NBC's today show

For those on the west coast, I just saw a short intro from the Cleveland Clinic. The NBC doctor/reporter was in the lab with the EP observing. Sounds like AF to me. The full feature is coming up soon.

Watching it right now. Didn't call it afib, but sure sounds like it. Arrhythmia and rapid heart beat. Is interesting to see it on national news.

I believe it is AF although they didn't say it directly. The EP, Mauricio Arruda, another one of Jackman's fellows, is quite well known. He worked with Natale when he was still at CCF. He was asked by the Today host the success rate and he quoted 85-90% with the magnetic technology he was using. There will be a follow up with the patient to see how things turned out.

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Here is the archived video.

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I just watched this, and my question is this: my EP told me afib ablations require general anesthesia instead of sedation because it's so complicated and long. This lady only had sedation - is that because they are using such sophisticated equipment or is there something else?

Some EPs prefer general to lower the risk of complications particularly with manual ablation. If a patient shifts during ablation, excessive force can result and tamponade risk increases significantly because the EP is applying force when ablating and patient movement could be dangerous. There is also the mapping aspect. If a patient shifts, then the map that was acquired may have to completely redone. Magnetic navigation helps with the force aspect in that patient movement will not affect tissue contact or force. Mapping considerations I am not certain of but I am pretty sure it would have to re-acquired also although my understanding is that mapping with the magnetic system is much faster compared to manual mapping.

Thanks researcher,

This video was very interesting. Mike had a second ablation about 5 weeks ago using the magnet system. He is doing well.

Debbie

A success rate of 85-90% with the magnetic technology?

Is this an accurate statement?

Mark,

I hope so! I don't think the doctor made it clear if that success rate was with one or two ablations.

Debbie

Five years ago my EP told me he had a 75 percent success rate...two ablations later I still have AFIB every two weeks for about 10 hours a duration. The new technology certainly seems to be making a difference, but I am naturally somewhat skeptical. Of course, going on national television, one would think the EP would be pretty confident...

As with any advanced technology tools, the tools don't come with brains so success rate still depends on how well trained and skilled the clinician is. As of 2007, Cleveland Clinic manual success rate was already around the 80%+ range so it shouldn't be too big of a stretch to see higher success with better technology. As Hans has cautioned numerous times before, Arruda and CCF should publish long term data to validate the numbers stated in the interview. I have no doubt that he is stating what CCF EPs have observed thus far and that he gave his answer with his many years of experience of with manual and a few years with magnetics guidance. It would also be helpful if CCF uses the same strict rules used by Wilber et al in their CAF vs. AAD study to define success vs failure so apples can be compared to apples.

Can someone help me better understand what success means. To me it means no more AFIB for the reat of my life and no meds including warafin. Is there any standard on this?

I think the recent Wilber et al study has the most up to date definition of success. No AF lasting more than 30 seconds (measured by Holter monitor) at 12 months off AAD. Warafin is usually recommended for the first 90 days after ablation. A touch up procedure beyond the first 90 days is considered a failure.

As for long term success beyond 12 months, not many centers and clinicians track their patient population that long and publish about it. Pappone has tracked of patients and published some 3 and 5 year data. It still comes down to the question of whether one should continue with AAD and the quality of life for the patient, and cost of either path. For the grandma in the Today show, I think it was an easy decision to go with ablation given the likely quality of life improvement with the procedure and her life expectancy.

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Researcher,
Can you expound on the radiation risk differential between the magnetic system and the manual process? Having had 3 ablations, I am not sure I want to know the answer but...

I had to laugh though when she said the procedure didn't hurt. I was sedated for my first 2 and I have to say that I haven't experienced much greater pain than the insertion of the catheters - it was excruciating. And the back pain afterwards is pretty hard to describe.

On the other hand, when I was under general for the 3rd with Dr. Natale, it was all a walk in the park...

BTW, last Monday was 10 months A-Fib free...I try not to talk about it or think about as I am afraid I will jinx myself!

John F. Wow, how time flies. I can't believe it's been 10 months for you already. Good for you!

Regarding fluoro exposure time, the shorter the procedure the better off you are as far as exposure. The new mapping systems like Carto or NavX also helps because once the 3d model of the heart is created, fluoro use is minimize to situations where the EP is uncertain about catheter location or if complications happens. The magnetic system helps in making mapping faster and almost eliminating the chance for tamponade so things just move along faster. The today show intro segment happened a few minutes after 7:30 and the crew were all in the lab preparing. When the second segment came on a little after 8, Arruda was settled in the control room and mapping was finished. That is quick.

With regards to your groin pain during your first 2 procedures with Marchlinski, that is not good. Patient discomfort leads to movement and shifting around. That prolongs the procedure and probably reduced ablation efficacy. It was good that Natale put you under for the 3rd procedure. There seems to a movement towards general anesthesia from local because of experience like yours.

Hey John! 10 months!!!! I'll smile along with you. So glad you decided on Dr. Natale.

BTW, when I had my Natale ablation, he used conscious sedation at the time. However, for the catheter insertions, I didn't feel anything... knocked out before they introduced those, thankfully. Barbaric to do otherwise.

But as the sedation wore off, I was definitely doing deep breathing as I sensed the pain and was told to stop it so I can appreciate why going with the general is easier for the EP and safer overall for the patient.

Best to you, Jackie

Hi Researcher/Jackie,

Thanks for the good thoughts - yes, 10 months is hard to believe! I appreciate every day that I am not in a-fib, even if I don't know how long NSR will last.

I should clarify for other readers: yes, the insertion of the catheters was barbaric ( 2 groins and Foley ) and incredibly painful. That being said, once they were in, I did not feel further pain. I was awake during portions of the first 2 and was talking to the EP Lab staff, but felt no pain, I just felt the catheter weaving it's way through my chest. General anesthesia was the way to go in every respect and I was only on the table with Dr. Natale for 2.5 hours.

Unfortunately, I was on the table the first time for 6.5 hours and 9 hours the 2nd time, so I do sometimes find my mind drifting about the potential issues down the road from the radiation.

Thanks for sharing your insights. Good health to you both!

John

The NBC program rattled the cage of some apparently. The bloggers objected to the quoted success rate and also question the ethics of showing live procedures on TV. Seems to me that AF patients' viewpoint is missing from the controversy. I posted some comments under a pseudonym, Doug.

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Not that it would pertain to this particular segment, but Nancy Snyderman typically doesn't offer what I consider to be useful medical advice...it's pretty much glossy media hype. Also, University Hospital in the Cleveland area has always been under the shadow of the Cleveland Clinic which is has the #1 heart center rating. Maybe they felt the hyped up ablation 'show' would help divert patients from the CCF to University. Jackie

Jackie wrote:

> University Hospital in the Cleveland area has always been under
> the shadow of the Cleveland Clinic which is has the #1 heart
> center rating. Maybe they felt the hyped up ablation 'show'
> would help divert patients from the CCF to University.

Arruda has a following in his own right along with the others that left CCF when Natale departed. Schweikert at Akron and Marrouche at Utah as examples. Arruda is recognized particularly for leading the charge on discovering SVC triggering and isolation. All these top EPs will continue to have waiting list and CCF will always have a wait list. The more recent publications out of CCF are still ideas leftover from Natale days so I wonder if the younger guys remaining at the CCF like Saliba and Wazni can come up with innovative improvements on their own.