Dr John M

cardiac electrophysiologist, cyclist, learner

  • Home
  • About
    • About Me
    • About the Blog
      • General Cardiology and Internal Medicine
    • Six Reasons why I Blog
    • What’s Electrophysiology?
    • ICD/Pacemaker
    • Electrophysiology Column / Medscape
    • Contact
  • Afib
    • AFib
    • AF in Athletes
    • The best tool to treat AF
    • Know your CHADS-VASC Score
    • 3 non-warfarin anticoagulants
    • AF ablation
      • 13 things to know about AF
      • Atrial Fib Ablation -2012 Update
      • Gender-Spec results of AF ablation
    • Female gender and stroke risk in AF
    • My AF Story
  • Heart Healthy
    • Heart Disease (by DrJohnM)
    • Healthy Living
    • Exercise
    • Nutrition
    • inflammation
  • Policy
    • Policy
    • Health Care
    • Health Care Reform
  • Doctoring
    • Doctoring
    • Knowledge
    • Reflection
    • General Medicine
      • Does your cholesterol level matter?
    • General Cardiolgy – Medicine
      • What is a normal heart rate?
      • Cardiology/Internal Med
      • General Cardiology
      • Athletic heart
        • The ECG of an athlete
      • General Medicine
      • Stroke
      • Statins
  • Cycling
    • DrJohnM on Cycling
    • How I became a bike racer
    • My top 12 Likes on Cycling
    • Cyclocross
      • A CX-Primer
    • Fitness
    • Athletic heart
    • The Mysterious Athletic Heart

The reality of rationing complex procedures, like AF ablation…

April 26, 2010 By Dr John

Medical prowess has exploded in the past decade.  The toolbox of therapeutic options has grown so large that often times, the most challenging aspect of patient care is in matching the right tool to the right patient.  There is no better example than the expanding capability to ablate atrial fibrillation.

Now that I can successfully ablate AF, the question is, in whom should this aggressive therapy be offered as a viable option?  And, how should I decide?

This particular Friday in the office brought a steady stream of symptomatic AF patients. Since this is the real world, for every young healthy patient with AF, there were four overweight hypertensive, older patients with more long-standing AF, and more dilated heart chambers.

In the past, AF therapy was easy: either medicine, tolerance of drug side effects or live with the disease.  Sure, we could infuse some finesse into these strategies, but there were no home-runs.  Curative options were unavailable, drugs were given and the patients grew accustomed to the arrhythmia.  Growing accustomed didn’t mean they felt any better, just that feeling less well became the norm.  There was no such thing as ablation.

Last night, I spent a few hours reading a very interesting site (more than a blog), on the covert rationing of medical care in the present and future health-care delivery system.  Reading about the rationing of health-care made me think about Friday’s decisions on which patients to offer AF ablation as an option.

—-

The call to the primary care internist went something like this…

She is really symptomatic with her AF.  The medicine is partially effective.  There are days that are good, but the day she wore the 24-hour monitor–when she was in AF–was a bad one. I am sorry…I can’t ablate everybody. She is old, very fat, diabetic, and her AF has been around for many years. We will have to treat this AF more conventionally.  Sorry.

Background:

  • Atrial fibrillation is the most common cardiac diagnosis.  It is everywhere, like sore throats are to an urgent care center. In many cases, the symptoms of AF greatly diminish a patient’s quality of life. It is not always overt palpitations; sometimes it is generalized fatigue, and a vague shortness of air.   Some have no overt symptoms, but interestingly, patients with seemingly asymptomatic AF score less well on quality of life questionnaires.
  • Rhythm controlling drugs for AF work in less than half of all patients. Both inefficacy and intolerance to side effects limit the utility of these drugs.
  • There are well done studies that show that AF patients treated with just blood thinners and heart rate modulators live just as long as those who we keep trying to maintain regular rhythm.  In other words (or what I tell patients), is that if we let the heart stay irregular, as long as the rate is controlled and the blood thin (“rate-control strategy”), the prognosis is good.  We are not mandated to keep going with shocks, rhythm drugs and procedures–the aptly termed “rhythm-control” strategy.
  • The gratification in watching AF disappear with the delivery of RF burns (red-dots) is immense.  It fuels the fire.  It tempts you.  I remember where I was the first time someone told me of the notion of curing AF by ablation lesions.  It was like imagining an ipod in the era of the cassette tape.

This AF treatment paradigm worked well absent the ability to ablate AF.   Now though, we have in the “rhythm control” toolbox a much larger tool.  In 2010 the score is AF ablation-70% success, AF drugs-30%.

This sounds great.  Just go ahead and do more AF ablations. Procedures pay better than office visits, don’t they?

Ah, but the story is not that simple.  Because we (I) can ablate AF in some, does not mean it can be applied to the masses.  Here’s why–in my view.

AF ablation is a big deal.  It is not for the faint of heart.

Patient issues are…

  • It requires 3-4 hours of procedure time with either general anesthesia or significant sedation.
  • A harpoon-like needle has to be poked across the beating heart in a patient on blood thinners.
  • Over a hundred burns are made in the most sensitive of the heart’s four chambers.
  • In low-risk young patients–a minority of AF patients–the procedure successfully eliminates the AF in only a modest two-thirds of cases.
  • Almost half of these successes need to have a second procedure to touch up areas that “grow-back.”
  • Complications are real.  There is a risk of stroke, heart attack, perforation of a perfectly good heart, pulmonary vein stenosis, air embolism, esophageal damage, and of course death.  The overall complication rate is low, but since AF is not immediately life-threatening, any major complication becomes even more magnified.

The doctors issues…

  • The procedure is hard to do.  AF ablators know AF diminishes quality of life, but we also know the delicate balance of performing a life-enhancing procedure that has potential catastrophic complications. This tightrope makes me nervous. No other procedure induces a fraction of the mental worry of an AF ablation.
  • The procedure requires standing with a lead apron and focusing for three hours.  An AF ablation is hard on the doctor (human).   Not complaining, just stating the facts.  It limits what else you can do in a day.  In the past, AF ablations were once per week.  As ablation technology advances along with our skills, the temptation to help more patients has been hard for me to control.
  • In private practice EP, most can only ablate two full days per week. There are office patients to see, non-reimbursed patient phone calls to make and the mundane cardiac devices to implant.  Reality.

Stop whining and just refer these extras to other ablators, one might suggest.

I am glad you pointed this out.
You see, AF ablation is technically demanding, physically exhausting, potentially dangerous, and takes years to get good at. Also, it is compensated at the same rate as an ablation that takes 45 minutes.  It is not hard to imagine that there are only a few of us doctors who do this.  In my city of a million people, there are really only two other electrophysiologists who do this procedure enough to have sufficient skills. Sadly, there are many “dabblers” in AF ablation, which of course, means their are patients of “dabblers.” There are few other doctors to refer to. Reality, again.
Conclusions and Wishes…

We ablators are human.  In our present paradigm, it is impossible to ablate all potentially curable AF.  For every forty-something intermittent fibrillator with a normal heart, there are four older patients, with thighs as big as a waist, diabetes and sleep apnea. They have symptoms too, and look at you like they know you might be able fix them.  But, we are only human, and right now, despite the desire to do so, we cannot ablate every AF patient. Those patients in the grey of decision making are subjected to the rationing of realism.

A perfect world of AF care would entail many differences.  Just one fantasy, would be to have helpers in the EP lab.  I could train non-doctors to put sheaths in and handle catheters.  It is just a physical learnable skill.  That would help.  But this could never happen in our present legal climate. Forget it.  Especially in a state like KY, where I can’t tell you how many times I have heard nurse administrators speak the words, “that’s not in a nurses’ scope of practice.”

Another societal solution would entail having more doctors to do procedures like AF ablation.  That should be easy.  EP training took only eleven years and 110,000 dollars after college.  Then, as an experienced specialist, it took me four or five years to get really comfortable with the procedure.

This is a tug-of-war.  Modern medicine advances.  We can now successfully treat historically incurable diseases.  But to do so requires much from the doctor and from technology.  AF ablation may only be a metaphor for an upcoming paradox in medical therapeutics: treatments may exist, but they will necessarily be rationed because of the scarcity of human-power to perform them.

JMM
  • Email
  • LinkedIn
  • Facebook
  • Twitter
  • More
  • Reddit

Related posts:

  1. Five “real” world issues with the complex decision to recommend heart catheterization…
  2. Freezing in AF ablation: not so fast you all…
  3. Atrial fibrillation ablation in women…Are there any real differences?
  4. Atrial fibrillation ablation in the news. Some good science…

Filed Under: AF ablation, Atrial fibrillation, Doctoring Tagged With: Pulmonary Vein Isolation, Rationing health care.

John Mandrola, MD

Welcome, Enjoy, Interact. john-mandrola I am a cardiac electrophysiologist practicing in Louisville KY. I am also a husband to a palliative care doctor, a father, a bike racer, and a regular columnist at theHeart.org | Medscape

My First Book is Now Available…

Email Newsletter

Search the Site

Categories

Find me on theheart.org | Medscape Cardiology

  • Electrophysiology commentary on Medscape/Cardiology

Mandrola on Medscape

  • My Medscape column on general medical matters

For patients...Educational posts

  • 13 things to know about Atrial Fibrillation — 2014
  • A new cure of AF
  • Adding a new verb to doctoring: To deprescribe is to do a lot
  • AF ablation — 2015 A Cautionary Note
  • AF Ablation in 2012–An easier journey?
  • Atrial Flutter — 15 facts you may want to know.
  • Benign PVCs: A heart rhythm doctor’s approach.
  • Caution with early Cardioversion
  • Decisions of 2 low-risk cases of PAF
  • Defining success in AF ablation in 2014
  • Four commonly asked questions on AF ablation
  • Inflammation and AF — Get off the gas
  • Ten things to expect after AF ablation
  • The medical decsion as a gamble
  • The most important verb in our health crisis
  • Wellness Requires Ownership

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.