Could Ablation for AF Be an Elaborate Placebo?

I have not been reading or posting lately so I hope another person has not posted this. If they have, sorry. Dr. John Mandrola writes some interesting articles and should you decide to read the entire article, it can be found on this site. You will need to log in to read the entire article.


I've ablated AF many hundreds of times over the past 12 years. I do fewer AF ablations now. I go slower. Patients and I have long chats about AF; we discuss their symptoms, the reasons for these symptoms, the vast uncertainty of AF and its treatment, and, mostly, the expectations of ablation or no ablation. Could a nurturing, respectful, and optimistic doctor-patient interaction deliver antiarrhythmic effects?

Something clicked when I read the Turkish authors call for a sham-control trial. Their words reminded me how little we know about AF. The truth is we lack a true scientific understanding of what causes the arrhythmia, and we have little basic scientific insights into what is fibrillation itself.

It was a big step we made going from Haïssaguerre and colleagues first description of focal tachycardia in the pulmonary veins to extensive left atrial ablation.[16]

It is time to rethink our strategy. Better late than never.

And a few more excerpts:

But AF ablation is not just unproven, it's inelegant. This month, almost 2 decades after the first report of AF ablation, German authors called the 2-year results after cryoballoon ablation in patients with persistent AF "promising."[3] How promising? The procedure failed in 22 of the 50 patients (44%).

Not only are the results poor, but the procedure is big—ablation lesions in the left atrium, often millimeters away from the esophagus or phrenic nerve, general anesthesia, transseptal puncture, multiple vascular entries, and hours of bed rest put patients at significant risk. Creating scar to treat a disease that is often caused by scar hardly seems elegant.


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25 Replies

  • Thanks again Engmac for bringing this article to our attention.

    Its certainly thought provoking together with the comments from the medical professionals .


  • Very interesting article EngMac and thank you for the link.

    When I first described the ablation process to my husband - a microelectronics engineer - his reaction was 'very crude', so inelegant chimes with my thinking too.

    I know many on this forum have benefitted from ablation and don't think from their posts that there is much placebo effect in their obviously improved symptoms. But, my excellent cardiologist is advising me against AF ablation, citing risks, repeat interventions and perhaps still having AF and scarred atria afterwards - many of the points raised by John Mandrola. Cardiologist's words: Ablation is not the great white hope we once thought it was and there is no magic bullet for AF. My EP is of similar mind but will ablate for AF if I wish in the future.

    For me, psychological well-being is half the battle in trying to deal with the vagaries of this horrible condition and such support formally built into the management of patients with AF would be a big step forward, I think.

    In the meantime, I'll have to keep taking the tablets . . . .

  • Just when I thought I'd settled my mind to being on the waiting list for Cryoablation for vagally triggered PAF - I'm sitting quietly waiting for yet another AF episode to settle I read your unsettling post EngMac ! I can't decide if you're implying that afibbers who have already had the procedure done were fooled into it and the waiting listers like myself could be damaging ourselves for life - I'm scared but want to be free from this rogue condition and do not wish to be taking drugs which do not suit me for life - ' trapped between a rock and a hard place ' me thinks !! Cathy

  • It is not merely placebo. There is absolutely no doubt in my mind that the first, and later, second ablation did what they were supposed to do, physically rather than emotionally. I'm the most practical, almost cynical, person you could find, and when I went in for the first procedure with full AF for months and woke up in NSR, nobody could have been more surprised. I had no preconceived expectations before either one (life and and some people have taught me to keep my expectations low), so either outcome wouldn't have been the end of my world. Yet here I am, months later, with no AF and no heart meds! Back to normal life and energy! Mine and so many others' experiences on this forum with the positive results can't be the effect of mass "hypnosis".

  • Thankyou for your reassuring and logical reply teach2learn ! Thankfully today back to NSR with energy I can now rationalise and view the prospect of my upcoming Cryoablation without that dreaded fear I was experiencing yesterday when in the grips of AF. Cathy

  • I had cryo ablation 6 weeks ago. I had been having PAF for 8 months, 18 hours a day. ( but 11 years in total) Slow heart rate, unable to do anything. Going back into normal sinus rhythm was such a relief

    I was offered a pacemaker or ablation but because I do not get along at all well with drugs which were a condition of a pacemaker, I elected to have cryo ablation on the u derstanding that it will come back within 5 years. I do at the moment still know what it feels like to be in normal rhythm and wanted to hang on to that as long as possible.

    I u derstood the risks but had been feeling so bad that I just thought well, if it all goes wrong, I won't know anything about it.

    I have not had an arrhythmia since although I still have symptoms but they don't come to fruition. It is a huge relief not to be in PAF at least for a while. I am still very tired but have decided that I will just have to take things in my stride and do what I feel is possible rather that what everybody else thinks I should be doing

    There are a lot if critics including GPs, arryhthmia nurses and paramedics who have never experienced this but are all 'experts'

  • Hi Trilby8, sorry to hear your situation. Did you read the entire article? You should read it all. I am not trying to imply anything. I am just drawing attention to various opinions by experienced professionals. We all want a magic bullet; but so far it is not available. So we need to choose from what is and hope for improvement.

  • Hi,

    I read this a few weeks ago and found it to be interesting and there are points on which I agree...yes, an ablation is an inelegant procedure and there can be significant risks and side effects. And gosh, isn't it better to prevent AF and all heart issues with better health practices including heart healthy diet from a very young age, but hey, we are here, and we are all looking to get better in the best way for us. Anyone who knows me knows that I typically like Dr. John M.'s philosophy about wellness and preventing AF. What I found most irritating about this whole article was the remarks from some other health care professionals who clearly do not have an understand of what we with AF endure during our symptomatic times and as we chase down a way to correct the problem. I almost never refute other commenters on Medscape sites with articles but this one was the exception for me!

    Glad you posted this for discussion here!

  • See my reply to Anne.

  • Exactly the reasoning I had from my Cardiologist! Also my husband who is medically qualified!

    I'll keep on taking the tablets!

  • In all walks of life there are diametrically opposite views and those wh embrace change and push the boundaries and on the opposite those who are stuck in the status quo and the past. No one will ever know who is right. There are some EPs and medics who are 100% for NOACs and some who will only consider warfarin. The in my day scenario and behaviours/ opinions formed during training and early practice is prevalent.

    Without any doubt there will be patients on drugs who will end up worse off and and with side effects. Similarly with ablations.

  • This is exactly what I have had from mine as well - wait and see if real improvements can be made - but, if you have no other potential option and the tablets dont work/have bad side effects then thats a different matter...

  • Which is the reason I went for my first, second and third ablation. AF was very bad, meds failed me across the board and the side effects were awful anyway. The ablations were successful and two years on still pretty good. The options were little.


  • I also read this article some time back,but knowing some people can't access Medscape easily and doubting my own ability to summarise did not share. It is very interesting and ablation like any treatment option has to be a "fit"with one's own definition of the word health. For some, health is fewer GP visits, for others less medication. It may mean less invasive interventions for other people or management by good nutrition and exercise. The most important thing about any health care intervention is that you feel someone is in your corner listening ( really listening) to your beliefs and concerns and for you to feel supported in any decisions you make.

  • From the articles by JM that I've read, the conclusion appears to be that lifestyle changes can make a huge difference. AF is an inflammatory condition and the key is to find what is triggering your particular AF.

    In my case I had lone AF, where there is no known cause, and ablations do work very well in that particular group, as JM has said. However I believe that I had exercised excessively at times, so I cut back a bit on that, still exercising but not as hard. Also I had gum disease (which is associated with AF) so I eliminated that. I also had a genetic component - not much I could do about that! I then had a single successful ablation which has held so far...

    I don't think there is any point to having an ablation if the same inflammation conditions remain - these include being overweight, drinking excessively, being unfit, etc. I do read of a lot of unsuccessful ablations on this board but I wonder how many people are eliminating the underlying causes?


  • For those of us already striving to do all the healthy lifestyle interventions, ie exercise, diet, weight control, etc. and still unaccountably hit with AF (two siblings and numerous younger nephews and nieces, too, now experiencing it), it's pretty clearly also genetic, so I'll take whatever science has to offer!

  • I have lone A.F. with no other apparent predisposing factors except possibly genetic. I successfully made any relevant lifestyle changes with absolutely no effect. The A.F. continued merrily along its way with its own agenda! However the changes are hopefully going to improve the rest of my health. Fingers crossed. X

  • Absolutely agree with Mark I am another with lone af and there are only certain life style changes I can make!

    Also, aa a retired academic, I can confirm that many. In my field, will publish unsubstantiated and controversial articles just to stimulate discussion .....or to get themselves some attention! Dr John has a hypothesis... I.e a theory.... there is possibly a little truth in what he says but it is far from the full story. Ultimately that is the outcome of much medical research!

  • Well that`s a new slant ! I am sure that if it were so the NHS would have decried it & discontinued it & introduced a less costly method of controlling it . It may be a `Hit & Miss ` procedure something akin to Electro Convulsive Therapy or prefrontal leucotomy in psychiatric treatments but to define a procedure which is carried out whilst the patient is under GA as a placebo has to be challenged .

    It is a `hit or miss `procedure from what I know of it but not a placebo effect surely.


  • I find myself agreeing that it is not a very precise and reliable procedure and having had a complication I am no longer as dismissive of the risks as once I was BUT I really dont agree with the placebo thing. I really believed my ablation would work and after 3 months without any events my E.P. declared it a success and I totally believed him. When I came off flecanide though the A.F. came back with avengance. Surely if there was a placebo effect I would have been a perfect and willing candidate for a success story.

    I dont regret trying an ablation or two but am quite glad that the decision whether or not to have another has been taken from me as Im not sure I could have coped with the continuing uncertainty. X

  • I have had three ablations under Prof. Schilling at St.Barts. & the first two obviously ablated the incorrect area from where it was thought that the false impulses to contract were emanating from - but the third ablation found the area & `ablated` it .

    Why did the third ablation find the right area & the first two did not ? - I put it down to the `Mapping` . I read the reports by Prof.Schilling on the procedure & he found a focus from where an impulse was being emitted which was other than the Sino Atrial Node which was missed at the first two ablations & he ablated it & `Bingo` - he had hit the spot & I have had no further episodes of AF.

    So ! - luck? - maybe . Skill ? - definitely . Placebo effect ? - No never. .

  • I think that AF like art and beauty is subjective. I took the usual tablets for 3 years and felt dreadful, took Warfarin and had 3 brain bleeds, I then had an ablation 19 months ago and up to now apart from a few ectopics have been AF free. Definitely not a placebo and if the 'monster' returned would have another without hesitation, my quality of life improved dramatically.

  • I am a sceptic and also to some point a doctor hater (outing myself here), but with reason. The things they did to me and my family, the mistakes that were made are just too many and too important to justify trust.

    So I searched the Net before ablation, and I found just as much negative experiences as for drugs. So what he says in the article about people believing in ablation but not in drugs because of internet is simply wrong!

    44% failed for persistant AF would mean 56% success! That is a great chance.

    I do agree we know too little about long-term effects.

    I also agree it is wrong that doctors who did ablation should be the ones to decide whether it worked. There is possible bias there.

    But the biggest joke in my opinion is the placebo effect. As I said I mistrust and dislike most doctors. When during the first three month after my ablation I had so many problems I used to lie in bed just hating the professor who did it and whishing he could suffer as Ii did (yeah, I am a bad person). Now after five month still having AF but attacks are much shorter!!! I used to have 12-18 hours, now it is 2-5. For me that is a big step as I am not as exhausted afterwards and the day after. Also I feel they are "lighter" cannot explain that. I used to notice that when it started I kept running to the loo every 15 minutes. That is much less now even when it is on. So I suppose heart rate is less during attack (I am not on beta).

    So with me it took some healing to get an effect at all. And not in three months as doc told me. This forum is much more informative, what I learned here is intense and I am already passing on studies I hadn't found on to some docs of mine who are interested.

    I know for certain that with me thyroid hormones play an essential role in PAF attacks. I did not have any for 6 months when liver disfunction after chemo caused free T3 to drop below range. Usually once weekly. But I cannot reach a point when fit where PAF stops and I still have QOL. Meds fpr PAF don't work plus heavy side effects. So I have to look for other ways.

  • I haven't been on here much because I feel so much better now. When I had my first incident last July, ending up in A & E, I could hardly walk and felt terrible. My specialist put me on a range of tablets that made me feel worse, suicidal even. I moved house in November, which meant a different specialist. I saw an EP, who recommended cryo ablation. He had a cancellation and I was admitted in early December. I've not reverted back to as I was before I was ill, but my quality of life is so much better now and I'm completely drug free. I'm a healthy weight, don't drink, eat a good diet - why me? used to bother me – but now I'm just really grateful I'm OK and am able to get on with things. I've also been able to do my work again (self employed) so that is a big bonus.

    Life itself is a gamble. If the option is struggling on, taking pills that make me feel terrible or taking a chance that an operation that might give me a better quality of life, I'd still go for that option.

  • There is a psycho - somatic aspect to every disease or condition & this has to be taken into account when considering a diagnosis & also following treatment of a disease or condition . ECGs do not return to normal following a successful ablation because of any psycho - soma but due to the fact that the area which has caused the false impulses to arise has been successfully `ablated`. The NHS has poured hundreds of millions of pounds on funding centres to treat this debilitating condition .

    There are special centres & especially trained medical professionals all funded by the NHS & I cannot believe that the condition is in anyway psychological - If so then it would be better if we were referred to a psychiatrist for treatment & not a consultant cardiologist who will subject you to a treatment which is carried out under G .A . & for which you sign a consent form for .

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