As someone who (sometimes) cares for the injured esophagus, if we assume the efficacy for afib is similar, eliminating this complication is absolutely worth the switch from the EP cardiologist’s and patient’s perspective. Esophageal problems are the stuff of nightmares…
But is it worth it from your hospital’s perspective? How about my hospital’s perspective? Is PFA more expensive because of catheter cost? I think it must be? No study will support “statistical significance” for 1 out of 10,000 complication to justify the extra cost.
What do the Europeans have to say? Because they pay for the catheter AND the perforations. I bet they will save money even if the catheter costs more.
I am 77 years old. I have followed Dr. Mandrola's writings for at least ten years. Like Dr. Mandrola, I have been an avid and active cyclist. I was diagnosed with Afib 18 years ago, but my condition worsened in the past two years. In March, I was out of NSR 56% of the time. Less than one month ago, I had a PFA performed by Andrea Natale, M.D. It was a wonderful experience. I feel much better and my recovery was very brief.
My PFA was by Dr. Natale as well. My recovery was speedy, and I remain medication free two years now. My thought is that highly experienced EPs develop a sense about the procedure that leads to successful ablations. Something like major league pitchers knowing exactly where to put the pitch in order to strike out the batter. It’s science but it’s also skill.
John this is a great write-up. I love your circumspect nature, and ability to come back and revise your opinion. That 1 in 10K hazard is similar to the 1 in 5k to 10k myocarditis rates we were worried about at the outset of the mRNA vaccines, but which didn't surface in the trials (because they were not large enough). Is this another reason to keep pushing for larger trials perhaps?
Wise decision to remain open-minded and try this new technique. One important comment may be that PFA does not require electro-anatomical mapping, which makes it a lot faster, cheaper and easier to learn than RF. This may make PVI a less exclusive therapy for more patients with AF.
Is AFIB for some related to alcohol over consumption. ? Like 5+ drinks in 1 night . Me 15 years ago New Year’s Eve?? Was never a habit , neighbor kept pouring very good wine and we had a fun night. Then stress of a 2 mile jog , drunk at 2am then 4 hours of sleep then an 8 mile run at 8 am?? AFIB showed up at 2pm that day . 150+crazy beats a min . Age 53. Then nothing for 12+ years then a virus earlier in the week and stress of coaching a very good HS Cross Country team, Covid?? At 66YO same 150+ . Converted to NSR and now 2+ years no AFIB . No ablation , just my metoprolol and lisinopril for BP control. Me happy. A lifetime runner healthy diet and perfect weight . Now very slow runner , new hip :)) They wanted to go ablation right away 2 years ago. I said let’s wait . Had been on Rythmol for 4 months after and ended up with heart block from drug . They took me off after echo stress test that showed it at peak exercise. So . … PFA maybe if it happens again . The possibility of being dead from the procedure made me hesitant. Watch my stress levels , have none now retired . Exercises easy daily 4-6 mile jog ..Always ate well . Sooooo. And AFIB free .
Dr Natale performed my pvi + posterior wall ablation June of 2022; fingers crossed so far results have been excellent. I did experience a few PAC’s early on; started taking digestive enzymes and they never came back. No meds! Thankfully!
Ultimately this seems maybe like a faster and easier way to achieve the same thing (ie. PVI) as with “traditional” methods like RFA or cryo. This is a different way to skin a cat but likely isn’t a revolution that completely changes the principles of AF ablation.
I’d like to see a study combining non-inferiority for efficacy in “AF suppression” plus superiority in “safety” (except for the atrio-esophageal fistula thing which is too rare to come out in any trial).
I’d also wonder about longer term follow up for neurologic events given the cell cavitation/“bubbles” that occur during the procedure.
I have had three ablations, each fix lasted one to two years.
When the third one started failing, drugs were prescribed which were bad for my cycling.
Found an read your book Haywire Heart. Took your advice, no alcohol, no caffeine and increased sleep.
I wish I had read your book before the ablations. No drugs for over ten years. Thank you.
As someone who (sometimes) cares for the injured esophagus, if we assume the efficacy for afib is similar, eliminating this complication is absolutely worth the switch from the EP cardiologist’s and patient’s perspective. Esophageal problems are the stuff of nightmares…
But is it worth it from your hospital’s perspective? How about my hospital’s perspective? Is PFA more expensive because of catheter cost? I think it must be? No study will support “statistical significance” for 1 out of 10,000 complication to justify the extra cost.
What do the Europeans have to say? Because they pay for the catheter AND the perforations. I bet they will save money even if the catheter costs more.
I am 77 years old. I have followed Dr. Mandrola's writings for at least ten years. Like Dr. Mandrola, I have been an avid and active cyclist. I was diagnosed with Afib 18 years ago, but my condition worsened in the past two years. In March, I was out of NSR 56% of the time. Less than one month ago, I had a PFA performed by Andrea Natale, M.D. It was a wonderful experience. I feel much better and my recovery was very brief.
My PFA was by Dr. Natale as well. My recovery was speedy, and I remain medication free two years now. My thought is that highly experienced EPs develop a sense about the procedure that leads to successful ablations. Something like major league pitchers knowing exactly where to put the pitch in order to strike out the batter. It’s science but it’s also skill.
John this is a great write-up. I love your circumspect nature, and ability to come back and revise your opinion. That 1 in 10K hazard is similar to the 1 in 5k to 10k myocarditis rates we were worried about at the outset of the mRNA vaccines, but which didn't surface in the trials (because they were not large enough). Is this another reason to keep pushing for larger trials perhaps?
Very cool. Thanks for this.
Wise decision to remain open-minded and try this new technique. One important comment may be that PFA does not require electro-anatomical mapping, which makes it a lot faster, cheaper and easier to learn than RF. This may make PVI a less exclusive therapy for more patients with AF.
Strange how surgical procedures are being done for this condition which is largely iatrogenic and fairly easy to fix with proper thyroid. See
https://mattcook.substack.com/p/atrial-fibrillation-treatment-is
Is AFIB for some related to alcohol over consumption. ? Like 5+ drinks in 1 night . Me 15 years ago New Year’s Eve?? Was never a habit , neighbor kept pouring very good wine and we had a fun night. Then stress of a 2 mile jog , drunk at 2am then 4 hours of sleep then an 8 mile run at 8 am?? AFIB showed up at 2pm that day . 150+crazy beats a min . Age 53. Then nothing for 12+ years then a virus earlier in the week and stress of coaching a very good HS Cross Country team, Covid?? At 66YO same 150+ . Converted to NSR and now 2+ years no AFIB . No ablation , just my metoprolol and lisinopril for BP control. Me happy. A lifetime runner healthy diet and perfect weight . Now very slow runner , new hip :)) They wanted to go ablation right away 2 years ago. I said let’s wait . Had been on Rythmol for 4 months after and ended up with heart block from drug . They took me off after echo stress test that showed it at peak exercise. So . … PFA maybe if it happens again . The possibility of being dead from the procedure made me hesitant. Watch my stress levels , have none now retired . Exercises easy daily 4-6 mile jog ..Always ate well . Sooooo. And AFIB free .
Dr Natale performed my pvi + posterior wall ablation June of 2022; fingers crossed so far results have been excellent. I did experience a few PAC’s early on; started taking digestive enzymes and they never came back. No meds! Thankfully!
Steve
You have gone to the dark side ,John. What happened?
Ultimately this seems maybe like a faster and easier way to achieve the same thing (ie. PVI) as with “traditional” methods like RFA or cryo. This is a different way to skin a cat but likely isn’t a revolution that completely changes the principles of AF ablation.
I’d like to see a study combining non-inferiority for efficacy in “AF suppression” plus superiority in “safety” (except for the atrio-esophageal fistula thing which is too rare to come out in any trial).
I’d also wonder about longer term follow up for neurologic events given the cell cavitation/“bubbles” that occur during the procedure.
Shiny new toys come and go, but the fundamentals remain. Mapping, understanding the underlying mechanism, and contact/force all matter.
99,999 out of 10,000 ? Typo I assume
yes, thank you.