Success Rates: Dr Atul Verma vs Dr Pierre Jais vs Dr Andrea Natale

Hello, I am from Canada and I am still debating which doctor to perform my ablation. In Canada it is Free, but I am debating whether to travel to Bordeaux or USA for Pierre Jais or Andrea Natale. Is Pierre Jais the best at Bordeaux? Would you say its neccessary for my Afib, (24 years old, Paroxysmal Afib, Longest Episode 12 hours, 2 years since Diagnosis, Most likely only need PVI) or would you say Dr. Atul Verma is sufficient? Is Dr. Atul Verma the absolute best Afib Ablator/Electrophysiologist in the whole Canada? I am 24 years old so I really need to ensure that my ablation is successful with the most long lasting durable lesion, preventing chances of repeat procedures, ablation failures that might make things even worse (complications/developing new arrhythmias, and a high chance of being free of Afib with no life long lasting complications. I am so young and I want the best chance possible. I want the ablation to last the longest possible, with no complications or ablation failures, a durable, quality PVI lesions that will last a long time, and maybe early isolate potential other trigger sources if needed.

I know Dr Natale would be the best option, then it would be Bordeaux, Then Atul. I have heard of some stories of ablation failures with Atul Verma and rarely some with Bordeaux, but rarely with Dr Natale. But I want to hear anyones opinions whether my case of an ablation failure with even Atul Verma would be close to non-existent given my Afib is fairly new and and should be a reletively easy case/shouldn't be a complex case for them. Should I roll the dice and go with Atul and save my financial situation? Or invest all my life and debt into paying for an ablation overseas?

I really need help deciding which doctor asap before my Afib becomes persistent. I don't want to get an ablation to have one that didn't work/ablation failure/complications/not as good of a result and regret that I shouldve went to the other doctor! But then again, I don't want to break the bank and spend that amount of money if it is not neccessary. I just want a super successful ablation that can get rid of my Afib completely along with the PAC's, for the longest time possible, as high of a chance as possible, and as safe as possible, without killing me financially, so I can finally go back to living my normal life, and competing in sports again (sports and exertion is a big afib trigger)

If I end up going overseas for the ablation, would you recommend I get additional insurance for complications just in case?

Thank you all for taking the time to read this!

ATUL VERMA:
1. Time Frame: ?
2. AF Ablations Per Year: ?
3. Total AF Ablations: 8000+ ablations
4. What Energy Source: RF
5. Yearly Breaks from Performing Ablations due to Research/Leadership Roles: ?
6. Mortality/Complications Rate: ?
7. Afib Recurrence During & After Blanking Period Failure Rate: ?
8. Afib Free Lasting Over 5 Years Success Rate: ?

ANDREA NATALE:
1. Time Frame: 4-6 months
2. AF Ablations Per Year: 624/year @Los Robos + 324/year @Texas
3. Total AF Ablations: 12,000+ ablations
4. What Energy Source: RF
5. Yearly Breaks from Performing Ablations due to Research/Leadership Roles: 2-3 weeks
6. Mortality/Complications Rate: very low
7. Afib Recurrence During & After Blanking Period Failure Rate: ?
8. Afib Free Lasting Over 5 Years Success Rate: 85%+
9. Price: $45,000USD

PIERRE JAIS:
1. Time Frame: ?
2. AF Ablations Per Year: ?
3. Total AF Ablations: ?
4. What Energy Source: ?
5. Yearly Breaks from Performing Ablations due to Research/Leadership Roles: ?
6. Mortality/Complications Rate: ?
7. Afib Recurrence During & After Blanking Period Failure Rate: ?
8. Afib Free Lasting Over 5 Years Success Rate: ?
9: Price: ?


JASON ANDRADE:
1. Time Frame: 10-14 months
2. AF Ablations Per Year: 250
3. Total AF Ablations: 4000+
4. What Energy Source: Cryo
5. Yearly Breaks from Performing Ablations due to Research/Leadership Roles: 1-2 weeks
6. Mortality/Complications Rate: very low/bleeding ?
7. Afib Recurrence During & After Blanking Period Failure Rate: ?
8. Afib Free Lasting Over 5 Years Success Rate: ?



Edited 10 time(s). Last edit at 12/19/2023 07:45PM by Brian.

If Dr. Atul Verma is free, get him to do your ablation after all he has done 8000 of them. You've got to get good after 8000, I would think.

Some thoughts on these choices....

Now that PFA has been approved in the US by the FDA, I would expect Natale to use PFA where appropriate since he's highly experienced with it. Not sure about the others, but I don't believe it's approved in Canada yet.

I don't believe your numbers for Natale's annual number of ablations can be right since he does more in Texas than Los Robles.

I would not opt for cryo so I would rule out Andrade.

As I mentioned before, I don't think the 5-year success rate is a useful number. It will be about the same as the 1-year success rate, plus it's very hard to track numbers like that and I doubt that any EPs try. Ablations that are successful at 1-year are very unlikely to fail in the future because your body can't heal over year-old scar tissue. The only way you end up with afib 5 years later is if new sources develop outside of the monkey cage.

Also, mortality and complication rates are going to be very similar among experienced EPs. Most complications are short-lived and minor, and deaths due to the ablation are exceedingly rare.

If I were in your shoes, I would go with Verma because of the reasons you mention. It's your first ablation, you're young and healthy, and in all likelihood a simple PVI will solve your problem. Plus, it's virtually free for you vs. $45K for Natale. And keep in mind that if there are serious complications, that $45K could turn into $450K. I wouldn't seek an ablation in the US unless you can find insurance that will cover it. The best I could find required a 2-year waiting time on preexisting conditions and had a $50K maximum, but I didn't do a thorough search.

Thank you for the replies.

Would you say I should just suck it up and pay the $ for an ablation that can give me the highest chance of success and an ablation that will be the longest lasting?

I'm scared that going to Dr. Atul Verma for the reason to save a buck will leave me regretting if I have an ablation that didn't work or made things worse.

Is Pierre Jais the best in Bordeaux? How does he compare to Dr Natale ? Given that the procedure is with Pierre is a lot cheaper than Dr Natale but hes likely better than Dr Atul Verma.

Also, Is there particular reason not to do Cryo?

I don't think paying for Natale is cost effective. Verma has a lot of experience and you're a simple case, so paying $45K in "insurance" is a bit over the top. Very unlikely he'll make anything worse. If the Verma ablation doesn't prove successful THEN go see Natale.

Pierre Jais probably is the best in Bordeaux, but I don't think he's better than Natale. If you're going to fly to France you may as well just fly to Texas.

Cryo is a blunt instrument meant for less skilled operators. There's a reason top tier EPs usually don't use cryo.

Hi Brian,

Read all your posts and I think maybe you should step back for moment and decide whether or not getting an ablation now is the best course of action.

When my afib started acting up the way yours is now -- several time a month -- I went on a course of daily Flecainide, an anti-arrhythmic. It stopped my afib episodes, stopped my PACs and allowed me to carry on normally. The main reason I decided to have an ablation last year was because being in my mid 70's, I decided better to have the procedure while I was still healthy, not knowing what my health would be in my 80's.

But you're so young. The youngest or one of the youngest here I bet. And I think you first owe yourself a trial on an anti-arrhythmic like Flecainide. Hopefully it will stop your afib episodes, end or significantly reduce your PACs and allow you to get back to your life, your lifting and boxing and full relations with your girlfriend without worrying about having an episode.

Meanwhile afib research goes on and in the near term PFA no doubt will be perfected as we are only looking at first generation devices coming out of trial and operators will get more experienced and we will get more data. And beyond that, who knows, maybe "burning" as we know it now will become a thing of the past.

Not saying you should rule out ablation as it stands today, but just take pause and wait. And I don't care who you choose, there is no guarantee that if you ablate now that this will be your last. So why rush into a decision with someone you're uncomfortable with, or choose another who you're going to have to mortgage your house to pay for And will there be enough money if the ablation out of pocket requires a second touch up? Or a third?

As to your concern about going into "persistent". By definition, that means you've been in afib continuously for seven days. But "persistent" isn't really a problem as has been explained to me by multiple ep's at top ten US Cardiac hospitals. The problem would be long-term persistent, which is when you've been in afib continually for a year. In that territory, yes, the odds for a successful ablation does drop. So should you end up crossing the seven day mark, you still have ample time to make an ablation decision without compromising your chance for success.

Good luck with what you decide.

Jim

I'm sorry having to say this, but, IMO, there are no simple cases.
One only know a case was simple after the patient has been successfully ablated.
Don't believe you'll be fine with just a PVI. It could be true, and I hope so for you, but make sure your EP manages to track any other source of AFib and ablate it.

The majority of people who get an ablation use whatever EP they happen to find or whatever EP the country's health service assigns, they undergo a single PVI-only procedure, and that's it. They're done and afib-free. I don't know how to describe such patients other than "simple cases." These are the people who make cryo look good. Granted, you can't know in advance they will be simple, but the majority of patients are. The overall average of about 70% success across all EPs is proof of this.

Thank you all for the replies and insight:


Replying to mjamesone:
The plan to see if medications can stop my afib/pacs/allow me to get back to life is definitely an option. And thank you for for the insight truly. I just however read some new articles "EARLY AF" by Dr. Jason Andrade, claiming that while successful ablations have data that show it can "halt" the progression of Afib, MUCH more effective than medications though medications can still halt it to a certain extent. As it is stopping the problem at the root, instead of bandaging it/or masking it. It shows that people who are just on anti arrhythmic end up eventually developing persistent Afib, at much higher rates, and much faster than people who underwent successful ablations.

With medications, I had heard while they may be effective, they eventually lose effiicacy over time. Also, I had read that medications are not neccesarily benign as well, in the same study showing flecainide and sotalol had adverse events causing issues with complex atrial tachycardia, QT interval issues, and rare cases of bradycardia needing pacemaker. Though it is likely "long term" use of these drugs. These events are definitely with ablations as well.

Also, with regards to persistent Afib, I had heard elsewhere that being in Afib after "24 hours" will cause the ablation to be that much less effective, being after that time, it already caused enough structural/substrate change to the heart. There are also a few studies that show that successful ablations with Paroxsymal Afib is MUCH higher than with Persistent Afib. Though I am just reading about it I wouldn't know myself.

The reason why am leaning towards ablation is partly because of that; to ensure my Afib is still at the earliest stages possible, where ablation will have the highest chances of success.

Basically, I think that even if I do choose medication right now, though it may be effective temporarily in the short term, its not like its 100% benign, and its not like I can spend the rest of my life taking Anti arrhythmic drugs, that are not benign, lose efficacy over time, and cause fatigue/ affect quality of life and eventually I know it will progress, and I most likely will end up having an ablation when the drugs fail to work eventually, whether its RF or PFA some time in my life, so why not do it now while chances of success would be the highest right now.

What are your thoughts on this everyone? Is my thinking on the right track?

Im sorry to state so much, I wouldn't know anything about this disease, im just outputting stuff that I read, and am overwhelmed by the decisions with this disease.

Thank you all so much.



Edited 3 time(s). Last edit at 12/20/2023 09:08PM by Brian.

Quote
Brian
Also, with regards to persistent Afib, I had heard elsewhere that being in Afib after "24 hours" will cause the ablation to be that much less effective, being after that time, it already caused enough structural/substrate change to the heart.

That's not true. Remodeling happens over weeks and months, not hours. One 24-hour episode of afib won't change your chances of a successful ablation at all. However, multiple episodes over the course of years may.

Quote

What are your thoughts on this everyone? Is my thinking on the right track?

I think it is. Ablation is no longer considered a therapy of last resort and has become accepted as a front-line therapy. There really aren't any benefits to waiting.

Just personal history: I took antiarrythmics for 6 years, requiring increasing doses which meant more side-effects until I finally got a very serious side-effect from the high dose. The meds became less effective until by the time my ablation came around I was getting episodes most every day. By that time I had become a complicated case requiring an extensive ablation including LAA isolation. The main reason I waited so long was because my local EP didn’t recommend an ablation. In the end I myself chose to seek one. Luckily, thanks to what I had learned on forums, I knew to go to one of the best, Natale, and he could handle the complexity. Grateful.

Brian,

First of all, your worry about going into persistent is not evidence based. Wherever you heard "24 hours" is simply wrong. It would take many months in afib 24/7 before you got to that point.

I get that you want a one and done with the best possible method, but I think you're over estimating how successful ablations are. They could be a one and done, but often just the beginning of a series of procedures that will hopefully reduce your afib burden, but not necessarily cure it.

That said, jumping the meds and going straight to ablation is not unreasonable, but what are you planning on doing in the meantime? When do you expect to get ablated by Natale, or up in Canada? Probably many months? And what about your life between now and then? Your sports, your relations with your girlfriend? If you started a course now of an anti-arrhythmic such as Flecainide, arguably you could be back to your own life in a couple of weeks.

When I was at your stage of afib in terms of frequency and diminished quality of life, my ep suggested daily Flecainide, but he also suggested I set up an appointment for an ablation in three months in case the meds didn't work or weren't to my liking. He said that way I wouldn't lose any time if I didn't like the meds decided to ablate. And then I could simply cancel which would be fine since he has a long wait list of people looking for cancellations. I'm sure the same with Natale and other top ep's.

So that's something you might think about. Pick your ep and set up an appointment, but instead of putting your life on hold until the ablation, start on something like daily Flecainide now. If you still want to go ahead with the ablation then, great. If not, you could cancel like the plan I was offered.

All the best luck.

Jim

Atrial fibrillation begets more of it. So, I tend to favor getting it under control sooner than later, and that means medication...for now. But the most durable intervention, and that's ablation usually, should be undertaken sooner rather than when and as the disorder gains ground on you. Get that ball rolling, and meanwhile you can enjoy less stress and more normalcy with your heart in NSR almost all of the time using an antiarrhythmic and maybe metoprolol.

My 2 cents...

I was diagnosed with afib at 27. I am 33 now. I have also always been healthy and into exercising. Never been overweight. I am on daily flecainide and metropolol and for the most part I don’t get any afib at all (i was in afib 14% of the time when I was diagnosed according to the holter monitor). I get loud palpitations quite a bit but it feels to be in NSR. Aside from making sleep difficult sometimes my quality of life is fine. I exercise plenty and I’m fine (heavy exercise without warming up can still cause a little afib but it doesn’t last long).

I am from New Zealand and the population is only 5million - no one here has done a huge volume of ablations so I decided to go with the medicated route until I can comfortably afford an ablation later in life. If you’ve got free access in Canada to someone who has done 8000 plus ablations you should go with that. Don’t pay for one. 30 or 40 grand to a 24 year old is effectively the same as a million dollars to someone older in life (if you think about it from the compounding growth of capital perspective). Don’t set yourself back financially when you have a perfectly good option available for free.

Hi Brian,

How often are your episodes. AF sucks. at any age. sounds like your episodes are symptomatic. my first episode I was 30, as an elite athlete. I'm 53 now.
Canada has some excellent, skilled, EP surgeons. Essentially, I concur with mjamesone; 'take pause and wait'
and, yes, similarly to many others here,like Will1789, warming up to intense exercise has been a key part for me, too.

However, in the 'wait', or 'take flecainide for now' approach, I'd be getting curious - not hypochondriac - just interested / listening to YOUR body. I have learned to avoid MANY episodes by getting attuned to changes in my heart-rate in response to foods, emotions, types of exercise. Whether you have a genetic disposition, or it's brought on by intense exercise, or heated emotion, the impact of learning to track your nervous system can't be overstated. Whether you ablate or not, your overall health & well being will benefit. & it will no doubt impact your AF burden.