Answering the critics of atrial fibrillation ablation

In the gratifying category, few things rank higher than vanquishing atrial fibrillation with catheter ablation. But yet, not everyone thinks so highly of a procedure that has come to dominate my medical career.

Dr Rita Redberg, influential cardiologist and editor of the JAMA Internal Medicine “Less is More” series, said this about ablating AF:

“Because ablation has never been studied in a randomized blinded fashion, we cannot know whether patients experience fewer symptoms after ablation because subjective symptoms frequently decrease following a procedure or whether the ablation itself was beneficial.

Ffurthermore, the clinical benefit on survival and morbidity of this invasive procedure, which has substantial procedural risks, remains to be established.”

Let’s talk about this for a minute. Where to even start? Perhaps a deep cleansing breath.

***

I wish for a lot. I wish we better understood the disease of atrial fibrillation. I wish that people went to bed on time, exercised just the right amount, ate only good food, stopped worrying so much about over-achieving and inherited impeccable genes.

I wish that no one got AF. That we all just clicked away in perfect rhythm. And if not that, then I wish that AF did not cause life-altering symptoms or strokes or rate-related heart muscle weakness. I wish that it wasn’t such a serious malady.

Finally, I wish for better treatments. AF has been around for ages, but yet we have no reliable treatment. There is no penicillin of AF. (Wait, that’s a bad example these days.) Think about AF drugs for a second: terrible efficacy, frequent side effects and there’s this thing called ‘pro-arrhythmia’, where a rhythm-control drug can actually cause a life-threatening arrhythmia. And no, that’s not a typo–that’s the reality of treating AF. (A colleague likes to say “the heart won’t stop.”  The caveat here is unless an electrophysiologist gets involved.)

Sadly, none of these wishes have come true. People get atrial fibrillation. The disease impairs lifestyle and increases the risk of stroke and death. Although it’s a disease of wealthy societies, this doesn’t mean it’s any less troublesome for the afflicted.

These are the facts that make catheter ablation of AF so attractive.

The treasure of ablation is huge: no symptoms, no drugs and hopefully no future risk of stroke or heart failure or death. It’s not free though. There are serious trade-offs. For one, the procedure’s safety and efficacy depend on the manual dexterity and experience of another human. These are tough metrics to quantify. (I like to joke that I could teach someone to implant a pacemaker in a month, but this is not possible for AF ablation. It took me years to build up the neural pathways needed for AF ablation.) Another trade-off is that we don’t really understand AF, and this means the procedure can be done beautifully and still may not be effective. (We can electrically isolate Maine, Florida, Seattle and LA, but AF might be coming from Kansas.)

The toughest trade-off for AF patients is that the ablation procedure carries immediate risk while the majority of the risk from AF comes in the future. General anesthesia, poking a needle across a beating heart, (in an anti-coagulated patient) and then making 50 or so burns (or freezes) in the left atrium is not for the meek. Plus, it often takes multiple procedures. As treatments go, catheter ablation of AF is a big hammer.

And then there is the penalty for inaction: the longer AF is present, the harder it is to treat. Patients don’t have to decide this week to have an ablation, but if they come to me after being in AF for 2 years, that’s a problem.

For better or worse, I am an AF ablation-ist. It’s a narrow skill set that applies to a narrow group of patients. The procedure has improved greatly but it remains a highly imperfect therapy. Yet, when it works, and it really does, it is spectacular.

I don’t take it personally when smart doctors don’t think much of (my) procedure. I consider it a call to better explain this tough-to-explain disease.

During the recent American College of Cardiology meeting, I came across two studies that looked at long-term outcomes after AF ablation. They got me thinking about Dr. Rita Redberg’s important comments. I posted my thoughts on the matter over at theHeart.org. If you want to read more, here is the link:

Can catheter ablation of AF ever be compatible with a less-is-more approach?

JMM

 

6 comments

  1. BELOW IS WHAT I JUST POSTED ON THE attheHeart.org site (link given above in your last paragraph):

    GREAT post John! Your 1 paragraph summary at the end is perfect. As a noncardiologist – I agree totally with your last sentence: “AF ablation is a reasonable and compassionate therapy to discuss with patients”. Ablation isn’t perfect – but nothing is for AFib. Ablation has as much potential (if not more) for as-best-as-can-be-hoped-for outcome with AFib as any other therapy – so clearly MORE than reasonable to discuss with the patient in 2013!

  2. All I can add to this is that the pvi ablation I had 16 months ago completely transformed my life. I suffered miserably from episodes lasting 24-48 hours at least twice a month. Any kind of “real” excercise would almost always trigger an episode. Anti-arrhymthia meds only seems to make things worse. Now I am back doing century rides and enjoying them thoroughly, without being afraid of setting anything off. I am extremely grateful that this procedure was an option for me, and hate to think that others might not have this option.

  3. I am about to have a third RF ablation, having just gone through a six week cluster of weekly a-fib episodes. I can say that the first two ablations have increased my day to day happiness beyond measure. I too can exercise at will, and I am very, very thankful for that.

  4. Spreading doubt about a procedure that has the potential to “cure” a life-altering condition seems so wrong to me. Sure, I’m one of the lucky ones, my AF was increasing and preventing me from competing in races, hampering my recovery and preventing me from doing long mountain bike rides(no way to call the wife in the wilderness). I am 18 months post ablation and looking forward to a full year of racing and backcountry adventures. My only regret was that I waited 9 months to try meds before having the procedure.

  5. How does one conduct a blinded study of AF ablation? (I presume that double blinding is out of the question 🙂 ). Do you put the placebo patient under, make a few incisions, and then wake him up without doing anything more? Or do you actually insert the catheters, but don’t do any burning?

  6. John-o:

    Don’t forget to mention the importance of referring patients to the CABANA Trial – probably the only multicenter, prospective, randomized mortality trial comparing comparing drug therapy vs catheter ablation therapy head-to head-for the treatment of atrial fibrillation. The hypothesis: catheter ablation is superior to drug therapy. Whether that is the case remains to be seen, but after 1079 patients enrolled, the trial is still open and needs a total of 3000 patients so that (hopefully) we’ll get a definitive answer to which form of therapy is safest long-term.

Comments are closed.