Tag Archives: ablation

Ablation For Atrial Fibrillation: One Patient’s Experience

The skeptical cardiologist previously shared reader Mark Goldstein’s experience with atrial fibrillation which led him to choose to have an ablation.

Mark has subsequently undergone the ablation procedure and has kindly shared his thoughts and observations on the process. I’ve included a few comments (in green).


The Mystery of Afib and An Ablation

Everyone associated with afib knows how mysterious it seems to be. What triggers it? Why does it stop? Why does it affect marathoners, cross-country skiers, and NBA players more than other groups? Why is everyone’s experience as unique as popcorn granules? Recently Dr. Pearson invited me to talk about my accidental discover of afib, my unsuccessful cardioversions, and my decision to have an ablation.

In the last post, afib was affecting me every day when exercising. Moderate exercise would cause my heart to, as my electrocardiologist would say, “act like a drunken sailor.” It became hard. Exercise is important to me. Medication was not working for me. An ablation was the next step.

Choosing A Doctor

Before you decide on the cardiologist or electrophysiologist (EP)  to perform an ablation, do research. Ablations are not particularly dangerous. No one is opening your chest. The doctor is “redecorating” your heart…OK, killing tiny parts of your heart. People occasionally die. There can be complications like infections. How long has your doctor been doing ablations? How many a year? I asked my EP where he learned the technique. Turned out that he learned it from the French doctor who invented it. Peer recognition is good. My EP leads the Atrial Fibrillation Center at the big regional hospital where I had the work. Find out if they are involved in research since this suggests they keep up on the latest developments. I saw that my EP was doing research via the U.S. government’s Medline Plus clinical trial website (https://medlineplus.gov/clinicaltrials.html). And if you are reading about the latest research on the Internet, you can see if your doctor is keeping up with the latest. I asked my EC about a study that appeared days before our appointment. He read it and talked about it. He passed my tests.

(I’ve been meaning to write about a recent study which looked at the early mortality rate (<30 days after procedure) from catheter ablation for atrial fibrillation which  was 0.46% among more than 60,000 patients treated for A-fib ablation between 2010 and 2015.  These real-world rates are higher than those reported in randomized trials. This doesn’t necessarily make ablation a “dangerous” procedure but patients should know that there is a 1 in 200 chance of dying from it.)

Interestingly, and relevant to Mark’s point about choosing an EP who does a lot of ablations per year, mortality rate was higher in low volume hospital (<21 ablations per year). These data support choosing a high volume operator in a high volume hospital. 

Once you choose a doctor, the remainder is scheduling and insurance paperwork. My experience is that you should assume at least a day in the hospital and a day to recover.

I arrived early the day of the procedure. After my previous cardioversions I was experienced with the registration and prep process. A few hours later I was on a gurney entering “mission control.” The procedure room was full of large TV’s, reminding me of launching a rocket. It can be a bit intimidating, but I thought of it as a sports bar. Instead of watching games people were watching my heart. It wasn’t a long time in the room before I was told I’d be sleeping soon.

They were right because I “woke up” about four hours later in a recovery room. I immediately saw my heart rate was in the 70’s and steady. That was good. I put on my Apple Watch and started the ECG test. Without waiting for the watch to decide, I could see my beats were rhythmic. YEAH! I saw “normal sinus rhythm” on the watch and celebrated. Later I found out that I had almost four hours of a successful ablation. Apparently, that is a lot of work however the afib, aflutter, was gone.

After the procedure I felt pressure around my heart. Not surprising considering the “redecorating” that was done. It was more of an annoyance than painful. That lasted for a few days. The area around my groin was also sore from the insertion of the ablation instruments. Certainly not unbearable but not fun. A couple of hours after the procedure I asked if I could go for a walk. The staff accompanied me for a walk and saw that I was fine. I asked if I continue walking. After a mile of moderate walking around the hospital (thanks to the Apple Watch’s measurements), my groin felt much better. When my watch showed I walked three miles, I went to bed. The following morning before breakfast, I walked another three miles. After ablation, start walking as soon as you can. It helped me physically and probably more important mentally showing that I was OK.

My groin area was purple for about a week so the worst part of the ablation was I couldn’t wear a Speedo (nor did I want to wear one). It was ugly and a minor nuisance but didn’t affect my activities. Oddly the second day after the procedure I woke up feeling the aftermath of cramps in both of my calves. This was bothersome walking stairs especially. I hadn’t heard of cramps associated with an ablation so it may just have been coincidence. The next day I could walk fine.

Post-Ablation Early Recurrence

My heart was fine after the ablation. I checked it regularly with my Apple Watch and Kardia Mobile EKG. Life was good until 1:55AM a couple of weeks after the ablation. I was sleeping. Without explanation my heart rate jumped from 53 beats per minute to 110 in five minutes. When I woke hours later, I knew my heart was racing. The Kardia Mobile showed I had a “uncategorized” problem. It stayed around 110 beats no matter what I was doing. A few hours later my EP saw my EKG chart and said I needed another cardioversion. He reminded me that he told me the first time we discussed ablation that during the first three or four months I might have more rhythm problems as the heart returns to normal. He was right.

A few days later I had my third cardioversion. My heart immediately went from 110 back to 60/70 beats per minute after the procedure. Yeah! I was beating normally again.

One Month After Ablation

Today is a month after the last cardioversion. My Apple Watch, Kardia Mobile, and body tell me I am fine. The other metric I check regularly is my heart rate while sleeping since it should reflect my heart rate without activity. I’m averaging 54 beats per minute at night which is fine. I can now exercise moderately or intensely. I am celebrating by writing this article.

I continue to take a blood thinner because of my CHADS₂ score. Hopefully my afib adventure is over…but I will not be surprised if it returns.


So far, so good.

Hopefully, Mark will remain free of afib for many years if not a lifetime but given that he is empowered with both a Kardia 6L device and an Apple Watch for monitoring his rhythm I feel confident he will know when and if it returns.

Skeptically Yours,

-ACP

N.B. Here are the charges for the ablation procedure.

Hospital – 86,350

EC/EP – 7,365

Anesthesia – 4,550

Blood test – 120

Misc charge – 22

Mark ended up paying $200 out of pocket.

Mark Goldstein works in the field of cybersecurity in the Washington, DC area and can be contacted at https://www.linkedin.com

Catheter Ablation of Atrial Fibrillation: Will It Reduce Your Risk of Death, Serious Bleeding or Stroke?

The wide-spread public conception that catheter ablation cures atrial fibrillation and reduces one’s risk of stroke or dying has fueled a  $4.5 billion industry.  Until very recently there were no published randomized trials supporting this expensive and risky procedure.

The recently published landmark CABANA trial found that in patients with afib “the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest. ”

So there is no proven benefit of ablation on death, stroke, bleeding or cardiac arrest. This means that a medical management approach to management of afib is always an acceptable approach. Especially an enlightened medical approach.

In CABANA, women and those patients >75 years of age did worse with ablation as this chart shows.

What about complications? I mentioned that ablation was risky and this is because any time you put a catheter in someone’s heart you can create life-threatening problems. When you then heat up the tip of that catheter it is possible to burn/damage/destroy things that  are not your target.

As John Mandrola has pointed out at least ablation was not more dangerous than medical management:

A reassuring finding of CABANA was that ablation did not do worse than drugs. But one of the messages I heard from HRS was that CABANA showed that AF ablation is safe. This is a problem.

The complications in the ablation arm were more serious and more numerous than those in the drug arm. We will have to wait for the published paper for formal comparisons.  CABANA likely represents a best-case scenario because it allowed only experienced operators and centers to be part of the trial. Many people undergo ablation by less experienced operators.

Another important safety issue is the asymmetry of procedural complications. When you talk privately with ablation doctors, many, perhaps most, relay the story of a tragic death of an otherwise healthy middle-aged adult from an atrial-esophageal fistula.

Yes. A well-recognized and highly feared complication of ablation , atrial-esophageal fistula, causes rapid death due to exsanguination through a channel between the left atrium and the esophagus which develop due to destruction/burning of the normal esophageal/atrial tissue.

In this chart taken from the CABANA abstract presentation you can see the complications which do not include a highly feared atrial-esophageal fistula.

 

Can Catheter Ablation Improve Quality of Life?

Basically, after the CABANA trial we have no evidence that ablation will  improve hard outcomes in afib patients. However, there are numerous patients who feel they have greatly benefited from the procedure, experiencing years of afib free existence.

This benefit of ablation, of improving quality of life and making patients feel better is important.

The CABANA trial also looked at quality of life and in part II of this article I’ll examine that in detail.

Skeptically Yours,

-ACP


Update 6/12/2019 357 PM.

Twitter follower @mrice5025 was kind of enough to read the above closely enough to realize that the number of atrial esophageal fistulae was actually zero in the CABANA trial and I have corrected the text accordingly.

I have seen a case of this mostly fatal complication in a patient who had an ablation done at an outside hospital 5 weeks earlier and who rapidly died from it and I try to be very aware of its possibility as early diagnosis and surgery is the key to survival.

This review article gives an overview:

AF ablation carries a small risk of complications with the most serious being atrioesophageal fistula (AEF). Although the incidence is less than 0.1%, it is usually fatal Esophageal perforation or fistula was reported in 31 patients (0.016%) in the Global Survey of Esophageal and Gastric Injury in Atrial Fibrillation study. Symptom onset for esophageal perforation or fistula was reported on average 19.3 days after the ablation procedure but could appear as short as 6 days and as long as 59 days post ablation.Esophageal injury has been observed most frequently with percutaneous radiofrequency ablation, although it has also been reported with other energy sources including cryoablation,high-intensity focused ultrasound and even surgical ablation.

 


The featured image comes from this Cleveland Clinic video which has some great graphics and reasonable information (once you get by the annoying lady at the beginning who describes ablation as “an excellent minimally invasive” procedure.)

At my hospital, St. Luke’s, I have three outstanding electrophysiologists who do excellent ablations,, Jonas Cooper, Cary Fredman, and Mauricio Sanchez.