Simple ablation is the best.

Can someone put the entire article into context?

"Simplicity is key. Don't ablate too much, especially at advanced stages," said lead study author Dr. Nassir Marrouche, director of the Tulane Heart and Vascular Institute and The Research Innovation for Arrhythmia Discoveries (TRIAD) at Tulane University School of Medicine. "Too much ablation is not helping our patients today. It is putting them at higher risk. This is a practice-changing finding from our study."

[medicalxpress.com]

[a-fib.com]

Dr Jais is a top tier ablation expert and EP experienced wizard. He wrote about LAA closure/removal but the concept of saving heart tissue remains:

“But some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib. For a patient made A-Fib free, would their heart function better or more normally if they still had their LAA? In the words of Dr. Pierre Jais of the Bordeaux Group at the 2020 AF Symposium, “We have ablated too much…Those patients when they have the (Left Atrial) Appendage taken out, they have very poor residual LA (Left Atrium) function. I don’t want that to happen anymore. If we can avoid it, I think we should.” Dr. Jais later added, “Sinus rhythm is by definition superior to persistent A-Fib. But the best ablation strategy is the one that restores sinus rhythm at the least tissue cost, thereby preserving as much as possible the LA function.”



Edited 1 time(s). Last edit at 06/23/2022 05:55PM by susan.d.

Well...
1.
I think the sample is too small to get very reliable conclusions.
2.
Once more, they study a bunch of afibbers, but we all know there are different kinds of afibbers, and they don't say which kind of afibbers are considered, and their proportion in each group.
3.
For many afibbers, a PVI would be enough to have them afib free for years. How did they decide which patients wouldn't get more than a PVI ? Those who couldn't have any afib induced after their PVI had been performed ? If this is the case, patients requiring more than a simple PVI are likely difficult cases.

All that does not mean I think the conclusions are worthless, but I have serious doubts about the method used to get said conclusions.

My take is if you are getting more than a PVI, you need to have a very top notch EP.

They based their decision on which additional areas to ablate on the results of an MRI, not on the electrophysiology of actually finding sources of afib in those areas. That's a theoretical strategy and not one I've ever heard of an EP using.

I think it's a badly flawed study and its sweeping conclusions are unwarranted.

Flawed…yes but the following by Dr. Marrouche mimics Dr Jais opinion of saving heart tissue:

“Simplicity is key. Don't ablate too much, especially at advanced stages," said lead study author Dr. Nassir Marrouche, director of the Tulane Heart and Vascular Institute and The Research Innovation for Arrhythmia Discoveries (TRIAD) at Tulane University School of Medicine. "Too much ablation is not helping our patients today.“

How many of you guys pre ablation ever had flutter, as an example, which is contributed by scar heart tissue from burns used to eliminate afib…but got flutter afterwards? You sacrificed tissue to get nsr but at what cost if you get flutter afterwards? And yes not everyone gets flutter but I’ve read quite a few posts here from those who did.

I agree about the "minimalist" approach, and wouldn't doubt about Pr Jais' expertise.
I have doubts about the reliability of the reported study.

The general concept of burning as little tissue as needed to do the job is of course valid, but I don't think choosing tissue to burn based on MRI results is. If after a PVI is complete and afib can't be provoked with isoproterenol and electrical stimulation then I'd say the ablation is complete. However, failing to seek out non-PVI sources is an extremely common mistake and costs many people a second (and more) procedure.

And yes, I've had flutter after 5 of my 6 ablations. I also failed the first 3 precisely because the EP was too timid to make durable lesions, so not burning enough ended up costing me more risk and scar tissue in the long-term than a more extensive first procedure would have. The most common cause of flutter isn't that the EP burned too much, it's that they left a tiny gap in an ablation line. One little gap and flutter is the result.

It all comes down to the skill level of the EP, not how much he burns. Natale is considered overly aggressive by many (lesser) EPs, and yet look at his success rate. He routinely resolves afib that multiple other EPs failed at.

Anyway, I think the conclusions of the study are invalid for several reasons. I think the better conclusion is that a lot fewer EPs should be doing ablations because they don't know how and when to be aggressive, they don't know how to find sources outside the PVI, and they don't make durable burns because they're too timid.

Susan,

How many procedures have you had to date?

Would you consider yourself someone who might have been better off with the conclusions offered?