Atrial Fibrillation
 RESOURCES FOR PATIENTS

QUESTIONS FOR DOCTORS

    Not all Electrophysiologists perform 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:

1. Q. "What treatments do you recommend for curing my A-Fib?"
       If the doctor only talks about different medications, you should probably talk to other doctors on your list. The best results today in curing A-Fib are being achieved using a nonpharmacological procedure called Pulmonary Vein Ablation (Isolation).
    
2. Q. "Do you perform Focal Catheter Ablation or Pulmonary Vein Ablation for 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 Focal Point 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. Unless you have a Sinus Node problem and need a pacemaker, you should probably talk to other doctors on your list. 
       Response #3. "We make circular RF lesions (cuts or scars) around the pulmonary veins to isolate them from the rest of the heart."
       This response indicates this doctor and/or medical center is both knowledgeable and experienced in Pulmonary Vein Ablation of A-Fib. However, it is difficult to make circular lesions around the four left atrium pulmonary veins. If there is a gap in the lesions, you may still have A-Fib.
       The success rate with circular lesions isn't as good as with other procedures, but you still have a good chance of being cured.
       Response #4. "We use linear lesions to create anatomical barriers to prevent A-Fib impulses from spreading throughout the heart."
        Creating continuous linear lesions in the left atrium is even more difficult than creating circular lesions, because of the hills and valleys in heart tissue. Currently there is a greater risk of medical complications with linear ablation because it's a much more extensive procedure.
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       Response #5. "We use Segmental Ablation to eliminate A-Fib." Or, "We use Circumferential (Empirical) Ablation to eliminate A-Fib."  Or "We use Anatomically Based Circumferential Ablation (also referred to as Left Atrial Ablation) to eliminate A-Fib."
       "Segmental," "Circumferential," "Anatomically Based Circumferential," and "Left Atrial" are refinements or different techniques of what is called Pulmonary Vein Ablation (Isolation). 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 (Empirical) Ablation a circular catheter is used to ablate all four pulmonary vein openings. Though this author believes that "Segmental" is slightly better than "Circumferential" from a patient's perspective, you stand a good chance of being cured using either technique. (See PVA (PVI).) "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 Pappone "Anatomically Based Circumferential Ablation" procedure may be responsible for isolated cases of Atrial Esophageal Fistula in which a high wattage catheter burns a hole from the heart to the esophagus which can result in death. If your doctor uses this procedure, ask him what steps he/she takes to prevent burning a hole in the esophagus.
       Response #6. "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 using Focal Catheter Ablation of A-Fib which was the first procedure used to ablate A-Fib. (See PVA (PVI).) However, most centers today use either Segmental or Circumferential 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.
    
3. Q. "How long have you been performing Pulmonary Vein Ablation of A-Fib? How experienced are you in it?"
       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 experimental stage. There are several medical centers that have been doing Pulmonary Vein Ablations for years and have done hundreds of Pulmonary Vein Ablations (see Facilities).
    
4.   Q. "Have you had any problems with swelling of Pulmonary Vein openings?" "How do you monitor for swelling of the Pulmonary Vein opening (called "PV Stenosis") after ablation?"
       Some heart centers have had problems with PV Stenosis. If the openings of the pulmonary veins into the left atrium swell, narrow and close up because of catheter ablation, this restricts blood flow from your lungs to your heart. This could lead to fatigue, flu-like symptoms, and pneumonia.  If this doctor/heart center doesn't monitor for this type of swelling or doesn't keep records of results, you should talk to other doctors on your list.

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