A more procedural question regarding ablation. During my EP visit last week when it was agreed we would proceed with the procedure, I forgot to ask two questions, so I asked via the patient portal, set up for non-emergency messaging with physicians in the Medical School related practice.

The questions and his response are below. I understand he is the physician and I am not a physician. I like and trust him as much as is possible at this point. He’s been doing it for many years and performs @ 250 per year. I’m certainly not an imaging expert either however, I was a little surprised/disappointed that a University Med school of the size we have here does not use what I assumed to be the latest imaging technology for an ablation. Or maybe they do and I simply don’t understand all the nomenclature. Any cause for concern? Would appreciate anyone’s feedback on the response. As always, thanks.


My Questions...............

1. I assume you use 3D imaging during the mapping process. Is this correct?

2. I have paroxysmal Afib. How do you know what tissue to scar if I am not actually in Afib at the time of the procedure?


EP Response.....................

We obtain CT of the heart before all AFib procedures unless kidney function is compromised. We also use ultrasound during the procedure to visualize the anatomy. We will perform the procedure in normal rhythm most of the time and get a better assessment of scar burden that way.

I think you got a hasty answer from someone who didn't really answer your first question very well. They probably use intracardiac echo (ICE), which is a small ultrasound transducer on the end of a catheter. That does give them 3D imaging from inside the heart, which is the latest imaging technology. It's hard to get a better view. Plus the CT gives them a precise anatomical view of your heart and that will be fed into their mapping system.

Many ablations are done with the patient in normal sinus rhythm. It's not strictly necessary to be in afib at the time for them to know where to ablate. The major and most important part of the procedure is isolation of your pulmonary veins, and that doesn't require any fancy mapping. They just need to know exactly where your PVs are and how large they are, which the CT tells them.

But what most EPs will also do is try to provoke afib once they believe they're done ablating. They may administer isoproterenol, which is an adrenalin-like stimulant that increases your heart rate and makes any badly behaved cells more likely to fire and reveal themselves. They will also stimulate parts of your atria electrically to see if they can induce afib.

I don't think you have any reason for concern about an EP who does 4-5 ablations per week.

One question i learned years ago on this site: who inserts the catheters??? You want the EP to say i do

Hi Tom,

A bit more nuanced question a patient might ask the EP prior to the procedure is: 1. "If you are at a teaching hospital, consider confirming if your primary ablation EP will be the only operator inside your heart (inside the right and left atria) during the procedure"

Actually, whether it is a teaching hospital or a front-line elite-level ablation center, for peace of mind just confirm that your primary ablation EP you have hired will be the only operator working inside your heart during your ablation procedure.

That is a very reasonable request and is usually a given with top-tier ablation operators, especially when the patient has had the good fortune of having a solid vetting process themselves from an experienced patient education and advocacy resource like Afibbers.org and other established groups like Stop-Afib.org and a few others.

Just keep in mind that if your femoral vein catheters are threaded by a #2 operator from the initial insertion point on the two sides of the groin on up to just before entry into the right atria ... that is perfectly fine.

Cheers!
Shannon



Edited 1 time(s). Last edit at 03/06/2022 12:34PM by Shannon.

As always here, thank you all much for your feedback. Much appreciated!

Maybe the cath insertion is an outa date assumption but i just remember years ago a customer in my store had an ablation and they nicked and vein going in and it was a disaster. And: no ablation. So ill assume nowdays its not a frequent accident
Thanks Shannon

I think your doc gave you the shortest, least informative answers possible without ignoring you altogether. As I found out from my first ablation, they indeed isolate the pulmonary veins, which is the source for 89% of people with paroxysmal Afib. How hard they look for other triggers likely varies by EP. I don’t understand your doctors answer about a better assessment of scar burden in sinus rhythm. I’d ask him to explain that further. And while generally a doctor that does more procedures is better, there are doctors that do procedures repeatedly while doing them badly. Ask your doctor for his success stats. Good luck!



Edited 1 time(s). Last edit at 03/07/2022 09:07PM by jasams.

This thread, at least for me, amplifies the variety of ways afib is treated by medical professionals (absolutely no criticism intended). In 2016 I sought and received a second opinion on my persistent afib from the head of the EP department of a major regional university medical school. My specific second opinion was about whether or not cryoablation would work. The answer I received was cryoablation would not work on me but what they would do was put me on Tikosyn. I did my research on the drug and my response was, "Holy cow!" -- not exactly, but as you can imagine, much worse. Subsequently I was put in touch with Shannon, soon thereafter became a Natale patient and the rest is very good history.

Quote
MarkL
A more procedural question regarding ablation. During my EP visit last week when it was agreed we would proceed with the procedure, I forgot to ask two questions, so I asked via the patient portal, set up for non-emergency messaging with physicians in the Medical School related practice.

The questions and his response are below. I understand he is the physician and I am not a physician. I like and trust him as much as is possible at this point. He’s been doing it for many years and performs @ 250 per year. I’m certainly not an imaging expert either however, I was a little surprised/disappointed that a University Med school of the size we have here does not use what I assumed to be the latest imaging technology for an ablation. Or maybe they do and I simply don’t understand all the nomenclature. Any cause for concern? Would appreciate anyone’s feedback on the response. As always, thanks.


My Questions...............

1. I assume you use 3D imaging during the mapping process. Is this correct?

2. I have paroxysmal Afib. How do you know what tissue to scar if I am not actually in Afib at the time of the procedure?


EP Response.....................

We obtain CT of the heart before all AFib procedures unless kidney function is compromised. We also use ultrasound during the procedure to visualize the anatomy. We will perform the procedure in normal rhythm most of the time and get a better assessment of scar burden that way.

As Carey explained they use different substances to induce AFIB. in my case I was in normal sinus rhythm, they then induced the AFib, ablated, tried to induce again and were unsuccessful and thus they are pretty sure they fixed the issue.