He seeks me out for another opinion about his atrial fibrillation. This is good.
“Doc, you know I had one of those ablation procedures (at another hospital) last year. It hasn’t seemed to work, as I am having lots of AF.”
About that time, my MA comes in the room with a copy of the procedure note. I’ve underlined some of the key phrases.
“Dabbling,” in AF ablation is a “real-world” problem.
Pulmonary veins are either isolated or they are not. Leaving the right inferior vein electrically connected is like loading the dishwasher, and not turning it on. The rhythm “resembled” atrial flutter? Bi-directional block was not assessed. Oh my.
Of course, this patient still has AF. What do I tell him, other than I think it is worth another try? Fortunately, he does not ask me to comment on the previous procedure. It is true that AF ablation, even when done right, often requires a second procedure for ultimate success. I can offer that fact and move on.
It is ironic that this procedure was done at a huge hospital, endowed with much treasure, which they put to use aggressively in their marketing campaign. Billboards, radio spots and TV ads all proclaim this hospital’s superiority in cardiac care.
The problem is that AF ablation is delivered primarily by physicians, who possess varying degrees of experience and skill.
The dabblers still get referrals. This is so for many reasons: the primary care doctors–most of whom are not in the hospital anymore–do not know the experience level of the specialist, patients don’t know it either, and now, many referrals are made solely on the fact that the specialist is owned by the same hospital as the primary care doctor.
Frown.
It takes a very savvy patient to navigate this complex health-care maze. My guess is navigation to the non-dabbling doctors will become even more challenging in the future.
JMM
5 replies on “Dabbling in ablation is not so good…”
How then, does one choose the correct ablationer (ablationist? ablationista?)? Is there a weekly number of procedures the practitioner should be doing? A certain ratio of success to failure? I am familiar with the short comings of PCP surgical recommendations. They mean well, but often it's no better than gossip.
AM,
Ahhh, the 64K dollar question.
Like my shoulder (AC) reconstruction. I read, and read and then read some more. I sought out four opinions (two from out of town), talked to many doctor friends, and finally, maybe the best source, the head OR nurse. Yet, despite picking seemingly the best surgeon for the job, the reconstruction fell apart, and I required a second operation. The face of my surgeon when he saw his failed repair, my clavicle pointing northward, said it all. I wanted to hug him, and say it's ok, I know how you feel.
So it is with AF ablation. Even more complicated is the idea of seeking out the experts at the major academic institutions. In this case, do you get the junior faculty or the real expert? Does the new EP fellow put in your sheaths? How long does the EP fellow get to navigate around before the attending takes over. (If the attending always does the procedure, how do the fellows learn?)
You can't even go by the doctor's demeanor, as friendliness and likability do not correlate with skill.
That said, though, with enough investigation and persistence odds are that you will find a good ablationist. There are many more than used to be.
JMM
So is the right inferior pulmonary vein particularly arrhythmogenic? Would it always be worth isolating, particularly when it can often lie immediately adjacent to the esophagus?
As a staff member, it is very frustrating and sometimes scary to work with the "dabblers!" As you have stated, sometimes the best advice comes from the staff (example: head OR nurse) who work with the physicians on a daily basis and see the depth of their skills first hand.
Good stuff: A 48 year old woman who contacted my site http://adventuresincardiology.com/ is now a widow because of just such a situation.
Local center, little experience.