Atrial Fibrillation Ablation: Time For A Team Approach?

For many proceduralists in medicine and surgery, there is a tendency to overestimate the value and underestimate the risk of the intervention that they perform. This factor, plus the current medical reimbursement system in the US, which rewards physicians primarily on the quantity of services performed rather than the quality of care, fosters a strong incentive for proceduralists to perform their procedures early and often.

It is rare for a proceduralist to publicly advocate a cautious and circumspect approach to their procedure; the usual public expressions are highly enthusiastic endorsements intended for marketing and increasing volume.

In this regard, it is particularly refreshing to read the thoughts today of a clinical electrophysiologist, whose bread and butter partially consists of doing ablations of atrial fibrillation (AF.)

John Mandrola (who writes a great blog at DrjohnM.org and reports for theheart.org) has written an excellent summary of the things that patients should consider prior to getting an AF ablation which I shall reblog below.

Mandrola asks us to consider whether the decision for AF ablation should be made by a team rather than by the proceduralist who stands to benefit from performing the ablation.

I’ve emphasized some points from his post:

-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%.

-Many patients have to undergo a second procedure, or even third or fourth procedures.

-Some questions an AF team might ask:

  • 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, not infrequently, refer appropriate patients to excellent and thoughtful electrophysiologists for a discussion of the pros and cons of ablation and consideration of its performance .  Before sending them, I try to act like the “team” that Mandrola envisions and review the risks and benefits along with alternative approaches.

Below is John’s post in its entirety:

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

10 thoughts on “Atrial Fibrillation Ablation: Time For A Team Approach?”

  1. Excellent articles, yours and his.
    Except, you both should understand that the final arbiter making the “decision” must be the one whose heart is on the table – all other members of the team having imparted to him/her their full knowledge and understanding.

  2. I would submit, concerning the fifth bullet point, that atrial fibrillation is deadly. Deadly, at least, to Quality of Life. It’s been observed to be progressive over time – from paroxysmal through persistent to permanent. Brain volume decreases in AF and dementia increases. The most effective anti-arrhythmic medications can be the most debilitating to QOL, indeed toxic. You must choose between an increased risk of stroke and an increased risk of serious bleed. Enter deadliness to life.

    1. Doctors like to limit death to its strict meaning-absence of life.
      Quality of life, of course, is important, and for many, more important than duration.
      Brain volume and function changes are more likely related to strokes, silent and otherwise, in AF which can be addressed by blood thinners or LAA appendage modification.
      Of course, there is no evidence that AF ablation reduces stroke risk. One of my concerns about AF ablation is that it makes Afibbers less vigilant about stroke risk and possibly less aware when they are in afib and more likely to suffer strokes.
      Anti-arrhythmics….so much to say, so little time.

  3. Thanks Anthony. I appreciate your support, and your blog.
    Your readers should know that you are one of the smartest cardiologists I’ve worked with. Keep up the great work.

  4. My electrophysiologist at Lahey Clinic is doing a study – not complete yet – that seems to indicate coagulation incidents can be removed in time by a factor of months from the AF episodes logically associated with them. So, being vigilant about the risk seems futile. But, completion of the study and reproducing the results will no doubt be required to really understand this.
    Also, a recent paper on absence-of-life percentages in AF:
    http://www.ncbi.nlm.nih.gov/pubmed/27297859?dopt=Abstract
    Just tryin’ to understand here, Boss.

    1. Not entirely clear about the Lahey Clinic study you mention. Are you saying the study finds that thromboembolic events may not temporarily coincide with episodes of AF?
      I don’t see a lot of useful info from the Framingham study on AF you referenced.
      They report that AF patients in their population without comorbidities have lower mortality and cardiovascular events than those with which seems obvious.
      The Af patients without comorbidities have a higher mortality and CV event rate than matched patients without AF. The AF patients could easily have underlying, undiagnosed cardiac structural disease increasing that risk or the risk could be intrinsic to the AF or it could be due to treatment utilized for AF (like ablations:))

      1. It was word-of-mouth from my Lahey doc. It’s my understanding that there was as much of a time gap as a month+ between any AF event and any coagulation event (TIA, stroke). They couldn’t even tell if the AF was cause or effect. So using an anticoagulant at the first sign of arrhythmia might well not be as effective as continual preventive anticoagulation. It seems to counter this:
        http://www.medpagetoday.com/clinical-context/Strokes/57829
        I’ll see if I can find out more.

        Along these lines, these two articles seem to qualify each other:
        http://www.medpagetoday.com/Cardiology/Strokes/53485
        http://www.jafib.com/news.php?id=64

        Then: I guess there’s always going to be some degree of underlying unknown unknowns. (Ah, Rumsfeld.)
        But then you seem to be saying that ablation as treatment could have deadly side effects 🙂 ??

  5. More insight into AF & stroke. . . more complexity:

    “The prevailing model of AF and thromboembolism is likely incomplete. A straightforward association between AF and stroke does not convincingly demonstrate temporality, specificity, or a biological gradient, and it is not concordant with the totality of the available experimental evidence.”
    http://stroke.ahajournals.org/content/47/3/895.long

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