- [Dr. Morales] Hey everybody, I'm Dr. Morales.
I'm at the Heart Rhythm Society Conference and I have
the honor of talking with Dr. Miguel Valderrabano.
Dr. Valderrabano is an electrophysiologist based out of
Houston, Texas which I've actually known for several years.
Dr. Valderrabano, thank you for taking the time out to
interview for Dr. AFib.
- [Dr. Valderrabano] My pleasure.
- So today we're gonna talk about, what happens when an
ablation doesn't work.
There's a lotta patients out there, or they may hear from
other doctors say, "Ablations doesn't work."
And we know that the success rate from ablations
aren't perfect, so there are many people out there who get
an ablation done and then it comes back.
And the AFib comes back or just not the success that
people want.
What sort of the first steps, if you meet people who
have had an ablation that doesn't work.
How do you start counseling people on that?
- So, first, you wanna talk about this before you
do ablation.
This cannot be a surprise for the patient.
When you do an ablation they need to know that a certain
amount of patients are going to need to have a touch-up
or need for a new visit to the Ablation Catheter Lab.
First I will distinguish early failures so patients
that have an ablation and then the next week
they're in AFib, they need to be reassured that
sometimes it's just a matter of tissue healing and
the acute inflammation of the ablation has to be,
has to settle down and a scar has to be formed.
And only when that scar has completed, that's when we say,
"Okay, did we fail, did we not fail?"
Once we talk about beyond that acute period, which is up to
three months, then the ablation didn't work and the patient
is having symptoms.
I divide the failures in two kinds.
One is a technical failure, meaning when we did the ablation
we tried to get pulmonary vein isolation.
We ablate the areas where AFib is supposed to harbor-
where the triggers for AFib are coming from.
The goal is to achieve pulmonary vein isolation and
some patients they have reconnection of the pulmonary veins.
Whether tissue grows back or the ablation was not as
thorough as we intended it to be, they have a technical
failure of pulmonary vein isolation.
The pulmonary veins are not isolated.
So that simply needs to be redone.
The other kind of failures are what I like to call
mechanistic failures.
You may have a perfectly well-done pulmonary vein
isolation, but it turns out that in that patient the AFib
comes from somewhere else. - Yeah.
- Then we need to get smarter.
Then we need to look for other triggers.
Is this, ya know, triggered like the Vein of Marshall?
The superior vena cava?
Where is this AFib coming from in this particular patient
in which I have achieved PV Isolation and yet they still
have AFib?
And then a third kind is flutters.
Patients may come back with a flutter, for many people
this is a regular electricity, usually spinning and
increasingly regularly somewhere around the atria.
Those patients have a very easy second procedure.
This we map and we find where the electricity spins.
We do a smart ablation guided by the activation patterns,
and we succeed.
- Now there are some patients out there that have had three,
four ablations done and it's still sub-optimal
and in those types of patients,
I know that you do a lot of research protocols.
Is there something that people should look out for that's
maybe out of the usual, you know?
When should somebody really be looking at an academic
medical center, somebody that does research protocols,
things that are a little bit out of the usual box?
- So, I mean I think
in the community two procedures should be enough.
A competent operator like yourself guaranteed that in two
procedures the pulmonary veins are gonna be isolated.
You can perhaps include the posterior wall in some patients.
But if that hasn't worked, typically it's
patients with persistent AFibs, sometimes long-standing
persistent AFibs, you may need to explore other triggers.
Like we talked about, we did a lot of research together in
the Vein of Marshall alcohol, that's a source of triggers
for AFib that does not normally get ablated with
standard RF because it's so much in the
outer surface of the heart.
Appendage isolation, so you may need to ablate
so extensively that you disconnect electricity
from the appendage and that is very controversial.
Everybody has their own opinions but it has been linked to a
higher risk of stroke, even higher than plain AFib.
If you're ready to do appendage isolation, which is not
technically that easy, you should be ready to close that
appendage with an occlusion device.
- Sure.
- That's when the complexity escalates.
And then for sure there's very rare cases that have a
right atrial origin.
That requires the patients to map and be, you know,
to spend time in mapping every single corner of the atria
figuring out where the AFib is coming in that patient.
That takes sometimes multiple hours of a procedure.
- Is there at any point where you say to a patient,
"You know what, we cannot do any more ablations,
you've had enough, there's no more that we can do"?
- As I get older it gets less and less.
I guess I'm more confident in being able to always-
In most of my experience when someone has had two, three
ablations, the tough ones will have every now and then a
flutter here and there.
Flutter here and there, you may still be able to map.
What is the maximum number of ablations that I've ever done
in a patient?
I'm embarrassed to say but I think of one patient,
not entirely all of mine, but I had one patient that had
six ablations, of which I did four.
The last three were flutters.
Sometimes the flutters come from
septal areas, close to sometimes the coronary sinus ostium,
close to the
AV node.
Then you get even more risks.
- And I think another point to point out is that AFib is
a progressive condition.
Even if somebody has a very good ablation, everything's done
well, years later as they age or other comorbidities develop
they may develop new areas that weren't
ablated the first time.
That's why things need to be readjust.
Dr. Valderrabano, I really appreciate you coming by,
taking a few minutes of your time.
Thank you for being here. - Pleasure, bye.