AF Ablation is Overused in the US

A colleague recently asked me if atrial fibrillation (AF) ablation was overused.

Yes it is. AF ablation has become the wild west of electrophysiology. There is essentially no scrutiny of this invasive, expensive and risky procedure. I also include here the add-on “maze-like” procedures done during heart surgery for other conditions. I believe they too are overused.

The lack of scrutiny of AF ablation differs from other common heart procedures. Stenting of coronary vessels and implantation of ICDs and pacemakers must meet rigid criteria. Some would argue too rigid, but overuse of these procedures contributed to the intense oversight.

I – No scrutiny before AF ablation:  

Getting an AF ablation approved is easy. All a doctor has to say is that the patient is “symptomatic” and/or failed a drug. You don’t have to say what sort of drug; you don’t have to say what dose of the drug (low doses often fail), and you don’t have to say anything about the nature of the symptoms. I’ve seen people undergo ablation for brief (less than an hour) episodes occurring once every three months. That is wrong.

Doctors don’t have to try treating obesity or sleep apnea before AF ablation. I’ve seen massively obese people undergo futile AF ablation. Doctors don’t have to recommend reducing alcohol intake. I’ve seen people have AF ablation so they could keep drinking 3+ cocktails per night. In athletes, you don’t have to discuss the possibility that exercise addiction may be causing AF, and that if they go back to the same pattern, the AF will likely come back.

Repeat ablations feed the machine: Done well, redo rates of AF ablation approach 20%, and re-do procedures are reimbursed at the same rate as the first. If the first procedure is done with less attention to good quality lesions (e.g. faster), redo procedures become more likely because of electrical re-connection of the pulmonary veins.

On the other hand, if you do too much ablation (there are add-on codes for extra ablation), then redo procedures for scar-related flutter is likely. I call this the if-you-give-a-mouse-a-cookie effect: once you start doing extra burns in the left atrium, flutters rotating around the burns become more likely. Guess what the treatment of those are? Yes. More ablation procedures.

What’s more, there are experts in the field who stand up at meetings and say it’s normal to do 3,4,5,6 procedures on a patient. Charges for these procedures are more than $100,000.

II – No scrutiny during the AF ablation procedure:

Unlike a pacer or a stent, the endpoints of an AF ablation are not obvious. In many ablation labs, the staff are borrowed from the cath lab; and they have no idea whether the procedure is done right. What’s more, in cases of persistent AF, it’s nearly impossible to define what “done right” means. Experts do not agree on the best technique.

III – No scrutiny after the procedure:

Most recently, after more than 15 years of AF ablation, there is a nominal effort underway to measure severe complications of the procedure, such as cardiac perforation. But not poking a hole a heart is hardly a reliable measure of a good ablation doctor. Few centers measure outcomes or success of AF ablation. Heck, we can’t agree on how to define “success.” It’s fantasy to think any regular person could know which doctors are good at ablation.

IV – Common examples of AF ablation misadventures from the real world:

I have seen patients undergo AF ablation without first having their fears of AF allayed. Fear extraction is vital. People with minimal or no symptoms of AF should not have ablation because they fear AF. All patients should be told there is no randomized controlled trial showing the procedure lowers the probability of stroke, heart failure or death.

I have done redo ablation on patients who have had their first ablation done elsewhere, and observed no conduction delay (evidence of ablation) from the first procedure. In other words, their first ablation was akin to a sham procedure.

I have seen patients referred for AF ablation whose AF was clearly due to a recent illness or stressful event. No time was given to let the AF resolve on its own. AF episodes can come in flurries. You should read about regression to the mean.

I have seen obese patients have AF ablation without a sleep study or counseling on weight loss. This is terrible because it’s a lost opportunity to help people with an obvious cause of the AF. And not addressing causes of AF means exposing patients to the harms of the procedure without maximizing its chance of success.

V – Reasons for Overuse of AF Ablation in the US:

One reason for overuse is misaligned incentives. AF ablation makes doctors and hospitals a lot of money. We are paid per procedure. The more procedures we do, the more we make. Here I reference Upton Sinclair.

Another reason for overuse is our lack of courage in accepting expert centers of excellence. Unlike places like India, US policymakers allow AF ablation to be done anywhere there is an EP lab. In my medium-sized city (1 million) there are at least six hospitals and more than a dozen doctors doing AF ablation. That is too many.

The third reason for overuse of AF ablation is a global misunderstanding of AF. Orwell said “to see what is in front of one’s nose needs a constant struggle.” For years, we have not been able to see the obvious fact that AF is (most often) a result of atrial disease—not a primary condition. We have too broadly applied a procedure when we should have been treating the underlying causes.

VI – Conclusion:

AF ablation can be useful for highly selected and thoroughly educated patients. (Excess modifiers in that sentence used intentionally.)

I feel confident that I have helped people with this procedure–even when it takes multiple procedures. I do AF ablation every week. But I do it with careful vetting, lots of patient education and an unease that history may kick me in the butt.

Cardiology leadership had better wake up. I see us heading in the same direction we went with stents and ICDs.

Thus far, our attempts at policing ourselves look dubious. Soon, others will police for us.

JMM

16 comments

  1. I am so happy my EP has not mentioned the “A” word. He took me off meds I was not tolerating and put me on PIP. Most importantly to me, he got in my face and convinced me healthy lifestyle changes were in my best interest. That was 9 mo ago, Ive lost 30 of 60 excess pounds, exercise daily, trying to eat heart healthy and my life has done a 180. Last a fib was 6 mo ago, very mild 90 minutes as compared to 10 hour symptomatic episodes while on sotalol. I am so very happy I have an EP who isnt ” albation happy”, Dr Sandeep Gautam at University of Mo, Columbia, Mo… my heart hero!

  2. It took courage to write this.

    7 years ago I was _this_ close to an AF ablation. I have been in normal rhythm for 6 years because I learned to slow down, sleep better, and take it easier on the bike.

    I appreciate the effort you put into reaching out.

    Thanks.

      1. This article really applies to me right now. I have ablation surgery scheduled in 2 weeks but I’m apprehensive about it. I had 2 long duration episodes of A Fib in Nov and Dec 2016. Both were triggered by alcohol/diet and/or stress. I’ve been on a beta blocker since but thats the only med (other than aspirin). No A Fib in 3 months. So I’m wondering if ablation surgery really is right for me at this time. Seeing someone recover from a fib and not have an episodes in 6 years without ablation really gives me something to think about…

        1. I’m talking out of turn here, not being an expert at all in AF or ablation.

          I’ll say this based on my own observation from the outside looking in. AF ablation is changing fast. Best practices 10 years ago were different than they are now. From where I sit, as a patient, waiting a few years can give the field some time to shake things out and learn a lot. It’s not like AVnRT ablation, for example, where the mechanism is well understood and the ablation almost always works.

          I’m sure AF treatment 10 years from now will look substantially different than it does now.

          Something to think about.

  3. I’m really glad you brought this up, John. Although you’re talking about AF ablation here, which I know can be done as a palliative strategy, it so happens that in the last month, I’ve had two patients on my palliative care service with very advanced dementia, failing to thrive and with what their families described as “no quality of life,” who both had undergone AV node ablations for AF within the last few months, leaving them pacemaker dependent. The ramifications of pacemaker dependence had never been discussed with the family (or the surrogate decision-maker), so it created a level of complexity and surprise when I brought up the fact that the pacer could be turned off. Even though I’d discussed the fact that it is ethically permissible to turn off a device (and that the patient would likely die afterwards), it reminded me how critically important it is for cardiologists and primary care physicians to discuss possible outcomes of inducing pacemaker dependence, especially in people with dementia. Even though I’m aware of the HRS consensus statement on CIEDs (thanks to you!), and I pull it out whenever a cardiologist or device rep tries to tell me that disabling a device is “euthanasia,” in these cases, even I would have felt uncomfortable having them turned off because both these patients were alert and somewhat interactive (eyes open but with very few words, as is common in advanced dementia, along with severe sundowning and other behaviors), with some months left to live, rather than imminently dying in the next few says where the pacer is just prolonging the death. Neither patient had done an advance healthcare directive or indicated what they would have wanted, so we were all left guessing. When I discussed one case with a “world renowned” cardiologist at my institution who had earlier told one family that the pacer couldn’t be turned off, his response was, “Maybe we could just turn it down or something.” Anyway, my point is, I agree with you, these ablative procedures are being overused, and I’ve seen it from the palliative care standpoint. It’s so important to have conversations about the “what if’s” when it comes to procedures that induce pacemaker dependence, especially in people who are already critically ill. The same is true for LVADs, but that’s for another rant.

  4. I’ve had too many ablations, including AV node. Also had a maze procedure. I’m still in and out of atrial flutter. Each time the EPs said afterwards that the ablations failed. As EPs ablated one site, errant electrical signals popped up elsewhere. I have a weakened heart as a result. One EP said I had too much scar tissue and not to have any more procedures. Recently another EP suggested that ablating the flutter would be an easy fix. I finally know that is not true.

  5. I have just had an ablation at the end of December and then a redo in February.After being diagnosed with paroxysmal AF i took Flecainide for 3 years 50 mg am and 100 mg pm every day and had no episodes during the 3 years.My GP wanted to put me on blood thinners so i went to see a cardiologist who does lots of ablations.They suggested an ablation but i preferred to stay on the Flecainide.They sent me for a CT scan for a calcium score which came back over 500.The Cardiologist told me to come off the flecainide as it was dangerouse with the coronary heart diesase that they discovered. Went on to Solotol and had some minor episodes of AF always self coverting.Then my Cardiologist suggested PVI ablation which i had as previously mentioned.Has it been successful….i not sure ….i am off Sotolol so thats a plus.I am male 67
    Fit and healthy otherwise.I am in Australia

  6. DR. JOhn. I’ve had paroxysmal afib for 30 years. About 6 months ago I started taking a substance called Arjuna, used in India to treat arrhythmias. For the first time in 30 years, I feel like I have my life back. I realize I may merely be in remission, but I truly think the Arjuna has made the difference. Do you know anything about the efficacy of this substance?

  7. These are really insightful observations, John. I salute your courage to speak out on these issues in your subspecialty!
    I have similar concerns in my area of noninvasive cardiac imaging

  8. How about for SVT specifically? There is so much discussion on whether to get an ablation or manage SVT through lifestyle changes (some of which you mention here). Would love to hear your thoughts, because my first one failed and am considering a second. But first, I want to completely change my lifestyle.

    1. True PSVT is a fluke. It’s due to an aberrant pathway. It’s a completely different condition. SVT is not due to lifestyle patterns and not really modifiable with lifestyle changes. SVT ablation should be 95-99% successful. It’s very uncommon to need two procedures for SVT ablation.

      1. Well, I guess I am in that 1-5% because I have symptoms post ablation. Not as intense, slower rate like 120 – but definitely symptoms every few months. Also headed to a new doctor this time. Thank you for answering my question.

  9. The proliferation of AF ablations and re-do and re-do re-do ablations really got fueled with the addition of more billing codes. In our lab, folks decided to do the bare minimum when it was a one price procedure. As soon as the codes expanded and the “sky was the limit” these same operators decided to chase after CFE’s and “doodle” inside the LA with roof lines, MVI lines, anterior septal lines, and bill like crazy. I was one of a few who went the opposite direction. I used 2 or 3 or 4 AADs before I brought folks to the lab. I actively discouraged octogenarians not to commit to an ablative strategy. And once STAR AF2 came out, and 2nd gen Arctic Front came out, all I did was a cryo WACA and no extra lines. So what happened? My volume took a dip and my billings dropped. But my patients did just as well if not better. My atypical flutter rates plummeted.

    John, Ed Gerstenfeld wrote an editorial in JACC that resonated with me. He said that when it comes to AF ablations, EP has “lost its way”. We, EPs, need to do better. We need to stop overbilling and stop the willful ignorance. All of society is watching and I can guarantee there is a lot of e-Surveillance of our billing behavior at the Federal level.

    We need to embrace EP as a Science again and ask the basic questions.

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