forum on surgical management of AF

[real.ctsnet.org]

If the above link doesn't work, then go to the bottom of the following link and click on the video link.

[www.ctsnet.org]

Researcher

I use Firefox as my browser and it doesn't know which program to use to open the RAM file. Any clues?

Gill

You need the Real Player plug-in. No other choice in this case unfortunately. I personally don't like Real Player because of all the garbage that comes with it. I use chrome (beta version) and it blocks out the garbage pretty well so I ok with it.

Thanks Researcher

Gill

This is a subject that has my attention...I am considering three options: (1) another cath ablation, (2) the surgical ablation, or (3) try to wait for the hybrid to develop.

This link is three years old, correct?

Mark, yes with regards to the timing of the forum. Surgical techniques and tools has not changed much since then. The whole hour is well worth your time if you are considering surgical options including the minimally invasive ones. The 3 panelists give divergent views so you get a pretty good cross section of surgeons' thinking. The principal limitation of the forum in my opinion is that the surgeons talk as if surgery is offers near 100% cure and that's not close to being true unless they do a Cox Maze III or IV. But only 450 of those get done a year and only in cases where there are other heart issues to work on such as valve job or CABG. You would need to follow up with review of more recent literature to assess success rates of surgical options. Technique wise, I saw a recent study sponsored by Atricure. Also, surgical outcome is highly dependent on the skills of the individual surgeon.

Researcher,

Thanks. I came across some information from the Washington University School of Medicine in St Louis that indicated surgical ablations were still not even close to being a cure-all for AFIB. Of course, the Cox Maze III is so complex and difficult to perform it is not really an option and way too invasive for me anyway.

I am caught between two failed ablations and going for a third, or a surgical ablation, or a hybrid.

I will consult with a local surgeon (Niv Ad) here in the Washington DC area, but I think a second option and trip to St Louis makes sense. I also have a consult with Natale in June (Texas facility) and was interested to learn after the Boston symposium that they are exploring the option of hybrids.

It may be that I just have to hold on another year or more…my vagal AFIB genearlly occurs every two weeks, but I have daily occurrences of atrial flutter, pvc’s, etc. My new PIP strategy seems to be help minimize my time in AFIB, which until more recently was about 10-16 hours before getting back into NSR.

The burden of this thing is beyond words.

Sorry to hear of the 2 fail ablations. Natale is not one to shy away from recommending surgery if that's what he thinks is best for a patient. He was the biggest referrer to Cox Maze when he was at the Cleveland Clinic. Too bad you have to wait until June to see him. Who and where did you get your ablation if you don't mind telling?

Johns Hopkins. Hugh Calkins. But, of course, Johns Hopkins is a teaching hospital, which my current EP (not Calkins) doesn't think is an issue, but....

I get the impression from reviewing publications over the last few years that the Hopkins EP program is very average in terms of success rate while higher than average on complications. Not a good combination. Giving some other center the 3rd try is a good idea especially in this case.

Get rid of your burden and sign up with Dr. Natale, Mark. He's the expert in the US and cleans up many botched ablations. Jackie

My EP suggest that the Natale approach was “carpet bombing the heart”, but I am not necessarily deterred and don’t place much emphasis on that statement. He might be somewhat disappointed I am going outside of his practice for a consult, but then again he suggested that odds were not in my favor for beating AFIB with a third ablation, which statistically speaking is true…unless you go to the very best and that is why I will be traveling to Austin in June. I am very curious about the hybrid procedure, but whatever low risk procedure works best is what I am after. I have got to beat this thing. The quality of my life is going downhill fast with more frequent, longer episodes of AFIB. So whether it is another ablation, surgery, or a combination of the two--I have got to find something that works. Meanwhile, I plan to keep the supplements going and with a modified diet.

For some info on surgical approaches:

[www.af-ideas.com]

<[www.af-ideas.com];

I have been especially interested in Dr James Edgerton's approach, as described here in this 2009 interview:

[www.stopafib.org]

Dr Ralph Damiano is also looking ahead, as in this video which you will find on the links on the left:

[www.stopafib.org]

and here:

<[www.a-fib.com];

You can find out more about choosing between surgery and CA for the different types of AF here:

<[www.af-ideas.com]; (I think I need to re-work this discussion...)



-- Dick

Dick, Nice job on the write up. I mentioned an Atricure sponsored study being reported recently. You may want to add it to your reference list. The results were not very good.

===============================================
Management of Recurrent Atrial Arrhythmias After Minimally Invasive Surgical Pulmonary Vein Isolation and Ganglionic Plexi Ablation for Atrial Fibrillation

Jordana Kron, MD, Vigneshwar Kasirajan, MD, Mark A. Wood, MD, FHRS, Marcin Kowalski, MD, Frederick T. Han, MD, Kenneth A. Ellenbogen, MD, FHRS
Received 10 November 2009; accepted 8 December 2009. published online 14 December 2009.
Uncorrected Proof

Background

Minimally invasive thoracoscopic procedures have evolved for surgical treatment of atrial fibrillation (AF). The spectrum and management of arrhythmias after minimally invasive epicardial radiofrequency ablation of the pulmonary vein (PV) antrum has not been well studied.

Objective

The aim of this study was to describe the spectrum and treatment of recurrent atrial tachyarrhythmias (AT) after minimally invasive AF surgery.

Methods

Fifty patients underwent bipolar radiofrequency (RF) ablation of the PV antrum, parasympathetic ganglionated plexi, and ligament of Marshall. Twenty patients (40%) had recurrent AT, and 13 underwent electrophysiology study 100 to 948 days postoperatively (mean 383 ± 234).

Results

Fourteen arrhythmias were identified in 13 patients 90 to 666 days (mean 214 ± 162) after AF surgery. The most common arrhythmias were AF (N = 8) and atrial flutter (N = 3). Of 44 PVs examined, 22 (50%) had reconnected. Seven of 8 patients with recurrent AF had either 2 or 3 veins reconnected, and 6 of 8 had reconnection of the left superior PV. On average, 25.6% of each PV reconnected and showed conduction delay between the left atrium and PV. Two of 4 postoperative atrial flutters were due to isthmus-dependent re-entry. After catheter ablation, 2 patients had symptomatic recurrence of AT.

Conclusion

Recurrent AT occurs in up to 40% of patients after minimally invasive thoracoscopic AF surgery during a minimal follow-up of 12 months. PV reconnection accounts for most recurrences. Postoperative AT appears amenable to catheter ablation, often in conjunction with medical therapy, with high intermediate-term success.

Address reprint requests and correspondence: Dr. Jordana Kron, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, Virginia 23298-0053

Dr. Kasirajan has received honoraria and research support from Atricure, Inc. Dr. Wood has received honoraria and research support from Atricure, Inc. Dr. Ellenbogen has received honoraria, consulting fees, and research grants from Atricure, Inc, Ablation Frontiers, Cryocath, and Biosense Webster.

Clinical Trial Registration Information: www.clinicaltrials.gov.

ClinicalTrials.gov identifier: NCT00747838.

Researcher,

Do you whether or not there is any truth to a rumour I heard that Bordeaux are looking at and/or trialing the Ablation Frontiers PVAC & Genius tech?? It certainly looks promising to me: would you accord?

What's your own view as regards the promise or otherwise of the cryo-balloon approach?? (An EP in London called Schilling - who you've commented upon previously as being impressively cautious in his approach - has used the cryo-balloon tech on 12 patients (up until early 09 at least, likely more since then) with all 12 of those (PAF) having being 100% free of AF at 6mths FU.

Here in the UK an EP called Steve Furniss at Eastbourne is definately using the aforementioned PVAC and claims 80% success for PAF with one procedure. Have you heard of Steve Furniss? If yes, what have you heard?

My own brief history is PAF since 1999, always nocturnal/vagal, 5 self-converting episodes 1999-2005, 4 episodes terminated 300mg Flec PiP 2005-2007, 75mg Flec BID since March 2008 to date with one breakthrough Oct 09 (excessive drinking involved). As such, I'm holding out with the 75mg Flec BID as long as I can: Schilling told me not to go over 100mg BID. My other obvious option is ablation: Haissageurre, Furniss and Schilling all told me to stay on the Flec for now, and then get in touch with them again when the Flec loses efficacy. I could have ablation on the National Health Service here in the UK (Furniss or Schilling) or go to Bordeaux and pay. The ostensibly obvious option I suppose is to go to Furniss or Schilling, but money is only money after all and my bet is that you'd advise a trip to Bordeaux!

TIA,

Mike F.

Researcher,

I'd like to ask your opinion on another matter please.

With each 75mg Flec that I take BID I take 10mg propranolol just to kind of reassure myself as regards a bit of protection against any chance of late-Flec-induced-proarrythmia. I suspect that 10mg Prop BID is almost sub-theraputic and that 2.5mg Bisoprolol or a low dose of Diltiazem would be a better choice. I'm not looking for some kind of a consult here, but would be interested to learn your views as to the merits or otherwise of my approach and what the best option would be.

TIA again,

Mike F.

Mike F. ,

It won't surprise me if any of the top experts are trying out newer tools from time to time. With regards to ablation frontier tools specifically, long term results are needed. The results published recently on "single-shot" tools including balloon cryo haven't been very impressive. I don't know if ablation frontier's multi-array tools will do any better. The idea of single-shot tools is to map, ablate continuous lesions once a catheter has seated at an appropriate location. People's heart anatomy has high variability if you listened to the surgeons panelists on the forum at the top of this thread. Cryo does have the advantage of reducing the risk of esophageal fistula but then there is increased risks of phrenic nerve palsy. Perhaps it would just be better to have a cooling balloon down in the esophagus and go with RF if that is the only advantage.

I looked up Furniss to see what he worked on. He has been around a while and was actually quite brave in trying to tackle scar related VT with ablation way back in the 90's. If he can handle VT ablation with the rudimentary tools back then, I am sure he can handle AF now. So I think you will be OK with either Furniss or Schilling. You can always save Bordeaux as a last resort and do tell your EP that you are thinking that way so they don't have to be too heroic or risky.

With regards to AADs, I don't have the biochem background to help you. Perhaps Jackie or Hans can chime in.

Researcher: Re: the balloon cryo ... I'd be curious to know where they use those tips.

Years back when I prepared for my Natale PVI ablation, we were discussing ablating in the pulmonary veins and the stenosis risks. Some time before then, the balloon catheter tips were used with RAF - not cryo - and the problem Natale said was the balloons being round/spherical so the veins did not adapt to the shape since veins grow in all sorts of configurations. Therefore, he wasn't interested inpursuing and he eventually decided not to ablate unless absolutely required inside the veins but developed his antrum procedure.

I'm wondering if the report mentions where they applied the cryo?

Jackie

Researcher,

Thanks for the further response.

Re cryo-balloon, I thought - again coming at this as a layman - that the main advantage of the balloon is that it causes a continuous ring of scar tissue in one go rather than trying to join a series of dots together, rather than the cooler running as such.

Furniss's stated aim (to me at least) is that he wants to develop the simplest and least invasive ablation approach that can be most readily used at as many centres as possible so as to properly tackle the ever-increasing number of people with AF. Whilst eminently sensible and admirable, I suppose the downside of such an approach is that it a) to some extent assumes that a one-size approach will fit all when individual cardiac anatomies are very different and b) to some extent disregards the accepted fact that it the the experience/expertise of the EP that is paramount rather than the finer details of the anatomical approach deployed. Whatever one's views in the aforementioned regard, Furniss certainly seems a really decent bloke who's been willing and able to communicate with me in a friendly helpful manner without any hint of being patronising or imperious!

Best Regards,
Mike F.

Mike F.,


> Re cryo-balloon, I thought - again coming at this as a layman -
> that the main advantage of the balloon is that it causes a
> continuous ring of scar tissue in one go rather than trying to
> join a series of dots together, rather than the cooler running
> as such.

Yes, that is in theory how it works and it does work like that acutely. However, 12 month follow results show a higher reconnection rate than RF lesions. The Schilling et al AVNRT results suggest that there is about a 10% penalty from cooling not working as well as heating in creating long lasting lesions. The other consideration as Jackie posted is that there are anatomical variations in people and that one size (there are 2 sizes of the Articfront balloon) does not fit all. The articfront balloon is designed to seat outside of the ostia to avoid stenosis. You can clarify further when you talk with Furniss or Schilling.

Mark,

You might be interested in Kerry Acker's story in the May 2007 issue of the AFIB Report:

[www.afibbers.org]

He supplies his email in the article so I suppose it would be ok to contact him:

kacker4@hotmail.com.

He visited a number of practitioners (as you plan to do), in his case before before making the rather unusual and controversial decision to have a stand-alone Full Maze done by Dr Niv Ad for his lone AF.

IMO, your choice is a difficult one. I think you will find out more from the people you consult, as they will have the opportunity to review the details of your case, including what work was done in the first two ablations and the implications of this (amount of scarring, for example) for the probability of success of further intervention.

There are patients who have had two ablations that choose to have another ablation, to have a PVI-centered surgery, or to have a version of the Full Maze (see the links in my previous post for more or surgical approaches).

The hybrid of Dr Richard Lee and Natale's convergent approach consist of a PVI-centered surgery plus other features such as LAA removal or occlusion, followed by a CA if needed -- so in your case, I would think that the difference is mainly one of packaging rather than unique content.

[www.or-live.com]

[www.tcainstitute.com]

It will interesting to hear what Dr Natale has to say. Will he predict that the lines around the PVs have broken down and that either surgery or another CA could redo them with a successful outcome? Or would he predict that the work that might need to be done could be better accomplished by surgery?

Will Dr Ad give a good argument for going for his version of a Full Maze, which would add unbroken, transmural lines in addition to the PVI that are difficult for an EP to create? How much weight will he give to LAA removal -- especially with dabigatran possibly on the verge of approval? What is his success rate with patients like you?

And the approach described here offer intriguing but untested possibilities:

[www.af-ideas.com]

You can ask the doctors you consult what the opinion of these approaches.

You of course should ask each doctor you consult about his success- and complication rates, the number of cases on which this estimate is based and the way he measures success (see [www.af-ideas.com])

Let us know what you find out. I know you will feel more comfortable once you gather information from doctors you trust and settle on a strategy.

-- Dick

Dick,

Just to say thanks for your well-written and very informative posts. You do come across as something of an expert! Do you work in the field of AF/medicine or are you 'just' an extremely competent layman??

The info at

[www.ohioafib.com]

was very interesting and, publicity gloss notwithstanding, seems to show great promise for persistent/permanent AFrs.

Mike F.

Thanks Dick.

I appreciate the helpful information and will keep you apprised of developments.

FYI, I talked with Niv Ad, just about a year ago. It happens that Doctor Ad is an acquaintance of a family member and he heard about my dilemma with AFIB, so I went in just to have a general discussion, not because I was keen on surgery.

Dr Ad was confident surgery could take care of my problem, but I didn’t want to go for it…I am still a little gun shy after jumping into two failed CA’s. After the second one, I went into chronic AFIB for a month, which threw me into an absolute panic. Doctor Ad indicated the surgical technique he performs would not change radically in the near future, but I still naturally prefer to see a stronger track record before making the decision. I also wonder whether he will team with EP's to provide the hybrid as an alternative. Of course, regardless of my hesitation, I think surgery is something to consider when I am in the throws of another AFIB episode. I am one of those very symptomatic patients…I experience a deal of discomfort initially and, generally speaking, my AFIB completely wipes me out until I get into NSR (about 10-16 hours later). Even after I go into NSR there is about a two-day recovery before I start to feel okay. Two weeks later, it all starts over again. But then there are the daily PVC’s, etc.

Kerry Acker must have been in a persistent state of AFIB. A full maze sure seems aggressive. Of course, I was fairly aggressive pursuing two ablations, but I readily admit being lured in by some artificially high success rates. This too is a reason why I remain somewhat hesitate to conclude a surgical remedy is the way to go.

It sure would be nice to have everybody using the same standard to measure success between a CA and surgical ablation.

If I do the surgical approach, I would definitely want the LAA removed. Dabigatran certainly shows promise, but I would rather remove the LAA if I am going that far, just for piece of mind as I grow older.

Thanks again to you and Researcher for your guidance.


Mark

Dick, I went through your question list and they are excellent. If I may suggest another one for EPs:

>>>Have you had any procedural related deaths in your personal experience >>>and your center's? If so, how many and what are the circumstances and >>>how have procedures been improved to reduce mortality risks?

Personally, I would use that as the first screening question and take into account that average procedural related mortality has been around 1/10000. For somebody that is very busy, for example 200 complex procedures per year, the odds of having a patient die from a procedure is equivalent to one every 50 years. If an EP answers yes to the question, it doesn't necessarily eliminate them if for example it was something that happened a long time ago or if I think they were doing everything right and just being unlucky.

Thanks for your suggestion.

I will add something to that effect; however, I will probably tack it on to the question about complications to avoid arousing defensiveness unnecessarily by mmaking it the first question (I know... some say that if defensiveness is an issue, then one should look elsewhere...) It can still be used as an important screen.

-- Dick

Mark

Here is part of my email response to a person who looked at my site and wanted to know who I was:

"My name is Dick Inglis and I am a retired Ph.D. psychologist. My AF "career" is described on the site. It included immersing myself in the literature and other facets of the the field in order to make a the best decision I could concerning my own treatment. I continued to be interested, and the site is the result.

The statements I make and the conclusions I suggest on the site must therefore stand on their own merits. I think you will find that there is nothing I say (in the "Choosing treatments" section) that would not be subject to validation in the natural course of a patient's visits with his cardiologist, EP, or surgeon -- or by his or her reading of the materials listed in the Resource section. In any case, mostly what I offer are ways of gathering information rather than the information itself."

If I deviate from this general approach here, I expect to be called on it.

There are other "lay" people here who offer invaluable information (or links to it), as well as opinions based on their analysis of various types of data, from whom I learn and whom I respect very much.

Much of the information is especially useful because it complements that which if offered by busy doctors. And a patient's report of what a doctor has told them can be especially helpful for those whose situations are similar.

In any case, we're all in this together and I am happy to be a part of it.

-- Dick

Dick,

In so far as your above post was inadvertantly or otherwise directed to me who had asked your status/background, many thanks for the response!

Mike F