How successful is AF ablation?

Let’s talk about success.

At first glance, knowing whether a medical or surgical intervention achieves success seems quite simple. An antibiotic clears an infection–or it does not. A surgery removes a tumor with clean margins–or it does not. An angioplasty and stent open an artery during a heart attack–or it does not.

In the case of treating atrial fibrillation, however, it’s not like that. And this is especially true when one considers the use of catheter ablation–the biggest hammer in the toolbox of an electrophysiologist.

The doubters ask: why can’t it be simple? They say ablation cures other types of arrhythmia, such as supraventricular tachycardia (PSVT) and atrial flutter. In these cases, a patient is wheeled into your lab with an arrhythmia and wheeled out without it. Black and white. Success or not.

The confusion with AF stems from two big themes: One can be explained by looking at the definition of success:

 …the accomplishment of an aim or purpose.

When we speak about treating AF, aims and purposes are not as binary as whether an infection clears with antibiotics. I explain this to people using the aging analogy. Caregivers are not expected to cure aging, rather, we try to manage it. In many ways AF is the heart’s way of showing grey hair and wrinkles. (This is oversimplification, but allow me some leeway please.) So, at least in 2014, the aims and purposes of treating AF are often to manage it–gracefully.

It is true, sometimes we get lucky: a patient with AF hears our explanation; he stops inflaming himself, and, just like the patient with high blood pressure who starts exercises and stops overeating, the disease is rendered dormant. Did we cure AF or simply stave it off a decade or two?

That leads me to the second source of confusion surrounding AF: We simply don’t understand enough about what causes and maintains AF. A 34-year-old cyclist with an irregular heart beat has AF. So does an 80 year-old elderly woman with diabetes, arthritis, obesity and congestive heart failure. These two people are said to have the same disease, but surely they warrant different approaches to treatment.

Key-point alert: Treating a person is not the same as treating a disease.

Where I am going with this? What about AF ablation?

Last month, the highly influential academic cardiologist Sanjay Kaul said he wouldn’t be surprised if AF ablation turned out to be no better than a sham procedure. (Read the last paragraph of this post.)

I stewed about that comment for days. It got me thinking about the aims and purposes of AF ablation. What are we trying to do with this procedure? Are we looking to cure, as in eliminate all episodes of AF? Because if we could cure the disease that would greatly reduce the risk for stroke–a very “hard” outcome.

Or…is it enough to help another human being live a better life, one with less shortness of breath and better exercise tolerance, albeit with a continued stroke risk because of occasional AF breakthroughs? One’s view of this image surely depends on the perspective of his or her lens. When you can’t walk down the street because of breathlessness (perhaps due to the disease or its drugs), your aims and purposes change. Yes, 10-year stroke risk is important, but so is going to work next week.

Further, just because a procedure may not cure, should we withhold discussing it with a patient? How perfect does a procedure have to be? Who gets to judge that? Here we wade into deeply philosophical territory. How valuable is quality of life? What if a patient understands the risk of a procedure and is willing to accept the tradeoff? And this zinger: who gets to judge whether an $100K ablation is worth it?

A Twitter conversation I had recently sheds some light on these tough question.

Dr Prash Sanders (Australia) started the Friday evening discussion: (Ed note: an ILR is an implantable loop recorder–a $4000 USB-looking device that gets implanted under the skin in the chest. It records and downloads–with arguable accuracy–the heart rhythm for 36 months.)

His question gets to the issue of aims and purposes. When we ablate AF are we aiming to eliminate the disease, or, are we aiming to improve the quality of another person’s life? For if our aim is to cure AF, as if it is aging, we need more than a patient’s word that he feels better. (Perhaps we need a $4000 device made by a Fortune 500 company.)

Dr. Nassir Marrouchee (University of Utah) underscored the complexity of defining success of AF ablation:

Venture capitalist Dr.Justin Klein writes the word “dubious” in the same tweet as “reporting by patients.”

I’ve read somewhere that VCs like data:

With the ache of Dr Kaul’s sham-comment still buzzing in my head, I offered this to the doubters:

Dr Sanders closed the evening with this beauty:

—-

The next day, health policy expert Dr. Farzad Mostashari seemed to suggest that procedures need to do more than just improve symptoms and quality of life:

Dr Sanders nails it again:

There is much more to learn about both the disease AF. My guess is that as our knowledge of AF grows so will our aims and goals.

We may move from managing to treating. For now, helping patients with AF is a lot about managing aims and purposes.

JMM

Comments

  1. Ross Hawthorne says

    I may have missed something but I think the only way to silence the doubters is to compare ablation with a sham procedure. But of course you do need to decide on your outcome measure(s) first. :)

  2. Paul Fuller says

    Wow, this article goes right to the heart, or in my case directly to my 3x ablated heart. I am here to say, for me the risk has and was worth the trade off of being able to live my life without the nagging anxiety of when and where will another event occur.

    I became a liability for my friends when we went to the big mountains to ski, hike or climb. Twenty days on a river no way, to much risk for the group, no coffee, no alcohol, don’t stand up to peddle, just doing a pull up and now I’m in a-fib. None of this even comes close to matching the stress my wife felt whenever I had an episode that wouldn’t resolve on its own and we had to go to the ER for me to be
    cardioverted

    I have now gone eleven months without an episode and feel better than I have in seven years. If a-f ablation turns out to be a “sham,” then I have gotten away with fooling my heart into staying in sinus rhythm and I will take it.

    Thank you Dr. John for all of your words and for understanding your readers’ and patients’ needs for open dialog on all of life’s issues that you write about. I hope you know how important you are to us.

    • Don L says

      Ditto. I have been AF free since Nov 2011 after suffering through persistent AF for 3 years. After finally starting to resume normal sporting activities, I found out that my hips need replacing due to osteoarthritis. When my father commented on my ill fortune, I responded with “Dad, actually I feel lucky. So far everything that has gone wrong with me has been fixable. There are a lot of guys my age (mid 50s) who can’t say that”.

  3. David Albert says

    For the right patients. ( like those above ), ablation can be life saving. There are many failures and many will have multiple procedures and late recurrences. If an ablation wasn’t >$50k, this discussion might be moot. The payers ( and Fatzad used to work for the biggest one- Uncle Sam) are worried about getting their money’s worth. Also, we would all feel better about the cost if we finally see Kaplan-Meyer curves move out.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Notify me of followup comments via e-mail. You can also subscribe without commenting.