing the most likely outcome is success.

Brilliant cheers. It’s a 12 month wait list he said. So I can pull out of it if I want to. Or go onto daily meds as I only take a 50mg flecanide when I get an Afib attack

If a PIP of 50 mg flecainide is working for you now, I wouldn't change anything if I were you.

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Carey
If a PIP of 50 mg flecainide is working for you now, I wouldn't change anything if I were you.

Hi. You wouldn’t have the ablation? The doctor immediately said I’m perfect to get it done and should be highly successful?

As long as your afib episodes are short, not too frequent, self-ending or converting with the help of a low dose of flecainide (as PIP) and not too symptomatic... why going for an ablation?
50 mg of flecainide as PIP is a very low dose. How long do you have to wait to get back to NSR after taking it?
I'm asking because I used flec as PIP for some months, taking 100mg (my max authorised dose) if I didn't self convert after 1 hr in afib. Sometimes it took me one more hour to get back to NSR, sometimes just a couple minutes !!!
As flec needs some time to act (at least 20 to 30 min - I'm not sure about this), I began to believe that the glass of water was more effective for me than the drug.
Are you sure you wouldn't go back to NSR without taking the drug?

Quote
Pompon
As long as your afib episodes are short, not too frequent, self-ending or converting with the help of a low dose of flecainide (as PIP) and not too symptomatic... why going for an ablation?
50 mg of flecainide as PIP is a very low dose. How long do you have to wait to get back to NSR after taking it?
I'm asking because I used flec as PIP for some months, taking 100mg (my max authorised dose) if I didn't self convert after 1 hr in afib. Sometimes it took me one more hour to get back to NSR, sometimes just a couple minutes !!!
As flec needs some time to act (at least 20 to 30 min - I'm not sure about this), I began to believe that the glass of water was more effective for me than the drug.
Are you sure you wouldn't go back to NSR without taking the drug?

Hi. I’ve only had flecanide twice
Over the last few years I wa taking 2.5mg bisoprolol as a pip and it took me 12 to 24 hours to go back to normal
My neighbour has Afib and gave me one of his flecanide to try. (Yes I know he should not have) and I was back to normal after 2 to 3 hours

OK. Bisoprolol is a beta blocker. Not a rhythm drug. It may reduce your HR while in afib, but wouldn't likely help much to stop it.
Flecainide IS a HR drug and can be very efficient as PIP to bring you back to NSR.

Edit:
I think Carey is right, as usually. If a small dose of flecainide as PIP is enough to get you back to NSR, there's little reason to hurry towards an ablation.



Edited 1 time(s). Last edit at 01/10/2021 07:38AM by Pompon.

I agree with Pompon. If 50 mg of flecainide ended my afib episodes quickly and those episodes weren't too frequent, I would not undergo an ablation. I'm sure your doctor is confident and all, but ablations remain an invasive procedure with risks, and sometimes ablations require repeat procedures. I would stick with the flecainide for now. However, be aware that the ablation is probably inevitable somewhere down the road. The one predictable feature of AF is that it's progressive. It may stay the same for years, but sooner or later it usually gets worse. And by worse I mean more frequent and longer lasting episodes, eventually culminating in persistent AF. You don't want to put it off that long. Once the episodes start becoming more frequent, I would look into an ablation. But for now I wouldn't rush into it.

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Carey
I agree with Pompon. If 50 mg of flecainide ended my afib episodes quickly and those episodes weren't too frequent, I would not undergo an ablation. I'm sure your doctor is confident and all, but ablations remain an invasive procedure with risks, and sometimes ablations require repeat procedures. I would stick with the flecainide for now. However, be aware that the ablation is probably inevitable somewhere down the road. The one predictable feature of AF is that it's progressive. It may stay the same for years, but sooner or later it usually gets worse. And by worse I mean more frequent and longer lasting episodes, eventually culminating in persistent AF. You don't want to put it off that long. Once the episodes start becoming more frequent, I would look into an ablation. But for now I wouldn't rush into it.

Thnaks.
Well I’ve got probably a year to decide. I’m on the list for an ablation now anyway. The ep has also booked mr to go back for an ultrasound scan
Is this to check suitability for the ablation?

Quote
Lenlec
The ep has also booked mr to go back for an ultrasound scan
Is this to check suitability for the ablation?

Yes, to an extent, but it's probably mostly just a general fact finding mission. Do you have normal heart anatomy? Any clots lurking in your atria? Is your left atrium enlarged? Any valve issues? Is your ejection fraction normal?

Quote
Carey

The ep has also booked mr to go back for an ultrasound scan
Is this to check suitability for the ablation?

Yes, to an extent, but it's probably mostly just a general fact finding mission. Do you have normal heart anatomy? Any clots lurking in your atria? Is your left atrium enlarged? Any valve issues? Is your ejection fraction normal?

I had an ultrasound done a few years ago when 1st diagnosed. All wa fine and the doctors said I had lone Af

Okay, then he's mainly just looking to see if anything has changed, like left atrium enlargement, for example.

Quote
Carey
Okay, then he's mainly just looking to see if anything has changed, like left atrium enlargement, for example.

Thanks again
Why would the left atrium enlarge ? Is This a bad problem ?

Prolonged afib (and other health issues like high BP) can lead to LA enlargement.
Athletes (endurance) often show enlarged heart chambers too, and this enlargement can lead to... afib. A vicious cycle.
But, AFAIK, this can be somewhat reversed...

Some other thoughts about ablation:

- Patients opting for ablation hope to get a "one and done". 60-70% of them are lucky, but many require a second procedure.
- There are people still having afib after repeated procedures. They're rare, but you'll find some of them here (like me).
- Being afib free for at least 1 year after ablation is considered a success; but, as said, afib is evolutive; so, being ablated and afib free for years does not mean afib wouldn't come back in the future.
- Many ablatees (you'll find some here) are afib free, but are then bothered by ectopics. Afib is a serious issue. Ectopics, OTOH, are usually benign, but they can be incredibly annoying. Making burns in one's heart chambers is a brutal process, and ectopics might be a consequence of it. Having afib without any associated comorbidities (what was called "lone afib") usually means genetics are involved in the issue. I guess one's vagal tone can be temperamental and cause ectopics once it can't induce afib any more.

CAUTION : This forum is highly informative, but don't forget its members are "unlucky" for most. Lucky patients soon forget about their afib and rarely come here to talk.

Quote
Pompon
Prolonged afib (and other health issues like high BP) can lead to LA enlargement.
Athletes (endurance) often show enlarged heart chambers too, and this enlargement can lead to... afib. A vicious cycle.
But, AFAIK, this can be somewhat reversed...

Some other thoughts about ablation:

- Patients opting for ablation hope to get a "one and done". 60-70% of them are lucky, but many require a second procedure.
- There are people still having afib after repeated procedures. They're rare, but you'll find some of them here (like me).
- Being afib free for at least 1 year after ablation is considered a success; but, as said, afib is evolutive; so, being ablated and afib free for years does not mean afib wouldn't come back in the future.
- Many ablatees (you'll find some here) are afib free, but are then bothered by ectopics. Afib is a serious issue. Ectopics, OTOH, are usually benign, but they can be incredibly annoying. Making burns in one's heart chambers is a brutal process, and ectopics might be a consequence of it. Having afib without any associated comorbidities (what was called "lone afib") usually means genetics are involved in the issue. I guess one's vagal tone can be temperamental and cause ectopics once it can't induce afib any more.

CAUTION : This forum is highly informative, but don't forget its members are "unlucky" for most. Lucky patients soon forget about their afib and rarely come here to talk.

Good summary!