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Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA

A Tale of Two Ablations and Why All EPs Are Not Equal

I just received an email and O.R. (Operating Room) reports from Louis who in 2014 had a successful catheter ablation by Dr. David Wilber at Loyola in Chicago. Dr. Wilber is nationally known for both his ablation skills and experience, as well as for his research.

First Ablation with Dr. David Wilber

Dr. Wilbur’s ablation of Louis was textbook. Louis’ A-Fib terminated during his ablation procedure, which is considered the ideal outcome.

But Dr. Wilber didn’t stop there.

Dr. Wilber didn’t stop there; he found A-Fib signals coming from the Superior Vena Cava (SVC).

He used isoproterenol (IV medication) to try to induce non-PV triggers and found A-Fib signals coming from the Superior Vena Cava (SVC). He isolated the SVC and could no longer induce any arrhythmias in Louis. (Some EPs would not work that hard, and would have trouble finding and ablating non-PV triggers.)

Relocation, Then Second Ablation―Failure!

But later Louis did develop A-Fib/Flutter again. He had relocated to a distant state so he selected a second EP and had a second ablation there. This ablation was a failure.

After touching up the right pulmonary veins (PVs), the second EP used adenosine and pacing to try to induce arrhythmia signals. He induced Flutter and isolated the right atrium by making a cavo-tricuspid isthmus line. He documented bidirectional block in the right atrium, but Louis still had Flutter.

The second EP didn’t map and track down the flutter.

Rather than map and track down the source of the Flutter, the EP simply Electrocardioverted Louis and stopped the ablation at that point. Then he put Louis on the dreaded antiarrhythmic drug amiodarone.

Still in Flutter―Amiodarone Side Effects

But after the second ablation, Louis still had A-Fib/Flutter.

On amiodarone, Louis developed the symptoms of loss of weight, thinning hair, extreme dry mouth, increased hand tremors, etc. Louis was taken off of amiodarone and is doing better. But he is still bothered by Flutter. See Amiodarone Effective but Toxic.

I’m working with Louis to get him to a “master” EP, a highly skilled EP with a high success rate with difficult A-Fib cases.

What Went Wrong with Louis’ Second Ablation?

From what can be deduced from Louis’ O.R. (Operating Room) report, there seems to be no mention of checking for entrance and exit block after ablating Louis’ pulmonary veins.

As a “crutch”, he put Louis on amiodarone, the most effective but also the most toxic of the antiarrhythmic drugs.

The second EP did use adenosine and pacing and induced a Flutter circuit. He ablated the right atrium and made a cavo-tricuspid isthmus line to make sure no Flutter came from the right atrium. But Louis still had Flutter.

Instead of using any of today’s advanced mapping and isolation strategies, Louis’ EP simply Electrocardioverted him to restore him to sinus. Then he stopped the ablation.

As a “crutch”, he put Louis on amiodarone, the most effective but also the most toxic of the antiarrhythmic drugs.

All EPs are Not Equal―It May Take Work to Find the Right EP

I’m sorry to say, the second EP Louis went to is indeed listed in our directory of EPs. He has all the proper credentials and is a member of the Heart Rhythm Society. But all EPs are obviously not equal. (See my editorial, Huge Growth in Number of EPs Doing Catheter Ablations, But All EPs Are Not Equal.)

Don’t just go to the EP whose office is near you. Go to the best, most experienced EP you can reasonably find. I know it’s a lot of effort. But you have to work at finding the right EP for you.

Do your due diligence. Seek recommendations from your General Practitioner (GP) and from other A-Fib patients (see our Resources/Bulletin Boards for a list of online discussion groups).

If you know nurses or support staff who work in the cardiology field or in Electrophysiology (EP) labs, they can be great resources.

Don’t rely on a single online source when researching and selecting doctors. Be cautious of all doctor informational listings you find on web sites (yes, including this one).

Be prepared to travel if that’s what it takes.

Learn How to Select Your EP

On our page Finding the Right Doctor for You and your A-Fib, we take you step-by-step to finding the right EP for you and your treatment goals.

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