New thinking on definition of 'successful ablation'

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Peter M. Kistler, MBBS, PhD is the EP being interviewed. He proposes that AF burden reduction after ablation should be the metric to define a successful ablation. The punchline is illustrated by this image from Supplement 2 from the CAPLA trial.


Basically he's saying that if you take persistent afibber to where they have infrequent paroxysmal episodes, it should be considered a clinical success. In the graph, the median burden is 0% or no afib. The IQR or interquartile range is 0-2.8% & 0-2.3% for PVI only and PVI + PWI respectively. This means that half of the ablatee's had no afib. The next 25% had between 0-2.8% & 0-2.3% depending on the procedure. Those in the last quartile had burden between 2.8% & 2.3% up to ~90+%

I would speculate that the unsuccessful ablations in the graph represent mainly the lesser skilled Drs. No guarantee even from the best EPs, but the odds of a "no afib episodes" success is much greater. I have had two ablations, the first = no afib for 13 years. Number two = Now 3 years with no afib. Very successful!

The definition of "Successful" is fluid.

Agree with 'fluid'. Maybe consider as 'on a spectrum'.

The interior of the heart is being cauterized. Understood, it's the best option today but still a major intervention on a vital organ. Burning/scarring the inside of your heart.

Best case would be a one and done ablation and less than 10% of function diminished. Functions being max heart rate, VO2, ejection fraction and other metrics.

One and done with greater degrees of less function.

One and follow up with greater degrees of less function.

Multiple follow ups and or complications due to the ablation.

Worst cases; multiple ablations with no relief, a stroke, and death.

In the future ablations will fall into the same class of barbaric treatments that prefrontal lobotomies reside today.

Just ask Rosemary Kennedy, she'd tell you if she could.

King Fizzy- your worst case scenario maybe incorrect. Chances of death from afib is not the absolute end game if one takes NOACs or gets a watchman and is on a rate control drug to keep their heart rate low enough to not incur heart failure.

If one is part of the rare percentage of patients who did not get successful ablations after ablations from perhaps their generic disposition to afib or other reasons,and if one month they are hospitalized 12 times in high tachycardia and all drugs fail, then there is a final, can’t-reverse-option. That is a pacemaker and an av node ablation. The upper chambers can go ape crazy but one’s ventricles are steadily pace beating at the settings of one’s pacemaker.

I’m talking from experience. My pacemaker is zapping each beat (PM dependent) at 60hr. I feel the caged monkey when my atrium is >300, but it doesn’t matter, not dangerous because it’s been neutered and my ventricles are at a steady 60. If my pacemaker is doing burst therapy (settings if atrium is high), I feel the zaps.

But I have a life, free from ER and ECVs (54) and hospitalizations and free of further burns to a vital organ and free from arrhythmia drugs except for my optional Eliquis after my watchman. An EP once told me there is just so much healthy cardiac tissue left after each touchup. Everyone is different and some have 5-6 ablations and feel great..others perhaps not with PVCs and other issues.

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KingFizzy
The interior of the heart is being cauterized. Understood, it's the best option today but still a major intervention on a vital organ. Burning/scarring the inside of your heart.

Agree, and that is what kept me holding off on an ablation…until the drugs failed and gave dangerous side-effects. By that time my arrhythmias had become more complicated and I needed a more extensive ablation, so we’re just in that in between stage before some breakthrough in treatment where we have to choose the least worst, option. In my case it seems to have worked well and I haven’t noticed any decrease in function—but I did go to one of the top guys.

Daisy-I wish you a long long remission in nsr. Hopefully by then they will figure it out and have a better solution to rid afib.

On the topic of the OP - using AF burden as a metric to define successful ablation. In AMA1952's post on using a TENS device to stimulate the vagus nerve, in the paper I read closely (her 2nd link & I linked the full text later in the thread), they used AF burden as a metric.

When I apply this to my own case, in my first four months of afib in 2004, I had an AF burden of 57%. After I implemented my afib remission protocol, even in my worst years, my burden was never above 1%. Most years were less than 0.02%. While not zero, it gives me perspective & I'd be in the very bottom of the 3rd quartile (with the 1st and 2nd quartiles being the best with an AF burden of 0 ) in the paper. Hence I'm happy to stay where I am.

There's the fact that some patients may be fine with 5%, while others might find 0.5% unbearable.
IMO, a successful ablation is the one restoring a good quality of life.

I decided to check out my recorded afib history between 2001 and 2006 (6 years) where I documented all episodes and length of each. 192 total episodes. My afib burden ranged from 1.8 percent for year one to a high of 5.3 percent for year 6. Then my successful ablation. While my afib was annoying, it didn't impact my lifestyle except that I didn't work out when in afib. Too much O2 debt. I have always been in excellent physical condition, which I believe minimizes the impact of afib, but could also be cause from my earlier days as a competitive swimmer at the highest level.

That is what my cardio suggested when he learned of my history of competitive running. He concluded that my heart was finely tuned for high effort over extended distances, but that when I developed sleep apnea it became irritable...cranky. And, in my case, I knew immediately the first instance of AF that something has gone wrong. It was in the last two km of a 10 km run when I was 63 years of age. From then on, it seemed to be a slow circling of the drain for me with increasing frequency and duration, and the symptoms were highly intrusive for me.

Perhaps, then, the definition of 'burden' needs some refinement along with 'successful ablation'.

For people who had successfully ablations, do you feel 100% normal as pre-Afib? I am 7 weeks post ablation and thankfully no Afib. However, my heart and lung don't have the same capacity as before. I used to walk 3 miles every day, now 1-mile slow walking makes me tired and dizzy. I know I am still in blanking period and blood pressure still low (80'/50'), but I can't help to worry that I may never be the same because the pulmonary veins and heart are scarred permanently?

My own output is greatly reduced, but I don't think it is due to the surgery. I feel completely normal now, thank God, but I simply don't have the capacity to do a run/walking combination for any distance or my HR rises to 150 which is absolute max for me at 71. Not the brightest idea, methinks. I attribute the reduction to being sedentary during the onset of the worst symptoms and beyond. I would, without a word of a lie, break into AF when laughing at sitcoms. It wore me down, and I lived doing all I could to keep from entering AF. That lost me a lot of ground.

Just in the past three weeks I have noticed a change, though, and have found that my capacity for more aerobic activity has improved markedly and I feel that I might be at least able to walk rapidly. I hope you find the same thing in time.

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Yuxi
For people who had successfully ablations, do you feel 100% normal as pre-Afib? I am 7 weeks post ablation and thankfully no Afib. However, my heart and lung don't have the same capacity as before. I used to walk 3 miles every day, now 1-mile slow walking makes me tired and dizzy. I know I am still in blanking period and blood pressure still low (80'/50'), but I can't help to worry that I may never be the same because the pulmonary veins and heart are scarred permanently?

While in NSR, I'm perfectly normal, but I'm not the same as before my very first AFib episode... because :

- I'm growing older
- I know I've a heart rhythm issue, so I'm more cautious.

gloaming and Pompon, thank you for sharing your thoughts with me. I need to trust this process and be more patient with myself.

By the way I like your ID names

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Yuxi
gloaming and Pompon, thank you for sharing your thoughts with me. I need to trust this process and be more patient with myself.

By the way I like your ID names

You're welcome !