Question For Cardiac Nurses

Havin' A Party!, ASN, RN · Dec 5, 2003

The Cleveland Clinic is just one of several quality facilities doing AF and flutter ablations. Think one of the pioneers (Natale) in this field has a practice there. After an EP study is done, the relevant sites (tissues and veins) are identified and zapped. Fabulous success rates are being touted.

Re: anti-coag treatment: I was referring to patients without underlying cardiac risk factors (heart failure, hypertension, diabetes, coronary artery disease, mitral stenosis, prior stroke or heart or transient ischemic attack, rheumatic heart disease, thyrotoxicosis, or left ventricular ejection fraction of less than 0.35). We need to be concerned with the higher frequency of hemorrhage associated with the certain anticoagulents. A lot times the focus is too strictly on effectiveness in preventing stroke. Realize that's very important, but that's not the only issue, especially in the category of patients addressed above. Don't know of any respectable, published study on this relating exclusively to younger folks without heart probs.

Din, thanks for sharing your insight.

Season's greetings to all!

Dinith88 · Dec 6, 2003

Originally posted by LarryG
***The Cleveland Clinic is just one of several quality facilities doing AF and flutter ablations. Think one of the pioneers (Natale) in this field has a practice there. After an EP study is done, the relevant sites (tissues and veins) are identified and zapped. Fabulous success rates are being touted.***

Yes LG, thats the way ablations are done. The problem w/most a-fibs is that a 'relevant site' can't be mapped w/an ep-study because there is no site to 'find'. The type of patients that can be curatively ablated must have a focus (site) that is triggering the A-fib....(which is not the majority of a-fibbers). For instance, a person with a cardiomyopathy induced a-fib has a disease in the entire heart'muscle' rather than in one specific 'spot'. (eg,, a-fib from underlying pulmonary disease would be another a-fib unable to be ablated.)
HOWEVER, if these a-fib patients have rates that are causing symptoms and are refractory to medications/cardioversions, they may have the previously mentioned AV-node ablation with pacemaker implantation....but that is always a last resort and doesn't 'cure' the fibrillating atria.

This new 'curative' ablation for a-fib is not widely done...and i'm not sure why. It's either because the pt's with ablation 'curable' a-fibs are very rare, the procedure isn't all that successful, or it's still in development/experimentation. ...(as i've said, i'm now on a mission to find out and will pick the brains of the 2 electrophysiologts i know...!!)

***Re: anti-coag treatment: I was referring to patients without underlying cardiac risk factors (heart failure, hypertension, diabetes, coronary artery disease, mitral stenosis, prior stroke or heart or transient ischemic attack, rheumatic heart disease, thyrotoxicosis, or left ventricular ejection fraction of less than 0.35). We need to be concerned with the higher frequency of hemorrhage associated with the certain anticoagulents. A lot times the focus is too strictly on effectiveness in preventing stroke. Realize that's very important, but that's not the only issue, especially in the category of patients addressed above. Don't know of any respectable, published study on this relating exclusively to younger folks without heart probs.***

I'm still not quite sure what you're meaning?? You're saying that a-fib in patients with no other medical Hx (under 65 yrs old) don't need coumadin?? Thats still a mistake. (also, a-fib usually doens't happen in a vaccum...it's usually the result of an underlying problem) . A person anticoagulated w/coumadin who DOES have some of the problems you mentioned would actually benefit from the anticoagulation(eg. ischemic/embolic stroke)In fact, some cardiologists will put patients on coumadin soley because their ejection fraction is terrible (

LG, i'm not arguing/disagreeing with you soley for the sake of arguing. It's just that coumadin use in a-fib is an established treatment (THE best treatment!) in preventing a-fib thrombus formation. It's taught and practiced throughout the county (the world's!) med-schools, nursing schools, hospitals. I beleive that to say otherwise is a big bit of mis-information and should be corrected...especially here in a nurses forum.

Havin' A Party!, ASN, RN · Dec 6, 2003

Hi again, Din. We may be saying close to the same thing but expressing it differently on the coag issue. Agree that coumadin is the standard protocol for typical fibbers. But from the summary info presented here, we don't know if the person being discussed is that. If he's young and has no underlying prob's (lone or idiopathic), or is an avid athlete and / or is otherwise in great physical shape, the stroke risk would be significantly less. Hence, my greater concern for a cranial bleed.

On the ablation: Not convinced that the present state of EP medicine is that the majority of AF incidence can't be successfully treated. Think it's the opposite situation.

Very much appreciate our discussion.

Dinith88 · Dec 6, 2003

LG, whether you're a super-star athlete w/no other problems, or a sickly elderly lady, a fibrillating heart is a fibrillating heart.

The risk of thrombus/stroke happens SOLEY because of this fibrillation ('quiverring'). The blood can pool, become 'stagnant' and form a clot regardless of what shape the rest of your body is in. You're not 'more' or 'less' at risk because of anything else. A-fib is A-fib. Period.

And EP/Ablation therapy is not a 'new' procedure. If the majority of a-fib could be 'cured' by this 1hr procedure, don't you think they'd be curing everyone with it???

Why would we be going through the hassles w/cardioversions, medications, etc..if an ablation could fix this common(but potentially life-threatening) problem? Sounds kindda ridiculous to me that we'd NOT ablate all a-fibs if we COULD.??? ?

As i've said, the facility where i'm employed has an active ep-lab that does LOTS of ablations....and we've never done a 'curative' ablation for a-fib (but we DO ablate AV-nodes and implant pacemakers on symptomatic, refractory a-fibs...and it's always a last resort, and does not stop the fibrillation),....

sorry that i'm starting to sound like a broken record...i'll come back to the forum modnday or tuesday w/an update....

Havin' A Party!, ASN, RN · Dec 6, 2003

Hey, Din. Guess we'll just have to agree to disagree.

No way I can accept that a young, otherwise healthy fibber has the same statistical risk of stroke as that of an older one with severe, underlying cardiac prob's.

As to the present state of ablation practice, the Cleveland Clinic I mentioned earlier I believe is citing success stats above 90% re: AF.

Have a great weekend!

Dinith88 · Dec 7, 2003

LG, i did an internet search for coumadin-vs-aspirin in preventing thrombus in a-fib, and i've discovered that the internet is splattered with studies that suggest aspirin may be an acceptable alternative to coumadin in certain patient sub-groups (ie your younger healthy variety). Please allow me to graciously remove my foot from my mouth. However, before i completely fall from my high-horse, i want to add that this sub-set is the exception rather than the rule (just ask any nurse who cares for a-fib pt's..and the md's prescribing the stuff). Aspirin (or any drug with 'anticoagulant/antiplatelet' properties) will undoubtedly cut this risk somewhat....coumadin is just better at it.

(i'm terribly curious as to how frequently cardiologists prescribe asa in new AF...again, i'll pick some md-brains and get their opinions/numbers)

But i wont bend on the a-fib ablation thing. That 90% number you saw in that study is misleading. I'm betting it meant 90% of ABLATBLE a-fibs are being cured. Again, 'ablatable/curable' a-fibs are surely a miniscule minority, or they'd be curing everyone of this not uncommon dysrhythmia.

I've already given the example of various cardiomyopathies, pulmonary htn induced a-fib, etc. Perhaps the simpleist(sp?) example would be this: A-fib is very common post-CABG...but it's not because of some bad 'trigger' that can be burned away...it's because of the irritation caused during surgery...And i would suspect the only way to stop this fib w/an ablation is to take a blow-torch to the patients entire atria....a-fib would be stopped for sure.

I'll have numbers for you soon (from the mouth of an electophysiologist that DOES LOTS of ablations)....and if i have to pull the other foot from my mouth, i won't hesitate to tell you!)

Havin' A Party!, ASN, RN · Dec 8, 2003

Hi, Din -- Just wanna say I value your experience and knowledge in this area. And I much appreciate your input. After graduation (have a while to go), cardiology will likely be the field I'll be specializing in. So I'm open to all kinds of learning / input on this subject.

I'll have to try and remember (and or locate) where I came across the over 90% ablation success rate of the CC. Will let ya know when I find it.

Below is a recent article (November 2003) publicizing the University of Michigan's facility's over 85% rate. Hope you consider this of interest.

http://www.med.umich.edu/opm/newspage/2003/atrialfibrillation.htm

Please keep in touch and advise of any new info that passes your way. I'll do the same.

Later.

Dinith88 · Dec 9, 2003

LG, ... I finally had the opportunity to pick the brains of a gaggle of EP-nurses and one of the Electrophysiologists regarding a-fib ablations. I also cornered 3 different cardiologists and got their opinions on the whole a-fib aspirin thing...i hope this'll shed some light on these two issues...

First off, the article you posted. It certainly has a sensational(sp?) title and a first paragraph that completely agrees w/what you were saying. However, the article's title and opening paragraph are very misleading. It's by a University journalist/reporter rather than the people involved in the trials(who probably doesnt really quite have a handle on a-fib and it's various causes and treatments). If you read into it, the report makes this revealing statement.."trial involving 80 patients with the paroxysmal, or intermittent FORM OF A-FIB..." This study that the reporter is trying to explain isn't about ablating a-fib's but rather a new 'technique' for ablating a-fibs...that is, the 'ablatable' variety...(are you able to get copies of the studies rather than a 'report'??) which brings me back to the EP-doc i spoke with...

As it turns out, a-fib ablations have been around since about 1997 or so(maybe earlier?). It's been determined that a small percentage of a-fibs (the doc gave me a number of

And as far as aspirin and a-fib...i asked 3 board certified cardiologists about aspirin in a-fib thrombus prevention. All three agreed that lone a-fib is rare and comprises less than 15% of all a-fibs...(10%,

My suggestion to you would be to go ask the Docs. On your next clinical day, try and track down an electrophysiologist and ask him directly about ablating a-fibs (if one is available...they arent all that common). But cardiologists ARE readily available at most hospitals. Ask one of these guys...I suspect they'll agree with the Docs i spoke with.

And good luck to you in nursing school...however i doubt you'll need it....as you certainly know how to do your homework.

Havin' A Party!, ASN, RN · Dec 11, 2003

Wow, Din! What a trooper you are to take it upon your shoulders to interview a pack of pros, and then care enough to fill us all in on their comments. Those folks had to be impressed with your interest and professionalism. Feather in your cap, for sure. Sincere thanks for all you did. And also for the kind words in your closing. :kiss

Wish I had more time to get into this. But I'm in the middle of completing a crammed three-week course between terms... so I'm kinda strapped presently.

Anyhoot, did wanna give ya my feedback on a few items and also lay out some things I plan to follow up on when time allows.

Totally understand your take on the UoM article. It does seem a bit hyped. OTOH, the author -- presuming the truthfulness of the stated credentials -- isn't your typical marketing / ad-guy, but a medical Phd. Moreover, I gotta believe -- based on the rep of the university -- that one or more of the participating cardios blessed the final draft.

On the paroxysmal / persistent issue. While the UoM article speaks in terms of the former, please note that the pages referenced below (from the Cleveland Clinic's Heart Center and the University of Chicago) cite similar success stats (80 to 85% on the first ablation, and 95% for those requiring a "touch-up"; and 90%, respectively). But both pages explain that the stated procedure is indicated for both of the above flavors of AF (paroxysmal and chronic). (BTW, that isn't the source of my original comments regarding the CC. Haven't located that article to date. Sorry.) I agree that the exact meaning of the stated rates isn't fully elaborated on. Easy to see how many folks could be misled.

http://www.clevelandclinic.org/heartcenter/pub/atrial_fibrillation/pulmonaryvein_ablation.htm

http://heart.uchospitals.edu/services/arrhythmias/atrial-fibrillation.html

You're correct on the duration of the procedure. What I was alluding to wasn't the one-hour deal, but the one involving the left atrium and the pulmonary veins. Stenosis is an important consideration that I believe is monitored at the time of the surgery and beyond. Think I've read that this is a concern, but a manageable one if it arises.

Also think you're right with regard to the "who-knows-what-the future-will bring" notion. Seem to recollect that my MIA CC article defined success as remaining in NSR a year out and without meds. But years down the pike, who knows?

On the aspirin prejudice. My gut tells me the bulk of this stems from a legal basis, rather than a medical one. You know, once the industry proclaims an official protocol, God help the practitioner that deviates from it in a court of law. Throw into the mix the financial power of the big manufacturers, and its ability to persuade professional committees, politicos and the government.

Don't mean to drag this out. But there's a lot here.

The 20% figure for the lone species of fibbers sounds about right from what I remember.

Another interesting contrast. Unless memory fails, from my readings, the paroxysmal patient has a greater likelihood of a clot than one who is persistent.

Don't have the access to cardios that you do. But wish we could both address those in the CC and the UoM. Haven't seen much out of Hershey MC or the University of PA on this stuff.

Thanks for putting up with a sometimes, hardheaded student. Would love to hear your take on the above if you get a few minutes.

Best regards.

P.S. FWIW, saw a source indicating ablations were first done in 1991.