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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:

 

-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

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