Article by John Mandrola, the American EP, at the World Heart Rhythm society annual meeting. He makes a number of points indicating that the field of EP has moved on only a little in the last 20+ years.
In particular, he says success rates are only marginally better in 2022 compared with 1998. He also makes the point that Pulsed Field Ablation is just another way to destroy cardiac tissue with success rates only marginally better. PFA is faster but there are serious complications including stroke and tamponade. There is little advance in treating the underlying causes of AF.
I remember a talk I gave in 2008 at HRC when I compared treatment of AF with aviation and suggested that if the first ablation equated to the Wright Brothers' first flight, then we were about the end of the first world war and that I expected rapid advancement very soon.
Afterwards Richard Schilling told me in his view that development had plateaued and that most developments had not increased success but merely made life easier for the EPs.
Made life AND lifestyle easier, at least in the U.S. Afib has turned into a multi-billion dollar industry and it has to be fed with ablations and devices! Ablation didn't even exist when I had my first episode and they actually believed in "Watchful Waiting" which worked fine for me at least for 35 years-- no daily pills, no nothing. Now, it's a beta blocker out the door and when you can't tolerate the beta blocker it's "Now it's time for ablation"
It's a two edged sword. Afib seems under-treated or over-treated in a significant number of patients. In the US, many ep's are pushing ablation as first-line treatment without even trying watchful waiting or medications. On the other hand, I read here about very long waits for people who arguably should have had an ablation yesterday. Just read on a US forum about someone who came into the A&E with afib and had an ablation the next day
Equally I worry about the unreasonable haste for repeat procedures. We have seen here people going in within three months! I had at least a year between my three and was still having events at nine mnths after the third but then suddenly nothing for the last 15 years.
The phrase ROOT CAUSE of AF is an interesting one because
I had a Ischaemic Stroke in 2019 with AF (Embollic type) and then promptly found to have Papillary Thyroid cancer.
So was the my AF caused by thyroid hyper? It is stated that AF can be caused by inflammation in the body or is it cancer? Then there is anxiety, alcohol, big meals, etc or advancing age.
I do know that I had a high systollic rate. I was put on a Metoprolol deriviative Lorvestin or something which caused me tp lose protein in urine. So I stopped.
June last year I was diagnosed with a soft Systolic Heart Murmur.
Other specialists say the heart's electrical responses go heywhy! But if can happen after a virus eg Covid, heart operation, another operation it appears it can be a response to a body event.
As the 3td yearly thyroid scan shows no cancer I am hoping my heart will pop out of AF into being normal.
It may be that my English causes problems in communication with people whose native language is English. I am learning it underway and have progressed a great deal since I first attended this forum in ... 2013. Somebody has used this expression "root cause", not so very long ago, so I adopted it... Maybe not the right one...
BUT, here something about MDs and their knowledge. They either don't know enough, or they are not allowed to use the existing knowledge about dysautonomia. Here, why I think so. In one of the first pages of "HealingWell" forum (USA), you will find the list of chronic syndromes and disease, about 30 all together (in my opinion, all of them count to dysautonomia, with cardiac arrhythmia among them). Medicine admits not to know the cause for each and every of them, but also admits not to have the right treatments for them. Now, between ourselves, how probable is it, that there are 30 different causes, one for every one of the chronic diseases, which can not be traced!? Furthermore, these diseases can come to exist together, from two of them, to up to 10 at the same time. Maybe there are still worse cases, with more than 10 at once, but I have not met them, or people were lazy to add more than 10 to the list, lol.
High BP is one of the health problems which is often in the combination, maybe too often. If somebody has GERD and high BP at the same time, what causes GERD? High BP, of course! If somebody has arrhythmia and high BP at the same time, what causes arrhythmia? High BP, of course! But, what if somebody has AF and has no other issues??? It is "lone AF" and there is an end of conversation... They have no explanation! But, there is no "lone AF", every darn thing in this world has a cause.
None of your problems, which came in parallel with AF, was not the cause of AF. The cause is somewhere there, well hidden and waiting to be found. I sometimes think that all of the mentioned 30 health issues may have the same root cause, which manifests itself in many different ways. It may be the reason that so many disease can come to exist together, in the same human being. The cause, also, may be "non existent", meaning that the whole medical science has not the slightest idea that such thing may exist at all. If we take "energy meridians", which were well known to old Chinese, we will see that the medicine has not the detailed idea about them, not to mention to use them for disease detection or healing. They are invisible, hard to detect and still harder to understand.
Also included is anxiety and I had been turned down by our ACC and then
Dr referred me to Northshore Hospital under my and best surgeon for removing TVT Johnson & J Mesh and sling.
The negative reply from Northshore Hospital came a few days earlier but the letter arrived on that Monday. Stroke Tuesday 2am.
Our local hospital does not allow any surgeon including the one who put it in remove it.
In November my surgeon said evidence of damage now so indeed I was operated at Northshore paid for by ACC. All our Public hospitals under DHB are no longer in sectors and therefore anyone can go anywhere.
So anxiety, inflammation and thyroid caused the A.F.
Where the TVT sling was put in it was in subcutaneous layer and was causing inflammation and it was too tight.
I've been around the world several times but never been to Serbia. A guess are Serbians of Arab descent? Religion Islam?
It is nice to have folks on this forum from all places.
I live at the top of the North Island. European of English descent and Baha'i.
I fully understand your logic. If you were first diagnosed with anxiety, then with inflammation, then with thyroid problems and in the end with AF, it means that the first three have caused the last one. What would be the conclusion without AF? The first two caused thyroid problems etc. If you, instead of four, had 10 ailments, as I proposed it in previous comment, then the number of possibilities would be much, much larger!
In my view, all four ailments came to exist as the consequence of the same cause, which is still unknown. For my own purposes, I denote the 30 quoted ailments as "dysautonomia", suspecting that the cause may be the disturbance of autonomous nervous system. I know that the expression Dysautonomia is reserved for POTS and the like, but the term is much broader and some call it "umbrella disease".
As for the Serbs, I never researched much about the origin. Believe it or not, we are "normal" people like every other nation. We like to live in peace, to see children grow nicely and to have two TVs, as not to have to quarrel with the wife/husband about the remote controller, lol! As for the religion, we are orthodox Christians, but few people go to church nowadays. It is 21-st century, it is about the time to understand that us, the humans, have created gods because of our fears, and that gods exist only in our imagination. On this planet, humans have "invented" over 10.000 "gods", but most were of ill health, so only a few have remained to live long - Krishna, Allah, Jesus, Buddha,... Which one is the "right one"? Of course, our god, since otherwise, we were fools to believe in it, and we can not allow it, at any cost! The religion is a relict of the past, new times are coming, I dare to hope so!
I was diagnosed with anxiety I just knew there was worry there causing a 'pull' in my chest - heart. Thyroid Cancer - Papillary type is very slow growing. AF features were there before stroke like oversweating, exertion I had to stop and fatigue. A heart rapid and persistent.
Hey Peter, only one God and yes holy like and undescriptible. In our imagination.
But it is the man - perfect, although with higher education and learning we turn to for guidance, displaying all the traits of a good person to attain a world of unity, peace, love your neighbour, qualities to include all races and religions from God.
Bahai's believe 1 God, and Baha'u'llah being the latest manifestation of God. Before him Muhammad, Christ, Buddha, etc.
Every 1,000 years a new manifestation will appear.
Mankind needs to be lead by a greater power. Power given from the 1 God.
I pray for all AFers to be controlled like me.
I'll get a library book out to read about your country. I thought deserts!
Thanks for posting. Mandrola is well respected, but a bit of a contrarian who likes to hear himself talk That said, a worthwhile read and I agree afib treatments are somewhat stalled, but that is how it goes for most conditions. Medicine moves slow. Not sure I agree with his take on Pulse Field Ablation (PFA) however. To me, it seems the best of what is available and sometimes you just have to take what is available! I was an afib patient for 35 years and avoided ablation until six weeks ago. In my mid 70's, on daily anti-arrythmic's I don't like -- how much longer was I to wait
a bit of a contrarian who likes to hear himself talk
First time I recall his name. But after doing a cursory search, I agree with your opinion. It seems he is dedicated more to writing than practicing medicine and helping patients. Writers need to attract attention.
I would pay to hear or attend a seminar where he and 2-3 renown EP's from the Cleveland Clinic, Mayo, and top hospitals in the UK discuss atrial fibrillation.
And to hear him and Dr Wolff go one on one would be a classic. 🙂
I had a successful (for now) pulsed field ablation 9 months ago - and my understanding was/is that the complications risk - including stroke (based on the data available at the time) is lower than other techniques… never heard of Tamponade so had to look it up!
Might be worth checking out how EPs define successful when it comes to ablation. They only seem concerned with terminating arrhythmia in the operating room, not necessarily longer term outcomes like recurrence and subclinical heart problems likely caused by the ablation but which many of them seem to wash their hands of leaving patients depressed and confused. It's not unusual to hear forum members say "I never had this problem before I had the ablation!".
I've read so much over the years since my atrial flutter began in 2019 and my ablation followed. This doctor has always impressed me with his common-sense viewpoint and openness. I hadn't read this, so thanks for posting the link. As an aside, I recall in a previous life, before becoming a teacher, attending a medical conference in which a famous English cardiologist heavily mocked his American colleagues for their (as he claimed) general over-reliance on measurements and data rather than on the patient's visible condition. That experience has always brought me to prefer our own specialists and medical training.
However, this American doctor's comments seem spot on to me. The field has barely changed since way back, as he bemoans. I have written before on this forum of my belief that in the not-too-distant future, cardiologists will look back on ablation and say, "They did what? They scarred the heart!" And yet we still have no more effective treatments for arrhythmias than scarring, or rather risky antiarrhythmics.
What I have also read is that an arrhythmic heart might well be one of the end-results of other more general inflammatory processes, rather than a purely cardiac issue. The causes of arrhythmia, an alteration in the myocyte transport mechanism of electrolytes such as K++, Na++, Ca++, etc. seems often to be a downstream effect of an upstream problem. The problem seems highly likely to be lifestyle and diet related, along with genetics and the general effects of ageing.
It's a disappointment to read that we still seem far from being sure what to do with a heart that isn't working quite right and that there is still too much room for art rather than science, but that seems to be the way of things.
My feeling is that if meds control you should not go down the track of Ablation. There seems too much of it around! You seem queasy at the talk of it.
One can only have 3.
Not many Afers have a H/Spec try carefully for safety on CCB Calcium Channel Blockers.
With a combination of CCB AM and BB PM I reached the CONTROL. Then a ear into this regime my H/R Day dropped further Day but at night stays down at 47 avge. CCB must wear off as the 24 hour clock ticks on.
Scarring the heart sounds drastic and my National Heart Specialist used to do it but has stopped.
Rhymn s controlled if the BP and H/R are. Why jump the trial of meds first.
Good thoughts, too, Joy. I'm not queasy at the thought so much as aware that ablation is (well, seems to be) a rather blunt tool to use (but drugs are also, at present, far from "smart" as very specifically acting drugs are these days called). One thing I have noticed is that the money available for research because of covid seems to have enormously increased the research into the fine details of the heart's workings. If I'm right, then at least something good has come out of this otherwise dreadful pandemic.
The thing which could be a problem with CCB Diltiazem, NZ does not have a lower dose than 120mg. Gone 2 years ago are the 30mg and perhaps another dose.
When I suddenly dropped H/R from 77-90s Day to 62-29 H/Rate I thought it was time to stop Diltiazem, and just depend on Bisoprolol this did not work and when Dr came back after Christmas gone, she explained relax and take your CCB. BBs do not have a drastic effect in reducing H/Rate like CCBs do.
But I remain watchful.
Talking about science and biology (which was my top study) I'm glad I decllned RAI Radio Active Iodine and suppression of TSH which was a 'have to' procedures after operation for thyroidectomy. 2 years after the top Surgeon for treating by removal of thyroid cancer has now stated that
Low Risk Thyroid Cancer should by-pass the above usual procedures.
I had my TRIAGE team arguing. The surgeon stood up for me and said "I'm not going to twist Joy's arm to have these procedures".
Happily I have had 3 yearly neck scans 'ALL CLEAR'.
I also declined Radiation after 0 cancer milk duct carcinoma. 2005! I'm still here.
You’ve certainly done well, Joy. As I’ve said before it must be that New Zealand air and climate! ☺️
I would have a second ablation if I felt as bad as I did before the first, although I’m no fan of the procedure at all. My son’s colleague, still teaching part time at 76 has had five, I believe. Goodness me! His AF has now returned sadly, along with atrial flutter this time and he can have no more work done. He’s fine though on tablets, my son reports, although I haven’t spoken to him. I ought to.
In my case, I was told I can’t take flecainide or sotalol, so if things took a turn for the worse, I suspect an ablation is likely the only option for me as I already have some bradycardia on 1.25mg bisoprolol. I guess some kind of pacemaker is likely but I try not to think about it.
it can be different when things turn persistent. When I was still in and out of sinus rhythm, 1.25mg of Bisoprolol gave me a resting HR in the 40s. I had to stand up to get a Kardia reading that didn’t say ‘bradycardia’. Also had some huge dips when reverting to sinus rhythm.
Since it’s turned persistent, followed by an ablation that only lasted two days, it’s totally different. At first I was incredibly disappointed that further ablations or even a cardioversion weren’t recommended. Yet, I seem to have adjusted to 2 x 2.5mg of Bisoprolol each day, alongside Apixaban.
According to my watch, my resting rate is back in the 50s. Though it might not be accurate. Average is a bit over 80. My walking rate is higher than it was, though on a good day it stays under 100. Sometimes it’s around 118, especially if I’ve just eaten. However, I feel fairly normal to be honest, there’s not the leaps up and down. More tired than I used to be on hills and stairs - my legs just feel really heavy, then I stop to let my heart catch up! I’m lucky in that I don’t get breathless. More inclined to feel sleepy in the daytime.
So really, I guess my EP was right, and that I will be fine on rate control. I’m glad now that I wasn’t put through more treatments and that he made that judgement of the situation. Though I would have been happy to agree to further ablations, it could just have been a waste of time for me. Plus a strain on the heart with each one. I do like to have the back-up option of pace & ablate, if the rate control doesn’t work out in the long run.
Age comes into it too though, if I were younger then I could well pursue the mini-maze.
That's encouraging to read and thanks for posting. My main fear is that some kind of heart failure will set in, and I imagine many would have the same feeling. It was good to read that the higher dose of bisoprolol hasn't affected the bradycardia. Before my ablation, in 2019, I went up to 10mg, so my current fears are likely unfounded, although back then, the atrial flutter and tachycardia were permanent, so the 10mg had more to work on, as it were. Now, my typical resting rate is low, but otherwise I feel it is normal. tiredness and similar are a part of my life, partly the heart, I suppose, but a lot from my persistent insomnia - a curse if ever there was one.
it’s the permanent AFib that makes the difference I guess, so that the bradycardia doesn’t set in. Though the ablation will also have raised my HR I guess.
I do inevitably worry about heart disease and dementia too, with being in AFib constantly. I keep checking for swollen ankles!
I had persistent flutter in 2019 but with 155bpm, and that was an incredibly bad time for me.
As for swollen ankles, same here - it's terrible, isn't it? I once convinced myself my they were somewhat puffy but my GP said not. I don't know - life's a worry at times. My elderly friend has had permanent AF for years now with no problems of note, although his rate remains in the normal range. He'll be 90 in August, so I am twenty years behind him. I never feel I'll get to that fine age.
I have 70 coming up next year, but I’m not 69 yet so had better slow down with the age thing. My left ankle used to swell a little, but that seems to have stopped. Maybe losing just a few pounds did it. I think I obsess a bit due to the sister who didn’t manage her AFib well, became really inactive and had very swollen ankles. It makes me determined to keep up with walking. I’ve convinced myself that the secret is to just keep going.
That is the secret and not a very well kept one. Walking is my enjoyment, so long as I have a pair of binoculars around my neck (I'm a keen bird watcher!).
My AFib journey is very similar but I have not chosen the ablation route and am presently rate controlled with Metoprolol. (70-90 bpm). Does excel like yours with activities you mention.
May I ask which medication you take for rate control ?
I am on bisoprolol 2 x 2.5mg per day. It’s taken me a while to get used to it, and the idea of being in A Fib from now on, but really there are a lot worse things!
Hasn't your son's ultimate non success with ablations give you a message?
My NT ProBNP has gone from 2021 158 to 151 and last year down to 111.
It reads 106 for a 35 yr old - 75 yr old. I was 73 - 111.
Is that good?
I started on CCB Diltiazem in Dec 2021 but then the manufacturer was changed to ACCORD and last month I was able to pick up the orginal SAFEMED one. It does infer with B12.
Now B12 is unable to get, SOLGAR bi-lingual. No Dr injections available! Really.
I have send away for 2 more jars which cost me $13.50 for delivery.
I've had no problems with prescriptions being filled, but my local chemist (pharmacist...) told me that many medicines, and even more over the counter medicines are in short supply. Apparently it can be for all sorts of reasons, packaging materials included. It's all very odd and must in some way be either Brexit or covid related.
My son's colleague had his first ablation way back and must have been one of the earliest. He seems happy with the many he's had over the years but I would worry about the effect on my heart myself, if I were him. Scarring is not, surely, a "good" idea overall.
The fact is that all persons should have an ECHO before undergoing any Ablation.
Also meds are better if they control BP and H/R.
Metoprolol gave me pauses at night discovered when I wore a 24-hr monitor. And been on this med 1 year 3 months without any tests done. Uncontrolled I had a H/R avge 187.
Bisoprolol no pauses but at 156 avge Day H/R stilll unconstrolled.
Left again Dr Locum referred me to a private H/Specialist where CCB Calcium Channel Blocker lowered my H/R Day. Only 47 H/R Night.
But I still needed 2.5mg BB Bisoprolol at night.
So tests are important and especially ECG, ECHO and 24-hr monitor when put on any med, if a change etc. I had 3x 24-hr monitors in 2021.
None in hospital and no follow up after a stroke!
What is behind me wasn't nice, no quality of life for me and my heart. I spoke out at surveys!
Do manage your own health. Read up on everything.
My AF was caused by undiagnosed Thyroid cancer. 3 year neck scans show no cancer.
It is disappointing that treatments haven't had the leaps that may have happened in other avenues. My EP basically had the same things to say when I first started seeing him and I was looking into my first ablation. He said he's been doing this 20 years and while it has been made safer via all they've learned over the years, that basically nothing has really occurred that is game changing. He was excited for Pulse Field to finally hit the US market one day since it does seem to be an improvement, especially in avoiding the esophageal problems that can occur. He's also disappointed in the US patient, as it seems more and more people than ever are having heart problems due to lifestyle and diet and it's happening ever younger. In my own case, I have no other underlying conditions and my AFib must be via genetic lottery. I for one would have probably had them tonight to ablation if I had the choice back when hospitalized with increasingly persistent AFib! But it is not a perfect solution for sure..and so much of it seems mysterious still, even to the experts. They appear to have little to do but play the percentages as they've come to learn them over two decades and often lean toward the conservative for their own sake. And yes, money can never be taken out of the equation, especially when it comes to medical treatments. But I sure agree..if I could choose, I would not choose 200 scars on my heart, and headaches popping in constantly, and increasing powerful meds as I wait for a second burn session! But patients don't have much else to try to get off this stupid AFib treadmill. Hopefully someday a better electrical approach can be found .. but as most folk in AFib will agree.. we'll do most anything to get out of that condition when you're in it.
I think that the conduction system pacing mentioned near the end of the article sounds really promising. Especially for those who might end up with the ‘pace and ablate’ option. I know that at least one forum member has had His-bundle pacing for instance. It appears to be a way of pacing the heart in a way that is closer to a ‘normal’ heartbeat.
Yes, it doesn’t get rid of the AFib totally of course.
I believe and this is just my opinion is that most Ablations fail because they are burning muscle and not enough of the actual nerves causing afib. Having 2 failed ablations has me convinced that it really doesn't work for afib. I meet so many people that have had the same experience that it tends to tell me they are just burning Heart tissue with very little success. I will probably be sent to the gallows for saying this 😐
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Afib has turned into a multi-billion dollar industry and it has to be fed with ablations and devices! Ablation didn't even exist when I had my first episode and they actually believed in "Watchful Waiting" which worked fine for me at least for 35 years-- no daily pills, no nothing. Now, it's a beta blocker out the door and when you can't tolerate the beta blocker it's "Now it's time for ablation" 
Cryoballon Ablation
Mini Maze Procedures, there is a place for all, my personal view
According to EP JOHN MANDROLA, MD "AF-rhythm drugs (propafenone, flecainide for example) often make atrial flutter worse." 
Ablations for permanent AF
