“Forget about the blanking period after ablation - it is inflating the success rate of ablations”. (EP John Mandrola)

[Abbyroza]

American Electrophysiologist John Mandrola, who has performed hundreds of ablations, including the new ‘pulse field technology’-ones, is known in the cardiology trade for his critical stance and his patient-oriented approach. I like citing him, because his opinion is often less biased that that of some of his colleagues, who tend to promote ablations without much regard for their patient.

In his last publication, also delivered as a speech during a world cardiology conference, he asks himself and his colleagues: “are we inflating the succes rates of AF ablation?

His answer is a stunning ‘yes!’

Read the contents of EP Mandrola’s speech here:

“Since the inception of AF ablation, electrophysiologists have considered it normal to exclude episodes of atrial arrhythmia up to 3 months after the procedure when measuring procedural success. Nearly every trial ever done for AF ablation includes such a blanking period. 

Yet, our patient is in a lumpy hospital bed with scratchy sheets, an IV in his arm; he is served terrible food, woken up for vital signs at 3 AM, for blood work at 4 AM, and yet another person does his ECG at 5 AM. He surely has a different view of whether this arrhythmia counts. 

I will outline our case for eliminating the blanking period after AF ablation. 

Why Don’t Early Recurrences of AF Count?

The blanking period began with the decades-old observation that thermal ablation to isolate the pulmonary veins often results in early recurrences of AF or atrial flutter. These early tachycardias were associated with a higher rate of late recurrences of AF (procedural failure), but the correlation was not perfect. Sometimes the early AF episodes would resolve and patients would remain free of AF over the long term. 

Early recurrences can occur because of true procedural failure, either due to reconnection of the pulmonary veins (the pulmonary vein isolation did not hold) or because the wrong area was targeted. Other potential causes of early recurrence that dissipates with time are direct mechanical trauma, inflammation, and/or autonomic changes, similar to the proposed causes of AF after cardiac surgery. 

These latter causes led to the establishment of a 90-day blanking period after the procedure. The best argument for the blanking period is that it encourages us to wait before doing a repeat ablation, and because many of these early AF episodes resolve, we avoid overtreatment. 

But I see better reasons to eliminate the blanking period. 

Reasons to Eliminate the Blanking Period

The first is that it inflates the true success rate of AF ablation. A recent study from the Canadian CIRCA-DOSE trialists found that the success rate of the procedure dropped from 55% to 50% if you included early recurrences of AF. Swiss authors confirmed this finding in a reanalysis of a randomized controlled trial of two cryoballoons.

But you hardly need studies to know that excluding recurrences during the blanking period favors the procedure. This is important in trials that measure AF recurrence as a primary endpoint. Consider that some trials end at a year, so a 90-day blanking period excludes 25% of the follow-up period. 

The second reason to eliminate the blanking period is that I can think of few other areas of cardiology that use one. For example, if the ISCHEMIA trial comparing invasive vs conservative management of patients with a positive ischemic stress test had a blanking period, the results would have been different. 

The primary outcome of the ISCHEMIA trial was a composite of myocardial infarction (MI), hospitalization for unstable angina or heart failure, cardiovascular death, or resuscitated cardiac arrest. The main result found no significant differences between the two strategies. Debate centered on rates of MI. The main result counted all MIs (including periprocedural MIs). In a secondary analysis that excluded periprocedural MI (ie, a blanking period), the invasive arm showed a significant reduction in MI (hazard ratio, 0.67; 95% CI, 0.53-0.83).

I have been critical of the OPTION trial, which compared left atrial appendage closure added to AF ablation with direct-acting oral anticoagulants after AF ablation. Trialists chose a primary safety endpoint that excluded bleeding at the time of the procedure. Using a peri-procedural blanking period allowed the investigators to declare the LAAC/Ablation strategy superior in safety to DOAC/Ablation. Without a blanking period, superiority would not have been established. Of course, patients cannot exclude bleeding events around the procedure. 

Pulsed Field Ablation 

The third reason to eliminate the blanking period concerns the advance of pulsed field ablation. Pulsed field ablation uses electrical rather than thermal energy. Although its efficacy and safety have been found similar to thermal ablation, there are probably different postprocedural effects.

This multicenter observational study of more than 300 patients treated with pulsed field ablation found that early recurrence of atrial tachyarrhythmias was common and 100% of patients who had recurrences in the second or third month post-procedure had late recurrences. 

German electrophysiologist and early adopter of pulsed-field ablation Stefano Bordignon emailed me that he increasingly believes that a recurrence after pulsed field ablation at any time should count as a true recurrence. He reasons that in experienced hands, pulsed field ablation is so effective at isolating the pulmonary vein, that a recurrence indicates a nonresponder and someone who may benefit from an early re-do ablation. 

Bordignon also believes that many of the treatment failures observed with pulsed field ablation are due to poor patient selection. Because the procedure is so fast and safe, doctors are offering it to patients who previously would have been ruled out for ablation due to likely treatment failure. For many of these patients, comorbidities that won’t be "fixed" by ablation are the drivers of their AF. 

Conclusions 

It is time to right a wrong. Blanking periods bias in favor of ablation, complicate trial interpretation, and ignore patient-centered outcomes. Few if any other areas of cardiology exclude the days and weeks after a procedure. 

The advent of pulsed field ablation further exposes the problems with blanking periods because it is increasingly clear that AF recurrences after pulsed field ablation predict procedural failure. 

Patients can’t pause to ignore their symptoms after ablation; neither should doctors. To the purists who insist on a blanking period, we can make it a secondary endpoint of trials. The primary endpoint should be all episodes from the moment of randomization, as was done in the ISCHEMIA trial”.

[Efka]

Yes another fascinating Substack from him.

[Abbyroza in reply to Efka]

Yes, he is one of the most patient-centered and honest EP’s in the trade. Always interesting to read his opinion.

[Ppiman in reply to Abbyroza]

By implication, I would doubt that many EPs are dishonest, you know. They have different viewpoints and experiences, of course and some are out to get rich, of course (but aren't we all!).

Steve

[Abbyroza in reply to Ppiman]

I would never call any of those dedicated professionals ‘dishonest’, but I have experienced firsthand that many of them have a tendency to skip a few other, workable solutions in order to arrive as fast as possible to their preferred one: ablations.

This is very understandable, because they are the catheter wizards, with the beautiful hi-tech equipment and promotional video’s from Boston Scientific, in which ablations are presented as the nec plus ultra of the trade. Every professional likes to use state-of-the-art equipment.

So I would rather call it a slight ‘bias in their choice’, instead of dishonesty. That bias is not always a disadvantage for the patient, unless he or she could have gotten rid of AF with a less invasive and expensive procedure.

Out of 5 cardiologists that I consulted, 4 immediately presented ablation as the best solution. Luckily, I had my friend cardiologist to get a second opinion from.

After my heart attack, a fantastic team of professionals did their utmost to limit the damage to my heart. I would feel like I was betraying those wonderful people now if I would have my heart damaged on purpose by an ablation.

[Ppiman in reply to Abbyroza]

It was your feeling the need for the statement that Mandrola was honest that led me to ask.

Also, your case is rather unusual, I suppose, given the heart issues?

My “EP” seems very balanced in his views of ablation. He has the new kit, though. I’m on a waiting list but will if needed pay for a private consultation with him to have the time to discuss whether ablation really is my best way forward. I also have LBBB which causes bradycardia and light-headedness so I will be asking about a possible PM, too.

Thanks for your useful input.

Steve

[Abbyroza in reply to Ppiman]

The ‘heart issue’ is not so unusual. In fact, many people develop AF shortly after a heart attack. The damaged ( dead) tissue is the culprit, probably. In my case, thanks to the swift response in the local cathlab, (a life-saving cash cow in this case, haha) the damage is very limited. That’s why I cringe when I think about ablations. Causing new damage on purpose goes somewhat against my actual mindset. 😉

[Ppiman in reply to Abbyroza]

I meant that I thought that few here would have other structural cardiac issues. That’s likely on the other site, where AF is more an aspect of that.

But I am with you in your thinking.

Steve

[Auriculaire in reply to Ppiman]

No we are not all out to get rich!

[Ppiman in reply to Auriculaire]

Really? Let's put it differently, none of us wish to be poor.

Steve

[Auriculaire in reply to Ppiman]

I would agree with that! But I have no desire to be any richer than I am. I do not hanker after the trappings of riches. Indeed I have a make do and mend attitude to life and try not to consume a lot.

[Ppiman in reply to Auriculaire]

The heart of the socialist's dilemma I always think is, "How rich is rich enough?" and "Who decides?"

Steve

[Abbyroza in reply to Auriculaire]

I would not mind, though. 😂

[BobD Volunteer]

Goes against everthng I was told. i e the blanking period was to allow the scar tissue to form as it is this that blocks the rogue impulses rather than initial burns.

[Abbyroza in reply to BobD]

That’s exactly why I posted this. Many of us are not told the whole truth regarding ablations.

3 internationally renowned EP’s (Mohammed Ruzieh, John M Mandrola and Andrew J Foy) just published a paper in the American Heart Journal, entitled: “Patients' lives don't pause for blanking periods”.

In it, they write: “Atrial tachyarrhythmia events during the first 90-days following an AF ablation procedure are common. Liang et al. and Willems et al. showed that approximately half of patients undergoing AF ablation experience atrial tachyarrhythmias within this timeframe, and about half of them experience recurrent episodes.

These findings highlight that atrial tachyarrhythmias during the 90-day blanking period are common, frequently symptomatic and often necessitates interventions. We propose not ignoring these episodes.

The inclusion of a blanking period in an RCT of AF ablation introduces complexities in interpreting the results and poses challenges for shared decision-making because patients are concerned about ALL symptomatic events. Since these periods exclude a large number of events from being counted, they bias trial results in favor of AF ablation”.

The elimination of the blanking period would make it possible to finally know the real success percentage of ablation procedures. I estimate it below 50 %, and so do the authors of the paper.

[Karendeena in reply to Abbyroza]

The 50%you continue to quote is based on patients who have persistent AF not those who are paroxysmal

[Abbyroza in reply to Karendeena]

No, based on the average of all AF cases.

[Karendeena in reply to Abbyroza]

Incorrect, read more the 50% is quoted for those who have been in AF for a considerable time. I will trust the word of my experienced EP thank you

[Abbyroza in reply to BobD]

“Early recurrences can occur because of true procedural failure, either due to reconnection of the pulmonary veins (the pulmonary vein isolation did not hold) or because the wrong area was targeted. Other potential causes of early recurrence that dissipates with time are direct mechanical trauma, inflammation, and/or autonomic changes, similar to the proposed causes of AF after cardiac surgery”. 

[Karendeena in reply to BobD]

I agree with you Bob, scars need to form to block the signals. There are so many studies and opinions out there but I will always listen to my EP

[MWIC in reply to BobD]

My experience was that there was absolutely a blanking period as 1 week after ablation it went to hell for 3 or 4 weeks then settled and no sign of AFib since about 8 or 9 weeks and that was nearly a year ago

[Abbyroza in reply to MWIC]

Were you so symptomatic and was your quality of life with AF so bad that it was worth ‘going to hell for 3 to 4 weeks’? And did you try all other options before (different meds, lifestyle changes, stress reduction, etc…)?

If that’s the case, ablation certainly was the only sensible thing to do.

All the best and eternal sinus!

[MWIC in reply to Abbyroza]

Truth is it was - highly symptomatic and increased to the point of episodes at some point every day - the downside of being resilient and adaptable is you can get to a point without fully realising at the time how bad your life has become - due to a previous heart attack from which I have had no problems since I could have no Meds other than Bisoprolol and that brought by heart rate too low. No guarantees with this thing unfortunately but if it comes back I’d have no hesitation getting it done again

[Abbyroza in reply to MWIC]

After my massive heart attack, 7 years ago, I also got AF.

Last year, episodes occurred almost daily, and I was very symptomatic: high HR, dizziness, tiredness, urinating every 5 minutes… the works! Flecainide did not help any longer.

So I decided to try one last thing: I stopped the Flecainide altogether, and started taking 3 supplements: D-Ribose, L-Carnitine and Ubiquinol , plus (temporary) Xanax to destress.

After one week, the daily episodes stopped and I was 2 months in sinus rhythm. Then there was a short breakthrough of 4 hours (stopped with 300 mg. Flecainide as ‘pill in pocket’). Since then, 3 months AF-free.

Just to show that there are many alternatives. But I’m glad that ablation was the solution for you. Everyone is different.

[MWIC in reply to Abbyroza]

Agree and we’re all different - so great to hear of more than one way to tackle - what led you to start taking that mix of supplements ?

[Abbyroza in reply to MWIC]

The advice of one of our best friends, an MD who read about the advantages of D-Ribose.

[Karendeena in reply to Abbyroza]

But your afib is still lurking and no doubt will come back with a vengeance one day. I am not saying ablation cures but for some it doesn't reoccur for years if at all

[Abbyroza in reply to Karendeena]

If that should happen, I count on living to be 94 (at least) like my beloved mother did, with permanent AF. ‘You have the heart of a young girl’ her cardiologist used to say.

My own heart is doing quite well, too. During the last stress test on the static bike, two months ago, I reached 174 watts. That’s 135 % of the average male my age. And that’s after a heart attack and many, many episodes of AF.

AF is a benign condition in most cases.

[Karendeena in reply to Abbyroza]

My mum has AF and is 97!

[Abbyroza in reply to Karendeena]

Perfect! Wish her all the best.

[ozziebob in reply to Karendeena]

I wish you wouldn't remind me of my poor genes ... my mother died on her birthday at age 66 from a heart related disease. 🤔

94, 97 ... I should be so lucky!

[Abbyroza in reply to ozziebob]

You will be! As you have had a gene warning, I’m sure you have lived the healthiest life possible!

[Karendeena in reply to ozziebob]

ozziebob you could get there! My grandmother (mum's mum) died in 1966 aged 66 so where mum got her longevity from goodness knows. If you ask her she would say it's because she doesn't worry, never has and never will. She says worrying will kill me 🤪We have a rare genetic condition in our family called HLRCC mum passed it on to me it exposes us to a very aggressive kidney cancer so I have an MRI every 12 months, waiting for results now 🤞

[sdweller in reply to Abbyroza]

I agree with you! This used to be the attitude from EP's. My grandmother had afib issues starting when she was in her 40's, and was in permanent AF for the last 35 years, and lived to 95. She was not on blood thinners for the first 20 years or so of that, (unbelievably), and never had an ablation or any other meds for it. Lived a normal happy life. My dad is following in her footsteps, but he did have a couple ablations that helped keep him in NSR longer... but he is now in permanent and has been for about 10 years now. He is 86. I had the advantage of 2 MUCH better ablations, at the Cleveland Clinic, that have kept me in NSR to date. The stats on strokes show that the extra risk is very low for afibbers, especially when younger and for those that stay more fit, and healthier.

[TM93 in reply to Abbyroza]

What supplement dosage do you take?

[Abbyroza in reply to TM93]

15 grams of D-Ribose, 500 mg of Magnesium taurate, 500 mg of L-Carnitine, 50 mg of Ubiquinol.

[TM93 in reply to Abbyroza]

Thank you. I agree with much of what you say.

[Ppiman in reply to Abbyroza]

Good questions. I enjoy your input and Mandrola’s views were enlightening. You have touched on a sore spot, though. The study to which I referred showing a four week cut off was a good one and in light of Mandrola’s comments makes much sense.

Steve

[Abbyroza in reply to Ppiman]

I could not agree more. One month seems very logical.

[Amiodaroneluck in reply to MWIC]

In my last ablation, I had some what I would consider ectopic beats during the week or two after my ablation. But thankfully, I've been in NSR since then and my 6 mo. followup was as good as one could hope.

[Abbyroza in reply to Amiodaroneluck]

Nice to read! All the best.

[mjames1]

Yes, episodes during blanking have meaning, but the most important number is the longer-term result. If you don't ignore blanking, episodes, then those results will not reflect many actual success stories and I will include myself here although my one episode was a few months out of blanking

Jim

[Karendeena in reply to mjames1]

Agree 💯 Jim. The scars need to form. True success is based on long term results that's what I was told and understand

[mjames1]

3 internationally renowned EP’s (Mohammed Ruzieh, John M Mandrola and Andrew J Foy)

Foy and Ruzieh are not electrophysiologists, but general cardiologists. And Mandrola is not an "internationally renowned" EP. He has a relatively low volume ablation practice and spends most of his time with general cardiology and blogging a contrarian point of view like this article here. Nothing wrong with that, but just pointing out who he is and what he does.

Jim

[Abbyroza in reply to mjames1]

I could not agree more: the records are important, so let’s describe the experience of the three authors in some more detail:

Mohammed Ruzieh, M.D., is an assistant professor of cardiovascular medicine at the University of Florida College of Medicine.

Andrew Foy is a Cardiologist in Camp Hill, Pennsylvania. His top areas of expertise are Atrial Fibrillation, Atrial Tachycardia, His Bundle Tachycardia, Heart Bypass Surgery, and Hormone Replacement Therapy (HRT)

Dr. John Mandrola is a Cardiac Electrophysiology Specialist in Louisville, Kentucky. Having more than 36 years (!) of diverse experiences, especially in CARDIAC ELECTROPHYSIOLOGY, and CARDIOVASCULAR DISEASE.

Their paper and their suggestion are both very valuable as they pointed out that the principle of a 90-day “blanking period” creates a distorted view of the effectiveness of ablations. “If arrhythmias occurring shortly after the procedure are also taken into account, the success rate drops to around 50%,” they wrote in last month’s American Heart Journal.

A failure rate of 1 in 2 is hardly a statistic to be proud of. Yet, in recent years, hundreds of thousands of patients worldwide have been convinced to undergo an ablation based on these inflated success rates. I think that is stunning, and a far cry from ‘informed consent’, sadly.

Ablations are “big business,” as they are performed in expensive catheterization labs using costly equipment. Using the correct efficacy figures is therefore essential to give the patient the proper guidance and to control spending of medical funds. With distorted efficacy results due to an arbitrary and contested ‘blanking period’ this can hardly ever be the case…

[mjames1 in reply to Abbyroza]

So you're saying not counting blanking is distorting. I'm saying that counting blanking episodes distorts the numbers.

I think many people, including myself, are willing to put up with one or two post operative episodes, knowing that the longer term numbers are much better.

Big business or not, most people are very happy with their ablations. But it's sometimes hard to tell on forums like these where the people who have had successful ablations tend to leave the forums and go on with their lives, while the ones with failed ablations tend to stay gor more support.

Jim

[Abbyroza in reply to mjames1]

I’m not saying anything, I couldn’t, as I’m not qualified. I’m quoting three professionals who are. I do think they’re right: ignoring arrhythmia during the ‘blanking period’ is distorting the efficacy figures big time. A drop from 70 to 50 % is very significant. I can imagine that someone who was reluctantly choosing for an ablation would certainly have changed their mind after learning that the odds were far less in favor of succes than originally presented. That is worrisome, to say the least.

I’m glad that the trio opened this can of worms and I sincerely hope that more honest and correct information about the real efficacy of ablations will find it’s way to potential patients.

People who are about to undergo a risky, envasive procedure that will cause irreversible damage to their heart deserve to get the correct scientific facts, not just the marketing blabla of catheter manufacturers .

[Karendeena in reply to Abbyroza]

Please stop quoting risky invasive procedure that is an opinion as the risks are there but minimal and it's minimally invasive

[Abbyroza in reply to Karendeena]

Cardiologists and EP’s who emphasize that ablation is invasive are making a valid point because, despite being a catheter-based procedure rather than open-heart surgery, it still involves:

1. Insertion of catheters into the heart – This requires threading multiple catheters through veins (usually the femoral veins) into the heart, which carries risks like bleeding, infection, or vascular injury.

2. Tissue destruction – Whether using radiofrequency (burning) or cryoablation (freezing), ablation deliberately scars heart tissue to disrupt abnormal electrical signals. This is a controlled injury, but it’s still injury.

3. Potential complications – While generally safe in experienced hands, ablation can lead to serious risks, including stroke, pulmonary vein stenosis, tamponade (fluid around the heart), or damage to nearby structures like the esophagus or phrenic nerve.

4. General anesthesia or sedation – Many ablation procedures require at least conscious sedation, and some involve general anesthesia, adding another layer of risk.

Compared to major surgeries, ablation could thus be called ‘minimally invasive’, but compared to medication or lifestyle management, it’s undeniably an invasive intervention. Some cardiologists emphasize this to ensure patients fully understand the risks before opting for the procedure.

I think that’s a very sound approach.

[Karendeena in reply to Abbyroza]

I didn't say it was without risk but nothing is! You have to weigh the risks with the benefits and to me being 12 months free of AF having endured episodes of high heart rate lasting 36 hours everyone, I would say that's a benefit

[Karendeena in reply to mjames1]

Agree 💯

[Karendeena in reply to mjames1]

Agree 💯

[Karendeena in reply to Abbyroza]

I wish you would stop quoting 'ablations are big business'! You speak of America. In the UK I can assure you that it's not for making money as many are done on the NHS and it is to give patients a better quality of life. My EP tried his hardest to control my AF through medication but it just didn't work. He then said if I had an ablation the success rate was far greater if carried out before it progresses to persistent which, like you say, reduces the success rates to around 50,%

[Abbyroza in reply to Karendeena]

No, I do not ‘speak of America’. Ablations are ‘big business’ all over the modern world, because they are very expensive procedures, anywhere. It does not make any difference if insurance, the state, or the patient pays, the cost is the same and the bill is always picked up by one of these three parties. Cathlabs are the cash cows of many hospitals.

[Karendeena in reply to Abbyroza]

Please stop saying 'cash cows of the cath labs', ablations have helped many of us here and given back some quality of life. You are making sweeping statements based on your opinions. I do not want to hear this again. On another note, medications are extremely expensive too and if you are on those for life then the cost is also there

[Abbyroza in reply to Karendeena]

Prescription glasses are also known as ‘cash cows’ of the opticians, but I wear them too. An item being a cash cow of an industry does not imply that it is not necessary or valuable to the ones who need it.

And as I already stated, this is not MY opinion, it is the opinion of members of the medical profession. The honest, straightforward ones.

[Karendeena in reply to Abbyroza]

It's a horrible wording

[Abbyroza in reply to Karendeena]

I can use ‘profit maker’ in the future if that pleases you more. 😉

[Karendeena in reply to Abbyroza]

None of it does because I don't believe it in this Country. I am not saying targets don't exist but I truly believe our specialist consultants have our best interests at heart

[Abbyroza in reply to Karendeena]

So did the doctors who prescribed Softenon. They’re only human.

[Auriculaire in reply to Karendeena]

You are being naive. All medical procedures are making profit for somebody whether it is drug companies or the manufacture of medical equipment. Only lifestyle changes like improving diet, exercise ( not gym based ones as gym owners too will make profits!) or getting more sunshine and fresh air could be said to be free from this. Many specialist consultants get money from Pharma to promote certain drugs. How many doctors are influenced by such KOLs and will stick you on a statin if your cholesterol creeps over the magic number rather than give diet advice?

[mcpacs in reply to Abbyroza]

I had my ablation for paroxysmal Afib 14 years ago at age 56 and was told at that time the success rate was more in the 80 to 90 percent range. 50 percent sounds very discouraging, especially considering since my ablation 14 years ago, you would think success rates would be higher, not lower.

I have not had a recurrence of the Afib to date. However, I began developing ectopic beats, of premature atrial contractions (PACs), 5 years ago which have mostly resolved by a daily dose of Flecainide. But as a cautionary measure, my cardiologist is keeping a close eye on the extent of my coronary artery disease (CAD), as the CAST study had showed patients, who had had a recent heart attack, and were taking Flecainide for non-life threatening ventricular arrythmias, had higher mortality rates. drugs.com/sfx/flecainide-si...

I hope I can continue with the Flecainide as the ectopic PACs were almost as bad for me as being in Afib. I have always been very symptomatic to both.

[Abbyroza in reply to mcpacs]

A history of HA and Flecainide indeed do not always match well. I had to stop Flecainide after a few years because it started causing very bothersome pre-syncopes at the moment of conversion from AF to sinus, and my QTc-number went up above 500 msec, which represents a danger for torsades de pointe. So I stopped taking Flecainide and solved the AF with a cocktail of supplements.

I’m sure your cardiologist will check your QTc value regularly. Then you’re fine. All the best!

[mcpacs in reply to Abbyroza]

Thank you! All the best to you as well.

[HGates in reply to mjames1]

He presented the Paul Wood Lecture at the British Cardiovascular Society annual conference in Manchester, England in 2024 as well as lecturing at the Danish Cardiovascular Academy the same year. He also presents ‘This Week in Cardilogy’ for Medscape every week. He has nearly 70,000 followers on his X account. Even if you think ‘renowned’ is over-egging it, he can certainly be considered ‘internationally recognised’. Also, contrarian points of view are vital in medicine to counteract the ‘nodding dogs’ who are just happy to go along with what’s fashionable at the time.

[Karendeena in reply to mjames1]

Abbyroza quotes cardiologists a lot, they are not the specialists, you need a good EP

[Abbyroza in reply to Karendeena]

The three authors of the study are an experienced EP, an assistant cardiology professor and a cardiologist specialized in arrhythmia. Hard to find a more suited, multi-talented team to discuss the matter of the blanking period.

[mjames1 in reply to Abbyroza]

The three authors of the study are an experienced EP

Two of the three are general cardiologists and not electrophysiologists (ep's).

Since you keep repeating the mistake, you might want to learn the difference.

Jim

[Abbyroza in reply to mjames1]

‘An experienced EP’, as in ‘one experienced EP’.

Allow me to explain the differences and similarities between a cardiologist and an electrophysiologist, as this seems to be unclear.

Electrophysiology (EP) is a subspecialty of cardiology that focuses on the electrical system of the heart, diagnosing and treating arrhythmias. So, every electrophysiologist is a cardiologist first.

Of course, that does not prevent cardiologists to make the treatment of arrhythmia their field of expertise.

Many do, in fact, and that makes them ideal advisors for people with AF or other arrhythmia. EP’s tend to favour invasive procedures rather than medication or lifestyle changes. They love using the hi-tech equipment involved.

[mjames1 in reply to Abbyroza]

Please feel free to make up your own definitions, but that does not change what is universally accepted in the medical community.

[Abbyroza in reply to mjames1]

Not my definition. The definition of the medical community, of which one of my best friends is a member. A cardiologist. He knows the trade from the inside, unlike me and you. So I tend to value his opinion.

[Karendeena in reply to Abbyroza]

Here we go again, a friend who is a cardiologist, again just one opinion. I have a friend who is a chemist and owns a pharmaceutical company, making drugs and supplying internationally, there is not much he doesn't know about drugs and you would probably be horrified as to some of the black box warnings but I don't quote him or his knowledge on here that would/could put people off taking the meds they are on (including me) same as you are doing with ablations

[Abbyroza in reply to Karendeena]

Please do quote him, by all means. Correct and complete information has never hurt anyone.

[wischo in reply to Karendeena]

You are worse to waste your time with this mans ray of light posts. Hope after having a massive heart attack 7 years ago, he comes back in at least 19 yrs and at 94 yrs old and tells all on this forum how right his views were. Until then we will just have to go with the other few hundred thousand experts and let them do their best for us!! sure what would they know as apparently they are all cash cows??.

[Abbyroza in reply to wischo]

Thank you for the longevity wishes! 😉

[ozziebob in reply to Abbyroza]

I am disappointed that some on the Forum want to aggressively censure perfectly acceptable alternative insights. Truth has many colours, and all must be heard, lest we end up with a worldview like that of Trump, where truth is reduced to a monochrome of black and white only.

Keep up the good work. Very brave of you.

[Abbyroza in reply to ozziebob]

I have always thought that knowledge is power, so the more information one can get, the better.

The hostility that I meet here from time to time, for providing a wider view on things. therefore surprises me.

But that will not keep me from sharing the news that my friend cardiologist and myself dig up from the professional publications. Thank you for your support, and all the best!

[Auriculaire in reply to ozziebob]

Hear hear. There are too many people on this forum who wish to censor alternative views. Look at what happened over Covid.

[Abbyroza in reply to Auriculaire]

Whenever I post some new scientific information, I brace myself for the avalanche of negative reactions here.

At first, that surprised me, because I assumed that everyone would be interested in getting the last updates. Yet, especially when I post critical stances, like the ones often uttered by EP John Mandrola, or my own good friend R.R., a retired cardiologist, the usual suspects start ridiculing or rejecting these professional’s ideas.

I’m glad to have a very experienced cardiologist as my best friend and I assumed that sharing his experience here would be to the benefit of us all, but apparently that is not always the case for everyone.

Especially in ablation matters, I have to be very cautious about what I share, because any negative news about this procedure seems to upset many readers.

I can image that such information is sensitive for people who have chosen to undergo this procedure, but even then, knowing the most about it can only be beneficial, I should think.

Some readers here have even accused me of ‘fearmongering’ but I refuse to accept that sharing facts and opinions from critical professionals should create fear. On the contrary, it should help to understand and manage the condition we all share.

And if I point out that some members of the medical profession might be slightly ‘biased’ in their recommendations by the profit their advice brings them, that criticism is based on real-life experiences. Not on some wicked phantasy.

All the best, to all of you!

[Karendeena in reply to Abbyroza]

This reply to mjames1 is patronising, you are assuming he doesn't know the difference. Many if us have done extensive research and read lots of articles and selected appropriate EPs. I stand by what I said that EPs are not in it for the technology. My EP tried for 4 years to control mine with medication before we went for ablation

[Karendeena in reply to mjames1]

Hear hear! 👍

[Fryguy]

Does the Wolf Mini Maze procedure stop afib immediately? It's wild to me that they kick us out of the hospital and back too work in 10 dsys or so. My breath was never the same and I need another ablation. Does anyone snip the LAA in Canada or is that a Mini Maze procedure? What ablation has the best success rate ?

[Abbyroza in reply to Fryguy]

‘Snipping the LAA’ is a procedure to prevent clots from leaving the heart. It has no influence on the incidence or frequency of AF. All ablation methods have about the same success rate, with some advantages for the field pulse technique as far as possible complications, like heart or esophageal puncture, are concerned.

[Singwell]

This is all very nice indeed for someone who doesn't have AF! In particular I find this disturbing:

"Because the procedure is so fast and safe, doctors are offering it to patients who previously would have been ruled out for ablation due to likely treatment failure. "

What we need is a retrospective survey of patients who've had ablation and their QOL improvement across time irrespective of whether they still get outbreaks of not.

So- for example in my case - first ablation definitely a failure as I needed a GA, not sedation. Resulting in over 100 burn sites! Ablation #2 I had no detectable AF for 19 months. This enabled me to regain my confidence, get off all Cardiac meds and address long term subclinical hypothyroidism. Since then I do get AF episodes but they are usually not extended and if needed I take PiP to stop them. I spoke to my EP about this and he said that - as we age - there's a tendency to develop fibrosis of the scar tissue around the barrier that ablation has created. Hence the outbreaks. So at 68 it's unlikely I'll be offered a further ablation to see my AF off, at least in the UK NHS system.

Am I still glad I had my two procedures? Bet your life! I mange better, and my QOL is significantly improved. That is priceless.

[mjames1 in reply to Singwell]

So at 68 it's unlikely I'll be offered a further ablation to see my AF off, at least in the UK NHS system.

I cannot speak to the UK system however in the United States ablations are offered into the 90s. I had in my 70s.

Jim

[Singwell in reply to mjames1]

Yes - it's a bummer as we say over here! I imagine I'll have to wait for it to get worse and them maybe pace and ablate. Basically my EP said- we could do it again, but the same issue might arise. He was being pragmatic. I consider myself a young 68 (whatever that means) and in reasonable shape so it's frustrating. But resources in the NHS so limited ar present.

[mjames1 in reply to Singwell]

In the United States they are starting to ablate the ganglia plexi where standard PVI's are not working. I would be looking into that if available before a patient before a pacemaker snd ablate.

Jim

[ozziebob in reply to mjames1]

Actually the UK has now moved to offering only 2 catheter ablations to AF patients, as you acknowledged after a previous reply of mine. But it's true there are medical exceptions to this protocol.

[mjames1 in reply to ozziebob]

see my answer to Bob

[BobD Volunteer in reply to mjames1]

Lates NICE guidelines max 2 ablations in last five years here in UK Jim. ( Caveat--- some extreme cases may be argued with a board.)

[mjames1 in reply to BobD]

My understanding is that this is a guideline, not in stone, and flexible, and some members have recently been offered more than two. I know it was not recent, but how many were you offered and how would it have worked out for you if you were only offered two?

Jim

[Amiodaroneluck in reply to mjames1]

American here. I was 71 when I had my most recent ablation.

[Desanthony in reply to mjames1]

Ablations are offfered here into late 70’s and 80’s too

[Mugsy15]

As I understand it, and put as simply as I can, Mandrola thinks that if someone has an episode of AF during their blanking period then goes on to be AF-free, that should be considered a failure.

So here I am, over three years AF-and-medication-free.

But I had a couple of bouts of AF shortly after my ablation while it was all settling down, so I must consider the procedure a failure?

Really?

[Abbyroza in reply to Mugsy15]

Dr. Mandrola, and the other two authors are right that recurrences during the blanking period often indicate future problems. But the key word here is ‘often’, not always. The goal of ablation is long-term freedom from atrial fibrillation, not perfection during the healing phase.

You’re over three years AF-free, without medication—that’s a real success by any reasonable standard. Even if you had some early post-ablation episodes, they clearly didn’t translate into ongoing AF. So, whether Dr. Mandrola and his colleagues would technically call that a “failure” or not, your actual outcome is what matters: a heart that’s been in normal rhythm for years. All the best!

[Abbyroza in reply to Mugsy15]

An alternative is suggested in this study: lilt the blanking period to 1 month.

Objective

We investigated the significance of early recurrence as a risk factor for late recurrence in patients with AF receiving pulsed-field ablation (PFA).

Methods

Consecutive patients undergoing PFA were prospectively followed up for 1 year. All patients received isolation of pulmonary veins. Additional ablation procedures were performed per operator’s discretion. After the procedure, all remained on their previously ineffective antiarrhythmic drugs (AADs) during the 2-month blanking period after which the AADs were discontinued. Early recurrence was defined as atrial arrhythmia of >30-second duration during the 3-month blanking period, and any recurrence beyond 3 months was considered as late recurrence.

Results

A total of 337 patients undergoing PFA for AF were included. Early recurrence was recorded in 53 patients (15.7%): 10 in the first month, 12 in the second month, and 31 in the third month. Of the 10 patients having recurrence during the first month, 7 (70%) remained in sinus rhythm after cardioversion whereas 3 (30%) underwent a redo procedure because of late recurrence. At 1 year, all patients with recurrence in the second and third months experienced late recurrence; among these patients, 10 (83.3%) of 12 and 27 (87%) of 31 underwent a redo procedure and the remaining 6 patients were in sinus rhythm on AADs.

Conclusion

In this consecutive series of patients with AF, early recurrence in the second or third month after the PFA procedure was associated with a high risk of late recurrence. Thus, blanking period could be redefined as 1 month after PFA.“

[Mugsy15]

I agree with all of that - because you have included in your statement a moderation; an acknowledgement that is lacking in the broad-brush declaration of the 'three wise men', who would include the ablations performed on me and thousands like me in the failures bin.

I do think that, as you say, they're probably correct that recurrences of AF in the weeks immediately after ablation are often an indication of what is to come. However they surely should have, as you have done, acknowledged that this is often not the case too.

And perhaps more importantly, the blanking period must remain as behavioural advice to patients, who should allow the lesions to form fully and the inflammation to settle before making their heart work hard through exertion.

[BobD Volunteer]

It took around nine months for various arrhythmias to fade away after my third ablation but no AF (I am aware of) since 2009. As we say in our fact sheet on recovery. many people are still improving at nine months or a year. Remember this paper was writtn by patients not so called experts. Remember also Titanic was built by experts but an amateur built the Ark.Ex = has been, spurt = drip under pressure.

[Singwell in reply to BobD]

Spot on Bob! Hence my point about doing a retrospective study of improved QOL for those who've had ablation.

[bayonnejoe1]

What stuck out for me in this article was: if you end up with a lower # for defining success, you are more likely to critically assess whether the patient is optimally suited for the procedure. That seems like a good thing to me.

[Abbyroza in reply to bayonnejoe1]

That is indeed the most important point, in my humble opinion.

[Hugheart]

Hi Abbyroza

As a physician I concur with Dr Mandrola’s honest appraisal that excluding the blanketing period falsely lowers the recurrence rate associated with cardiac ablations. Based on my own experience controlling my AF with a low- risk scientifically supported supplement protocol, I am hoping if the cardiology specialty can evaluate it without bias, it might be implemented before cardiac ablations to prevent recurrences after cardiac ablation.

Just a hopeful thought.

Hugheart

[Abbyroza in reply to Hugheart]

I think, and so do my dear friends in the medical business, that ablation should never be the first-line treatment for atrial fibrillation, especially if other options haven’t been explored.

The treatment approach should be a stepwise strategy, in our opinion, including: adapting life style, and addressing high blood pressure, obesity, sleep apnea, alcohol intake, and other triggers.

Medications –rate control (e.g., beta-blockers, calcium channel blockers) and/or rhythm control should be tried first before considering ablation.

Ablation should only be recommended if medications fail, if AF is severely affecting quality of life, or if there are specific reasons to avoid long-term medication use.

If a cardiologist or an EP jumps straight to ablation without discussing other options, I would certainly seek a second opinion. A good doctor should explain all choices, including the risks and benefits, before recommending an invasive procedure.

So, I surely think that controlling AF with a low- risk scientifically supported supplement protocol like yours should be offered long before an ablation.

[Singwell in reply to Abbyroza]

This is all very well but in my case, as a self employed person I was unable to work if AF kicked in and without the ablation it would've been difficult for me to continue earning money.

[Abbyroza in reply to Singwell]

I hear from friends who are in permanent AF that it is more bearable than paroxysmal, provided there is sufficient rate control. They say it is less stressful.

[Singwell in reply to Abbyroza]

Well, that's my point really - the ablation made it all more bearable. Shorter episodes, less frequent and less symptomatic

[Tiburon in reply to Hugheart]

Can you describe your supplement protocol?

[ozziebob in reply to Tiburon]

I suggest you read Hugheart 's Bio.🤔

[Hugheart in reply to Tiburon]

Please contact me by PM

HUGHEART

[Hugheart]

Hi again

I am not suggesting that it replace ablations but if they are medically indicated then my hope is the cardiology specialty consider my protocol as a low-risk approach to be implemented before scheduled ablation as it may prevent recurrences of AF during the blanketing period and even beyond. Ideally it might reduce the need for repeat cardiac ablations. I know my thoughts are countercurrent to prevailing guidelines by the AHA and British cardiology organizations, but from my experience which has been carefully documented and statistically corroborated, I don’t see a downside if it is implemented under health care professional supervision to be sure each individual is a candidate as outlined in my protocol.

Hugheart

[sponable98]

Interesting article from your sources, but I find the discussion counter-productive to patient's mental states post ablation! I would recommend letting the experts debate these details until a consensus is reached and filters down to us through our trusted EP's. I will continue to strongly recommend, an EP advised, ablation procedure for any friend who suffers from symptomatic AF or flutter. Ablation therapy has significantly improved my QOL for the last 14 years.

[Singwell in reply to sponable98]

Same

[Abbyroza in reply to sponable98]

I should think that getting updated scientific information is always interesting. Especially for people who are in the process of deciding which solution to choose. They can never have ‘too much’ information. At least, that’s what I would want.

[Hugheart in reply to sponable98]

Hi Sponable98

As a physician with a history of AF for 2 yrs my scientifically published supplement protocol converted my to SR now for 18 months. My point needs emphasizing. I am not against EP advised cardiac ablations. Instead I am raising the possibility that EPs do a reappraisal on the value of properly administered supplements based on under appreciated observations on AF and Mg. A small trial by EPs with my protocol started a few months before planned cardiac ablations might determine if my low-risk protocol could minimize blanketing post ablation and even reduce need for repeat ablations. I don’t have the bandwidth to influence EPs but individuals who are candidates for my protocol might discuss this option with their EP.

Hugheart

[Ppiman]

I had read an excellent recent study which claimed that a 28-day blanking period was a good cut off point for thermal ablations on the basis that the thermal activity had upset the electrical balance of the heart and 4weeks was a fair time for that to heal.

The use of PF ablation seems to be the way to go in general, for reasons of speed and safety. I do worry though that for anyone with a more general arrhythmia, i.e. atrial multifocal ectopy, they won't likely benefit form even this.

And that might well mean me.

Steve

[Lenlec]

really interesting post. Thanks 🙏. Excellent reading

[Abbyroza in reply to Lenlec]

Thank you. All the best!