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-likeâ€ 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: Â
Getting an AF ablation approved is easy. All a doctor has to say is that the patient is â€œsymptomaticâ€ and/or failed a drug. You donâ€™t have to say what sort of drug; you donâ€™t have to say what dose of the drug (low doses often fail), and you donâ€™t have to say anything about the nature of the symptoms. Iâ€™ve seen people undergo ablation for brief (less than an hour) episodes occurring once every three months. That is wrong.
Doctors donâ€™t have to try treating obesity or sleep apnea before AF ablation. Iâ€™ve seen massively obese people undergo futile AF ablation. Doctors donâ€™t have to recommend reducing alcohol intake. Iâ€™ve seen people have AF ablation so they could keep drinking 3+ cocktails per night. In athletes, you donâ€™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 itâ€™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, itâ€™s nearly impossible to define what â€œdone rightâ€ 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 canâ€™t agree on how to define â€œsuccess.â€ 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 itâ€™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 â€œto see what is in front of one’s nose needs a constant struggle.â€ For years, we have not been able to see the obvious fact that AF is (most often) a result of atrial diseaseâ€”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.