PFA vs RF ablation

I want to get opinions. I now have persistent Afib, and have the chance to have a PFA at Mayo in two weeks with a Dr I’ve had virtual visits with. Because it’s new technology this Dr would be performing the PFA, but there will be other EPs in the room observing as well as reps from the company ensuring that their equipment is functioning as expected. My Dr has only done a couple PFAs, but has performed hundreds if not thousands of RF ablations. I understand that PFA showed shorter procedure times but longer fluoroscopy times, higher levels of hs troponin. I presume those numbers will go back to normal days/weeks after the procedure. Also noted that the catheter is larger than the RF ablation catheter.
I can also have a traditional RF ablation with my Ep that I’ve seen for 11 years, who has done thousands of the RF ablations. This ablation would be in one month.
Would like your opinions on the two options.
Thanks!

PFA can only do a PVI, and I'll be surprised if that's sufficient to terminate persistent afib. Most likely the EP will have to do a combination procedure PFA/RF, or a second RF ablation.

Like Carey said, PFA is best at PVI, so if you're going with the PFA team,
make sure they're prepared to use RF outside of the pulmonary veins, if needed.

Of course, you're not going to find anyone who's done thousands of PFA's at this point and really not necessary, however
not sure how comfortable I would be being number three, which may be why so many in the room.

Jim

The risks associated with either procedure are very small. If it were me, and I was anxious, or worried about atrial enlargement now that it's pretty much full-time AF, or if the symptoms were bloody awful...I would take the first decent chance at remediation offered to me. And, if it turns out that you need more, I have had two ablations and couldn't wait for the second one. It's just matter-of-fact if the aim is to be AF-free. IOW, if the PFA only does 80%, the recourse will be a second ablation, but this time touching up the old fashioned way.

Thanks for all of input



Edited 2 time(s). Last edit at 02/28/2024 09:14PM by Dini.

Based on the comment above are you saying that a PFA wouldn’t be successful because of my now persistent Afib, therefore would having the traditional RFA be a better option?

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Dini
Based on the comment above are you saying that a PFA wouldn’t be successful because of my now persistent Afib, therefore would having the traditional RFA be a better option?

If you're referring to my comment, then what I meant was PFA alone might not be successful because it provides only a PVI ablation and persistent afib usually involves more than just the pulmonary veins. But a combined procedure using both PFA and RFA still gives you the increased safety of the PFA while allowing the EP to address other areas with RF. The PVI is where most of the risks of an ablation are, so it would be a significant reduction in risk while still allowing all the problem areas to be addressed.

Needless to say, you want a highly experienced EP for an ablation of persistent afib no matter what technology is used. Average EPs have pretty poor success rates with persistent afib (~40%), but elite EPs can achieve 75-90% success rates.

Thank you so much for clarifying. I’m not sure what the EPs plan is regarding the use of RF in addition to the PFA, but will find out.
So thankful for this forum, and all of the helpful information.

Carey - You mentioned success rates of 75 - 90% for elite EPs in the post above and I was wondering where you found these numbers.
Mary

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NoTrigger
Carey - You mentioned success rates of 75 - 90% for elite EPs in the post above and I was wondering where you found these numbers.
Mary

This is a study published by Natale et al. in 2017. The list of authors reads like a Who's Who of the elite electrophysiology world.

The study group was composed of people who had failed 2 or more previous ablations, so the study group was composed entirely of difficult cases. I quote from the Results section:

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At 1 year, 90% were arrhythmia free off-AAD in non-PV ablation group, and 72% who did not receive non-PV triggers ablation at the index procedure (P = 0.035). The success rate of empirical LAA and CS isolation was 78.5% and 82% after the index and repeat procedure, respectively.

What they mean by non-PV ablation group is the patients who had areas outside the pulmonary veins ablated. The LAA and CS refer to the left atrial appendage and the coronary sinus. Those were patients in whom they couldn't find sources of afib anywhere else.

I have a pre-publication copy of the study, so if anyone wants to read the whole study just drop me a PM and I can send it to you. Since it's a non-published version, I can't publish it here.

Carey
Thanks for pointing me to this and other studies I found through the link. It seems to be that PV ablation is the holy grail for many so I went back to the notes of my 3 ablations to figure out what was done. As you can imagine they use a lot of acronyms in their procedure notes so it was difficult to decipher. I believe they focused on both PV and PW areas in all 3. The first one failed so I had another within months. The second one held for a little over a year which therefore qualifies as a "success" The 3rd lasted for 4 years, which feels more like a success to me. I am sure they did other areas as well but will have to clarify that when I talk to my EP next week and try to understand the flip flopping in terms of whether I should get another ablation.
I am wondering I could send you the summaries of the procedures to confirm my understanding and shed further light.
Thanks
Mary

Sure, I've sent you a private message with my email address where you can send it.

Carey - For some reason this and other posts did not show up for me. I had to search for it. I wonder why?

I have no idea, but have you read the PM I sent you? A PM won't show up here. You find it by clicking "Private Messages" near the top right of the page.

Any thoughts on the findings of this study that suggests that non-PV triggers play a bigger role?
Paradigm shift in ablations from PV to non-PV triggers

The minute I saw your description of the article I knew I was going to see Natale's name on it. He's been preaching this for years. If all you do is isolate the pulmonary veins, you're going to have a lot of unsuccessful ablations.