EP Question

I just took care of a pt last night who had an atrial flutter ablation, but did not have a pacemaker put in. We don't see a great deal of ablation patients.

AV node ablations are pretty common, and we do it maybe 2 times a week. We usually reserve it for people who haven't responded to medical therapy or ablation AND who are totally miserable. We can usually do it in less than two hours, and it really takes more time to put in the pacemaker than to do the ablation itself.

This is different from flutter ablations or a-fib ablations. Neither of those require a pacer and you are really trying to fix the problem with these.

AV node ablations are pretty common, and we do it maybe 2 times a week. We usually reserve it for people who haven't responded to medical therapy or ablation AND who are totally miserable. We can usually do it in less than two hours, and it really takes more time to put in the pacemaker than to do the ablation itself.

This is different from flutter ablations or a-fib ablations. Neither of those require a pacer and you are really trying to fix the problem with these.

Thanks for the info. You stated that it's reserved for pt's who've not responded to meds or ablations....Does this mean that the majority of the '2 a week' patients that you do have had but 'failed' ablation attempts?

Some people have an arrhythmia that wasn't ablatable, so we do an AV node ablation if medications don't control their symptoms. Does that make sense?

Some people have an arrhythmia that wasn't ablatable, so we do an AV node ablation if medications don't control their symptoms. Does that make sense?

Yes it makes complete sense. So, according to you, some (apparently 'many') a-fibs are considered incurable with ablations...(as evidenced by your doing 2 avn-ablations a week...)).

I've an interesting article by the head of EP at Northwestern Memorial Hospital in Chicago (Alan H Kadish MD) in which he states that the high-percentage of curable (ablatable) a-fibs touted by lots of studies is misleading because the patients selected had certain 'type' of a-fib (ie lone a-fib in younger adults)...and because long-term follow-up studies have not been done.

Your statements would support this...

Also, he mentions that because an AF ablation is technically much trickier/more difficult (left heart circulation, septal-wall puncture, etc.) and has a higher percentage of complications than tradtional (right heart) ablations, medical treatment of symptomatic AF is still the standard.

As an aside, one of the EP-docs at my place of employment mentioned that the reason AF-ablations arent routinely done outside of University/teaching-type centers is because the procedure is difficult, very time consuming, and not always successful. (in my opinion it's because if he were doing these LONG cases he'd be bringing in less $$$...but thats just me :) ).

Thank you so much for answering my questions!

It's funny that you mention the reimbursement for the a-fib ablations. I think you're right. EP is not (entirely) beyond the "move the meat" mentality. Yes, the A-fib ablations are out there for some patients. It's a difficult thing to do. Many EP docs don't know how to do a transeptal puncture or don't want to do one. It can be quite dangerous.

We do A-fib ablations, but we have to spend 4-5 hours doing one. They're a pain, but we're getting better at them every week. They're time-consuming, high-risk procedures, where an AV node ablation takes less than half the time (including the ppm implant).