Decided to have an Ablation - PFA - Questions

I have had lone paroxysmal atrial fibrillation for the last eight years. I have an event about five times a year, lasting 4-6 hours. For my last event I was in atrial fibrillation for 24 hours and had an ECV to get back to NSR.

I’m 63 years old, was an endurance runner. I have spent many years attempting to control my atrial fibrillation. Zero caffeine, zero alcohol, vitamin D, changing my running regimen, diet, etc. etc.. I know immediately when I enter atrial fibrillation. I have kept records of every event. The occurrence rate really hasn’t changed much. My advice would be to forget trying to fix this and get treatment as early as possible.

Since I have now required an ECV to convert to NSR, I have decided to go ahead with a PFA for my atrial fibrillation.

This has generated a number of questions and I’m hoping to get some help on the forum.

Thank you.




1. Any thoughts on the clinical significance of the damage to red blood cells during the PFA? [www.ahajournals.org]

2. Some EP’s claim they can use zero fluoroscopy. How is this possible? Should this influence the choice of EP (the amount of fluoroscopy they use).

3. During the ablation procedure can the EP determine if the PV’s have, in fact, been isolated? How is this done?

4. Does PVI prevent both initiation and continuation of atrial fibrillation

5. If you have atrial fibrillation after the PFA, how soon after the ablation can you have an ECV.? Does the ablation need to heal before a subsequent ECV?

6. Since PFA is immediately effective does PFA still require a blanking period?

7. I’m confused on the importance of mapping for a PVI. If you are only doing the PV why map the rest of the heart?

8. If 90% of atrial fibrillation starts in the PV’s. Is it possible to determine prior to procedure if you’re in the 10%?

9. If you have a PFA, can you have further ablations using RF?

10. How soon after a PFA can you travel internationally?

Good list of questions!

1. More of a theoretical concern than a significant clinical concern.

2. It's possible with the use of intracardiac echocardiography (ICE). Among the several catheters in your atrium during the procedure, one of them is an ultrasound transceiver. With this they can see the interior of the chamber and exactly where the catheters are.

3. Yes. They stimulate cells on one side of the ablation line and using a mapping catheter look to see if it excites cells on the other side of the line. If not then the isolation is complete.

4. Yes.

5. An ECV can be performed at any time, even during the procedure or immediately after.

6. Yes, but the period can be shorter. One month instead of 3 is common.

7. The pulmonary veins are often not the only source of afib. Mapping the entire atria is important to make sure all sources are isolated.

8. Nope.

9. Yes, and many EPs will use both PFA and RF in the same procedure.

10. The day you're released from the hospital. However, you'll need someone to carry your luggage for the first week.

Carey,

Thanks for a quick response. Great answers.


1. It does affect red blood cell (RBC) count. Seems only to be a clinical issue if you have pre-existing kidney problems. Has anyone discussed this with their EP? No concerns? The paper does recommend having as short titration as possible to reduce RBC damage.


2. What is most common; ICE, fluoroscopy or both. How much of a real concern is the amount of fluoroscopy?


7. This is a very important question.

Do most EP’s do a full mapping of the atria for the very first ablation?

I’m thinking it would be better to initially do just a PVI and see it that works. Rather than potentially and unnecessarily, ablate various other parts of the atrium which might cause other issues. Comments?

If it is important for the first ablation to check the whole atria, shouldn’t I seek out an EP with the very best mapping equipment. These are just my logical thoughts.


Cheers,

mbd

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mbd
If it is important for the first ablation to check the whole atria, shouldn’t I seek out an EP with the very best mapping equipment.

From my perspective it is important to seek out the very best EP. In my opinion, the very best EP will be using the equipment that works well for them.

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mbd
1. It does affect red blood cell (RBC) count. Seems only to be a clinical issue if you have pre-existing kidney problems. Has anyone discussed this with their EP? No concerns? The paper does recommend having as short titration as possible to reduce RBC damage.


2. What is most common; ICE, fluoroscopy or both. How much of a real concern is the amount of fluoroscopy?


7. This is a very important question.

Do most EP’s do a full mapping of the atria for the very first ablation?

I’m thinking it would be better to initially do just a PVI and see it that works. Rather than potentially and unnecessarily, ablate various other parts of the atrium which might cause other issues. Comments?

If it is important for the first ablation to check the whole atria, shouldn’t I seek out an EP with the very best mapping equipment. These are just my logical thoughts.

1. I wouldn't be concerned about it unless I had comorbidities that could be negatively affected.

2. I think right now it's probably an even split but ICE is becoming more common. Many EPs use both. I've had 6 ablations, all of which used fluoroscopy. I've also had 4 chest CT scans. I'm not concerned, though I wouldn't allow anyone to aim an x-ray at my thorax without solid justification. There won't be any lung cancer screening procedures for me (that's what 3 of those chest CTs were).

7. The good ones map the entire atria and address all the sources of afib they find. Why would you want to double the risk and double the cost by doing two procedures instead of one? There's no significant additional risk to isolating other sources of afib, so just doing a PVI and hoping for the best is a really poor strategy. Only inexperienced EPs with limited skills would do something like that. It's like surgery -- you do everything that needs doing "while you're in there." Don't worry about trying to find the EP with the best mapping equipment. There are only a few manufacturers of the equipment and all their stuff is pretty comparable.

Although you're asking good questions, I think you're examining the trees so carefully that you may be missing the forest. Pick the most highly experienced EP you can who has done thousands of ablations at a large medical center, and everything else will fall into place. Don't be deceived by impressive credentials and titles. Experience doing afib ablations is almost the only measure you need to know. Again, like surgery, you pick the guy or gal who's done the procedure the most. I wouldn't hesitate to travel almost anywhere for a procedure with that person over the local EP who's good but not stellar. I would accept only stellar, and those six ablations are why.

Mbd, thank you for all these great questions and thank you, Carey and George, for your answers! Very helpful!

If you'd like a third set of answers, almost certainly with a lot of overlap, here are mine:

1. Your body eliminates red blood cells all the time. They have a finite life anyway, so they're apoptosed and they die and become recyclable material filtered through the kidneys. An ablation might add 5% to the overall 'burden' on the day;

2. Depending on the application (RF or PFA, for example), they'll use a TEE (trans-esophageal echocardiogram) inserted into the esophagus, or as Carey suggested, an ICE. I believe they used the TEE and flouroscopy on me. In fact, I've had two MIBI stress tests, each worth about 500 chest X-rays.;. I'm not happy about it......if you ask.......but.....;

3. Yes, although it's not foolproof. The EP will normally 'challenge' the heart prior to releasing you, and my EP would also normally cardiovert. He says he didn't bother on my second ablation, his second attempt on me within seven months, because while he was isolating the third pulmonary vein, my heart jumped into NSR and he stood back and watched for a few minutes. He felt that I didn't need a cardioversion; he had just closed that last little gap;

4. PVI isolates, or dams, or places a 'stockade' of scar tissue around the entire pulmonary vein ostia...their mouths. Imagine making a circle, about four cm in diameter, by placing the tip of a pen on the paper, lifting and moving it 2 mm over, and repeating this until you have a circle of closely spaced dots. That's what the burning process does in RF (not in PFA!). So, if the EP gets it 'right', there is no place for the spurious signal to issue out from the pulmonary vein ostia and outward as a rapidly spreading surface wave...which is how the atrium gets its signal to beat. No spreading second wave, no ectopy; No cycling vortex, or 'rotor' as it is commonly called, no extra beats;

5. Carey answered this the way I would....it can, and should, be done any time you go more than 24 hours in AF in the weeks that comprise the blanking period; In fact, none of the four cardioversions I have had (I guess five since Dr. Novak must have cardioverted me upon release from my first ablation), lasted more than six days, most failing inside of a few hours. With that record, while having a prolonged bout of AF at the two-week mark after my second ablation, the ER attending declined to cardiovert me. She reasoned that I don't respond properly to such interventions. However, when I reported this to my outreach nurse from the cath lab at Royal Jubilee, she immediately replied that they made the wrong decision. She stated that an ablated heart is a 'reset' heart, and that I should have been cardioverted;

6. Yes, the blanking period is a confirmation that you are effectively blocked from the extra signal. The heart lives and works in real time. Real time is what happens during an 8-week blanking period. During that time, the remodeling heart might establish new foci, or it might heal the lesions created during the ablation and reveal, when the inflammation subsides, a minor gap through which the signal can continue to cause ectopy;

7. My EP shook his head when I asked if he does LAA ablations or in other places. He said he only does a PVI initially because that's where the heavy preponderance of paroxysmal AF sufferers are...and I was paroxysmal. He added that if I failed that ablation, he would consider other approaches, but not the first time. Even so, he did challenge my heart prior to releasing me from the cath lab. Had he found me still fibrillating, he'd have had to consider the situation: how long had I been sedated, how much cauterization had he done, how are my vitals, did he have time remaining to map and see if he could zap another focus or re-entrant if he found one, etc. Other EPs might adopt a different, more aggressive approach and continue to ablate where he/she finds the entry;

8. No, not to my knowledge. The mapping is done internally, after piercing the septum and inserting the mapping wand;

9. Yes, as deemed expedient and safe by the EP performing the ablation; and

10. You can travel the next day if you're up to traveling, but I would caution as follows: most of us mortals, especially if north of 60, would probably be smart to rest at least 24-48 hours to 'see how it goes.' Our bodies don't often let us know 'how it is' until after a night's sleep. Secondly, if travel/medical insurance is a consideration, what is the insurer's policy about previous health issues, their treatment and control, etc?

I agree you must seek out the most highly experienced EP. For me details matter and give me a much clearer, total picture.

Here is my logic(probably flawed!) and just presented for discussion.

We know just doing the PVI has a high success rate. When the atria is mapped and other “hot spots” are identified, do we know for sure these areas will cause atrial fibrillation? Not sure zapping other parts of the atria are risk free.

There has to be a balance, but also don’t want an EP to start zapping my heart when just an PVI will work.


I just asked ChatGPT and got the following. Much better answer than mine!


In pulmonary vein isolation (PVI) for atrial fibrillation (AF), the primary goal is to electrically isolate the pulmonary veins (PVs) from the left atrium to prevent triggers from initiating AF. Whether additional mapping and ablation outside the PVs are needed depends on the specific case and the type of atrial fibrillation being treated:

1. Paroxysmal Atrial Fibrillation:
• In cases of paroxysmal AF, where the arrhythmia is triggered primarily by ectopic foci from the PVs, PVI alone is often sufficient.
• Mapping and ablation of other areas are generally not routine unless there is evidence of additional arrhythmogenic foci outside the PVs.

2. Persistent or Long-standing Persistent Atrial Fibrillation:
• In persistent AF, the arrhythmogenic substrate may involve more extensive areas of the atria beyond the PVs.
• Electrophysiologists may choose to perform additional mapping to identify:
• Complex fractionated atrial electrograms (CFAEs).
• Rotors or other specific drivers of AF (if using mapping systems capable of identifying such mechanisms).
• Additional ablation targets may include:
• The posterior wall of the left atrium.
• Non-PV triggers identified during mapping.
• Left atrial appendage (in selected cases).
• However, the benefit of these additional lesions is debated and must be weighed against the increased risk of complications such as atrial scarring and atrial tachycardia.

3. Tailored Approach:
• Real-time assessment using high-density mapping systems or activation mapping during AF can guide ablation in areas with abnormal conduction or arrhythmogenic activity.
• Non-invasive mapping or focal trigger identification may also influence whether other atrial areas are targeted.

4. Key Considerations:
• Patient-specific factors: Age, duration of AF, atrial size, comorbidities, and prior ablations.
• Risks: Ablating additional areas can increase risks such as atrial scarring, proarrhythmia, or complications (e.g., esophageal injury if ablating near the posterior wall).
• Outcomes: The benefit of non-PV ablation for persistent AF remains controversial, with variable results in clinical studies.

In summary, routine mapping and ablation of other atrial areas are not standard in all PVI procedures but may be considered in persistent AF or complex cases where triggers or substrates outside the PVs are identified. The approach should be individualized based on the patient and intra-procedural findings.

Key Considerations
• Non-PV triggers are more commonly seen in persistent AF or long-standing AF patients.
• Identifying and targeting these triggers can improve outcomes in select cases but may increase procedural complexity and risk.

Thanks gloaming, another set of great answers. Really helps.

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mbd
We know just doing the PVI has a high success rate. When the atria is mapped and other “hot spots” are identified, do we know for sure these areas will cause atrial fibrillation? Not sure zapping other parts of the atria are risk free.

Yes, the EP knows which non-PV areas produce afib because that's how they're identified. That's what mapping is all about. You're assigning far more risk to these additional steps than exists. It's extremely minimal, but doing two procedures instead of one literally doubles the risks you incur. In what realm of logic does that make sense?

I’m learning as am going!

Reading the ChatGPT response above, it seems dependent on whether you are paroxysmal or permanent.

Also said ablating additional areas increases risks of atrial scarring, proarrthymia and other complications such as esophageal injury.

This also increases the time of the procedure.

It seems if you’ve been in atrial fibrillation for long periods, this increases the chance that other areas of the atria are causing it. This makes sense since PVI is less successful for permanent afib vs paroxysmal.

Also, it seems the mapping works best if you are in atrial fibrillation during the procedure. If you’re paroxysmal, this might not be the case?

So, for me, it does seem there is a choice to be made for the initial ablation for paroxysmal atrial fibrillation.



Edited 1 time(s). Last edit at 01/21/2025 05:23PM by mbd.

This was also surprising

“ The benefit of non-PV ablation for persistent AF remains controversial, with variable results in clinical studies.”

In the right hands, non-PV ablation significantly improves results, especially with persistent afib. The trouble with clinical studies with these types of questions is you're looking at the results of dozens or hundreds of EPs, with the majority of them having an average level of skill and experience. Remember what I said about selecting the EP? Select a top-tier EP and all those risks and results change dramatically.

And the trouble with LLMs like ChatGPT is that all they're really doing is repeating what people have said on the internet. Which people? Pretty much everyone, including people who had no idea what they were talking about. This is why ChatGPT is known to sometimes produce flatly incorrect information. If enough people believe in some fallacy then guess what ChatGPT is likely to believe.

ChatGPT will also spit out outdated information because it's been fed years worth of text. Esophageal injury (specifically atrioesophageal fistula) is and always has been the most feared ablation complication of all. However, for that reason a great deal of learning and innovation has occurred over the years in efforts to prevent it, resulting in it now being an almost unheard of complication, and one that usually indicates an EP with inadequate experience and/or poor training. (Again, back to the EP.) So for ChatGPT to even mention that risk demonstrates its weakness. It's probably from digesting information from 20 years ago.

So if you want clinical data, I would recommend going to google scholar and finding papers directly rather than relying on AI bots.

If the Left Atrial Appendage is a potential source of triggers and future ablation I assume you would lose the ability to ablate there down the road if a Watchman is placed?

I agree you have to be very careful with ChatGPT.

Here is a very relevant and interesting study on non-PVI ablation success. It was a ten year study and published in 2023. Can’t comment on the skill level of the EP’s involved but it was conducted at a large multicenter.

[www.ahajournals.org]

“Conclusion:
In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population.”

You said “in the right hands” your results are significantly better. Intuitively that should be true but has it been shown to be true, other than anecdotally. Is there a study that shows top tier EP’s have a better success rate? You certainly are in good hands with the very best, but just how much worse are “average” EP’s at multi centers where this study was conducted?

Any idea if “local” EP’s are even trying to perform this type of non-PVI complex ablations?

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cjkdm
If the Left Atrial Appendage is a potential source of triggers and future ablation I assume you would lose the ability to ablate there down the road if a Watchman is placed?

Nope. Just as a PVI doesn't ablate the pulmonary veins directly, ablating the LAA doesn't ablate the LAA directly either. In both cases burns are made around the opening of the vein or LAA. The goal is to create an electrical barrier so the afib signals being generated in the LAA or PV can't escape and cause afib. My LAA was ablated in 2017 and then an LAA was placed in 2018, but it could have been the other way around.

Interestingly the biggest factor in success for non-PVI was the size of the left atria, independent of paroxysmal or permanent atrial fibrillation.

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mbd
“Conclusion:
In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population.”

You said “in the right hands” your results are significantly better. Intuitively that should be true but has it been shown to be true, other than anecdotally. Is there a study that shows top tier EP’s have a better success rate? You certainly are in good hands with the very best, but just how much worse are “average” EP’s at multi centers where this study was conducted?

Any idea if “local” EP’s are even trying to perform this type of non-PVI complex ablations?

Despite the fact that 56% of the patients in that study had persistent afib, I didn't see any mention of LAA isolations; and, as Natale proved, if you want a ~90% success rate in terminating persistent afib, the LAA has to be in play. Unfortunately, the majority of EPs in the world don't know how to isolate the LAA and won't attempt it. A smaller but significant percentage won't attempt anything beyond a PVI.

I don't know of any published studies comparing EP experience and training with ablation success, and I doubt such a study will ever be done. As you said, it's intuitive that increased experience and training leads to improved results. That's true across all branches of medicine and has been for a hundred years, so there's little reason for anyone to study it. I can only report on my own personal experiences and the experiences of the people Shannon and I have known here and elsewhere (which is a LOT), and that "data" is absolutely compelling. That's why there are only two EPs in the US I will recommend unconditionally, and only a much smaller number I'll give conditional recommendations for.

Is there more than anecdotal evidence? Yes. Have a look at this study, which looked at patients who had failed more than 2 previous ablations. I quote the conclusions of the study:

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Conclusion: In patients experiencing AF recurrence after multiple failed PVI, despite PV reconnection, non-PV triggers were found to be responsible for AF maintenance in the majority and ablating those triggers increased ablation success. Additionally, in the presence of permanent PVI and no non-PV triggers on isoproterenol, empirical isolation of LAA and CS provided high rate of arrhythmia-free survival.

Hey, it's your choice, but if I were in your shoes I would opt for the EP who knows how to solve the entire problem in one procedure rather than spending another year dealing with a failed ablation and having to undergo a second procedure. The risks of ablating outside the PV area really wouldn't figure into my equation because they're so minimal they're almost trivial.

Great discussion.

It seems for the study that you referenced, patients only had the LAA & CS ablated/isolated IF the PV was isolated AND non-PV triggers were NOT present.
("Empirical isolation of LA appendage (LAA) and coronary sinus (CS) was performed if the PVs were silent and no non-PV triggers were detected.")

Check I'm reading this correctly. From the study, if you have a robust PVI and still have atrial fibrillation you can get a 90% success rate if you ablate the non-PV triggers (without working on the LAA). If you are still having atrial fibrillation with a robust PVI, without any non-PV triggers then you can get a 82% success rate by ablated/isolating the LAA/CS

Are you suggesting that for paroxysmal atrial fibrillation and a first ablation the LAA/CS should be either isolated or ablated?

Here is another study that shows less than 10% of first time ablation patients have non-PV triggers. It also shows that, persistent afib, atrial size, previous heart problems, are all independent factors that determine if you will have non-PV triggers.

The study also includes, “A set of pre-procedural risk factors can risk stratify patients at high risk for non-PV triggers and guide choice of optimal ablation strategy at first procedure.”

[www.ahajournals.org]

In order to detect non-PV triggers, “provocation maneuvers included cardioversion of AF if present at baseline, incremental isoproterenol (ISO) infusion (3-30mcg/min), and atrial burst pacing to induce focal atrial tachycardia (AT) or induce AF followed by cardioversion on 3-6mcg/min ISO or during high dose ISO washout.” Is required.

Identifying a subset of patients with higher likelihood of having non-PV triggers can guide more efficient use of these provocative maneuvers.

I’ll do some research on the risks for mapping and ablating non-PV triggers.

All the discussion really helps with the decisions. It’s important to factor the individual person; persistent or paroxysmal, atrial size, other heart problems, etc.

You've made reference to atrial size as an important predictor of long-term ablation success. Have you also undergone any studies (eg, strain echocardiography or LGE-MRI) to evaluate the presence or degree of fibrosis in your case?

That's really the other most important prognostic factor in afib and ablation outcome.

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mbd
Are you suggesting that for paroxysmal atrial fibrillation and a first ablation the LAA/CS should be either isolated or ablated?

No, nothing should be ablated that isn't a source of afib. Mapping carries no risk and there's absolutely no reason not to look for sources of afib beyond the PVs. If found, it would be negligent to just ignore them. But no EP goes around ablating non-PV areas "just because."

This process has really helped. Thanks.

I believe I have found answers to questions 7 & 8

7. I’m confused on the importance of mapping for a PVI. If you are only doing the PV why map the rest of the heart?

8. If 90% of atrial fibrillation starts in the PV’s. Is it possible to determine prior to procedure if you’re in the 10%?


For question 7: I'm in agreement with gloaming "My EP shook his head when I asked if he does LAA ablations or in other places. He said he only does a PVI initially because that's where the heavy preponderance of paroxysmal AF sufferers are...and I was paroxysmal. He added that if I failed that ablation, he would consider other approaches, but not the first time."

To look for non-PV triggers (NPVT’s) requires isoproterenol infusion, cardioversion, typically requires vasopressor support and increased procedure time. This adds complexity and duration to the procedure, which both ADD risk.


For question 8: The study I referenced from the Hospital of University of Pennsylvania shows that you can statistically predict who is most likely to be in the 10%.

The decision whether to go looking for NVPT’s and the LAA on the first ablation becomes based on the patient; size of atrium, persistent Afib, age, OSA, prior cardiac surgery, etc, etc.


It seems the medical consensus for a young male with no other health issues but the paroxysmal Afib the first step would be just a PVI.

For me, I will now be looking for a very experienced EP with thousands of catheter PVI’s under his/her belt and that has the most experience with PFA’s.

mbd

I disagree with some of your conclusions but the top two EPs in the US would be Andrea Natale at Texas Cardiac Arrhythmia Institute and Pasquale Santangeli at Cleveland Clinic. I would look no further than those two. They both participated in the PFA clinical trials so their experience is going to match or exceed pretty much any other EP.

7. The EP will have to map the PVs to ensure that he isn't ablating there unnecessarily. What if it's only the coronary sinus, the septum, or the LAA and not the PV where the focus or rotor is? What if he finds that the Vein of Marshal is actually the culprit and there's no sign of a re-entrant near or inside the mouths of the pulmonary veins?

8. No. Hence he piercing of the septum first, and then commencement of the mapping. If it turns out to be Ye Olde PVI, that's what he'll do. That and no more than a challenge and a quick recheck if the challenge produces more ectopics.

Gloaming, I'm confused. You said in your original answer to 7, that your EP only does PVI on the first ablation????

I thought EP's test the PV's for isolation after ablation. So your saying they map PV's? I thought mapping, if performed is done on the atria. If the PV's are isolated what are they mapping on the PV's?

I think you've gone a bit far down this rabbit hole of mapping and are misunderstanding it a bit. You can't test the success of an ablation without a mapping catheter even if it's just a PVI. Mapping is a crucial component of any type of ablation. A good EP will map the entire atria, and the PV ostium is part of the left atrium. That's the opening in the left atrium where the PVs enter. That's where a PVI happens. Nobody maps or ablates the PVs themselves (though they used to, and then learned not to).

If you're really convinced that you want a 100% PVI-only ablation with no mapping, no ablation of other sources of afib, etc, then find an EP who uses cryo and does exactly that. You may enjoy complete success. Just be aware you'll probably be dealing with a less experienced, less highly trained EP. The two EPs I recommended will definitely not do that for you.

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NBeener
You've made reference to atrial size as an important predictor of long-term ablation success. Have you also undergone any studies (eg, strain echocardiography or LGE-MRI) to evaluate the presence or degree of fibrosis in your case?

That's really the other most important prognostic factor in afib and ablation outcome.

I did have a nuclear stress test and MRI a couple of years ago.

Thanks for explaining that it is opening of the PV’s that are ablated not the PV’s themselves.

I didn’t think my questions would take us so far down the rabbit hole!

Using the mapping catheter to test for isolation of the PV’s is NOT the same as mapping the whole atria. As I think I explained earlier mapping involves: “provocation maneuvers included cardioversion of AF if present at baseline, incremental isoproterenol (ISO) infusion (3-30mcg/min), and atrial burst pacing to induce focal atrial tachycardia (AT) or induce AF followed by cardioversion on 3-6mcg/min ISO or during high dose ISO washout.” These things are not required to test for PVI isolation post PV ablation.

I’ll give my logic one more try…….Can we agree that 90% of paroxysmal AF can be stopped by PVI and these 90% do not have triggers outside of the PV’s. That means in 90% of these cases the mapping procedures above would be unnecessary. Agreed?

I’m not talking about complex cases with multiple failed ablations or for ablations for permanent Afib.

The Hospital of the University of Pennsylvania, performs six times the national standard of AF procedures. The purpose of their study was to eliminate these unnecessary mapping procedures. An honest question, why are they trying to do that, eliminate the mapping?

I’m not 100% convinced of anything! Just trying to gain as much knowledge as possible to make the best possible decision.

I think it is unfair to call an EP that has been doing cryo for decades inexperienced or untrained. I certainly wouldn’t want him/her to start working on my LAA but that’s not the issue.

“The two EPs I recommended will definitely not do that for you.” Are you sure that would be the case for a young male with no other health issues but paroxysmal Afib? If you are correct, I believe HUP would disagree with that approach.



Edited 2 time(s). Last edit at 01/23/2025 03:46AM by mbd.

"...The Hospital of the University of Pennsylvania, performs six times the national standard of AF procedures. The purpose of their study was to eliminate these unnecessary mapping procedures. An honest question, why are they trying to do that, eliminate the mapping?...'

I don't quite understand this, especially the first sentence. Are they doing six times the number of ablations that other hospitals do on average across America?

Yes, my EP state that his first crack at my heart was going to be a PVI. I wasn't conscious when he did all the did, so I don't know what all went on while I as out. He did tell me that he challenged my heart prior to releasing me to recovery. I must have passed, but six days later I was in my ER with AF again, and it was fast and intractable. Long story after that. On his second attempt seven months later, he found the gap he'd missed somewhere around my third pulmonary vein.

I think you might need to watch a video or two on heart structure. The pulmonary veins empty oxygenated blood into the posterior high wall of the left atrium. Endothelial tissue from the atrium sometimes wends its way into the mouths of those veins, and that tissue is receptive to voltage propagation. In people with paroxysmal AF, the pulmonary veins get voltage inside them near their mouths, and since some of the atrial endothelium has migrated into those mouths, it picks up the extra focus voltage and propagates it outward across the atrial wall, making the atrium contract. Except the SA node is also sending a competing signal, usually a fraction of a second prior to or after the fibrillating signal. The point of isolating the pulmonary veins is to make a circle of damaged tissue, which is impervious to the voltage, around all the vein ostia. This is what is meant by 'isolating'. And yes, they still have to map that area to find the precise location where they need to burn.

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NBeener

You've made reference to atrial size as an important predictor of long-term ablation success. Have you also undergone any studies (eg, strain echocardiography or LGE-MRI) to evaluate the presence or degree of fibrosis in your case?

That's really the other most important prognostic factor in afib and ablation outcome.

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mbd
I did have a nuclear stress test and MRI a couple of years ago.

Did either of those tests indicate whether/how much fibrosis you have?

As I say ... you're putting a great deal (I'm not judging whether it's enough or too much) of thought into many aspects of a possible ablation. I wouldn't want you to give short shrift to another factor that has a huge bearing on outcomes.

Gloaming:

Fascinating, thanks for another great explanation.

I don’t quite understand it either, but it sounds impressive! I forgot to include quotes “” since it was copied from their web site. Maybe someone can figure out exactly what it means. [www.pennmedicine.org]#

Was the second ablation that “plugged” the gap successful? Do you know if the EP mapped and/or ablated other areas of your heart in this second ablation?


NBeeber:

The amount of fibrosis hasn’t previously been mentioned by my cardiologists, or in reference to the test results. Thanks for the advice. I’ll definitely do some digging.

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mbd
I’ll give my logic one more try…….Can we agree that 90% of paroxysmal AF can be stopped by PVI and these 90% do not have triggers outside of the PV’s. That means in 90% of these cases the mapping procedures above would be unnecessary. Agreed?

No, not really. If that were true, success rates for cryo should be 90% and they're not.

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“The two EPs I recommended will definitely not do that for you.” Are you sure that would be the case for a young male with no other health issues but paroxysmal Afib? If you are correct, I believe HUP would disagree with that approach.

Yeah, I'm sure. Their approach is always to find and eliminate all sources of afib in a single procedure, and they usually find them. The minutes it takes to do that are well worth the avoidance of a repeat procedure. That's one of the reasons their success rates are much higher than average.

You keep saying you're young but I don't recall you giving an age. May I ask what your age is?

NBeeber

Thanks for the suggestion.

Here is my ChatGPT session on fibrosis that is very educational and extremely helpful.

[chatgpt.com]

'...Was the second ablation that “plugged” the gap successful? Do you know if the EP mapped and/or ablated other areas of your heart in this second ablation?...'

Yes, He told me, when he came by after the surgery, that he was in process of re-burning the third of the four pulmonary veins when my heart suddenly stopped fibrillating and resumed normal sinus rhythm. They watched for a while, maybe even challenged the heart again (I'd guess he did, but again I was unconscious..), and found that the rhythm was durable. So, my assumption is that he elected to do no further ablation, and for that I am in agreement and grateful.

And for your second question, my understanding is that he was redoing the PVI since it had seemed to stem the arrhythmia at the time he released me initially . As the lesions healed over the ensuing days, a small gap must have opened and allowed some signal to emerge from the circular dam of lesions he had put around my veins. (Or, equally likely, my progressive disorder established a new focus that just happened to become active at the same time, except it was still near the pulmonary veins...?) His assumption was that it was a gap, and he had re-ablated two veins already when he found the gap in the third vein.

Carey,

The success rate for the initial PVI is 60-70% and after a second PVI is 85% (not 90%). This is without any non-PV ablations.

I wasn't referring to myself when I said young. I wanted to illustrate that treatment should perhaps be tailored to where the patient is in their Afib journey.

I do have a decision to make, either select a highly experienced EP in PVI's with a proven track record of durable isolation. Or select an EP from just a handful of masters in the art of non-PV ablation. I feel the worst decision would be to go with an EP who thinks he can fix non-PV sources,

For those folks in the 85% group, going to a "master" wouldn't have made any difference. There are probably 10's of thousands PVI ablations done in the US. Unfortunately it is just not practical for everyone to go to a master to get just a PVI. I would think the majority of the "masters" patients fall into the 15% group. A much better use of their time, no?

I'm 63 years young 😀

mbd

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mbd
I feel the worst decision would be to go with an EP who thinks he can fix non-PV sources,

What?! Seriously? What do you mean "thinks" they can? They do it day in and day out. I'm a living example and there are dozens more here like me.

I think you've elevated this issue far beyond reason. Once your PVI is complete but you're still in afib or it can still be provoked, do you really want your EP to just shrug, close up, and tell you that you'll need another procedure? That's what you seem to be saying.

What I expect from an EP would be a PVI, and then after the PVI is complete if afib has been terminated and can't be provoked, the EP would stop there and call it a day. Otherwise, the EP would be capable of finding and ablating the other source(s) and would do exactly that. Their goal would be to have me in NSR when I leave that lab.

You know what I think would be really helpful for you? You should schedule a virtual consultation with Natale or Santangeli and get their input. I think the handful of papers you've read have given you a warped understanding of ablation procedures.

I wasn't referring to one of the "masters".

Correct me if I'm wrong but you give the impression that any EP other than the two you recommend aren't to be trusted, other than doing PVI's?

Warped? Are these not true statements?

"The success rate for the initial PVI is 60-70% and after a second PVI is 85% (not 90%). This is without any non-PV ablations."

"For those folks in the 85% group, going to a "master" wouldn't have made any difference. There are probably 10's of thousands PVI ablations done in the US. Unfortunately it is just not practical for everyone to go to a master to get just a PVI. I would think the majority of the "masters" patients fall into the 15% group. A much better use of their time, no?"



Edited 2 time(s). Last edit at 01/23/2025 08:42PM by mbd.

"Once your PVI is complete but you're still in afib or it can still be provoked, do you really want your EP to just shrug, close up, and tell you that you'll need another procedure?"

Yes. But you have completely missed the point. The goal is minimize the probability of that occurring, because not everyone can have their first ablation with just one or two EP masters.

If they have decent insurance or can afford to self-pay, they most certainly can.

If that's really what you want then just find an EP who does only cryo. Finding an EP who uses RF or PFA and who does only PVIs even if more is needed will actually be more difficult.

Carey,

"You know what I think would be really helpful for you? You should schedule a virtual consultation with Natale or Santangeli and get their input."

I think that would be great. How do I make that happen? Who do I contact?

Thanks,

mbd

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mbd
I think that would be great. How do I make that happen? Who do I contact?

His scheduler's name is Norma. Give her a call at 512-615-6205. (That's her direct number.) Tell her you're considering an ablation and would like to schedule a telemedicine consult with him. She should be able to get that done for you.

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Carey

I think that would be great. How do I make that happen? Who do I contact?


His scheduler's name is Norma. Give her a call at 512-615-6205. (That's her direct number.) Tell her you're considering an ablation and would like to schedule a telemedicine consult with him. She should be able to get that done for you.

Thanks

Natale: [tcainstitute.com]

Santangeli: [my.clevelandclinic.org]

ETA: should have refreshed the page before posting this ;-)



Edited 1 time(s). Last edit at 01/24/2025 12:22AM by NBeener.

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NBeener
Natale: [tcainstitute.com]

Santangeli: [my.clevelandclinic.org]

ETA: should have refreshed the page before posting this ;-)