- Hey everybody, I'm Dr. Morales,
I'm here at the Heart Rhythm Society conference,
and I'm here with Dr. Akash Makkar,
who is an electrophysiologist in the Phoenix area.
Dr. Makkar, thank you for being here
and taking a few minutes of your time.
And so, today we're gonna talk about,
a little bit more about what happens
when an ablation doesn't work.
You know, there are patients out there
that can get very frustrated,
you know, they hear that ablations don't work
or maybe they had one that didn't work,
and so how do you approach
that with your patients, you know, let's say
Let's start off with: you meet a patient
that had an ablation someplace else and it didn't work,
so how do start with that counseling with them?
- Well the thing is, I think patient education
is a big part of it, so when I approach a patient,
if I'm seeing a patient for the first time,
I do tell them that it's not possible
that 100% ablations do work.
There are a lot of factors; how weak is their heart,
how big is their left heart chamber,
how long they'd AFib for?
Were they cardio worded before
and maintained a rhythm, versus them having
an AFib for 10 plus years,
also how leaky the valve is?
And so I do give them a realistic approach,
and what's possible, and then obviously
we do the investigation, basically an echocardiogram
that tells us that, um.
Based on what, how big all these characteristics
which I mentioned are, then is it going to work
or what is the chance?
And I do prepare them, that especially
the persistent AFib patients.
Now the perks to an AFib patient
in which AFib comes and goes,
their better amenable to treatment as you know.
But the peristent ones, I tell them that
it's a possibility it may not work
and then obviously at that point
we decide whether it's worth going
for a second, redo procedure.
And the recurrence is more AFib or atypical flutter.
Because atypical flutter are more available,
to catheter treatment than AFib.
And obviously there is a very small sector
of patients, in which we know AFib has been
there for 20 plus years, no attempt has been made
to convert or canister them
the left chamber is similarly dilated
the value is really leaky, you know on those things
ablation is not going to work
no matter what technique you use.
And for those sub select patients
we plan on doing, um, you know
AV node ablation with a pacemaker placement.
And obliviously we proceed with those patients
they're not a long term anticoagulation candidate.
The problem with blood thinners
we can consider Watchmen or appendage
occlusion for ablations.
- When it comes back to ablations, you know
sometimes people ask, is there a certain
number that is too many, you know,
if somebody has two you can't have anymore
after that, you know.
- So, I tell people, we don't, nowadays
we talk about catheter ablations
more than surgical ablations.
My understanding is if it's a cardiac surgery
you open, open chest and what not
you can do one or two maybe surgeries.
Catheter ablations is like angiograms,
they do angiograms, they have tens, tens of angiograms.
It's very similar to that,
there's some scaring in the groin, but
it's actually, there's no limit
to how many ablations you can do.
In select patients, if they've had
more recurrences with, um,
AFib and I know they're good subset
they don't have much other medical conditions that
the chamber is reasonably sized and what not
and I know that I've got a good chance
of fixing that, I've done up to four ablations
with those patients.
- Now, you've touched upon surgical ablations
so, does somebody know if a surgical ablation
is better for them versus a catheter ablation?
- Okay, we go back old times when we
didn't have all these tools.
People we were bad with AFib and at that point
they were going for open heart surgery
for something like this.
In today's world people can say whatever
but, I think surgical ablation is too invasive.
Compared to catheter ablation the results are
not better, look at any study.
They actually just did EKG as follow up
rather than doing the event monitoring
or loop recorded monitoring which we do.
So, if you look at the data we have much
more regular data with catheter ablation.
Now, only patients, only patients
I recommend surgical ablations
if they're going for heart surgery anyways.
They're going for a bypass, they're going to
have their chest open anyways.
At that point, the chest is open,
the surgeon can cut the appendage
or lariat the appendage.
And do an amazing procedure at the same time.
If they are going for a mitral valve surgery
because the valve is so leaky,
100% they should consider surgical ablation
because they are going for it anyways.
No point in doing a catheter ablation
and then get sent for mitral valve surgery.
There is only subset which I think works
for surgical ablation, not (muffled)
the patient is going for a surgical ablation per say.
- As you know surgical ablations are advertised a lot
to patients, they try to tell patients
this is the way to go, has better success rates
but they don't always talk about
it's not necessarily better
but it's also a significant more procedure
much longer recovery time.
- Yeah, it's, it's like, heart surgery
you understand, they sometimes they say they can do
mini-canthotomy, like a mini chest incision surgery.
Look at that, you're talking about
no scar, pretty much there's no incision
for catheter ablation, we just have IV lines.
And we do through it but in surgical ablation
it's, a hard surgical and there's too much
morbidity associated with it,
and look at the data, where is the long term data?
We have very more robust data
with catheter ablation compared to that.
So why would we do it?
- And in addition, another point many times
people who have AFib have a lot of other
health conditions as well, they might be
more older in age, but have other medical conditions.
- If they have conic kidney disease,
there's a good chance that they were going
to this heart and lung bypass
and they will end up on dialysis after the surgery.
It's not worth it.
- Yeah
- I totally am against it.
- Well, Dr. Makkar thank you for taking
a few minutes of your time, really appreciate
you giving your insights on managing Afib.
Okay, thank you.
- Thank you.