Afib Master Class with Dr. Eric Prystowsky — Catheter Ablation
January 30, 2019
- Summary: Watch this complimentary Afib Master Class on catheter ablation featuring world-renowned electrophysiologist Eric N. Prystowsky, MD
- Reading time: 1 minute
Discover some of the considerations your doctors make when deciding whether an ablation procedure should be part of your treatment plan, including the concept of whether there is a “window of opportunity” to have a successful ablation, and what your other options might be. Dr. Prystowsky shares his insight on how to choose a provider if you and your doctors decide an ablation is right for you. Finally, he shares his insights on the important and influential CABANA Study and its implications for people living with afib.
Note: If you haven’t heard of the CABANA Study, or have heard of it but aren’t sure what it means, we encourage you to watch the videos about it. Its implications may have an impact on what you discuss with your doctors as you develop your treatment plan.
How Do You Know When to Consider an Ablation Procedure?
[00:10] In the rhythm control portfolio, you have drugs, and you have ablation. Years ago, we made it clear (and I was part of this; I was on the initial guideline writing committees), the data on catheter ablation was in its early years. We didn’t feel there were enough data to support as a first line option. When we say first line option, we don’t mean you need to do an ablation. We mean, it’s part of your initial choice of therapies. But, there are substantial data published now, to in my own opinion, and I think of many of the current guideline writers, that if you have a center that does good volume, good results with ablation, it should be in the mix, and it should be part of the initial discussion with the patient.
[01:02] So, let’s say having said all that, the patient says, “I like that. Thanks, Dr. P, I want to try that flecainide.” That’s fine. Have your flecainide.
[01:11] You know, in three months, they come back in the office. “How you doing?”
[01:14] “Well, you know, I’ve been having a lot of episodes. And, you know, I’m already taking it. I’m already getting a little side effects, a little dizziness. I don’t really want to go up on the dose.”
[01:22] Well, then you have a choice to make. Either, they stay miserable, which is to me not a good choice, but it is the patient’s choice if they want. Usually, that’s not a choice. Let’s try a different drug, or let’s move on to ablation.
[01:35] If somebody comes out, let’s take that same patient, and now every year I see him twice a year. They’ve been on 100 milligrams of flecainide twice a day, zero side effects, feeling great. Now, it’s three years later, and they’re coming to see me. I never tell the patient, “You know what? You ought to move onto an ablation.”
[01:55] That is, to me, inappropriate. I’m not saying you couldn’t do it. I always remind patients they still have another option, if they so choose. And, then if they say, “Well, is there a reason I should do it now?” My answer is no. I mean, if a patient is tolerating a drug, and it’s effective, there is no reason that they have to go on to an ablation.
[02:17] I think ablation is a patient’s choice more than a doctor’s choice. That’s a personal opinion. I always offer it. I mean, sometimes, I will say, “Look, we’re getting to a point where I think you need to consider ablation because your only choice is amiodarone, and you’re 55 years old. Do I really want you taking amio for years? Not really. I think that the better choice there for you is to consider an ablation.” So, ablation can be up front.
[02:44] I have a patient recently who saw me, who’s an athlete. Now, I’ll promise you, an athlete is not going to take drugs. Okay, end of story. They never take drugs. They don’t want beta blockers; they don’t want any drugs. I mean, even anticoagulants are a struggle with athletes, and they sure as heck don’t want antiarrhythmic drugs. I mean, his rate in my office was 45. Okay. He’s fine. Any drug I give him is going to lower it, and he’s set up for an ablation. There’s no question, those kind of folks just need right to the ablation lab.
[03:13] So, I think it’s an individual thing. But, if you’re not doing well on the drug, either effectiveness or side effects, move on to ablation. That, I think, is an easy path for a patient. If you’re doing great, with no side effects, and great efficacy, if you want to get off the drug and take an ablation, fine. If you don’t, then don’t. I think there’s no compelling reason to do an ablation.
Is There a Window of Opportunity to Have a Successful Ablation?
[00:10] One of the most disheartening consults I get is the following: 64-year-old gentleman comes in to see me. He’s been in atrial fibrillation, by his reckoning, at least four to five years. We’re not exactly sure. Yeah, he has some symptoms. He’s been a little fatigued, and he’s getting a little worse. Right. Okay. His wife tells me, “By the way, you know, he’s not remembering as much.”
[00:38] And, he says, “You know, Dr. Prystowsky, the reason I’m coming to see you is I know you guys have a big ablation center. I need to be ablated.”
[00:44] Okay, so then you say, “You’ve had four-plus years of constant atrial fib.” I know right away what I’m going to get into. I can bet money his left atrium is dilated and fibrosed, which is going to make any ablation much, much harder to do. And, then you go get your studies. You get either an MRI, or you get echo[cardiogram]s, and it confirms everything. And, then you just have to be honest with the patient, and say, “Look, I’ll do it because drugs almost surely won’t work, but you need to know a single procedure success rate is low. If somebody told you it was 60 percent, either they were drinking something they shouldn’t have been drinking, or they’re just trying to build business, but they’re not telling the truth. Okay?” You don’t get a 60-percent one-procedure success with somebody who’s been in afib for four-plus years, and has a huge left atrium.
[01:36] So, prevention is the issue. Do not let somebody stay in afib four years. If they don’t want sinus rhythm, and you’ve had that discussion four years ago, fine. I think they made a decision.
[01:51] This is why every patient who has afib needs to see some specialist early on to figure out what their options are now and in the future. Atrial fib is a lifelong disease for most people. Okay? And, therefore, decisions made today will affect your life for decades, sometimes, to come. So, try to avoid that situation.
[02:17] We’re happy to try the ablation, if you go into it, eyes open, realizing that we have a likelihood of success that’s low. Some patients will say anyway, that’s fine. That’s okay. As long as we’ve been honest with the patient, we’ll do it. But, once the patient realizes what they’re up against, sometimes they just say, “You know what? Forget about it.”
[02:36] But, you don’t want that to have to happen. That could have all been avoidable if the patient had this discussion four years ago.
What Are Other Options Besides a Catheter Ablation?
[00:10] Let’s take a patient who’s had years of afib with an enlarged left atrium, with a clear-cut reduction in success rate with a routine catheter ablation, no matter which technique you like to use. There are alternatives if they really want to get more aggressive.
[00:25] There are surgical procedures. There’s a mini maze, or there’s a hardcore get-in-there and do a regular maze procedure.
[00:32] But, I want to tell you something with these patients. I’ve had some of the patients say, “I want to do the surgery.” Surgeons often don’t see them back, and they quote very high success rates. I’m here to tell you their success rates aren’t that high in those patients because I see them back after they’ve gone through an atrial reduction procedure and lines all over the atrium, you know, sliced and diced and the left atrial appendage removed, which is great to have them do, for sure. And, then they come back and see me a couple months later, and they’re either in atrial fib or in atrial tach.
[01:06] It’s just hard. I don’t care what technique you use.
[01:09] But, again, it’s all about patient education. Patients should know there are alternatives. If you have a competent surgeon who can help them, they should talk to them, but they should be honest discussions.
[01:20] Again, maybe other groups are seeing much better success. But, in my experience, you have someone who’s been in long-time atrial fib — they just have scarred-down dysfunctional atria — and they’re very hard to cure, no matter what technique you use.
How Do Patients Select the Right Provider for a Catheter Ablation?
[00:10] Patients will, not infrequently, come see me just as a second opinion regarding ablation. If they’ve already decided they want an ablation, but they’re struggling with the literature on it — websites, you know, chit-chat with other patients.
[00:24] I tell you, the worst thing for me are other patients, because if another patient had a good result with whatever that procedure was, that’s all they talk about. “You must have a cryo. You cannot have anything but a cryo.” You meet somebody else who didn’t have a good cryo experience, and they’ll say, “Don’t ever do a cryo.” That’s all nonsense. The literature’s out there and most of these procedures, in good hands, are comparable in paroxysmal afib.
[00:52] Persistent afib is a little different animal that we’re dealing with.
[00:56] So, I would say to anybody who has decided to have a procedure (ablation) who has paroxysmal afib, don’t get hung up on if somebody does cryo or if somebody does radiofrequency. Get hung up on who’s doing it, and what their numbers are, and their success rates. And, ask them. You know, you sit there and say, “How many of these things do you do a year? What’s your success rate been? What’s your complication rate?” And, if they’re doing 20 or 30 a year, find someone else. I don’t care who it is.
[01:26] And, if they tell you they almost never get complications, find someone else, because no one’s God in this business. Okay? There’s no 100-0.
[01:37] And, I have people sent to me sometimes who have been told, “This is a no-big-deal procedure.” Guess what? It’s a big-deal procedure. I mean it has risk, it has benefits. There’s some serious complications. It is a big-deal procedure. It’s not, it’s not open heart surgery, but it’s still a big-deal procedure, and patients have to be educated on the procedure.
[01:58] Now, there are certain circumstances where I simply know that there are some better people, and not necessarily even in my group, but in the country, to do some boutique-type things. There are patients who have mechanical valves, and not everybody’s comfortable doing a patient like that. So, what you have to do is make sure that, with your situation, whoever you’re going to see has experience.
[02:23] And, if you have persistent afib — you’ve been in it a long time — sometimes, just isolating the veins isn’t enough, and that’s where you really need to get a sophisticated person.
[02:31] So, I wish I could tell you exactly what you should do. I would tell you that, sometimes, asking that question to your electrophysiologist won’t get you anywhere because, if they’re preparing to do your ablation, they’re not necessarily going to say, “Hey, Bill down the road is who you should see.” I mean, let’s be honest, you know, if you’re going to buy a Mercedes, the Mercedes dealer is not going to say, “Hey, by the way, did you check out the Porsches down the road before you buy my car?” I mean, hey, let’s be reasonable.
[03:00] But, you can find out. I mean, you can take a search. You can see some additional things. And, you could go to places like the Heart Rhythm [Society], and just make sure you get a second opinion.
[03:12] So, let’s say you’re not sure. What should you do? It’s your life, it’s your procedure, and you’re just not sure. Get a second opinion from a different group, and then compare and see what you want.
[03:24] But, above and beyond everything, make sure your operator is doing a sizable number of these every year — more than 50 a year — and has good results and good complication results.
[03:34] That’s the best I can advise you without specific instances.
What Should Patients Look for in a Doctor To Do a Catheter Ablation?
[00:10] What you want in your doctor who does your afib ablation is somebody who’s smart, who’s capable, and who has a good track record, in afib ablations. Not, like they do VT all week long and do an occasional afib. The people who do multiple afibs a week.
[00:29] So, you have to sort of take their word on it. I mean, if you ask your doctor how many afib ablations do you do a year, and they say hundreds, I mean, I don’t know. Maybe they don’t do hundreds, and maybe they had a lapse of memory, or maybe they think they’re doing hundreds. I think you have to either believe them or not. I don’t know how to verify that without getting into billing records, which you’re not going to be privy to. Right?
[00:57] And, you have to accept their results. If they say, “I have a 60 percent result success,” I guess if you say, “No, you don’t,” you have to prove that. I mean, they know what their results are.
[01:08] Be careful of the outliers. If somebody quotes you less than one percent complications and a greater than 90 percent success, I’m going to tell you to look elsewhere. I mean, would that be the one person that you lucked into that beats the entire world’s literature? Maybe. Maybe you have that one jewel at the bottom of the ocean that no one knew about, but I kinda doubt it. So, there is a lot of data out there you can look at that tells you the average success rates.
[01:39] If you’re not sure, get a second opinion. Patients will come to me. And, get it from someone who has a national profile, who has no iron in the fire that they’re trying to steal anyone’s patients.
[01:50] It’s not uncommon I get second opinions. And, I know what a second opinion is. A second opinion is not me to take over your care. Second opinion is to give you guidance. You know, sometimes patients may want to go to you. That’s not a second opinion though. It’s to give you guidance, and I kind of know who does what, you know. So, sometimes, I’ll hear them out, and if somebody has quoted a ridiculous number, I’ll be gentle about it, but I’ll just say, “You know, he must be, or she must be, the only one in the world getting those numbers. Don’t you think that’s a little strange? While I’m not going to call them a liar, that would be wrong. I just want to tell you; nobody else is getting those numbers. So, you should think about that.”
[02:30] So, if you’re not sure, ask around. There’s just no registry I know of that says Bob down the street does this many, and Billy does that many. I don’t know of any such registry. So, I guess you sort of have to take them on their word.
What Is a Fellow of the Heart Rhythm Society (FHRS)?
[00:09] One of the things you can do, and people ask me this about trying to find a good doctor in your area, is to go to the Heart Rhythm [Society] website, hrsonline.org. There’s a section on there that says “Find a Specialist,” and then you can kind of look at your area, your area code, and you can figure out kind of a geographic area you’re comfortable looking for someone. There’s codes in there; one of them is Fellow of the Heart Rhythm Society (FHRS).
[00:39] Now, I’m going to tell you that doesn’t guarantee, you know some, it’s like a stamp of approval; you know, the Good Housekeeping seal. It does tell you they have at least a certain level of accomplishment.
[00:54] They’re not going to tell you how good their hands are. They’re not going to tell you if they think through every problem right. But, they do tell you they’ve at least become a Fellow of the Heart Rhythm Society, and certainly, not everyone gets to that point. So, if you don’t know anything, you at least know that you’re dealing with somebody who’s been given a designation that says they passed a certain hurdle. And, that’s a good starting point if you don’t know anyone.
Is Radiofrequency or Cryo Ablation Better for Afib Patients?
[00:10] Probably the most common question I get. We do both of these procedures at our institution, but we do more radiofrequency (RF) than cryoablation. That’s just because of how we grew up at our place.
[00:21] Some places are sort of enamored with cryo. But, the thing you need to know is they both work in people with paroxysmal afib if done correctly, with someone with experience with the procedure. I don’t see a difference.
[00:36] Now, I’ll sometimes send a patient of mine for a cryoablation based on what I see in that patient. And, sometimes, if you held my feet to the fire and say, “Why exactly that patient,” it’s kind of a gestalt.
[00:51] But, if you said the cryo wasn’t working that day, I’d say do the RF. I don’t think there’s a difference, in my opinion. The world’s literature would tend to back that up.
[01:00] Again, both techniques are good. It’s not the technique; it’s the hands and mind behind the technique that’s going to ensure your best outcome.
What Can We Learn From the CABANA Study?
[00:10] CABANA is in the air. Okay. And, the official article isn’t published, but I know a fair amount about it for a couple of reasons, not the least of which, at the Heart Rhythm Society Late Breaking Trial section, I was asked to be what’s called the discussant, which meant I got some of the results early and was able to sort through them and think about them.
[00:38] Also, [principal investigator] Doug Packer happens to be a close friend of mine, so it’s not that he’s broken any rules, but once the CABANA was out there, he and I had a chance to talk about it in more detail.
[00:51] And, it’s an unbelievably important trial, and I’m going to tell you, hats off to Dr. Packer, who spent what a decade-plus of his life doing this trial.
[01:01] So, now CABANA is finished, and CABANA is presented. And, as with many trials, you get two sides ready to go. I don’t know why people can’t just simply accept the data and wait til the full manuscript is out. But, no, that’s not what happened.
[01:21] So, let’s talk CABANA for a second. Let’s talk the intention-to-treat analysis because this is what’s created most of the fervor. Trialists are off-the-charts upset by some of the comments that were made, what’s called secondary analyses. But, I was a discussant, and let me tell you how I tried to put it into perspective from my view as a consultant electrophysiologist who sees lots and lots of patients with afib.
[01:52] First of all, the intention-to-treat analysis, which for people who don’t know all the statistical things, means that 20 people get into Group A, 20 people get into Group B, you send them on their way. We don’t care what you do — we don’t care you never did the ablation; we don’t care that you decided to go party for four years; we really don’t care what you did. In the end of the analysis, we’re going to look at both groups, and we’re going to say, “What were the endpoints?” Even if you didn’t get the procedure done, or even if you didn’t take the drug you were supposed to, we don’t care. The intention-to-treat limb is what we’re looking at. So, if you look at that, there was no difference — statistically, no difference between drugs and ablation in major outcomes.
[02:33] Now, you can look at that as a glass half full, or as the glass half empty. I look at it, frankly, as the glass half full. For years, people have said, “Don’t do ablation. Do drugs. Only do ablation when drugs fail.” Well, how do those people now feel? Some of those people were the loudest voices out there screaming about CABANA, but they’ve been anti-ablation for years. They’re druggies, frankly, from their careers — that doesn’t mean it’s bad — I’m just saying that all their career work has been in the drug area.
[03:05] Well, let’s look at the data. If there’s no difference, shouldn’t I be able to — in my office, with any patient I see — offer upfront a choice of drugs or ablation? You’ve got to at least give me that. Okay, and that was part of what my discussion was. That major outcomes were the same.
[03:25] If major outcomes are the same, then at the very least, it should be in the initial discussion, or it’s not fair to the patients because you didn’t see one was better than the other with major outcomes. And, that’s how I’ve interpreted it.
[03:37] Now, dig deeper. I know I’m going to hear from people. This video presentation will be seen by somebody who will undoubtedly write me a negative note, or do some tweet, or whatever people like to do that don’t like what you have to say.
[03:54] But, as a doctor, and as a patient you should ask the following. “Well, how did the people actually do who received therapy, whether it be drugs or ablation?” Well, guess what, gang? The people who actually received an ablation did pretty well, okay, in many metrics.
[04:12] Now, that wasn’t the primary outcome of the study, and I’m not going to present it as such, but it’s still worthwhile information on my part. I mean, there’s a group of people who got the ablation, and they actually did well.
[04:24] And, there’s also an analysis that’s been published, been presented in the European meetings, that show quality of life was better for the ablation group than the drug group, although both seemed to do better than neither having either one of them, which supports what I’ve been yelling for years that sinus rhythm, I think, is better than rate control. I mean, that’s not the outcome of the study, but that’s one of the things I took away from this regarding symptom control, at least in this study.
[04:52] So, I’m waiting for the final manuscript to come out. So, until that time, here’s what we know.
[04:58] We know that major outcomes were similar (i.e., if you’re the patient, you should be allowed to pick either one in your treatment strategy.) Why not? They were no different as far as complications, as far as anything.
[05:11] Number two, you should know, that of the group that received ablation, actually received it, they did pretty well. They had much less afib than the drug group.
[05:20] You need to know that. What, are you supposed to hide that because it wasn’t the intention-to-treat analysis? A 10-plus year study and you’re supposed to say, “Oh, I’m only going to look at one figure?” Well, if you’re a sort of anti-ablation person, yeah, I guess you are going to hide it. If you’re the patient, would you not like to know that fact?
[05:39] Forget ablation versus drugs. Let’s say, it was a surgery on your back issue. And, let’s say you found no difference in two metrics. Okay? So, you could either do the surgery or conservative treatment. But, then they also found, but the people who got back surgery over the course of the year had less mobility problems, had less this, had less that. Do you not care to know that?
[06:04] So, I think, for the people who only want to see one figure, fine, don’t turn the page. But, for the rest of us who want to see the full dataset, I’m looking forward to the article.
What Do You Tell Patients About the CABANA Study?
[00:09] The intention-to-treat analysis in CABANA showed no difference in major outcomes for ablation versus drugs. So, now I have changed my discussion with patients. I explain CABANA to them when I see them at the first visit. And, I say, “Look, if you’re going to go rate control, I just want you to know a major study has shown these two pathways, drugs and ablation, for major outcomes were comparable. So, you should think about that if you want to pick a drug or ablation. It’s still your choice, but you should know that piece of information.”
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