In Your 80s? Are You Doomed to Live In A-Fib?
A-Fib is age related. In particular, more people in their 80s are developing A-Fib.
Yet many A-Fib centers have a policy of not performing a catheter ablation on anyone 80 years old or older. But these are often the patients who need a PVI the most. Up to 25% of strokes occurring in octogenarians can be attributed to A-Fib.
It seems arbitrarily cruel to force someone to “live in A-Fib” just because they are older.
It seems arbitrarily cruel to force someone to “live in A-Fib” just because they are older. Isn’t this age discrimination? Why exclude octogenarians from a potentially curative treatment like catheter ablation (PVI)?
Study of Octogenarians Who Had a Catheter Ablation (PVI)
Dr. Pasquale Santangeli and his colleagues at the Texas Cardiac Arrhythmia Institute in Austin, TX examined data from 103 octogenarians who had an RF catheter ablation between 2008 and 2011. They compared this older group to younger patients who underwent the same procedure.
• There was no difference in the rate of success between the octogenarians and the younger group (69% vs. 71%).
• The rate of procedure-related complications was also not significantly different between the two groups, even when looking at different types of A-Fib such as paroxysmal and non-paroxysmal A-Fib.
• Octogenarians with paroxysmal A-Fib had more non-pulmonary vein trigger sites, and consequently required longer procedural time to effectively isolate such non-pulmonary vein areas. (Dr. Santangeli suggested a hypothesis that the underlying pathology of A-Fib in older patients might be different from younger patients.)
What Patients Need To Know
If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs. Dr. Santangeli’s work is very hopeful and encouraging.
But in practice, octogenarians have been largely excluded from clinical trials of catheter ablation. Current guidelines are also very conservative, because there has been a lack of adequate clinical studies in this area. Dr. Santangeli’s report is a step in the right direction.
People who live to be 80 often have developed good life habits and are more apt to be healthy.
Look At the Individual, Not Just Their Age
What Dr. Santangeli is basically saying is that doctors should look at the health (and mental attitude) of an individual rather than set arbitrary age limits to having a catheter ablation.
People who live to be 80 often have developed good life habits and are more apt to be healthy, maybe even more so than many of their younger peers.
A Rebuttal Point of View
Dr. Michael Kim of Northwestern University in Chicago, IL, wrote a rebuttal editorial pointing out that the octogenarians in Dr. Santangeli’s study were nearly as healthy as the younger patients. They likely had “excellent functional and health status.”
But then he added “old is old and octogenarians are different than the mid 50- to 60-year-old patient traditionally undergoing atrial fibrillation ablation.” He recommended forms of medicine for octogenarians with A-Fib.
When Old Isn’t Necessarily Old
Contrary to Dr. Kim editorial, Dr. Santangeli’s point is that in the real world old isn’t necessarily old. People in their 80s may indeed have ‘excellent functional and health status” which would make them good candidates for a catheter ablation.
Most healthy 80-year-olds aren’t so frail that they can’t have a catheter ablation.
After all, a catheter ablation is a non-invasive procedure. It isn’t like open heart surgery which is incredibly taxing and physically demanding. You don’t have to be a Johnny Atlas muscleman to have a catheter ablation. Most healthy 80-year-olds aren’t so frail that they can’t have a catheter ablation.
In your 80s? Find an EP Experienced in Non-PV Triggers
If you’re in your 80s, you most likely can still have a catheter ablation.
But, how to find the right EP? Make sure you select an EP with a proven track record of finding and isolating non-PV triggers. (Dr. Santangeli’s research found that octogenarians have more non-pulmonary vein trigger sites.) Some EPs can’t or won’t make the extra effort to map and ablate non-PV triggers.
(I’ve read O.R. reports where the patient was still in A-Fib after the EP had ablated their PVs. Instead of trying to map and ablate non-PV triggers, the EP simply electrocardioverted [shocked] the patient back into sinus rhythm. After a short time, the patient went back into A-Fib.)
Questions to Ask a Prospective EP
When interviewing a prospective EP, ask:
• “What do you do if I’m still in A-Fib after you’ve ablated my pulmonary veins?” (You want a reply such as “I search for triggers in other areas of the heart”.)
• “How do you ablate non-PV triggers?”
Remember: You need to become your own best patient advocate. Aim to be free of the burden of Atrial Fibrillation.
We are indebted to Dr. Santangeli and his colleagues for showing that octogenarians can have a successful, safe ablation, and shouldn’t be excluded from a catheter ablation simply on the basis of their age.