US Centers performing the Hybrid Surgery/Ablation Procedure

When your family doctor first suspects you have A-Fib, they will probably send you to a cardiologist, a doctor who specializes in the heart.

The cardiologist will probably put you on different medications (called Drug Therapy) over the next six months to a year or more to see if any of these medications will stop or control your A-Fib. But current A-Fib medications are not very effective and often have bad side effects.

In addition, time is of the essence in treating A-Fib. The longer you wait, the more your A-Fib may “remodel” your heart (i.e., change it physically and electrically). Drug therapy may not be the best option for you.

 HOW TO START YOUR SEARCH

To seek treatments beyond medications, you may need to change doctors.

You should see a cardiac Electrophysiologist (EP)—a cardiologist who specializes in the electrical activity of the heart and in the diagnosis and treatment of heart rhythm disorders.

To be cured of your A-Fib, you need to find the best doctor for you and your treatment goals. You need a doctor who will work with you to create a treatment plan—a path to finding your cure or best outcome.

To find the right doctor for you, start by creating a list of possible doctors to consider. Seek recommendations from your GP and from other A-Fib patients (see 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 are often a great resource.

 And use the internet. To find a local Electrophysiologist yourself, we recommend the Heart Rhythm Society website and their feature called ‘Finding a Heart Rhythm Specialist’. ‘Check’ the box “to limit the results to Fellows of the Heart Rhythm Society (FHRS)”. (EPs with the FHRS designation have been recognized by their peers and are experienced heart rhythm professionals working in the field of electrophysiology and/or pacing; see more about FHRS below).

When you type in a U.S. city and state, (or country) the site gives you a list of Electrophysiologists in your area. Check for their list of specialties (not all EPs perform PVIs; some focus on pacing/pacemakers, or clinical research, for example). Look for additional information such as which medical insurance they accept.

Unfortunately this FHRS list leaves out many younger A-Fib EPs who are doing excellent work. (We haven’t found an unbiased way of identifying these younger A-Fib doctors and welcome suggestions as to how to do this,)

Start your research with a notebook and a three-ring binder…to organize the information you will be collecting.

 Our A-Fib.com Directory

This A-Fib.com Directory of Doctors and Facilities is an evolving list of the physicians and medical centers in the U.S. and internationally treating patients with atrial fibrillation. It is offered as a service and convenience to A-Fib patients.

In addition, I’ve compiled several rosters of doctors by specialty called ‘Steve’s Lists’.

For a list of EPs with the FHRS credential listed by state and city, see Steve’s Lists: Doctors by Specialties and more specifically, US EPs with FHRS-designation Performing A-Fib Ablations by US State/City.

We strongly encourage you to get in the habit of keeping a copy of every test result you get in your three-ring binder. Don’t leave your doctor’s office or hospital without a copy of every test they perform. Or if the test result isn’t immediately available, have them mail it to you.

 Organize Your Research

To find the right doctor to cure your A-Fib, start your research with a notebook and a three-ring binder or a file folder.

You need to organize the information you will be collecting: printouts of information from the internet, copies of documents from your local public library or medical center library, notes from phone calls, and answers to “interview” questions during doctor consultations.

Obtain Copies of Your Medical Records, Tests, and Images

Your 3-ring binder, or file folder is also where to collect copies of all your lab tests, doctor visits, etc.

We strongly encourage you to get in the habit of keeping a copy of every test result you get in your three-ring binder. Don’t leave your doctor’s office or hospital without a copy of every test they perform. Or if the test result isn’t immediately available, have them mail it to you.

If you need to request copies of some medical records, read our article, How to Request Copies of your Medical Records. We give you three ways to request your medical records from your doctors and medical providers.

Later, when you are ready to interview new doctors, you will want to send each office a packet with your medical records, test results, and images or X-rays. When you arrive at the EP’s office, make sure they have indeed received your up-to-date medical records. As a back-up, bring your own three-ring binder with the originals.

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 Researching Doctors and Centers

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). Doctors may be listed or appear most prominently because they pay for that privilege (but not so at A-Fib.com).

Don’t depend entirely on the typical doctor informational websites or online directories. A doctor with a good lawyer can keep their name free of sanctions and board actions. And the patient surveys on these sites aren’t very scientific and lend themselves to manipulation (one can get friends or paid people to respond to the survey). Consult several sites.

Please bear in mind than not all EPs perform and have sufficient experience in Pulmonary Vein Ablation. See my “Choosing the Right Doctor: 7 Questions You’ve Got to Ask” page and my list  Doctors/Facilities/Steve’s Lists/EPs Performing Pulmonary Vein Ablation’ to help find the right Electrophysiologist for you.

Over the last several years there has been an astounding and welcome growth of US centers and doctors who do Pulmonary Vein Isolation (PVI) procedures. But some are low volume centers with limited facilities and training who may do as little as 20 PVAs a year.

It’s tough to quantify experience with specific numbers. But if a doctor only does 20 PVAs a year, that may not be enough to maintain and develop ablation skills. A typical experienced EP does over 50 PVIs a year. For more see our article, Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor.

 How to Find the Information

You must do your own homework. To narrow down your list of prospective doctors you will want to scrutinize their credentials. You’ll be looking for information such as:

• Where did they attend medical school?
• Where did they do their residency program?
• What board certifications have they received?
• What are their hospital affiliations?
• Where and from whom did the doctor receive special training to treat A-Fib?

On the negative side:

• Have they lost privileges with any hospitals?
• Have they been sanctioned by any medical entity?

To research each doctor, consult the internet or your local library. The following online resources may be helpful.

• The Heart Rhythm Society ‘Find a Specialist’ online searchable directory; Also: includes the doctor’s specialties, insurance accepted, and more
• The American Board of Medical Specialists (ABMS) Directory of Board Certified Medical Specialists
• The American Board of Internal Medicine. http://www.abim.org/services/verify-a-physician.aspx; to check on a doctor’s certification
• The Cardiothoracic Surgeon’s Network Directory of Surgeons
• HealthGrades, Vitals, and RateMDs: independent healthcare ratings organizations which provides physician’s profile, education, awards & recognition, insurance accepted, hospital affiliations, and malpractice and sanctions. But be aware that these sites usually don’t review a doctor’s competence.
• Online discussion groups and forums; read what other A-Fib patients have written about specific doctors. (see Resources/Bulletin Boards.)
• FindACase™ http://co.findacase.com

 Create Your ‘Short’ List

Narrow down your list to the top three-to-five doctors. The next step is to get specific information from each doctor or their office personnel (call their physician assistant, nurse practitioner or office manager). Hint: you get better service if you ask for a specific doctor by name or for their physician assistant or nurse. (When you call, sound like you know the doctor.)

Note: some EPs have a “referrals only” policy, which means they won’t talk to you directly. You have to be referred by a cardiologist or a family doctor.

Gather the following Information about each prospective doctor:

1. How long have you been performing Pulmonary Vein Ablation for my type of A-Fib? How experienced are you with RF and/or Cryo? How many procedures do you perform a year?
2. What is your success rate with PVI/PVA? How do you define ‘success’? (No A-Fib and drug-free, for example.)
3. What kind of complications have you had? What kind of precautions do you take to prevent complications like Atrial Esophageal Fistula?
4. What kind of A-Fib ablation procedures and equipment do you use? What would you use for my type of A-Fib? 
5. Do you refer patients to surgeons for a Cox Maze or Mini-Maze operation?

Most doctors and centers will welcome these questions and respond frankly to you. If they don’t, that may be a sign you need to look elsewhere. For a list of specific questions to ask doctors and how to interpret their answers, see my Questions for Doctors page.

Be Cautious: information from the doctor or their practice is ‘self-reporting data’. There is no independent entity to verify the doctor’s or their office’s responses to you. If it sounds too good to be true, it probably is.

If the doctor or their office seems reluctant to give you the info you need, it might be wise to talk with another doctor.

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 Your Consultation Appointments

Select your top three doctors. Now you are ready to set up a consultation appointment with each doctor. Think of this as an interview. Don’t worry, doctors are also ‘interviewing’ you to determine if they can help you.

Send Your Medical Records Beforehand

Learn what to include in your packet of medical records. Read Why You Need an A-Fib Notebook and 3-Ring Binder and Your Personal A-Fib Medical Summary.

Before your appointment, send each doctor a packet with your A-Fib-related medical records. When you arrive at the doctors offices’, make sure they have indeed received your medical records. As a back-up, bring your own originals from your three-ring A-Fib binder.

Questions to Ask: Use Our Free Worksheet

To help you scrutinize prospective doctors, we’ve written a set of 10 interview questions to help you find the right doctor for your treatment goals. Use our free PDF download, ‘Questions for Doctors Worksheet‘, to interview and question each prospective doctor.

Download the FREE PDF and save to your hard drive. Then, print a worksheet for each doctor you interview. 

During Your “Interview”

Never go to any doctor appointment alone. Always carry a notepad and pen to take lots of notes.

Audio recording: In addition, consider using an audio recorder to help you remember things. (Most doctors don’t mind, but always ask permission beforehand.) Many cell phones can make a recording for you.

Take Along a Trusted Friend: You may want to take along a trusted friend or family member. As needed, your ‘personal advocate’ can question the doctor for you and verify your list of questions have been answered. Afterwards they can help you evaluate the doctor’s answers, discuss anything that’s unclear and comment on the doctor’s demeanor.

Afterwards: How to Interpret the Answers You Received

Back home, compare answers and your notes about each doctor. To ‘interpret’ the doctors’ answers, see our article, “Choosing the Right Doctor: 10 Questions You’ve Got to Ask (And What Their Answers Mean)“.  We’ve included the various responses you might receive, and what each response means to you when searching for the right doctor for you and your treatment goals.

Your relationship with your doctor is important. Read our post: Do You ‘Like’ Your Doctor, Do You ‘Connect’?…How it Affects Your Health

Also Assess the Doctor’s Manner and Personality

You’ll also want to assess the doctor’s manner and personality. Is this someone who will work with you? Someone who listens to how A-Fib makes you feel? Does this doctor inspire confidence? Is this someone you feel comfortable with and trust with your health care?

Rudeness, bad temper, boorish behavior, etc. from a doctor, no matter how highly recommended, should be a red flag for you. That kind of behavior is not just personally offensive but can be dangerous for your health.

Gender bias: Does he/she respect you? Women in particular should be wary of condescending behavior. “It’s all in your mind.” “Take a Valium.” Women in the US often don’t receive the proper diagnosis and treatment of their A-Fib. To read more about gender bias by doctors, read The Facts About Women with A-Fib: Mother Nature and Gender Bias—Or—Get Thee to an EP ASAP/

Does the poor behavior also extend to how the doctor treats his staff? Patients of doctors “who don’t show respect for their medical staff have much higher rates of adverse effects, than patients of their more congenial colleagues.” “As a patient, you’re also a member of the health-care team,” explains Gerald B. Hickson, MD of Vanderbilt University Medical Center.¹ If your doctor is condescending or dismisses your concerns, you’re getting poor care. If a doctor is too busy to talk with you and answer your concerns, he’s probably too busy to take care of you properly.

But do give the doctor a break. They may be having a bad day or may have heard your questions too many times before. So, say something, speak up! Or contact the patient-relations representative at the heart center. They want to know if a doctor is rude (those patients are more likely to sue!). Once a doctor’s bad behavior is called to his attention, they are likely to do better. And so will you.

Overview of All of Treatment Options

 Treatmant Option: Catheter Ablation

A Pulmonary Vein Isolation Ablation PVA/I is the most challenging, demanding and complex catheter ablation an Electrophysiologist performs.

But surprisingly, no specific certification is required. Any EP is allowed to do PVIs. When doing your basic research, make sure the EP has obtained “Clinical Cardiac Electrophysiology” Certification. It’s surprising how many EPs never pass this exam but still do PVIs. Certification in “General Cardiology” or “Internal Medicine” are more basic and not what you’re looking for.

Patients are advised to consider the more experienced EPs in the PVI field. One indicator is the credential “FHRS” after a doctor’s name. A Fellow of the Heart Rhythm Society (FHRS), is an EP certified by the American Board of Internal Medicine (ABIM) in clinical cardiac electrophysiology (CCEP), has letters of support from current FHRS members, and has been vetted by the HRS Membership Committee. Learn about FHRS designations.

According to the Heart Rhythm Society:

“The FHRS designation distinguishes members among health care providers for their specialization in electrophysiology, clarifies the referral process, and serves as a credential for quality care for patients, media and government. FHRS members are characterized by advanced training, certification, and prominence in research.”²

Since Pulmonary Vein Ablation (Isolation) is a relatively new procedure, select facilities and doctors who are more experienced with it. For more, see our article, Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor.

In this author’s opinion, although certain centers and doctors are more experienced than others, there is no first and second tier of A-Fib doctors. In general, Electrophysiologists performing Pulmonary Vein Ablation (Isolation) are highly trained, experienced and technically gifted. Your chances of being cured by a PVA(I) are very good at most A-Fib medical centers.

 Steve’s Lists: Electrophysiologists Performing Catheter Ablation Procedures

For a list of cardiologists doing Catheter Ablation procedures, see Steve’s Lists/US EPs with FHRS-designation performing A-Fib ablations by US State/City.

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 Treatment Option: Maze or Mini-Maze

After your consultation, your Electrophysiologist may recommend a Cox Maze or Mini-Maze operation for your A-Fib. Your EP will probably recommend a short list of surgeons. You will conduct the same research for finding the right surgeon as you did for finding the right EP. Unfortunately, we’re not aware of a database that lists A-Fib Surgeons by geographic area, except for the list on A-Fib.com (see Steve’s Lists/Surgeons Performing Cox-Maze and Mini-Maze Operations).

Caution: Any surgeon is allowed to perform a Maze and Mini-Maze operation, but not all have a great deal of experience doing it. There are currently no training courses or certification exams specifically required for Maze and Mini-Maze surgeries. (The same is true to some extent for catheter ablation.)

A study from the Un. of Michigan found that surgical death rates are directly related to experience with the particular operation being performed. You are four times more likely to die if your surgeon performs your operation only rarely, compared to a surgeon who performs it regularly.³ Ask your surgeon or his office how often he performs the Maze and/or Mini Maze. Call other doctors in this field to see how often they perform Mazes. Be cautious about a surgeon who performs Maze operations far less than the average.

If a surgeon specializes in exactly your condition and if 50% or more of his practice relates to your type of A-Fib, they may be a good choice.

It’s hard to establish a specific number that indicates sufficient experience and skill level, but here’s an example that may help, The death rate after pancreas surgery is 14.7% for surgeons who average fewer than two operations a year. It is 4.6% for those who do four or more. A survey done by the New York State Department of Health found that hospitals with surgeons who did relatively few operations had patient-mortality rates that were four times higher than the state average.⁴

Steve’s Lists: US Surgeons Performing Maze and Mini-Maze Operations

For surgeons performing Maze/Mini-Maze operations, see Doctors & Facilities/Steve’s Lists Doctors by Specialties and more specifically, US Surgeons performing Maze and Mini-Maze operations.

 Other considerations: Surgeons vs. EPs

You may also want to consider the mind set and attitudes of Surgeons vs. Electrophysiologists.

Keep in mind: a surgeon’s primary concern is in performing a successful operation, whereas EPs have devoted their careers to dealing with heart rhythm problems. The EP’s primary concern is creating a ‘treatment plan’—an organized path to finding your A-Fib cure or best outcome.

In an ideal world, a surgeon would work with and consult with an EP, especially if the surgery didn’t work. But, with certain exceptions, that generally isn’t the case today.

The Hybrid Surgery/Ablation

For more about surgeons and EPs performing procedures together, see our Treatments/Maze/Mini-Maze/Hybrid Procedures page.

You may also want to read: Advantages of the Convergent Procedure by Kiser/Mounsey, and Boston AF 2011/Edgerton “Hybrid Ablation (Combining Surgery with Catheter Ablation) for Persistent A-Fib“.

 Additional Readings

• Physician Credentials and Acronyms: What They Mean for Atrial Fibrillation Patients
• How to Request Your Medical Records: Instructions and a sample letter (for US patients)
• Pre-visit Appointment Worksheet: From American Heart Association (www.heart.org)

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 Return to A-Fib.com Where to Start

Last updated: Tuesday, December 6, 2016