Does this clinic sound like a place to go for an ablation?

I found an EP Lab Digest article featuring an interview with one of the EPs who do ablations at a clinic near my home. I’m wondering if this clinic sounds like a good place to be treated for PAF with ablation.

Spotlight Interview: John MacGregor, MD, FHRS, Associate Medical Director for Cardiac Electrophysiology

“For a city of 91,000 people, [ Bellingham, WA ] I am quite proud of what we’ve accomplished and the track record that we have earned.”

“Our EP program is quite comprehensive, especially in the context of our community. We implant pacemakers, ICDs, biventricular systems, and leadless (Micra transcatheter pacing system, Medtronic) pacemakers. We have a robust WATCHMAN (Boston Scientific) program that is now just over 4 years old. We perform ablations for every type of SVT, atrial fibrillation (AF) (using a mix of cryo and radiofrequency depending upon circumstances), PVCs, and ventricular tachycardia.”

“We perform 19 cases per week on average. This includes 10 CRM devices, 7 catheter ablations, and 2 LAAO/lead extractions.”

“The cryoballoon ablation system has been our workhorse for index pulmonary vein isolation (PVI) procedures for the past 8 years, but we see competition on the horizon from other manufacturers who are exploring not only cryotechnology, but also laser and ultrasound balloons for PVI. Pulsed field ablation also appears to hold tremendous promise as a safe and effective technology of the near future, and we are excited to see how it evolves.”

“Our comfort level with intracardiac echo (ICE) imaging has increased dramatically over the past 10 years, and most of our reduction in fluoro can be attributed to embracing the power of ICE imaging, often in conjunction with 3D mapping. Although fluoro times have been greatly reduced, only a handful of cases have been completed without any fluoro thus far. This remains a goal of ours in the future, but we must balance patient safety with the desire to go fluoro free. A couple of minutes of fluoro and no tamponade seems like a reasonable compromise.”

There are 2 full time EPs at this clinic:
John F. MacGregor, MD, FHRS.
Michel Barakat, MD, FACC

David L

3½ each per week? It takes a lot more than that to become skilled at this procedure, which is one of the most difficult that EPS have to do. To get the best results you need someone who has done thousands.

Gill (female, pronounced Jill, ablation in Bordeaux for long term persistent AF in 2003, nsr since then)



Edited 1 time(s). Last edit at 12/06/2021 01:38PM by Gill.

I agree with Gill.

I've seen many favorable comments here about Natale. I'm wondering if there aren't competent labs somewhat closer to me in Bellingham, i.e NW Washington state.

There probably are and we can help you find them, but I think you're going to need to expand your search to Seattle and possibly Portland.

To be clear, we're not saying those folks are incompetent. I'm sure they're not. But if you're considering an ablation then you need to be considering only the most experienced, high-volume doctors and centers available. Generally you're only going to find them in big cities.

Dr. Robert Rho (Over Lake) has worked with Dr. Natale and is probably one of the top RF ablation operators here in the Pacific NW. I have interviewed 5 of the "top" EP's here in WA state (Seattle area)and most we're all using cryoballon as their instrument of choice.

I faced same decision, local EP or arguably the best EP on planet earth. Only advice I can give is don't let convenience make your decision!

Nearly 2 years no afibb

You don’t need to leave the west coast to see Dr. Natale if you are in Seattle. One week a month he is in the west coast. Monday and Tuesday at Scripps in San Diego, CA and Wednesday, Thursday and Friday he is ablating in Thousand Oaks, CA at a fantastic all rooms are private- Los Robles Hospital. He then flies back Saturday.

I have an interview tomorrow with a representative of the EP program at Peace Health in Bellingham. I'll be asking what procedure they will use, why they propose to use it, what equipment they will use, how they define success, and can I see data on ablations they have performed. I'll ask about Natale. Who would they refer me to given I would consider travelling. Why would they refer?

I'll also ask how long it would take for them to schedule a procedure once I tell them I would like them to do it? Do people have suggestions as to what else I might ask?

I am in normal sinus rhythm now. More than 3 years ago, which was the last time I was experiencing A-fib episode after A-fib episode, I was facing doctors telling me I had no alternative but to submit to a surgical procedure or to immediately start to take a powerful drug with substantial side effects. I decided to slow down the train and see what else was available. I found that by practicing meditation I became A-fib free for more than 3 years. If I had taken their drug, and not experienced A-fib, they would have said that's why you've been A-fib free. If I had had an ablation they would have said that's why you've been A-fib free. But if I say now, I've been A-fib free for more than 3 years because meditation allowed me to reduce the effect of stress, which I decided was the trigger for my episodes, they don't say much. Its an anecdotal report. Who knows, they look like they are thinking. You probably have been experiencing symptomless episodes. Etc.

Now that I have experienced two recent episodes and the doctors are telling me the identical things as 3 years ago, I am studying the situation. Is it possible I can stave off drugs and ablation for many more years? I have no real idea.

I don't think I will schedule any procedure with anyone until I decide that this time, I won't be able to bring this under control. However I am much more interested in figuring out what I will do if I decide I need an ablation.

Hi David,

First, congratulations on what you've accomplished with meditation!

Curious, how frequent and how long were your episodes were 3 years ago? Were they all self converting (i.e. no med & no electrocardioversion)?

What about now?

I'm 66 and I've had afib for 17 1/2 years. In the first 4 1/2 months, I had a 2 1/2 month episode starting at about the end of month 2. My EP wanted me to remain out of rhythm. I proposed a "Plan B" that he accepted. Subsequently, I've averaged a couple of episodes/year, though have had two years with significantly more. My afib path was chronic fitness, My remission program includes avoiding really high intensity, long duration activities, while remaining very fit. It also includes electrolytes. I do use a med, flecainide to aid in conversion, so my episodes typically last an hour or two though a few have lasted as long as 9 hours (not counting the 2 1/2 month episode or the first one after, which lasted 20. I have occasionally used flec on a daily basis a low dosage (50mg, once per day), as an aid while I was recalibrating the non-pharma part of my program.

I view the med as well as an ablation, if I needed one, as tools I will employ as necessary. Always trying to use the "lightest touch" that I can. For years, I have referred personal friends to Dr. Natale, even though it does take convincing to get them to travel. One, my best friend from childhood thought I was crazy to insist he go to Austin. That was 6 or 7 years ago. Now he and his wife thank me profusely whenever we get together (we live in different states).

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GeorgeN
Curious, how frequent and how long were your episodes were 3 years ago? Were they all self converting (i.e. no med & no electrocardioversion)?

I experienced 4 episodes over a period of 4 months. #1 was 6 days, #2 was 5 days, #3 was 5 days, and #4 was a few hours. I visited the ED for all 4 episodes. The first 3 were highly symptomatic. The 4th was less so. The first 3 self converted. #2 the E.D. attempted cardioversion twice but my heart would only stay in NSR for about a minute each time. #4 the E.D. succeeded with cardioversion. I think they administered a large dose of intravenous metoprolol at each visit to the E.D. but I'm not certain.

Several weeks after episode #3 I started to learn meditation. Like some I have talked to about this, at first I believed I couldn't possibly be mediating correctly. The instructions were to focus on each breath as if you were breathing for the first time, to the exclusion of everything else, then focus on the next breath, etc, for at least 1/2 hour at a time, daily if possible. My mind would make it through a breath or two, then drift off thinking about the lifetime high stressful events I was experiencing. I'd be lost in thought about this event or that, then realize I was supposed to be meditating, and get back to the focus on the breath, then almost immediately get lost in thought again, etc. But I would ask other meditators and they would say that's the point, at first, you are learning how your mind operates. I didn't see how this could possibly affect my A-fib.

I was extremely motivated though. I was grasping at straws. I found a group of meditators who met weekly at the local Zen center to talk about their experiences with meditation, and to meditate together. Many would talk about how it was hard for them to find time to devote to meditation, which was one reason they met weekly, to sort of force them to at least get in one day's meditation a week.. In my case, I had concluded it was life or death. I had no trouble meditating for about an hour a day, every day. I guess I got the life or death thing after reading the FDA sheet on amiodarone. If the cardiologist thought a drug like this was something to hand out like candy saying emphatically if I didn't take it he'd bring out the "big guns" as he said, i.e. ablation, there must be something very dangerous about ablation, because the FDA sheet on amiodarone is incredible. I think I have a more nuanced view of A-fib and the various treatments these days, i.e. more informed.

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GeorgeN
What about now?

I have experienced two episodes in a month. #1 was 8 days. #2 was 12 days. They both self converted. I am taking 75 mg metoprolol, magnesium 400 mg, and xarelto at the moment.

I feel the way I handle stress sometimes, is the trigger for my episodes. However, as opposed to 3 years ago when ultrasound and stress testing showed my heart was in great shape, now they suspect coronary blockage which they are going to examine in detail Dec 17. I feel confident if drastically reducing the effect of the stress I was letting build up prior to these new episodes is helpful, I can do it. I can find a deep relaxation when meditating these days, and whatever I was allowing myself to become emotionally stressed out over I can just let go easily. This was not a lifetime high stress event. I have accepted that my heart is subject to A-fib as opposed to I never have to worry about it again.

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GeorgeN
Always trying to use the "lightest touch" that I can.

That is my mantra as well.

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GeorgeN
For years, I have referred personal friends to Dr. Natale, even though it does take convincing to get them to travel. One, my best friend from childhood thought I was crazy to insist he go to Austin. That was 6 or 7 years ago. Now he and his wife thank me profusely.

Maybe I'll feel that way one day as well. I have found a few videos where Dr. Natale briefly explains what he's doing. He is impressive. My wife seems very opposed to getting in a plane during the pandemic. She seems to think it is outlandish to seek out someone who actually comes up on some searches when you ask who is the best EP in the world.

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susan.d
You don’t need to leave the west coast to see Dr. Natale if you are in Seattle. One week a month he is in the west coast. Monday and Tuesday at Scripps in San Diego, CA and Wednesday, Thursday and Friday he is ablating in Thousand Oaks, CA at a fantastic all rooms are private- Los Robles Hospital. He then flies back Saturday.

Thanks for the info and the encouragement

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David_L
(I was wondering if there aren't competent labs somewhat closer to me in Bellingham).

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Carey
There probably are and we can help you find them, but I think you're going to need to expand your search to Seattle and possibly Portland.

Seattle or Portland seem quite feasible. I mean, Southern California sounds fine to me as well, but my wife, so far, would probably be easier to talk into this if we could use our travel trailer and not drive so far. We travelled quite a bit using it during the height of the pandemic and felt quite safe, as we were self contained for food preparation and the bathroom. I felt safer travelling than being at home, because her son lives with us and he was going out to a job serving the public every day bringing back who knows what. SoCal seems too far for me to chance it driving as my wife would be very anxious about what happens if I can't continue driving, although she grew up and worked for years down there so she might decide to go along with it.

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Kleinkp
Dr. Robert Rho (Over Lake) has worked with Dr. Natale and is probably one of the top RF ablation operators here in the Pacific NW. I have interviewed 5 of the "top" EP's here in WA state (Seattle area)and most we're all using cryoballon as their instrument of choice.

Thanks for the name. Is there some drawback to using cryoballoon, or did you see that as a feature?

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Kleinkp
I faced same decision, local EP or arguably the best EP on planet earth. Only advice I can give is don't let convenience make your decision!

Thanks everyone. It is very helpful to come here and hear what other A-fibbers think and do.

There is a fantastic affordable suites hotel very close to Los Robles hospital that is covid19 safe. It has a mini kitchen with sink, fridge and microwave and a living room. Signs all over say everywhere has been Purell. I brought my own and redid areas I would touch. I had a do not disturb sign up so nobody came in. Front desk practiced social distancing. It was very comfortable.

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David_L
My wife seems very opposed to getting in a plane during the pandemic. She seems to think it is outlandish to seek out someone who actually comes up on some searches when you ask who is the best EP in the world.

Then don't bring her along. I traveled to Austin twice for procedures (ablation and Watchman) and my wife stayed at home both times. It was pre-COVID but I couldn't see any reason to pay two plane fares when I was the only one who needed to be there. And if google searches aren't enough to convince her that skill and experience are critically important in your selection of EPs, then I would hope the advice and recommendations of many people here with many years of combined knowledge and experience would matter, at least a little. I really can't overstate how much it matters.

An advantage of bringing the spouse along is to lift your suitcase afterwards. 10 pound limit is nothing if your empty suitcase weighs 7 pounds.

Of course you can always have the hospital discharge transporter person load your suitcase to the Lyft/Uber and tip him to drop it off at the hotel and tip the bellboy to bring it to the room. Afterwards tip the bellboy to take it down, tip driver load your suitcase to car and drop it off at curbside check in…tip that guy. Get wheelchair assistance, tip that person, and have them get your suitcase at the carousel and bring it to the Lyft/Uber line and tip the driver to load to trunk and afterwards take directly to your front door. Then spouse can bring the suitcase in..and you save that tip. :-)

I always am solo at my local hospital and I do the above except for bellhop and airport. My suitcase is loaded onto the Lyft/Uber and when I arrive home my spouse takes it inside. It solves the 10# weight restriction.



Edited 1 time(s). Last edit at 12/09/2021 01:25PM by susan.d.

I had no problem flying to Austin and back twice with a bag that weighed less than 10 pounds. (If your bag weighs 7 pounds empty then you need to visit Amazon and find a 1 pound bag.)

For those who need to bring CPAP machines it's probably impossible to keep it under 10 lbs, but if you don't need CPAP then all you need is three days worth of underwear, a shirt or two, and toiletries. It's not like you're going there to be partying and dressing in style. Shorts and t-shirts are perfectly fine and fit Austin weather 9 months of the year.

I bring survival food since zero hospitals (Robles is exempt) can feed me anything other than water because of my numerous allergies. Cpap bag with tube, cords, masks weighs a bit and I got a small travel unit. Cellphone and chargers for watch and phone and a few items of clothing, supplements and meds the hospital doesn’t carry (hospital pharmacy adds a label to my stuff) burn creams for ecv are all I bring, I’m in the hospital now and brought two days of survival food-almond milk weighs the most because they didn’t supply good for 24 hours. Today I’m well fed. It was a rough lifting my suitcase with 226 hr if the er didn’t help lift my bag for me. The Lyft driver brought it to the er.

Which one pound Suitcase did you find? A garbage bag? I couldn’t find anything light.

Susan, you're an unusual case and I agree you probably can't fly with less than a 10 pound bag, but most people who don't have CPAP or special needs can. I just used an old, cheap backpack I happen to have. I just checked and it weighs .83 pounds. (I had to use a food scale to weigh it.)

In any case, carrying luggage isn't a good reason to pay for a plane ticket for another person. As you yourself pointed out, there are solutions. Simply having a lifting restriction on the way home shouldn't be a show stopper.

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susan.d
Which one pound Suitcase did you find? A garbage bag? I couldn’t find anything light.

Search on daypack

Item Weight ‎0.26 Pounds

[www.amazon.com]

The most experienced EP at the local clinic my cardiologist referred me to met with me yesterday. He said he'd done more than 1,000 ablations, less than 2.000. I asked him if he, as opposed to his less experienced colleague, would be doing the procedure if I chose to have it done at his clinic. He would do it, he said.

I had read that they are trying to set up what they will call a dedicated AF clinic so I asked him about it. This hasn't happened yet.

I told him about an article I had read, with a quote from a Dr. Wazni, (from the Cleveland Clinic). The article was about the evidently rising death rate as ablation procedures become commonplace. Wazni thought that generally, EPs were becoming more confident about ablation as the years go by, so they are taking patients who are sicker and more prone to disastrous outcomes. But, Wazni also said this:

"patients aren't doing their part in seeking out the best possible centers"

I wanted to make it clear to this EP that I was trying to be one of those patients who was doing his part, however inadequately I might seem to be doing so, or how insulting I might seem to be.

When I asked if they do "outcome studies" he said "I don't have a coordinator". Yet he said the procedure he would do, PVI, given his assessment of my condition, had a reasonable success rate. I believe he stated 80%. I asked how he measured this. He listed some methods, patient reports, some device they strap on for several weeks at a time, periodically, after the procedure, etc. (I haven't re-listened to or transcribed my recording of the visit).

I asked, do you put my heart into A-fib during the procedure and look for areas other than the pulmonary veins. No, he said. If your heart happens to go into A-fib during the procedure, he said, then we look at what is happening (and, presumably, ablate other areas), but otherwise not.

I asked, if I decided to have you do a procedure today, how long would it take for you to get around to doing it? He said sometime in April.

This is a confident man, proud of what he has done building up his EP clinic over the decades to serve this fairly small town of 90,000 inhabitants near the Canadian border in the Pacific Northwest.

I don't understand how he can say he doesn't do outcome studies yet he does study some aspect of the outcomes by attempting to assess AF burden and frequency after ablation. I felt very inadequate to the task of interviewing him as I know so little about what I am asking about. I used the term "outcome studies" because the day before I had seen a Natale promo video where a Natale colleague was given a bit of time to explain how important Natale et al believe learning from detailed outcome studies is to their ongoing practice.

I didn't think to follow up at this point by asking him to clarify why he seemed defensive that they don't do outcome studies (yet) at his clinic whereas they do make some sort of effort to find out how their patients are doing post procedure.

I came away assuming his use of the term 80% success means somewhere in the literature some study of the particular way he does his particular procedure on patients somewhat or very similar to me it says 80% success over some time period. Maybe 80% to him in this context meant something entirely different. Maybe, when just isolating pulmonary veins on paroxysmal AF patients, he finds 80% of patients have been a-fib free for at least a year after his procedure using the investigative technique he described to me. Maybe, maybe, maybe. It is a bit depressing to have a meeting and not come away understanding very much.

When I first started getting serious about making a decision about ablation (which is only weeks ago) I hated the idea of being put into AF during the procedure. Every time I've been in AF the main fear waiting for me there is, do I come out of it, or is this (ack!) THE END.



Obviously this is irrational. But one part of me likes the idea of an EP who slides instruments into my heart quietly without trying to stir things up into AF, does the ablation thing, and slips out, hopefully leaving me still alive. But it seems inadequate.... Is it inadequate?

I told this EP that my plan was to wait and see. I still hold out some hope that I can manage the situation without these strong drug and surgical therapies, for at least some more years.

If I continue to experience AF, especially if episodes get worse, perhaps even just one more episode in this series, I said, I will make a decision, most likely to get an ablation. He agreed that his recommendation for me, having considered my case, was an ablation. Now that I am closer to making a decision, April seems very far away for someone who had just become clear that ablation was what they wanted to have done.

I think I will call Natale to see how busy he is.

Thanks for the encouraging descriptions of how easy it would be to travel for treatment. Do local cardiologists and/or EPs tend to not want to cooperate in treatment when a person has gone to an internationally renowned clinic thousands of miles away?



Edited 1 time(s). Last edit at 12/10/2021 06:15PM by David_L.

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David_L
I asked, do you put my heart into A-fib during the procedure and look for areas other than the pulmonary veins. No, he said. If your heart happens to go into A-fib during the procedure, he said, then we look at what is happening (and, presumably, ablate other areas), but otherwise not.

Then how does he know there are no other sources of afib? Sounds to me like this guy does a straight PVI and nothing else, not unlike a cryo ablation.

Once an EP thinks they have all your sources of afib isolated, what they (should) do is administer isoproterenol, which is a beta agonist (opposite of a beta blocker). It cranks up your heart rate and makes your ectopics prone to firing. If there's a source of afib still lurking somewhere, this will usually reveal it. If you go into afib, good. That means the job isn't done yet and your ablation would have been unsuccessful had the EP closed at that point. So they go find and isolate the offending area and try again. And don't worry about going back into afib during the procedure. You won't even be aware of it, and they have you in an EP lab already all wired up. The afib will terminate when they find and zap the offending area. Worst case they would simply cardiovert you out of it.

Call Natale. I would expect he can get you in well before April and you would be adding at least another 10 percentage points to your odds of success.

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Carey
Then how does he know there are no other sources of afib? Sounds to me like this guy does a straight PVI and nothing else, not unlike a cryo ablation.

He said he would just do a straight PVI. With the little I know, I found the statement disappointing. I didn't ask him to clarify and explain. I think at this point I started to believe I wouldn't be getting an ablation in this clinic. I guess he gets away with this often, or he's got a lot of patients coming back.

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Carey
Call Natale. I would expect he can get you in well before April and you would be adding at least another 10 percentage points to your odds of success

The thing is I have a potentially more serious heart issue. Next Friday I am scheduled for a coronary angiogram. I know less about this procedure than what I know about ablation. The cardiologist says depending what he finds he may install a stent or stents at that time, or, schedule a coronary bypass. He says there is a 10 -15% possibility that the nuclear stress test that led him to feel he needs to do the angiogram, is showing incorrect information and nothing may need to be done. The EP and the cardiologist both said if there is this kind of blockage in blood flow going to my heart this could explain the recurrence of my A-fib symptoms, and if the circulation can be restored it may allow me to proceed as before, with no symptoms of A-fib as long as I can reduce the effect of my triggers.

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David_L
He said he would just do a straight PVI. With the little I know, I found the statement disappointing. I didn't ask him to clarify and explain. I think at this point I started to believe I wouldn't be getting an ablation in this clinic. I guess he gets away with this often, or he's got a lot of patients coming back.

A straight PVI is not what you want and you should be disappointed, but not surprised. It speaks to his lack of experience and advanced training, which is all too common. Patients come back because they don't know what else to do.

I honestly don't believe ablations should be performed anywhere but major medical centers that do thousands per year. Yes, that means people in outlying areas will have to travel, but travel is a minor inconvenience for a few days or weeks. Compare that to dealing with a failed ablation for months or years. Your quality of life will suffer much, much more from an inexperienced EP than it will from a trip somewhere else. In my case, it dominated 7 years of my life.

And with your other potential issues, that's all the more reason to seek the best you can find.

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Carey
...Compare that to dealing with a failed ablation for months or years. Your quality of life will suffer much, much more from an inexperienced EP than it will from a trip somewhere else. In my case, it dominated 7 years of my life.

I'd like to hear more of your story.

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David_L
I'd like to hear more of your story.

Carey posted a lot of detail here [www.afibbers.org] (from 2017)
and a comment [www.afibbers.org]

and his heart has been perfectly quiet since.

And a post of mine from 2017, about a friend of a friend I sent to Natale. 3 local EP's thought he had vfib and had him in a "shocker vest." They were wrong. [www.afibbers.org] I chatted with him a year or so ago and he's still happily in NSR.



Edited 3 time(s). Last edit at 12/11/2021 07:55AM by GeorgeN.

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David_L
I'd like to hear more of your story.

That link George posted is the whole story.