Atrial Fibrillation - Questions for Doctors

QUESTIONS FOR DOCTORS

Not all Electrophysiologists perform Female Doctor with Clipboard and have sufficient experience in Pulmonary Vein Ablation (Isolation). Here are questions to ask in order to find the right Electrophysiologist. Also included are possible responses and how to interpret them:

"What treatments do you recommend for treating my 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 A-Fib. The best results today in making people A-Fib free are being achieved using a non-pharmacological procedure called Pulmonary Vein Ablation (Isolation)
"Do you perform Catheter Ablation for my type of A-Fib? What type of Catheter Ablation procedure do you use or prefer?"
    Here are some of the responses you may hear and what they might indicate.
    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 leave 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.
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    Response #3. "We use Segmental Ablation to eliminate A-Fib." Or "Circumferential Ablation." Or "Anatomically Based Circumferential Ablation (also referred to as Left Atrial Ablation or the Pappone technique)." Or "Pulmonary Vein Antrum Isolation (PVAI)."
    "Segmental," "Circumferential," "Anatomically Based Circumferential," "Left Atrial," "Pulmonary Vein Antrum Isolation" are refinements or different techniques of what is called Pulmonary Vein Ablation (Isolation). You stand a good chance of being made A-Fib free using each technique. (See PVA (PVI).)
    In Segmental Ablation, mapping techniques that identify Pulmonary Vein Potentials are used to find the sources of A-Fib pulses and ablate them. Usually all four Pulmonary Vein openings are ablated.
    In Circumferential Ablation a catheter is used to encircle all four pulmonary vein openings to isolate them from the rest of the heart. Circumferential Ablation is probably the most used strategy today.
    "Anatomically Based Circumferential Ablation" (also called "Left Atrial Ablation") creates blocking lesions in the left atrium similar to "Circumferential" ablation above. But instead of trying to make continuous, perfect linear lesions, a large diameter catheter at a high wattage is dropped and dragged to make the circular linear lesions. There may be gaps left in these lesions which may result in Atrial Flutter. But over time scar tissue usually closes these gaps (see Morady and Pappone). (Please be advised that the "Anatomically Based Circumferential Ablation" procedure may be responsible for isolated cases of Atrial Esophageal Fistula in which a hole forms between the atrium and the esophagus, often resulting in death. It is presumably caused by the use of high wattage catheters during catheter ablation procedures to fix A-Fib. If your doctor uses this procedure, ask him what steps he/she takes to prevent causing a hole to form in the esophagus.)
    In "Pulmonary Vein Antrum Isolation" instead of making encircling lesions around each of the pulmonary veins, wider ablations encircle each of the two left and two right pulmonary veins in the Antrum area around the veins.

    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. Normal heart beats come from the sinus node, not the pulmonary veins.) This response indicates the doctor and/or medical center is targeting (focusing on) specific spots generating the A-Fib signals. This is called Focal Catheter Ablation and was the first procedure used to ablate A-Fib. (See PVA (PVI).)
     However, most centers today use Circumferential or Segmental Ablation (Pulmonary Vein Ablation) to ablate or isolate all four Pulmonary Vein openings. If the A-Fib persists, then they try to locate the 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 is a new FDA-approved technology (December, 2010). In clinical trials it has proven effective, safer, and faster than the various types of RF ablation. See FDA APPROVES CRYOBALLOON ABLATION CATHETER and Cryoballoon Safer than RF
    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.
"What is your success rate?"
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.
"How long have you been performing Pulmonary Vein 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. But if the doctor says he/she has only done 20 Pulmonary Vein Ablations, he/she is probably still at the "training" stage or has just passed their certification. At a minimum, electrophysiologists should perform 100 procedures a year. If the doctor only does a few PVAs a year, that may not be enough to maintain and develop ablation skills.
There are several medical centers that have been doing Pulmonary Vein Ablations for years and have done hundreds (or thousands) of Pulmonary Vein Ablations (see Facilities). An active center does 300+ ablations a year.
"What kind of complications have you had?"
    Every A-Fib doctor has had some complications when doing Pulmonary Vein Ablation (Isolation) procedures. A PVA(I) is considered a lower risk, less invasive procedure then, for example, open heart surgery, but it is not risk free (See: PVA(I) Risks).
    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 (blood leaking into the Pericardial Sac around the heart, 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.
"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. For example: using an imaging and ablation 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 may aid in more precise placement of lesions or ablations.

    Damage to the esophagus during an ablation (called Atrial Esophageal Fistula) is a very rare (1/1000+) complication, but is often fatal. Heat from the RF catheter damages the esophagus which lies just behind the heart. Gastric acids, over 2-3 weeks after an ablation, can eventually eat through this weakened area of the esophagus. Most doctors and medical centers now take precautions to avoid this damage, including prescribing Proton Pump Inhibitors for 2-3 weeks after an ablation to prevent gastric acids from causing that damage.
    When you ask how doctors protect 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 hear answers like these, especially about taking Proton Pump Inhibitors after an ablation, it might be wise to talk with other doctors. (thanks to Sharon Zahnle for this question about Esophageal Fistula.)
Q. "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 to reject him. They may be concerned about a loss of quality control if they send patients to someone not formally trained in the field.
    (EPs and Surgeons are not really competitors for the same patient base. There are so many new cases of A-Fib each year---over 340,000 new cases in the US,¹⁴⁶ that EPs and Surgeons combined can only treat a fraction of the people developing A-Fib.)
Q. (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.
However, you may not find many Electrophysiologist who specialize in women's heart health.

Disclaimer: the authors of this Web site are not medical doctors and are not affiliated with any medical school or organization. The information on this site is not intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health professional prior to starting any new treatment or with any questions you may have regarding a medical condition. Nothing contained in this service is intended to be for medical diagnosis or treatment.

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(This page last updated 1/03/11)