Failure rates for different types of ablation?

[Outsidethelines]

Please can anybody tell me: Is the failure rate greater for RF ablation than for cryoablation? I’ve just spoken to a family friend who was told that the failure rate for RF was 30%, as against 10% for cryo. This was five years ago, so maybe things have changed since then? Nobody gave me these figures when I was asked to choose which type . I chose RF because I preferred to have a general anaesthetic. Now I’m panicked that I’ve made the wrong choice.

[BobD Volunteer]

I doubt that anybody can give you concrete data on that subject.

We are all different and our experiences ditto. Cryo is often used as a first attempt as it is quicker and easier to do but has limitations due to every person's heart. If your four pulmonary viens are all symmetrical then it is possible that Cryo may be better for you but many people do not. Many may have conjoined veins where the balloon cannot reach or wildly different shapes. The skill of the EP also plays a big part so important to find out their record of success or failure and of course just what they mean by success.

Personally all my RF ablations have been done using GA and I would not have had it any other way.

[mjames1 in reply to BobD]

Bob your information is outdated and is more pertinent to the first generation cryo- technology not the one that is being used today.

Jim

[Ppiman in reply to mjames1]

It seems to vary a good deal by centre and I have certainly read that second-generation cryo-ablation is equal to or better than RF. However, I just came across this new pre-publication online study which shows it to be less successful long term, and also, interestingly, something I hadn't read about before, that the radiation dose required during cryogenic-ablation was significantly higher.

"Comparison of Second-Generation Cryoballoon Ablation and Quantitative Radiofrequency Ablation Guided by Ablation Index for Atrial Fibrillation" by Qin-Dan Yan et al.

Steve

[mjames1 in reply to Ppiman]

I could not access the full text version, however, the study population seemed a lot smaller than the fire and ice trial. Fire and ice I believe followed patients for 1.5 years and found no difference in outcomes cryo vs rf. Do you know how long this trial followed patients?

The radiation issue is well known and I believe some centers are already reducing it.

I think both procedures have their pluses and minuses But still haven't seen anything that shows one superior to the other. And unfortunately, that seems to include pulse field as well.

Jim

[Ppiman in reply to mjames1]

Hi Jim

I've just noticed that the publisher has withdrawn the online version, with no reason given. The numbers involved were quite significant as I recall and the study seemed well carried out and analysed.

The radiation dosage has passed me by. I think I'd rather not know!

Steve

[Outsidethelines in reply to BobD]

Thank you Bob, this is helpful information

[Iamfuzzyduck]

My EP told me this year that cryo is less effective than RF …

[Outsidethelines in reply to Iamfuzzyduck]

Oh, well that’s interesting…

[mjames1]

The Fire and Ice trials showed similar results. The advantage of Cryo is that it's less operator dependent. That means unless you have a top flight ep, who does over 300 a year, Cryo may be a better choice. The idea that Cryo is somehow inferior for a basic PVI ablation is outdated and refers to the first generation of Cryo technology, not what you would get.

As to success rates, it depends on how you define "success". If you use the US trial definition of no afib episodes greater than 30 seconds six months post ablation (excluding blanking) then maybe 50-60%. If you use the definition of a substantial reduction in afib burden at six months post ablation, probably closer to 90%. After that, "touch ups" and additional ablations are not uncommon.

If you're looking for a more permanent and complete cure, consider a surgical ablation such as mini maze.

Jim

[mav7 in reply to mjames1]

The idea that Cryo is somehow inferior for a basic PVI ablation is outdated

If this is in reference to   BobD 's reply above, that is not what he said.

[mjames1 in reply to mav7]

The "limitations" he talks about are more pertinent to first generation cryo technology, which is outdated. Studies, including the AHA study you posted, show similar results for RF and the newer generation of Cryo technology.

Jim

[Outsidethelines in reply to mjames1]

Thanks Jim, very helpful

[Buffafly]

Bear in mind that RF is often used as first option for people who are more difficult cases. I had had AF for many years, because of my reaction to drugs they were no longer an option so the alternative was a pacemaker, and I had comorbities that meant that having one or more ‘touch ups’ were inadvisable. So my EP did a really thorough job, ablating areas that are often left for second or third ablations and ablating for flutter at the same time. A cryoablation would have been a waste of time especially as it turned out that I had an unusual shaped vein. I had two years free of AF which is technically a success.

[mav7 in reply to Buffafly]

Good reply, Buffafly ! Assume you had paroxysmal afib and may I ask your current status ?

[Buffafly in reply to mav7]

I now have occasional episodes of AF at a rate mainly under 100. My heart isn’t in great condition so I tend to get persistent AF in hot weather but my heart has always reverted to NSR on its own. I only take180mg of diltiazem daily.

[mav7 in reply to Buffafly]

Thanks ! Best to You !

[mjames1 in reply to Buffafly]

Bear in mind that RF is often used as first option for people who are more difficult cases.

Not necessarily.

Actually most top ep's that do cryo, also do RF and often during the same procedure, if and where needed.

For example, I had a cryo- ablation for afib, but my ep was prepared to use RF for any arrythmia's outside the pulmonary vein, such as flutter or SVT.

Also, at least in the US, a CT scan is usually performed prior to Cryo, so any abnormalities in the pulmonary veins would be apparent beforehand.

Jim

[Outsidethelines in reply to Buffafly]

Thanks, this is very helpful information

[mav7]

Outsidethelines Would recommend you "google" the subject for studies on the subject from NIH, BHF, AMA, etc and not independent studies. And do research the minimaze procedure and the Pulse Field Ablation (PFA).

We are not to post links but the below is a quote from an AHA study, Apr '21.

Conclusions:

PVI by RF and CRYO produce similar moderate to high PVI durability. Both treatments lead to marked reductions in AF burden, which is related to the number of durably isolated PVs. However, for one-fifth of paroxysmal AF patients, complete and durable PVI was not sufficient to prevent even short-term AF recurrence.

[Outsidethelines in reply to mav7]

Thanks for your reply, Mav7

[Lilypocket]

I have only had one ablation so far and it was was RF under General A. The advantage is if other rogue pathways are found away from the pulmonary veins during the procedure ( my case) the EP can deal with them there and then. If the problem is coming from the PVs then both methods are equally as successful as each other from what I have understood. Good luck with whatever you decide.

[Outsidethelines in reply to Lilypocket]

Thank you, that’s really helpful

[Foxey2]

I had a cryoablation in Oct 2021 and touch wood it’s still going strong, hopefully I’ll get a few more years AFib free. 😊

[Ppiman]

I suspect actual figures vary more according to the practising EP. I think this is owing to their naturally - indeed enforced - conservative approach. This is because the area to be ablated is on the inner cardiac atrial wall around the pulmonary veins and this can be very thin. Added to this there’s a fair chance that the oesophagus is pressing very closely against the outer wall of the pericardium, close to the atrium and pulmonary veins and is at risk from transference of heat or cold from the catheter tip.

Not surprisingly, some doctors are more conservative than others and might get a greater failure rate, whichever catheter device is used.

Steve

[Outsidethelines in reply to Ppiman]

Thanks Steve, scary stuff!

[Ppiman in reply to Outsidethelines]

Indeed - but we are in safe hands it seems as these problems are minor.

Steve

[Lilypocket in reply to Outsidethelines]

Steve is right that is why it is always a good idea to try and find out how many ablations the EP carries out per year on average. The EPs that are very experienced have probably dealt many times with arrythmias that are delicate to deal with so complications are less likely. My EP does on average about 600 ablations a year and always RF under GA. I think Cryro is excellent these days with good results but if the problem is away from the PVs then an EP who is very comfortable and skilled in these areas is a given. But the problem usually comes from the PVs and you have a good chance of a successful ablation without any problems and sedation means recovery is faster. Take care!

[Outsidethelines in reply to Lilypocket]

Thanks Lilypocket. My EP said his team carry out 500 cardiac ablations per year - 2/3 per day. Hope that means they’re well practised! They do both types - cryo under sedation and RF under GA. I have my pre-op tomorrow - nervous already!

[Lilypocket in reply to Outsidethelines]

It sounds as though you will be in very capable hands. 🙂Let us know how you get on.

[Outsidethelines in reply to Lilypocket]

Thank you for the reassurance, Lilypocket (great name, by the way). I know they do these operations all the time, but this is the first time for me and I’m scared. I’ve never even spent a night in hospital before, even when I had my children!

[Sixtychick in reply to Lilypocket]

The EP who did my ablation at Glenfield in Leicester, told me he’d done over 2,000 ablations, so hopefully, he did a good job on mine. 🤞🤞

[Lilypocket in reply to Sixtychick]

Cool! My has been doing 600 a year for the last 9 or so years ( he is in his early 40's or slightly younger) so that's a good tally. Fingers crossed for us🤞🤞

[Sixtychick in reply to Lilypocket]

Yes.🤞🤞🤞🤞

[Lilypocket]

Honestly if your Afib has become bothersome and is affecting your quality of life know that it is going to get worse as it is a progressive condition. So your best chance of a respite - hopefully a very long one 🙂 - is an ablation.Looking back I wonder why it took me so long to decide to have it. But I was frightened of the unknown and felt I could live ok with Afib. Also my cardiologist was very oriented by treating it with medication and I only found out about ablations on this site and it was the knowledge of some members that helped me decide. Best health decision I ever made!

But at the end of the day it is your decision with your medical team who know what is best for you and the success rates related to your own condition.

Take care!

[Outsidethelines in reply to Lilypocket]

I just got back from my pre-op, and they had me down for cryoablation with sedation, instead of RF ablation with GA, which is what I asked for. I’m booked for surgery in exactly one months time. The nurse was lovely and said she’d get hold of my EP today, and find out what’s going on. But she also said they may have to move me to a different date if I insist on sticking with GA. I suppose I shouldn’t be surprised by the cock-up but it’s upsetting all the same.

[Lilypocket]

I think getting a Cryroablation under sedation is more available and thus you can have the procedure more quickly . But if your symptoms permit waiting longer stick to your guns and have the procedure under GA if it is what you want. It's your choice at the end of the day.

[Madscientist16]

In the US, cryo-balloon ablation is usually attempted first. Patient comorbidities, surgeon skill or anatomical anomalies may impact the success rate. If/when AF returns the next ablation is RF on the areas that the first ablation may have missed.

Sedation should be ok. Ever have a colonoscopy? Did you remember anything? GA is riskier and has longer recovery.

[Madscientist16]

RF ablations are much more tedious for the surgeon and can result in missed areas. These surgeries are always much longer and AF tends to resume sooner. Cryo-balloon ablations are a great way to cover a larger amount of area in the pulmonary veins that is scarred for a shorter surgery. Of course, anatomical abnormality can affect success rate and it is also important to have good health habits before and after the procedure.

[Outsidethelines in reply to Madscientist16]

Thank you, MadScientist, this is interesting information. I’m hoping to get hold of someone today who can tell me what’s going on, why I’ve been listed for a different procedure from the one I agreed to. I’ve waited so long for this surgery, I don’t want the date to slip back much further