Four commonly asked questions on AF ablation

I receive a lot of emails from people afflicted with atrial fibrillation. It is humbling that another person would share such highly personal information with me, a stranger. Thanks for that.

It goes without saying that I cannot give specific medical advice. Though it is tempting. I’ll read a detailed story and think to myself…OMG, why in the world would they do or say that? And not infrequently a writer paints a picture that I have seen thousands of times. I want to be kind; I want to help. But it’s not even close to right to practice medicine without a patient-doctor relationship. I will continue to resist the urge.

But what if we talked about recurring themes/questions that come through emails and office visits? Perhaps addressing such commonalities will shed light on what the shared decision-making process surrounding AF ablation should look like—at least in my mind. Here are four examples:

My [EP] doctor wants to do an ablation on me:

I would consider it a complete failure of communication if a patient left my office thinking that I WANTED to do an ablation on them. Here is what I want:

I want to help my patients make the best possible decision for their unique situation. AF is a diverse disease that affects humans in vastly different ways. This is what makes it so challenging to treat. I want my patients to understand the benefits, the risks, the alternatives and the expectations of the many different approaches to treatment.

I have done thousands of ablations (including more than 500 AF ablations), and yet every time, I worry about doing harm. I ask this question of myself: If the patient suffered a terrible complication from the procedure, would I still have recommended it? Did the benefits really outweigh the risks by that much? It’s an easy call when patients are incapacitated by AF: Then yes, the benefits easily outweigh the risks. Recommend the procedure. It’s also easy when AF symptoms are minimal; say rare episodes that terminate easily. Then the disease is not problematic enough to warrant a major intervention. Most patients make it tougher; they present in the larger gray area between the extremes.

It may be that an AF ablation aligns well with the specific clinical scenario and the patient’s goals of care and risk tolerance. In this case, yes, I want to do an ablation. When these criteria are not met, however, say the clinical situation does not fit so well with ablation, or the patient does not want to take the procedural risk, than I support not doing an ablation. I never want a patient to think that I am attached to one way of treating AF. It’s their atria, their body, and their life. I try to offer my best opinion but in the rhythm-control category of AF treatment, there is rarely one right answer. It’s best to accept that fact.

My [cardiology] doctor wants me to quit over-thinking and just get the AF ablation. Fix the problem.

You could call this the stent solution (as if stents fix atherosclerosis). This kind of thinking hacks me off. Not only is such advice paternalistic and patronizing, it is also highly uniformed.

Rarely do I recommend to a patient that they “stop over-thinking” AF ablation. Believe me, if a cardiologist was about to undergo 50-60 burns in his heart, have general anesthesia and incur the chance of procedural stroke, he would not appreciate this sort of advice. Rhythm control therapy of AF is not like heart attack care. Treating a heart attack must be fast and free of over-thinking, as delays can be life-threatening. This is absolutely not the case for rhythm control treatment of AF. There is time to consider options, and speculate on what AF therapy might look like in 2-3 years. The hope of technology gains must be weighed against the AF-begets-AF phenomenon.

Patients with AF should not be rushed to decide about ablation. I liken their decision this way (with letter grades): In having an AF ablation, a patient might be hoping to improve their health from a ‘C’ to a ‘B’, but in doing so, they risk going to an ‘F.’ These are tough calls; they mandate some thinking.

Should I get another opinion?

I am not sure why this question comes up so often. Yes. Yes. It is always a good idea to get another opinion. If for no other reason than this is a fair test of whether you have a good doctor. It should be a huge red flag if a doctor hedges about a request for a second opinion. I welcome second and third opinions, and often offer them at the least look of doubt after my explanation.

I try to send patients to doctors who I consider equally qualified in AF ablation, but I don’t push too hard on which docs they see.

How do I pick an AF ablation doctor?

This is a tough one. The procedure turns on ‘feel’. It’s dependent on hand-eye-brain-connections. Being good at ablation requires oodles of experience, many years of training and a good base of electrophysiology knowledge. Truth be told, having done enough cases to have had complications makes an operator better. Another unfortunate truth: Some doctors have terrible bedside manner but are wizards with a catheter—and the reverse is true as well.

So now you may be thinking it’s hopeless. It’s just rotten luck picking a good AF doctor. Fortunately, there are a few general (common sense) rules of thumb: Does the doctor have a good reputation in the medical community? How many cases; how many years of AF ablation experience; and what training program(s) did the doctor attend should all be easy questions to answer.

You can ask about success rates, but this metric is not so helpful with AF ablation. “Success” has many definitions in the AF ablation world: Success with one procedure or two or three? Success with drugs or no drugs? Success clinically, or with intensive monitoring–if a patient has no symptoms and feels great but has 31 seconds of AF on a monitor, is that a failure? Experts disagree on that question. An AF center’s case mix also impacts success rates: patients with persistent AF have lower success rates than those with intermittent AF. None of these issues are deal-breakers or makers, but taken together, a picture begins to form.

I would also factor in the difficulty of getting an office appointment or scheduled for a procedure. The answer here may be surprising. A long waiting time may not be so bad. First, giving AF some time to settle down often helps guide the aggressiveness of treatment. I have seen patients whose arrhythmia quieted significantly by the time their appointment came around. Two months ago, the rhythm was on fire and everyone was ready to ablate or pace or medicate or do something serious. Now, the patient hasn’t had a single episode, and waiting on the ablation or trying a short course of medicine may be the best choice. Second, a long waiting time may mean the doctor is sought after. There are lots of patients with AF, but only a select few doctors who can ablate it. Third, a long waiting list indirectly implies that the doctor is not tempted to do marginal cases just to keep busy. (In the US fee-for-service system, be cautious of the doctor who can do an elective procedure on you tomorrow.)

I hope these words help. Please feel free to suggest other general questions in the comment section. I would ask those who comment to refrain from asking their-case specific questions. Remember, I cannot give specific medical advice and no two cases of AF are exactly alike.

JMM

Comments

  1. Joe says

    Fantastic!

    I hope you’ll consider offering some similar perspectives on avnrt ablation, or general EP studies when the exact nature of the problem is unclear.

  2. Ken Grauer, MD says

    GREAT post John! The Catch-22 that I saw when an attending in academia – is that new clinicians need to learn, and there is always a “first time” (with associated “learning curve”) – which even when closely supervised each-step-of-the-way is not quite like a procedure being done by the one with more experience – but all-in-all, I was overall positively impressed during my years as a teacher by the learning process (with full realistic understanding of the challenges the process presented).

    “Learning” a procedure takes a quantum leap with something as complex as AFib ablation, which as you insightfully describe takes terms like “precision” and “learning curve” (as you say, “doing enough cases to have had complications” ) to a whole new level.

    From a nonspecialist perspective – I was sold on potential benefits of EP referral and AFib ablation for selected AFib cases long before I began to read your column. Ablation truly offers potential for dramatic improvement (if not “cure”) for an increasingly common condition (AFib) that previously had only approaches that were far more problematic. Nothing is perfect and nothing is “risk-free”. Your balanced, insightful advice when considering an AFib ablative procedure is invaluable. KEY to success if decision is made to proceed with ablation is choosing one’s AFib ablation doctor wisely. THANKS (as always!) for posting your sage advice when patient or clinician are contemplating pros and cons of AFib ablation, and the process for deciding.

  3. Pete Capozzoli says

    Thank you Dr John. You captured what those of us with afib feel and what the the dilemma is: You might go from a “C” to a “B”, or you could go to an “F”. Reminds me of a game show. Groucho Marx in You Bet Your Life! (Ha! Ain’t that the truth!) These games play on people’s minds and the only thing that is for sure, it separates those that are willing to gamble from those that aren’t, and those that are grossly burdened with symptoms and those that aren’t. I can picture Groucho Marx asking a couple if they want to risk what they have already won to go on to the “ablation” questions. The ones with all the tough questions, like the 50 burns on the inside of your heart. You never know what the questions will be. Maybe you will luck out despite your risk taking impulsiveness and lack of research, and maybe you won’t. And to make it harder, you have to make your decision within a short period of time, or things get harder. But maybe you should wait as you might be smarter in a year if you can get back on the game show. Hmmmmmm. Oh I forgot to mention the secret word. For me, the secret word (or phrase) is “Rate Control and Anticoagulation”.. What the heck. It’s $50 bucks.

  4. Ann Fugler says

    As ever, I enjoy reading your posts!. This one was dear to me having just had an ablation last week……and I did ask myself all of the questions above which is reassuring! And seeking a second opinion gave me a better outcome.
    For your next topic, I would be interested in what to expect post-ablation? What is normal and when to seek advice.
    Believe me, being on the other side of ablation is just an unnerving as pre-ablation.

  5. Vince says

    Thanks for a helpful post. A couple of ideas for further topics:

    First, a post about multiple ablations. My understanding is that it’s reasonably common for AF patients to need more than one ablation to control AF, either because the original ablation didn’t eliminate or at least control the AF, or because the AF returns several years later, even though the original ablation was initially successful. How common is it for patients to need multiple ablations? Are there limits to the number of ablations that can be performed? Etc.

    Second, a post about rate control in AF for patients with low blood pressure. You’ve written in the recent past about some good reasons to avoid digoxin for AF patients, but for someone with low blood pressure are there good alternatives?

    Thanks for taking the time to write about this. Your posts are informative and upbeat, and are a really valuable contribution.