by Steve S. Ryan, PhD
In the June/July 2014 issue of The AFIB Report, Managing Editor, Shannon Dickson describes how Dr. Andrea Natale performed an ablation on his friend who was in persistent A-Fib. Shannon was an observer in Dr. Natale’s operating lab at the Scripps Clinic in La Jolla, CA.
“Dragging or Gliding” Ablation technique
Instead of using the dot-by-dot or point-by-point ablation technique commonly used in RF ablation, Dr. Natale positioned the catheter tip at an angle to the tissue and in contact with the Lasso circular mapping catheter and dragged or glided the catheter and Lasso together in one movement. Instead of making vertical downward dot-by-dot burns, he made continuous ablation lines or lesions. (This isn’t really a “new” ablation technique in that Dr. Natale has been perfecting this technique over many years.)
This dragging method allowed him to vary power and force depending on the variable wall thickness as he moved along. One result is potentially less inflammation swelling, which can form more readily around each discrete burn in the dot-by-dot technique. In turn, round dots of inflammation around each burn can potentially result is small gaps forming in between each ‘dot’.
Followup: Shannon Dickson’s writes that Dr. Natale’s ablation was a success and his friend is now A-Fib free!
Dr. Natale’s innovative RF ablation technique for persistent A-Fib patients seems like a major advance in ablation strategy. In addition to making better linear lesions, it’s probably a lot faster than the standard point-by-point RF ablation strategy.
So my next thought is: ‘Is this a technique dependent of the skill of the operator, or can it be taught to all EPs?’ (I will be sure to ask Dr. Natale this question at the next Orlando AF Symposium.)
Once again, I’m amazed that there’s no regulatory body requiring EPs to learn new skills or how to use new, proven equipment. Even if Dr. Natale’s new ablation technique is indeed teachable, it’s probable very few EPs will adopt it.
This is in stark contrast to other professions responsible for human lives. Case in point are commercial airline pilots. Pilots “undergo rigorous, continuing, high stakes assessments and examinations supported by mandatory training and retraining.”
A move in that direction has been started by the American Board of Medical Specialties (ABMS). They have begun a maintenance of certification (MOC) in order for a doctor to retain board certification; but physicians who received their board certification prior to this policy change remain certified for life. The American Board of Internal Medicine, the official “certifying” body of a large proportion of doctors in the US, has established a new re certification program which many doctors are up in arms about.
See Larry Huston’s Three Reasons Why You Don’t Need To Feel Sorry For Doctors
Last updated: Friday, February 27, 2015
By Steve S. Ryan, PhD
Pulmonary Vein Ablation of A-Fib is a relatively new procedure whose techniques and language are evolving. What follows is perhaps an oversimplified, somewhat biased attempt at explaining the catheter ablation procedures from a patient’s perspective. (Pulmonary Vein Ablation differs from other types of Catheter Ablation used in treating A-Fib, such as ‘Ablation of the AV Node’.)
‘Focal Catheter Ablation’ or ’Focal Point Catheter Ablation’
In this early procedure doctors mapped the sources of ectopic beats (beats that come from any region of the heart that ordinarily should not produce heart beat signals), then used a Radiofrequency (RF) catheter to “ablate” or burn off areas or points within the heart producing these ectopic beats. But if you weren’t in A-Fib at the time, it was difficult to identify the Focal Points or areas of the heart producing ectopic beats.
Doctors discovered that when a patient was not in A-Fib, the Focal Points producing A-Fib signals could still be found by identifying and mapping electrical potentials coming from these points. A potential is an electrical charge or energy—like the battery energy in your car. Even if your car isn’t running, you can still measure 12 volts “potential” at the battery. Similarly, in your heart any potential can be measured and pinpointed, even if you aren’t in A-Fib. When the area is ablated, the potential disappears. Like taking the battery out of your car, removing this potential eliminates your A-Fib. (Doctors today do not usually ablate within the Pulmonary Veins because of the risk of causing Stenosis (swelling). Instead they determine where the A-Fib signal(s) exits the Pulmonary Vein opening and ablate there to “Isolate” the A-Fib signal.)
‘Circumferential Ablation ‘or ‘Circumferential Pulmonary Vein Ablation’ (CPVA)
A circular catheter is used to make Circular Radiofrequency Ablation lines around each of the four Pulmonary Vein openings (ostia) in the left atrium of the heart. This procedure isolates the Pulmonary Veins from the rest of the heart and prevents any A-Fib signals from these veins from getting into the rest of the heart.
‘Anatomically-Based Circumferential PV Ablation’ or ‘Wide Area Circumferential Ablation’ (WACA)
Instead of trying to make continuous, perfect linear lesions around the Pulmonary Viens which can be difficult and time consuming, doctors use a “drop and drag” technique with a larger tip catheter which leaves gaps that are usually closed over time with scar tissue. This procedure originated in Italy. It has a good success rate with very few side effects both for Paroxysmal and for Chronic A-Fib.
The ‘Anatomically Based Circumferential PV Ablation’ procedure is faster, easier, requires less operator’s skill, and is more cost effective for doctors. But from a patient’s perspective it involves a lot of scarring of the heart by high wattage wide tipped catheters. And 20% of patients have atrial flutter after the procedure because of all the gaps in the lesion lines, though most of this flutter eventually disappears as these gaps fill in with scar tissue. Probably because of the gaps which caused patients a lot of problems, WACA doesn’t seem to be used much any more.
‘Pulmonary Vein (Wide Area) Antrum Isolation’(PVAI)
Instead on encircling each of the four Pulmonary Vein openings, one large encircling set of lesions isolates both the upper and lower left vein openings, another the upper and lower right vein openings. The encircling lesions are in the Antrum rather than near the vein openings.
Almost everyone doing RF ablations today seems to be using Antrum Isolation, for the main reason that the ablations are so far outside the Pulmonary Vein openings that the danger of creating stenosis (swelling of the pulmonary vein openings) is virtually eliminated.
In January 2014, I was privileged to observe doctors doing PVIs in their cath labs. Two of the leading EPs in Florida, Dr. Robert Fishel at JFK Medical Center in Atlantis/West Palm Beach, FL, and Dr. Sidney Peykar at Fawcett Memorial Hospital in Port Charlotte, FL, graciously let me observe, explained their procedures and answered my questions. Though they use different catheters and imaging systems, they both do PVAI and ablate in the antrum far away from the Pulmonary Vein openings as do most EPs today. Their point-by-point ablations burns are amazingly precise, consistent and normally leave no gaps. See my report, Visiting EP Labs as an Observer Instead of as a Patient.
‘Pulmonary Vein Ablation’ (PVA) or ‘Pulmonary Vein Isolation’ (PVI)
In general, types of PVA/PVI include: ‘Segmental Ablation’, ‘Circumferential Ablation’, ‘Anatomically-Based Circumferential PV Ablation’ and ‘Pulmonary Vein Antrum Isolation’. They are all similar in their approach. Their primary emphasis is the ablation/isolation of the Pulmonary Vein openings.
Note: Many use the term “Catheter Ablation” of A-Fib to include all of the above different ablation techniques.
Newer types of ablation have somewhat different ablation targets:
• ’Complex Fractionated Atrial Electrograms’ [CFAE]
• ‘Autonomic Ganglionated Plexi'[AGP]
Terms that still need to be re-defined
• Rather than ‘Isolation’, the term ‘electrical disconnection’ (used by The French Bordeaux group) may more aptly describes what ‘ablation’ does.
• The terms ‘Pulmonary Vein Potentials’ and ‘Pulmonary Vein Isolation’ both need to be re-defined because not all Potentials come from the Pulmonary Vein openings.
Which of the above procedures is the best? They all have somewhat similar success rates. Though the jury is still out on this, ‘Circumferential Ablation’ is quicker and faster for doctors and requires less mapping, but it’s difficult to make good circular ablations. The Pulmonary Vein openings aren’t always smooth, and the surfaces are not always easy to ablate. The inside of the heart is not a continuously smooth surface. Any gap in the circular ablation may result in more A-Fib. And not all A-Fib comes from the Pulmonary Veins. From a patient’s perspective, you’re better off with a doctor who will carefully map your heart to find out where exactly your A-Fib signals are coming from, and who will check for both Entrance and Exit Block (Isolation).
Also, with ‘Circumferential Ablation’ there might be a greater danger of Stenosis, a swelling of the Pulmonary Vein openings after ablation. PV Stenosis restricts blood flow into the heart and can lead to fatigue, flu-like symptoms and pneumonia. Most EPs now use Pulmonary Vein (Wide Area) Antrum Isolation and stay well away from ablating near the Pulmonary Vein openings.
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Treatments for Atrial Fibrillation include both short-term and long-term approaches aimed at controlling or eliminating the abnormal heart rhythm associated with A-Fib.
Doctors have several technologies and diagnostic tests to aid them in evaluating your A-Fib. Go to Diagnostic Testing ->
• Sleep Apnea: Home Testing Now Available
• A Primer: Ambulatory Heart Rhythm Monitors
• Guide to DIY Heart Rate Monitors & Handheld ECG Monitors (Part I)
• Guide to Heart Rate Monitors: How They Work For A-Fib Patients (Part II)
• Understanding the EKG Signal
• The CHADS2 Stroke-Risk Grading System
A deficiency in minerals like magnesium or potassium can force the heart into fatal arrhythmias. When you have A-Fib, a sensible starting point is to check for chemical imbalances or deficiencies. Go to Mineral Deficiencies ->
• Frequently Asked Questions: Mineral Deficiencies & Supplements
• ‘Natural’ Supplements for a Healthy Heart
• Alternative Remedies and Tips
• Acupuncture Helps A-Fib—Specific Acupuncture Sites Identified
• Low Serum Magnesium Linked with A-Fib
Medications (drug therapies) for A-Fib patients are designed to regain and maintain normal heart rhythm, control the heart rate (pulse), and prevent stroke. Go to Drug Therapies ->
• Frequently Asked Questions: Drug Therapies and Medicines
• Anticoagulant Therapy after Successful A-Fib Catheter Ablation: Is it Right for Me?
• Warfarin vs. Pradaxa and the Other New Anticoagulants
• Amiodarone: Most Effective and Most Toxic
• Research Findings: Anticoagulants for Stroke Prevention
• Watchman: the Alternative to Blood Thinners
The goal of cardioversion is to restore your heart to normal rhythm. There are two types of cardioversion: chemical and electrical. Cardioversion through the use of drugs is called chemical cardioversion. Electrical cardioversion uses a timed electrical shock to restore normal rhythm. Go to Cardiversion ->
RF and CryoBalloon catheter ablation are minimally invasive procedures that block electrical signals which trigger erratic heart rhythms like Atrial Fibrillation. Go to Catheter Ablation ->
• New Ablation Technique by Dr. Andrea Natale
• Frequently Asked Questions: Catheter Ablation, Pulmonary Vein Isolation, CyroBalloon Ablation
• Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor
• Ablation Success Rate Much Better With Weight Control
• A-Fib Research: Live Longer―Have a Catheter Ablation
• Recurrence of A-Fib After Successful Catheter Ablation
• A Cryo Ablation Primer
• Radiation Exposure During an Ablation Procedure: How to Protect Yourself from Damage
• Risks Associated with Pulmonary Vein Procedure
• The Evolving Terminology of Catheter Ablation
• Bordeaux Five-Step Ablation Protocol for Chronic A-Fib
• Bordeaux Procedures & Costs
The traditional open-heart Cox-Maze is usually performed concurrent with other heart disease treatments. More common are the various Mini-Maze surgeries which are stand-alone surgeries performed through small port-size incisions in the chest. Go to Maze, Mini-Maze & Hybrid ->
• Advantages of the Convergent Procedure by Dr. James Edgerton
• FAST Trial: Surgical Versus Catheter Ablation―Flawed Study, But Important Results for Patients
• Advances in Surgical Therapy for A-Fib by Dr. David Kess
• Role of the LAA & Removal Issues
From a patient’s point of view, this is a procedure of last resort. By ablating or eliminating the AV Node, your Atrial Fibrillation signals can’t get to the ventricles which does stop your heart from racing and improves your Quality of Life. But you must have a permanent pacemaker implanted in your heart for the rest of your life to replace your AV Node functions. And what’s worse, you still have Atrial Fibrillation. Go to Ablation of the AV Node->
Pacemakers may be implanted for pacing support, or in conjunction with Ablation of the AV Node (see above). Implanting a pacemaker seems to be most helpful if you have a slow heart rate or pauses as a result of taking A-Fib medications. But be advised that pacemakers tend to have bad effects over the long term.
ICDs which shock the heart to return it to normal rhythm are not usually used in A-Fib. Some people describe an ICD shock as like a horse kicking you in the chest. Because A-Fib attacks can occur relatively frequently, repeated ICD shocks can be very painful and disruptive. Patients with ICDs often live in fear of the next shock. Most patients would rather have A-Fib than risk being shocked throughout the day and night.
When considering treatments for atrial fibrillation, you may ask,“Which is the best A-Fib treatment option for me?” This is a decision only you and your doctor can make. Here are some guidelines to help you. I’ve listed A-Fib conditions as patients might describe them. Select one (or more) that best describes your A-Fib and read your possible options. Go to Decision About Treatment Options ->
A-Fib is a progressive disease – Don’t wait – Seek a CURE as soon as practical.
I Beat my A-Fib—So can YOU!
Last updated: Monday, November 21, 2016