Choosing the Right Doctor: 7 Questions You’ve Got to Ask (And What the Answers Mean)
This list of 7 questions (8 if you are female) is designed to solicit information to help you select the best doctor for you and your type of A-Fib. After each question, we’ve included typical doctor responses and an analysis of what those responses may mean to you.
1. What treatments do you recommend for dealing with or curing my type of A-Fib?
If the doctor only talks about different medications, you should probably talk to other doctors on your list. Overall, Drug Therapies have poor success rates, and don’t address the progressive nature of Atrial Fibrillation. Today, the best A-Fib treatments are with Catheter Ablation.
2. Do you perform Catheter Ablation procedures for my type of A-Fib? What type of procedures do you use, or prefer?
Response #1: “I only work or prefer to work in the right atrium.” Or, “I will eliminate the Atrial Flutter in your right atrium first.”
These responses indicate a doctor may not have the experience or be comfortable working in the left atrium. Though it’s more difficult to work in the left atrium, most A-Fib comes from the left atrium pulmonary veins. You may have Atrial Flutter in your right atrium along with your A-Fib, but it may well be triggered by the A-Fib coming from your left atrium.23 You should probably talk to other doctors on your list.
Response #2: “We recommend catheter ablation of the AV node and implanting a permanent pacemaker.”
Though this used to be one of the most common treatments for A-Fib, you don’t want to be burdened with a permanent pacemaker for the rest of your life when there are better options available.
Also, this procedure leaves you in A-Fib and dependent on medication for the rest of your life. Unless you have a Sinus Node problem and need a pacemaker, you should probably talk to other doctors on your list.
Response #3: “We use Circumferential Ablation to eliminate A-Fib.” Or “Segmental Ablation… .” Or “Anatomically-Based Circumferential Ablation….” Or “Pulmonary Vein Antrum Isolation… .”
Circumferential, Segmental, Anatomically-Based Circumferential (also referred to as Left Atrial Ablation or the Pappone technique) and Pulmonary Vein Antrum Isolation (PVAI) are refinements or different Pulmonary Vein Ablation procedure strategies. All offer you a good chance of being cured of your A-Fib.
Circumferential is the most used technique.
Response #4: “We use a special catheter sensor to pinpoint ectopic beats coming from areas of the heart, mostly from the Pulmonary Veins in the left atrium. We then ablate these areas.”
(Ectopic beats come from any region of the heart that ordinarily should not produce heart beat signals, such as the pulmonary veins).
This response indicates the doctor and/or medical center is targeting (focusing on) specific spots generating the A-Fib signals. This technique is called Focal Catheter Ablation which was the first technique developed to ablate A-Fib.
However, most centers today use either Circumferential or Segmental techniques to ablate or isolate the entire area around the openings of all four Pulmonary Veins. If the A-Fib signals persist, they will proceed to target and abate the specific source of the ectopic beats.
Response #5: “Besides RF catheters, we also use the CryoBalloon Catheter to isolate the Pulmonary Veins.”
The CryoBalloon Catheter for A-Fib Ablation (FDA-approved technology in December, 2010), it has proven effective, safer, and faster than the various types of RF ablation.
But it is a relatively new method of ablation without a long-term track record of extensive data validating its effectiveness. However, anyone using the CryoBalloon Catheter is probably innovative, knowledgeable, and experienced in A-Fib ablation.
3. What is your success rate for my type of A-Fib?
Major centers with a lot of experience have a success rate of around 70-85% for Paroxysmal (occasional) A-Fib, with a higher success rate if a second ablation is necessary. If their success rate is 50% or less, you should probably look elsewhere.
4. How long have you been performing catheter ablations for my type of A-Fib? How experienced are you with RF and/or Cryo? How many procedures do you perform a year?
It’s hard to quantify experience with specific numbers. When doctors say they have done a total of 20 Pulmonary Vein Ablations, they are probably still in their “training” stage or have just passed their certification. At a minimum, electrophysiologists should perform 100 procedures a year. Therefore, if a doctor only does a few PVAs a month, this may not be enough to maintain or develop ablation skills.
There are many electrophysiologists and several medical centers that have been doing Pulmonary Vein Ablations for years and have done hundreds (or thousands) of Pulmonary Vein Ablations.
5. What kind of complications have you had after ablations?
Every A-Fib doctor has had some complications when doing Pulmonary Vein Ablation procedures. A PVA is a low risk procedure, but it is not risk free. Possible complications include blood clots and stroke, PV Stenosis (post-op swelling of pulmonary vein openings which can restrict blood flow and lead to fatigue, flu-like symptoms, and pneumonia), Cardiac Tamponade (pooling of fluid around the heart that can cause a drop in blood pressure) and Phrenic Nerve Paralysis (related to the diaphragm, and usually temporary).
Doctors and their office staff are usually very open about the complications they have had and can usually give you statistics. If they are not, you may want to look elsewhere for your doctor.
6. Do you ever refer your patients for Maze or Mini-Maze surgery?
Some A-Fib patients might be better served by a Maze or Mini-Maze surgery. For example, someone who needs heart surgery for another problem might well combine that surgery with a Maze operation. Someone who can’t tolerate Coumadin or other blood thinners might be better served by a Mini-Maze surgery. Most Mini-Maze surgeries are the result of referrals by electrophysiologists.
If a doctor doesn’t normally refer patients for Maze surgeries, this isn’t necessarily a reason for rejection. They may be concerned about a loss of quality control if they send patients to someone who’s not a specialist in heart rhythm problems.
7. What techniques or technologies do you use to increase the safety and effectiveness of your procedures? For example, how do you protect the esophagus?
A doctor’s use of technology may improve their effectiveness compared to other doctors or medical centers. Examples: Using an imaging system that gives 3-D images of the inside of the heart, of the position of the esophagus, and of catheter placement and pressure; Using an energy source like the CryoBalloon catheter system to produce circular lesions around the pulmonary veins; Using magnetic or robotic arms that aid in more precise placements of lesions or ablations.
Damage to the esophagus during an ablation (called Atrial Esophageal Fistula) is a very rare complication (less than 1 in 1000+), but is often fatal. Heat from the RF catheter damages the esophagus which lies just behind the heart; over the next 2-3 weeks gastric acids can eat through the weakened area. Most doctors and medical centers take precautions to avoid this damage including prescribing Proton Pump Inhibitors to prevent gastric acid damage.
When you ask how the doctor protects the esophagus, you should hear answers like:
Response 1: “We use low power at the back of the heart.”
Response 2: “We use a temperature probe in the esophagus to make sure it doesn’t get too hot.”
Response 3: “We use barium paste in the esophagus so that we can see where it is when we make ablations and don’t make ablations near the esophagus.”
Response 4: “We give Proton Pump Inhibitors like Nexium for 2-3 weeks after an ablation to protect the esophagus.”
If you don’t get answers like these, especially about taking Proton Pump Inhibitors after an ablation, it might be wise to talk with other doctors.
8. (For female patients) What is the extent of your training specifically related to women’s heart health?
Women tend to have different symptoms of heart disease than men, in part because their bodies respond differently to risk factors such as high blood pressure. Cardiologists who specialize in women are more common than ever. Medical centers now have clinics devoted to women’s heart health. Women with A-Fib may want to seek out a specialist who is up-to-date in this field of research.
Last updated: Wednesday, May 6, 2015