CryoBalloon Ablation: Alarming O.R. Reports (Part I)
A two-part series by Steve S. Ryan, PhD
Often when A-Fib patients contact me, I’ll advise getting a copy of their O.R. (Operating Room) report so I can read exactly what was done during their ablation. The details in an O. R. report can be quite revealing and usually reassure me that their EP did a good job.
But sometimes the report is disappointing. I just read two O.R. reports of CryoBalloon ablations that left me alarmed and disturbed.
O.R. Report #1: Ablation Without Identifying the Source of A-Fib Signals
The first CryoBalloon ablation was performed at one of the most prestigious A-Fib centers in New York City.
At the beginning of the ablation, it appears the Electrophysiologist (EP) made no attempt to first map the source of the patient’s A-Fib signals (mapping at the beginning or before hand is standard procedure at most A-Fib centers).
During the ablation the EP did not check for non-PV triggers or even attempt to identify the source of her A-Fib signals or potentials. The EP merely ablated the pulmonary veins (PVs), but did check for entrance and exit block.
At the end of the CryoBalloon ablation, he did not verify all A-Fib signals had been terminated by trying to trigger A-Fib with pacing or drugs like isoproterenol. (Triggering A-Fib means a new round of A-Fib isolation.) Once again, this verifying step is standard protocol for most ablations at most centers.
Result: the CryoBalloon ablation appeared to successfully isolate the patient’s PVs, and luckily she seems to be doing well.
What’s alarming is what the EP didn’t do! This CryoBalloon ablation was less than the standard.
The very minimum steps were taken: isolate the Pulmonary Veins and little more. There was no effort to check for non-PV sources of A-Fib signals. No verification that all A-Fib sources were terminated. In fact, this patient may still have spots producing A-Fib signals.
Why go through an ablation if the EP didn’t do a thorough job? If the patient’s A-Fib returns, a second ablation may be required.
Now you know why I was disturbed by this O. R. report. Now, let’s look at the second report.
O.R Report #2: Non-PV Triggers Still Causing A-Fib
I read another O.R. report of a CryoBalloon Ablation on a patient who was in persistent A-Fib for two months before the ablation.
After isolating the PVs, the patient remained in A-Fib.
Instead of looking for and ablating the source of these non-PV triggers, the EP simply electrocardioverted the patient back into normal sinus rhythm. (That’s certainly faster and easier than looking for non-PV triggers.)
Result: The patient was back in A-Fib within a month.
According to the patient, when the patient and his family first met with the CryoBalloon ablationist, they asked the right questions:
“What will you do if I still have A-Fib after the ablation?”
The EP said he would not stop until all the A-Fib spots were found and ablated.
In reality, instead of doing that, he just electrocardioverted the patient back into normal sinus rhythm without looking for and ablating the patient’s still-firing non-PV triggers.
It’s no wonder the patient was back in A-Fib shortly after this ablation.
Again, I was alarmed and troubled by what I read.
Take Away: O. R. Reports
An O.R. report is a blow-by-blow account of your EP’s actions. Indeed, the details in an O. R. report can be quite revealing. In these two cases, alarmingly so.
If you’ve had an ablation that was less than successful, you want to know why! Your O.R. report would show what they found in your heart, what was done, and possibly why the ablation didn’t fulfill expectations.
Read more about O. R. reports in our Special Report How & Why to Read Your Operating Room Report.