Are We Inflating the Success Rate of AF Ablation?

Is the blanking period relevant?


[www.medscape.com]

Great find! Thanks for sharing!

When Mandrola writes stuff like this I always wonder what he does with his own patients and what he tells them. I can't imagine being scheduled for an ablation with him and coming across his writings.

Well there is zero chance you would schedule an ablation appointment with him.

It’s still a comprehensive well written article.

If there is such a thing as a 3 month blanking period, why would my EP tell me at my 1 month follow up ablation appointment that I’m no longer blanking but my ablation failed after a month? Wouldn’t he wait after all possibilities at the three month mark to make this determination?

Unless I’m special and I won the afib lottery and he knew from my prior two failed ablations because I’m special and that three months of blanking wouldn’t make a difference.

Ablations are not 100% successful and he knew mine was a goner from his experience. There are always those very few that ablations can’t help. Which makes a 3 month cut off blanking period just hope for those who are still getting afib. The 90 days is arbitrary.

I didn't criticize his writing skills. I just dislike the fact that everything he publishes is critical and negative, sometimes alarming, and he publishes on a patient-oriented site like medscape instead of journals where actual EPs will see it. But publishing in journals means being peer reviewed, of course, and most of his articles would never survive peer review. And if they did, I would expect he'll get responses like he did when Shannon himself published a rebuttal to one of his articles a few years back.

Is the 90 days arbitrary? Yes, largely. I mentally consider the blanking period to be about 6 weeks. If you're still experiencing afib after 6 weeks, I think you have dim prospects of calling the ablation successful later on.

What's the purpose of the blanking period? It's to give the lesions time to fully scar over and become fully protective. Notice how he didn't even mention that in the article? He portrays the blanking period as a contrivance to inflate success figures without acknowledging that it has valid clinical reasoning behind it. I don't find that very honest, but it gives him something to rant about.

Does the blanking period inflate success figures like he says? No, and I don't even understand his logic in saying it does. If you're experiencing afib in the first 3 months but not afterwards then how is that a failure? It's not. He seems to imagine that afib in the blanking period means the ablation was a failure but it's being concealed by the blanking period. That's nonsense. If you're not experiencing afib at 3 months and beyond then who cares what happened earlier? The real measure of success is being afib-free at 1 YEAR, not 1 month, not 3 months, or any other number.

I agree with Carey. I'm a case in point. First ablation, back in the ER inside of a week, and my EP saw my watch's ECG and agreed that he needed to do more for me. When he did, I went two weeks this time, had a 12 hour run of AF, and then none to this day. So, both times, well within the 3 month blanking period, I had AF. Second time, after that one oopsie, I went on through to the end of the blanking period and beyond, and here I am a full year after the semi-arbitrary 12 month cutoff (they could have picked two years, or four, but then their stats for 'successful ablation' would begin to sour, so 12 it is).

I posted research about blanking period AF events maybe two years ago now where they found that the prognosis for late-in-the-blanking-period AF events was almost universally poorer than if the odd event happened, say, in the first six weeks, and then stopped. Mandrola mentions this finding, and then concludes that the entire waiting period is a waste of time. I would have to quibble with that.

I also agree with Carey. I'm not sure how anyone takes this guy seriously. As far as the blanking period, from what I understand everyone heals differently post ablation and some take longer than others for the scar tissue to form. Some ablation have a much greater stress on the heart especially ablation of multiple areas.

I had an ablation for flutter on the right side and my EP said it was a very small area that needed to be ablated. Because of this, the blanking period in my case should of been less than the 90 days. Again, this is how I understand it and while many people will heal quicker than the 90 days some don't and that's why the 90 day number is used. If, after 90 days Afib is still present the ablation 100% failed.

I think this paper/study presents a more nuanced approach to the question:

[pubmed.ncbi.nlm.nih.gov]

Its conclusion:

Quote

Conclusion: Early atrial arrhythmia recurrence during the blanking period, particularly during the third month, is significantly associated with later recurrence. Although a blanking period is warranted, it should be abbreviated.

Pulsed Field Ablation seems similar ... so far:

[pmc.ncbi.nlm.nih.gov]

Quote

Conclusions: This study indicates high acute efficacy of PFA based PVI. 75% of patients are free of AF at one year. Blanking recurrence is an independent predictor for late recurrence after PFA-PVI: further studies are required to better define the duration of the BP after PFA PVI.

So ... maybe fine-tuning the blanking period, rather than simply jettisoning it (?).

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cornerbax
If, after 90 days Afib is still present the ablation 100% failed.

hmmm..I don't know about this and certainly hope this is not true. The only episode of AF happened to me after my PFA was in 7 months, when I thought I passed the blanking period already. I am 19-month post ablation today and hope to continue to be AF free.

Quote
hmmm..I don't know about this and certainly hope this is not true. The only episode of AF happened to me after my PFA was in 7 months, when I thought I passed the blanking period already. I am 19-month post ablation today and hope to continue to be AF free.

I'm sure others can chime in with good info but if you actually had AFIB 7 Months post ablation that would likely mean your ablation didn't completely prevent the erratic signals from getting through or you have another area or areas that are Causing Afib and which can progressively get worse over time.

Do you know definitively your one episode was Afib and not flutter or tachycardia, etc? What I meant is after 90 days if there are episodes of afib the ablation clearly wasn't successful in curing it. Either because the ablation simply wasn't successful or because afib is occurring in other areas.

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NBeener
So ... maybe fine-tuning the blanking period, rather than simply jettisoning it (?).

Yes, exactly.

Quote
cornerbax
I'm sure others can chime in with good info but if you actually had AFIB 7 Months post ablation that would likely mean your ablation didn't completely prevent the erratic signals from getting through or you have another area or areas that are Causing Afib and which can progressively get worse over time.

Do you know definitively your one episode was Afib and not flutter or tachycardia, etc? What I meant is after 90 days if there are episodes of afib the ablation clearly wasn't successful in curing it. Either because the ablation simply wasn't successful or because afib is occurring in other areas.

Yes, I am very symptomatic, and my Apple watch confirmed it. A friend of mine also had a few episodes of Afib up to 4.5 months after RF ablation, he has been Afib free since then and just celebrated his 6-year anniversary. I think everyone heals differently.

Time for my 2 cents. Does it matter what you call post cardiac AF? It is still AF whether operative induced or real spontaneous AF. Trying to make AF seem higher or lower makes no sense to me . What makes sense to me is post ablation has a failure rate depending on sources one reads. Frankly I am
more interested in why it occurs at a cellular level. If my theory is supported by more studies it is caused by net negative energy development in pacemaker heart cells . That is due to two causes:
1. Chronic inflammation is caused by overstimulation of an innate immune mechanism called NLRP-3- look it up for details and it causes secretion of inflammatory molecules called cytokines. One in particular called IL1beta inhibits an enzyme (ATPase)in heart cells needed to catalyze stored energy in a molecule called ATP to motor electrolyte pumps needed to make an electrical signal for sinus rhythm.
2. Elemental Mg++ ‘‘t is needed to make a conformational change of ATP so that ATPase can catalyze ATP for energy production,so if Mg++ Is deficient in pacemaker heart cels, as it is in majority of AF individuals , it adds to the energy deficit preventing SR.

So the combination of # 1 and 2 combine to create a net energy deficit allowing for AF. My conclusion is unless Mg++ is replenished in AF heart cells before ablation , then I would predict AF will continue post ablation in some individuals regardless of the operative insult to cardiac tissue.
If we can’t control the chronic inflammation as described then the only alternative is to optimize pacemaker heart cells with adequate Mg++ before elective cardiac ablations.

Just Hugging again

Sometimes he writes just to write. What he's stating has little relevance to patients. If I have a blanking episode and then remain essentially afib free after 90 days, I'm going to consider that ablation a success. Who wouldn't other than someone like Mandrola? In fact, I had an ablation two years ago with one documented afib episode at month six, and I consider that a success. I think one EP I spoke to put it best. He said his success rate was 90% if you considered success as a 95% decrease in afib burden and 60% if your looking for 100%. I'm very happy with my one episode.

Jim

Hi Jim
One further comment I think worthy of discussing about ablation success. You may be symptom free but unless you self monitor your EKGs as I do 3-4 times day( each just 30 seconds for 2 minutes in your day) you may discover something that is often unspoken, namely asymptomatic AF. I have read hundreds and hundreds of stories about post ablation experiences, and what amazes me is I do not hear EPs recomending close self monitoring , a 2 minute exercise to be sure one is truly free of AF. I suspect if that was a routine post ablation protocol, the recurrence rate of AF post ablation woukd be higher.
You might ask why is that necessary if you feel good. My answer is stroke risk continues if you have asymptomatic AF, yes at a lower rate on anticoagulants but still significantly higher than truly remaining in sinus rhythm. Remaining in symptomatic or asymptomatic AF makes no difference as to other consequences , namely heart failure and dementia.So in my humble opinion as a physician who has a history of AF,I will want to be sure I stay in sinus rhythm. Lastly I believe AF is a chronic condition no different than having diabetes. Diabetics self monitor with glucose measurements to stay in glucose balance. One could argue that is not a good comparison since a diabetic can do things like change their diet or adding more insulin. But based on my own ability to have converted my AF to sinus rhythm, there is similarity as I have done both; changed my diet to include foods fortified in magnesium and potassium and titrating my dose of magnesium supplementation depending on my heart rhythm.

I hope this is considered a helpful commentary for discussion.
Hugging

As the expression goes, I'm monitored for afib every which way, but loose

Jim