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Failed ablation, what next?

Heart Rhythm Conditions | Last Active: Oct 1 8:47am | Replies (21)

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Thank you, Gloaming for your detailed reply. My doctor ablated the pulmonary veins and he said that he ablated the back wall because he saw some scarring there. In the procedure's chronological log it is written "intracardiac EP 3D mapping was performed and EP comprehensive evaluation with induction of Arrhythmia with left atrial recording". So whatever that exactly means...

Years ago (I had RF ablation in 2004 for Aflutter) the doctor must have injected something to try to induce the aflutter, my heart wouldn't stay in aflutter for long, so he didn't see much)... but no aflutter for over 20 years after that RF ablation. I wonder if my current EP doctor likes doing the new PFA and knows that he'd have to use RF on me for better results?

I consulted with an EP in 2023, before PFA was being used in his facility and that EP (at a teaching hospital) said, ideally, he'd like me to be in AFIB going into the procedure so he can see what's going on. I was in my first AFIB episode that I couldn't convert on my own, while sitting in his office! That's when I became persistent after about 16 months of being paroxysmal. Here I am 28 months later, three electric cardioversions later.

I wonder if my current EP doctor just likes doing the new PFA and knows that he'd have to use RF on me, in different areas of the heart, to get better results? Thanks again for all the information you've given me. I'll be better able to ask the important questions at my next appointments.

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Replies to "Thank you, Gloaming for your detailed reply. My doctor ablated the pulmonary veins and he said..."

PFA is safer for the patient, and it normally doesn't require a TEE to ensure the energy isn't likely to damage the phrenic nerve and the esophagus, both of which run right behind the left atrium's outer rear wall. So, less to go wrong, less to do. It's effectiveness at 'success' is statistically insignificant at the moment between it and RF ablation. That may change, though, as more and more EPs become trained, acquire the equipment, and gain experience. It may be substantially better than RF, all things considered...just not at present.
A conscientious EP will challenge the heart in order to start AF or flutter so that he can map the rogue cell locations and zap them. They do use at least two chemicals, but even intravenous caffeine will do if nothing else. The two preferred are adenosine and isoproterenol. But more than that, before they release you to Recovery, they'll repeat that challenge. In my EP's case, he also routinely cardioverts the heart, even if it has turned to NSR by the time he's ready to call me done.
As a human being, if an EP is having poor success rates with PFA, you could appreciate that he would rather default to RF, certainly after a nasty run of failed ablations. I would. But considering that the failure rate for both techniques is about 25%, I would think that PFA would not have a higher rate of failures for any one (trained) EP than RF. I may be wrong, maybe only about your EP, but I don't think so. He would probably WANT TO do PFA because it presents less risk of damage to you on that basis alone.
If it helps, cardioversions have never worked for me. I know an aged woman who has had 50. !!! Obviously, none of them worked for her for more than a month or two. My longest lasting one was a whopping 16 hours. My first ever cardioversion never did work. To add insult to injury, I came to just as the tech pressed the button for the third, most powerful, jolt. That was NOT fun.
If you look for Dr. Lee's video channel on YouTube, and search for a recent one, 'Why do catheter ablations fail,' he goes into some detail about what is happening in the more complex cases and why some EPs are simply not experienced and/or skilled enough to do the job. So, if you have means and can afford to skip around looking for the very best EPs (that I have heard of in the USA, I'm Canadian), then you need to get in line behind Dr. Andrea Natale at the Texas Cardiac Arrhythmia Institute in Austin, or Dr. Pasquale Santangeli at Cleveland Clinic. They're worth the wait. Note that Natale has privileges in several mid-western and western hospitals, especially in CA. He often travels to them to perform in-situ operations for patients who can't travel much.
One last thing that I didn't get to, but as an afterthought: as it was in my case, sometimes the lesions created in a first PVI do not close properly against each other to create a contiguous 'dam' of fibrosis (over which the electrical impulses cannot pass, so no more AF!). If there is a sufficiently large, and clean, gap, those signals can escape the pulmonary vein ostia and do their worst. So, maybe a re-do of that simple and initial ablation is all that's really needed for you. Maybe. Your persistent category of AF doesn't bode well for that simple remedy, unfortunately, but with no experience as an EP, I can only guess. I think the EPs often redo the 'dam' of scarring, maybe using RF this time, and if the heart lurches back into NSR, then it's all done. Happened exactly that way for me on my second ablation, same EP. He was working around the third pulmonary vein when my heart suddenly resumed NSR as he did one zap. They stood back, watched, hi-fived, and he said he didn't even work on the fourth vein. He didn't even cardiovert me, which is his normal practice. He knew he had found what he'd missed the first time. As I said previously, I'm into my 30th month and going strong. Called his office on the first anniversary and introduced myself to Crystal, and said why I was calling, she actually laughed. I wanted them both to know how important their respective skills were to me.