Should AF ablation require approval from a heart team?

A patient presents with atrial fibrillation (AF) and a rapid rate. He doesn’t know he is in AF; all he knows is that he is short of breath and weak.

The doctors do the normal stuff. He is treated with drugs to slow the rate and undergoes cardioversion. During the hospital stay, he receives a stress test and an implantable loop recorder.

He goes home on a couple of medications. The expensive implanted monitor shows rare episodes of short-lived AF, less than 1% of the time. The patient feels great.

But here’s the kicker: his doctor recommends an AF ablation.

This is nuts. The man has had one episode of AF. He has no underlying heart disease. And he feels well while taking only basic meds. There’s been no discussion of weight loss, exercise, alcohol reduction, or sleep evaluation.

I don’t know how often this happens in the real world, but I suspect that it’s happening more and more. The number of doctors trained in electrophysiology have increased. And, trainees in academic centers spend most of their time mastering the AF ablation procedure.

The Dartmouth Atlas of Healthcare group have shown cardiology to be a supply-sensitive service. Meaning, the more cardiologists there are in an area, the more procedures get done. This build-it-and-they-will-come problem dogs much of US healthcare, not only cardiology. Think MRI and CT centers.

Might a solution to the overuse of AF ablation be a multi-disciplinary heart team?

We already do this for some heart valve surgeries, specifically, transaortic valve replacement (TAVR).

AF ablation is a multi-hour procedure that requires general anesthesia. Up to 80 burns are made in the left atrium, some close to the esophagus and phrenic nerve. There are significant risks to the procedure. The honest long-term success rate barely tops 50%. (Success rates depend somewhat on the type of AF.)

Then there are the repeat procedures. Many patients have to undergo a second procedure, or even third or fourth procedures. (All at many thousands of dollars per case.)

If doctors recommending the procedure had to present the patient to a team of peers, there may be more discussion about the sobering realities of AF care. Questions could arise:

  • Have you checked the patient for sleep apnea?
  • Have you asked him to reduce his alcohol intake or weight?
  • Will the AF resolve after the stress of a divorce has worn off?
  • Does the patient know there’s not a shred of evidence that AF ablation reduces stroke or death rates?
  • Does the patient know that AF is not deadly heart disease? In other words, has fear been sufficiently extracted from the decision?

I recognize that not every decision in medicine should be made by committee. AF ablation, however, might fit some sort of internal review.

The European Heart Journal just published a terrific review on the treatment of persistent AF. In this paper, the treatment of risk factors gets strong mention–as does the sobering results of AF ablation in more advanced forms of AF, and the vast uncertainty surrounding treatment approaches.

I’m not against AF ablation; I perform the procedure often. But after I’m sure all other aspects of atrial-health have been addressed, and the patient is fully informed. It’s a huge mistake to equate AF ablation with ablation of other focal (emphasis on focal) rhythm problems, like supraventricular tachycardia.

I’d have no trouble justifying my AF ablation procedures to a heart team.

JMM

9 comments

  1. Amen! So glad after 5 mo
    of PAF and miserable med side effects, I requested to see an EP.
    He never mentioned ablation but spent 45 min educating me on A Fib, and mostly lifestyle changes.
    Took me off Sotalol (thankyou God) and gave me PIP of Flecanide/ Metoprolol.
    So far, 3 months later no a fib, lost 15lb, 35 to go. Practicing mindfullness meditation, exercising daily, eating healthier and feel better than Ive felt in decades! I do thank God for this man being so honest. Even if a fib pops its ugly head back up, I feel I am doing my part on the road to my best health

    1. This article and your reply gives me hope as I haven’t had an PAF episode (5 months) since getting treatment for inflammation in the lung from radiation therapy and hope to someday be taken off Eliquis and Digoxin by the CE I am seeing. My Cardiologist was ready to sign me up for ablation right away.

  2. First thing my doctor told me to do 5 years ago when I was diagnosed: REDUCE stress which I had a lot of. Lose weight, limit sodium to 1500 mg a day, no caffeine, no alcohol, get plenty of rest. Didn’t smoke so that was easy.

    I have had a couple of issues of AFib where I was hospitalized. A year to 2 years apart. Came back to rhythm on my own. The only time I experienced any symptoms was when I was on Sotalol and Coreg eventually taken off both drugs at different times thank goodness.

    I do take Xarelto since August of 2014 and no side effects. I think I will get 2 opinions if ablation comes up after reading this.

  3. John,
    Brilliant! The components of the team are important and I think the team should have an unbiased member. A physician, well-versed in AF treatment modalities, who has no interest in more procedures being done at the facility.

  4. John – Nice post. I’m 34, in good health, and I’ve had one ablation for persistent Afib 2 years ago. Afib came back, but only paroxysmal. Curiously, regular exercise seems to keep it at bay. Any thoughts on the Vein of Marshall ablation (done now by Dr Valderrabano) as a lower risk ablation procedure?

  5. Pleasure to read your thoughts as always. I just finished my second cryo pulmonary vein isolation of the day for persistent AF in highly symptomatic patients refractory to at least one AAD and risk factor modification. Thankfully, both procedures went well.

    I have been working in my current position for just about a year now. When I finished my first AF ablation here, I turned to my scrub nurse, gave him a high five and said, “1 down, infinity to go.” It still often feels that way. I work in a region without a competitive health care system, and my remuneration is in no way based upon the volume of procedures that I perform. My only responsibility and incentive is to do the best job I can to take care of sick people. I fundamentally believe that, to the best of my ability to predict, the patients I bring to the lab for AF ablation have much more to gain than to lose from the procedure, that AF is a serious public health problem (often the symptom of other another problem, but still worthy of addressing through intervention), and that we now have a reasonably safe and effective treatment.

    Given the scale of the problem, throughput is relevant. As a trainee I had the privilege of observing Fred Morady do catheter ablation of AF. When a case started I didn’t know if it was going to take 4 hours or 8 hours. Those long case durations and unpredictability limited the number of patients who could have benefited from his masterful care. I am concerned that applying the Heart Team concept to AF ablation would place an additional barrier between patients and the treatment that can help them. Perhaps the reason why AF ablation is supply sensitive is because so many people need it, and our capacity as a field to provide the service is insufficient, at least outside of major cities.

    I believe that some providers are unscrupulous, but if such an individual is identified, the solution is not to impose further checks and balances — the solution is to remove the provider. EP remains a small community.

    I saw a 45 year old man in clinic yesterday that I had ablated for paroxysmal AF 3 months ago. Prior to ablation, AF would frequently induce with exercise. He was generally healthy, an athlete, and didn’t want to take an AAD. He underwent an uncomplicated cryo PVI. Symptoms are gone. Monitor shows normal rhythm. He’s back to training, and competing in a triathalon on Sunday. He hadn’t been able to exercise for 6 months prior to ablation. I wish all my patients were like him. But even the ones in worse shape usually gain significantly. Impeding their access is an issue.

  6. How about training programs that help EPs stay current on the latest research. Such as lifestyle modifications. Some are still prescribing asprin and arent up on the latest guidelines for when anticoagulation should be prescribed. These are very basic data points all EPs should be current on.

    Dr Mandrola’s example is an indication of a EP who does not seem to know about some of the research over the past couple years. I guess if keeping these doctors somewhat current is not possible, then a bureaucratic gate may be needed. Perhaps some continuing education every six months for an hour or two might solve most of these problems.

  7. How about a tri-fold brochure, given to prospective patients and families, with a title like “You might not need an ablation right now.”

    Unfortunately anecdotes are more convincing than data, so a cynic might put a testimonial on the front page.

  8. I guess it’s a bit of a ‘no brainer’ that if you address the symptom (AF) and not the causes (possible lifestyle modifications), outcomes will not be as good as we would like.

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