The reality of rationing complex procedures, like AF ablation…

Medical prowess has exploded in the past decade.  The toolbox of therapeutic options has grown so large that often times, the most challenging aspect of patient care is in matching the right tool to the right patient.  There is no better example than the expanding capability to ablate atrial fibrillation.

Now that I can successfully ablate AF, the question is, in whom should this aggressive therapy be offered as a viable option?  And, how should I decide?

This particular Friday in the office brought a steady stream of symptomatic AF patients. Since this is the real world, for every young healthy patient with AF, there were four overweight hypertensive, older patients with more long-standing AF, and more dilated heart chambers.

In the past, AF therapy was easy: either medicine, tolerance of drug side effects or live with the disease.  Sure, we could infuse some finesse into these strategies, but there were no home-runs.  Curative options were unavailable, drugs were given and the patients grew accustomed to the arrhythmia.  Growing accustomed didn’t mean they felt any better, just that feeling less well became the norm.  There was no such thing as ablation.

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She is really symptomatic with her AF.  The medicine is partially effective.  There are days that are good, but the day she wore the 24-hour monitor–when she was in AF–was a bad one. I am sorry…I can’t ablate everybody. She is old, very fat, diabetic, and her AF has been around for many years. We will have to treat this AF more conventionally.  Sorry.

Background:

• Atrial fibrillation is the most common cardiac diagnosis.  It is everywhere, like sore throats are to an urgent care center. In many cases, the symptoms of AF greatly diminish a patient’s quality of life. It is not always overt palpitations; sometimes it is generalized fatigue, and a vague shortness of air.   Some have no overt symptoms, but interestingly, patients with seemingly asymptomatic AF score less well on quality of life questionnaires.
• Rhythm controlling drugs for AF work in less than half of all patients. Both inefficacy and intolerance to side effects limit the utility of these drugs.
• There are well done studies that show that AF patients treated with just blood thinners and heart rate modulators live just as long as those who we keep trying to maintain regular rhythm.  In other words (or what I tell patients), is that if we let the heart stay irregular, as long as the rate is controlled and the blood thin (“rate-control strategy”), the prognosis is good.  We are not mandated to keep going with shocks, rhythm drugs and procedures–the aptly termed “rhythm-control” strategy.

• 
  The gratification in watching AF disappear with the delivery of RF burns (red-dots) is immense.  It fuels the fire.  It tempts you.  I remember where I was the first time someone told me of the notion of curing AF by ablation lesions.  It was like imagining an ipod in the era of the cassette tape.

This AF treatment paradigm worked well absent the ability to ablate AF.   Now though, we have in the “rhythm control” toolbox a much larger tool.  In 2010 the score is AF ablation-70% success, AF drugs-30%.

This sounds great.  Just go ahead and do more AF ablations. Procedures pay better than office visits, don’t they?

Ah, but the story is not that simple.  Because we (I) can ablate AF in some, does not mean it can be applied to the masses.  Here’s why–in my view.

AF ablation is a big deal.  It is not for the faint of heart.

Patient issues are…

• It requires 3-4 hours of procedure time with either general anesthesia or significant sedation.
• A harpoon-like needle has to be poked across the beating heart in a patient on blood thinners.
• Over a hundred burns are made in the most sensitive of the heart’s four chambers.
• In low-risk young patients–a minority of AF patients–the procedure successfully eliminates the AF in only a modest two-thirds of cases.
• Almost half of these successes need to have a second procedure to touch up areas that “grow-back.”
• Complications are real.  There is a risk of stroke, heart attack, perforation of a perfectly good heart, pulmonary vein stenosis, air embolism, esophageal damage, and of course death.  The overall complication rate is low, but since AF is not immediately life-threatening, any major complication becomes even more magnified.

The doctors issues…

• The procedure is hard to do.  AF ablators know AF diminishes quality of life, but we also know the delicate balance of performing a life-enhancing procedure that has potential catastrophic complications. This tightrope makes me nervous. No other procedure induces a fraction of the mental worry of an AF ablation.
• The procedure requires standing with a lead apron and focusing for three hours.  An AF ablation is hard on the doctor (human).   Not complaining, just stating the facts.  It limits what else you can do in a day.  In the past, AF ablations were once per week.  As ablation technology advances along with our skills, the temptation to help more patients has been hard for me to control.
• In private practice EP, most can only ablate two full days per week. There are office patients to see, non-reimbursed patient phone calls to make and the mundane cardiac devices to implant.  Reality.

Stop whining and just refer these extras to other ablators, one might suggest.