If the weekly AF attacks were a monkey on my back, that last 3-1/2 week AF episode felt like a gorilla. Needless to say it got Melinda and I talking about what to do next. The groovy cartoonish AF brochure they gave me in the hospital described an "ablation" procedure that might offer some relief. This procedure involved inserting catheters through leg veins into the heart and then using RF or other energy to burn the offending areas inside the heart. The grand cure-all procedure described in the brochure was an AV node ablation along with implanting a pacemaker. Remember the AV node is kind of a key part of the heart's own electrical system so burning it into oblivion would explain the need for a pacemaker. I'm sorry but all the happy silly cartoon characters in the world are not going to make me ready for this extreme.
That initial (and incorrect) impression of AF ablation procedures has stuck with me. It wasn't until it seemed like all else had failed that we started researching more seriously. Thankfully their was far more accurate and hopeful information available. The now current standard for AF ablation focuses on isolating the pulmonary veins. It was discovered in 1998 that the majority of the stray electrical signals that trigger an AF episode originate in the pulmonary veins. This approach leaves the normal electrical system of the heart intact which, to me, is very desirable.
A Pulmonary Vein Isolation (PVI) is a more complicated procedure compared to other ablation procedures for simpler and more defined arrhythmias. Part of this is because the pulmonary veins are located in the left atrium. Feeding catheters up from the leg veins leads to the right atrium so a needle is used to make a small hole between the right and left atria in the wall (septum) separating the two chambers (called a trans-septal puncture). The goal is to ablate (burn) lines around each of the pulmonary veins (typically 4 of them) one dot at a time. There is not much room to work - the left atrium is about 2" in diameter and the pulmonary veins are about a half inch diameter. PVI procedures can last 3 to 4 hours or longer.
A lot of what I read mentioned that the outcome of a PVI is highly operator (doctor) dependent. I guess this is understandable based on the complexity involved. There seemed to be a handful of doctors that were at the forefront for successful ablations. One name, Dr. Andrea Natale, was at the top of the list for doctors in the U.S. He had been practicing at the Cleveland Clinic but, because of his success rate, the backlog to see him was 18+ months. I had already decided if I was ever ready for an ablation he would be the doctor I would want to do it but a year and a half is a long time to wait. To our surprise, the very day we decided to pursue an ablation, Dr. Natale announced that after leaving the Cleveland Clinic, he was now practicing in the San Francisco area. What an amazing coincidence.
Dr. Natale actually makes himself available via e-mail so I began e-mailing him about my case. He felt my chances for a cure from AF where quite high given my age and that my AF had not yet progressed to chronic or permanent AF. Because of his recent move to California, his backlog was now only 6 weeks! Melinda and I discussed this over the course of a weekend and decided this was my best chance to find relief from AF and hopefully be able to get rid of all the heart meds with all the wonderful side effects. I expect I will still need something for blood pressure but some people have also seen their BP drop after an ablation.
Dr. Natale is currently seeing a 80% success rate for a single ablation procedure, and approaching 95% with a second procedure. The two local EP doctors I have seen since our decision didn't seem to like Dr. Natale (one doc even brought up his name before I said anything). When I asked them why the only thing they could offer was that the success rates that Dr. Natale quotes are too high - they seemed to think 60-70% was more realistic. I guess this is as good a reason as any to dislike someone. Inflated success rates or not, I wanted to go to Dr. Natale because he has done thousands of ablations compared to less than 100 for the local doc. A newsletter I subscribe to just published results of a survey of ablation outcomes. Dr. Natale, or the procedure he has developed (a variation of a standard PVI called a PVAI), had the highest success rates. All of this has confirmed our decision.
It took some work to get things in motion but everything is set now for an ablation with Dr. Natale on December 21. We will be at the hospital a good part of the day on the 20th with pre-admission testing and a consultation. The procedure is considered outpatient but I will still have to stay overnight. We fly into San Francisco on the 16th and hope to spend the few extra days sight-seeing. Our daughter and her fiance will be about an hour away visiting his family. She plans on coming down before the procedure and staying with us until I am feeling better back at our hotel. I am thankful Melinda will have someone to stay with her the night I'm in the hospital.
It seems all of this came together very fast and I'm not sure it has sunk in yet. So far I have tried not to focus too much on the procedure and instead I'm looking forward to some relief. In the meantime I just keep typing away on this silly blog.
Dave
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