One of my regrets -and worries- concerning atrial fibrillation is that the medical community is almost exclusively concentrating on finding ways to stop the condition in its tracks rather than preventing it to occur altogether.
Instead of allocating funds and time to study the triggers and causes of atrial fibrillation, -influencing the vagus nerve, for instance- labs and hardware companies are spending fortunes on developing new techniques and catheters to do ablations. A technique purely based on guesswork, and resulting in irreversible damage to heart tissue.
One of the electrophysiologists who share my worries is the experienced American Dr. John Mandrola.
This is his opinion on the newest hype in catheterland: Pulse Field Ablation or PFA:
“Pulsed Field Ablation for AF: Are US Electrophysiologists Too Easily Impressed?
My field of electrophysiology is abuzz with excitement over the new technology of pulsed field ablation (PFA). It dominated this year's heart rhythm meetings, and it dominates my private electrophysiologist chat groups. My Google alert for "AF ablation" most often includes notices on PFA and the expansion of the atrial fibrillation ablation market.
Yet, the excitement does not match the empirical data.
Despite having strong brains, electrophysiologists adopt new things as if we were emotional shoppers. Our neighbor buys a sports car and we think we need the same car. Left atrial appendage occlusion and subcutaneous defibrillators were past examples.
The most recent example of soft thinking (especially in the United States) is the enthusiasm and early adoption of first-generation PFA systems for the treatment of AF.
Readers of cardiac news (including some of my patients) might think PFA has solved the AF puzzle. It has not.
A true breakthrough in AF would be to find its cause. PFA is simply another way to destroy (ablate) cardiac myocytes. PFA uses electrical energy (think shocks) to create pores in the cell membranes of myocytes. It's delivered through various types of catheters.
The main theoretical advantage of PFA is cardioselectivity, which is possible because myocytes have lower thresholds for irreversible electroporation than surrounding tissues. The dose of electrical energy that ablates cardiac tissue does not affect surrounding tissues. Cardioselectivity decreases the chance of the most feared complication of standard AF ablation, thermal damage to the esophagus, which is often fatal. The esophagus lies immediately behind the posterior wall of the left atrium and can be inadvertently injured during thermal ablation.
The challenge in assessing this potential advantage is that thermal esophageal damage is, thankfully, exceedingly rare. Its incidence is in the range of 1 in 10,000 AF ablations. But it might be even lower than that in contemporary practice, because knowledge of esophageal injury has led to innovations that probably have reduced its incidence even further.
Proponents of PFA would rightly point to the fact that not having to worry about esophageal injury allows operators to add posterior wall ablation to the normal pulmonary vein isolation lesion set. This ability, they would argue, is likely to improve AF ablation outcomes. The problem is that the strongest and most recent trial of posterior wall isolation (with radiofrequency ablation) did not show better outcomes. A more recent observational analysis also showed no benefit to posterior wall isolation (using PFA) over pulmonary vein isolation alone.
What About PFA Efficacy?
I've long spoken and written about the lack of progress in AF ablation. In 1998, the first report on ablation of AF showed a 62% arrhythmia-free rate. Two decades later, in the carefully chosen labs treating patients in the CABANA trial, arrhythmia-free rates after AF ablation remain unchanged. We have improved our speed and ability to isolate pulmonary veins, but this has not increased our success in eliminating AF. The reason, I believe, is that we have made little to no progress in understanding the pathophysiology of AF.
The FDA regulatory trial called ADVENT randomly assigned more than 600 patients to thermal ablation or PFA, and the primary endpoint of ablation success was nearly identical. Single-center studies, observational registries, and single-arm studies have all shown similar efficacy of PFA and thermal ablation.
Proponents of PFA might argue that these early studies used first-generation PFA systems, and iteration will lead to better efficacy. Perhaps, but we've had 20 years of iteration of thermal ablation, and its efficacy has not budged.
What About PFA Safety?
In the ADVENT randomized trial, safety results were similar, though the one death, due to cardiac perforation and tamponade, occurred in the PFA arm. In the MANIFEST-17K multinational survey of PFA ablation, safety events were in the range reported with thermal ablation. PFA still involves placing catheters in the heart, and complications such as tamponade, stroke, and vascular damage occur.
The large MANIFEST-17K survey also exposed two PFA-specific complications: coronary artery spasm, which can occur when PFA is delivered close to coronary arteries; and hemolysis-related kidney failure — severe enough to require dialysis in five patients. Supporters of PFA speculate that hemolysis occurs because electrical energy within the atrium can shred red blood cells. Their solution is to strive for good contact and use hydration. The irony of this latter fix is that one of the best advances in thermal ablation has been catheters that deliver less fluid and less need for diuresis after the procedure.
No PFA study has shown a decreased incidence of thermal damage to the esophagus with PFA ablation. Of course, this is because it is such a low-incidence event.
One of my concerns with PFA is brain safety. PFA creates substantial microbubbles in the left atrium, which can then travel north to the brain. In a small series from ADVENT, three patients had brain lesions after PFA vs none with thermal ablation. PFA proponents wrote that brain safety was important to study, but few patients have been systematically studied with brain MRI scans. Asymptomatic brain lesions have been noted after many arterial procedures. The clinical significance of these is not known. As a new technology, and one that creates substantial microbubbles in the left atrium, I agree with the PFA proponents that brain safety should be thoroughly studied — before widespread adoption.
What About Speed and Cost?
Observational studies from European labs report fast procedure times. I have seen PFA procedures in Europe; they're fast — typically under an hour. A standard thermal ablation takes me about 60-70 minutes.
I am not sure that US operators can duplicate European procedural times. In the ADVENT regulatory trial, the mean procedure time was 105 minutes and that was in experienced US centers. While this still represents early experience with PFA, the culture of US AF ablation entails far more mapping and extra catheters than I have seen used in European labs.
Cost is a major issue. It's hard to sort out exact costs in the United States, but a PFA catheter costs approximately threefold more than a standard ablation catheter. A recent study from Liverpool, United Kingdom, found that PFA ablation was faster but more expensive than standard thermal ablation due to higher PFA equipment prices. For better or worse, US patients are not directly affected by the higher procedural costs. But the fact remains that PFA adds more costs to the healthcare system.
What Drives the Enthusiasm for First-Generation PFA?
So why all the enthusiasm? It's surely not the empirical data. Evidence thus far shows no obvious advantage in safety or efficacy. European use of PFA does seem to reduce procedure time. But in many EP labs in the United States, the rate-limiting step for AF ablation is not time in the lab but having enough staff to turn rooms around.
The main factor driving early acceptance of PFA relates to basic human nature. It is the fear of missing out. Marketing works on consumers, and it surely works on doctors. Companies that make PFA systems sponsor key opinion leaders to discuss PFA. These companies have beautiful booths in the expo of our meetings; they host dinners and talks. When a hospital in a city does PFA, the other hospitals feel the urge to keep up. It's hard to be a Top Person in EP and not be a PFA user.
One of my favorite comments came from a key opinion leader. He told me that he advised his administration to buy a PFA system, promote that they have it, and keep it in the closet until better systems are released.
Iteration in the medical device field is tricky. There are negatives to being too harsh on first-generation systems. Early cardiac resynchronization tools, for instance, were horrible. Now CRT is transformative in selected patients with heart failure.
It's possible (but not certain) that electrical ablative therapy will iterate and surpass thermal ablation in the future. Maybe.
But for now, the enthusiasm for PFA far outstrips its evidence. Until better evidence emerges, I will be a slow adopter. And I hope that our field gathers evidence before widespread adoption makes it impossible to do proper studies”.
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Abbyroza
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I don't normally use Chatty to answer a poster's questions. However, I will in this case, as your post is quite long and needs a well-thought-out answer. I'm very tired and need some sleep ~ Chatty answered it well.
A Thoughtful Critique on Current AF Research Priorities: Prevention vs. Intervention
One of the more pressing concerns in the contemporary management of atrial fibrillation (AF) is the notable imbalance between the resources devoted to interventional treatment strategies—particularly catheter ablation—and those allocated to understanding the underlying causes and prevention of the condition. It is both regrettable and somewhat troubling that despite the increasing prevalence of AF worldwide, the medical community and healthcare industry continue to emphasize technological innovation over etiological inquiry.
Dr. John Mandrola, a respected electrophysiologist, has articulated a view that echoes the sentiment of many patients and critical clinicians: that the prevailing enthusiasm for novel ablation technologies, such as Pulsed Field Ablation (PFA), far exceeds the strength of the empirical evidence supporting their clinical superiority. As Dr. Mandrola aptly notes, PFA—though theoretically promising in its tissue selectivity and procedural efficiency—remains fundamentally a technique aimed at destroying atrial tissue rather than addressing the upstream factors contributing to arrhythmogenesis.
From an academic perspective, this reflects a broader epistemological challenge in cardiology: the dominance of reactive over proactive medicine. While ablation may offer symptomatic relief for selected patients, it does not represent a curative or pathophysiologically grounded solution. The stagnation in success rates over the past two decades, despite successive iterations of thermal ablation techniques, underscores this limitation. The root causes of AF—whether involving vagal tone modulation, autonomic imbalance, inflammatory pathways, metabolic syndrome, or genetic predispositions—are still poorly understood and underexplored.
Furthermore, the rapid clinical adoption of PFA raises questions about the interplay between technological innovation and market forces in shaping treatment paradigms. As Dr. Mandrola observes, the marketing momentum and peer influence in the field may be contributing to a form of "groupthink," where the desire to adopt the latest technology risks outpacing the necessary scientific rigor. The lack of significant differences in clinical endpoints such as arrhythmia-free survival or major complication rates between PFA and conventional thermal ablation, should temper expectations and caution against premature standardization.
Moreover, the potential risks specific to PFA—such as coronary artery spasm, hemolysis-induced renal failure, and the concerning yet under-investigated issue of cerebral microemboli—require more robust investigation before widespread use can be ethically and clinically justified.
In conclusion, while innovation in electrophysiological techniques remains vital, it is imperative that equal, if not greater, attention be directed toward understanding the aetiology and prevention of AF. Investment in mechanistic research—particularly into autonomic modulation, structural remodeling, and systemic contributors to atrial pathology—offers the potential for more transformative breakthroughs than yet another modality of tissue destruction. As patients and clinicians navigate these complex therapeutic landscapes, a cautious, evidence-based, and prevention-oriented approach remains the most ethically sound and scientifically promising path forward.
My short two pennies for this and much - $cience - sadly. Trials for prevention are both lacking in profit potential and often involving more than a “pill for an ill” aka a multi-modal approach which trials frowns upon just look at something like Dr Bredensen and Alzheimer’s. He refers to it as a shotgun approach being needed rather than a singular silver bullet.
Lets cut to the chase here as much of what is written above has been known for some time. PFA is no better than any other method.
Regarding finding ways to stop AF occurring, good luck with that. Much of the problem is the individual genetics of each person. Yes, we know that athletes and fast jet pilots are prime cadidates for AF due to atrial enlargement and that obesity and alcohol both increase the likely hood yet there are skinny couch potatos who get AF just as often. With luck one day maybe a particular gene will be isolated but frankly I doubt it. Keep taking the tablets and enjoy life.
I have AF which is evidently familial - I am one of 5 sisters and a father who are affected, or in the case of my father, was, but AF had nothing to do with his death. MY eldest sister is 93 and only gave up teaching ballroom dancing last year. I have a list of seven genes that have already been linked to it,. The description that goes with the list says that many of these genes provide instructions as your heart forms on how the electrical channels should be 'wired'. Is now hoped to narrow it down to say one or two genes, or completely different ones? I will add that my son (an extreme athlete) had an ablation 20 years ago when he was 35, and has had no signs of AF since. I often wonder if that suggests a genetic predisposition and he should be aware of the possibility of recurrence in old age (my sisters and I were in our 70s when diagnosed, but obviously could have been affected before). None of us were extreme athletes!!
It appears that you missed Dr. Mandrola's more recent article on PFA, titled "Might Have Been Wrong About Pulsed Field Ablation for Atrial Fibrillation".
Based on more information he's now a fan of PFA ,or as much of a fan as his provocative and contrarian nature allows him to be!
Yes, the public should be educated on being proactive, but many of us do everything right and still suffer from atrial fibrillation. To think other words is a form of wellness shaming.
So instead of putting down ablation because it may not be perfect, we should be grateful that such an opportunity exists that has helped so many of us, including myself. My only regret with catheter ablation was that I didn't do it 10 years earlier.
My ablation was cryo, but had PFA been available at the time that would've been the way to go. And just don't take it from me ask your friend Dr. John Mandrola, now that he has changed his mind and is an advocate of PFA.
Of course I have read dr. Mandrola’s somewhat sunnier stance on PFA, but that does not change the fact that he still considers the procedure as ‘educated guesswork’, and invasive.
He would still rather see, just like me and many AF-sufferers, that more resources would be spent on research to prevent or stop AF in its earliest stages. That should be the future approach, not ‘playing’ with yet another set of beautiful, expensive catheters.
I agree that there should be a lot more resources targeted at prevention and also - individualised medicine - many reasons, many cures.
Unfortunately, having studied human nature for most of my life I have learned that no matter how bad things can get there are many people who will refuse to change their habits and continue to eat, drink, smoke and drug themselves to their graves. I’ve seen this close up, within my family and worked with many who prioritise gluttony, getting high and partying to excess then demand to be ‘fixed’. I have one such as a neighbour and it’s very sad to witness.
Given the influencers on media sites, maybe that would be the place to start a reform movement? Some how I don’t think it will catch on though as I am reminded of the old saying ‘when the student is ready, the teacher will appear’. Maybe we have to learn the hard way.
We are human, we always have to learn the hard way.
Addiction is addiction. Lifestyles are hard to break. How we raise and what we feed our kids (monkey see monkey do) , is also part of the puzzle.
But prevention and triggers are subjects that fill volumes, and we the sufferers and our cardio teams guessing.. .mine for example feels sleep apnea is a major contributing factor.
First of all: dr. Mandrola is not my ‘friend’ although I sincerely wish he was! And calling this experienced EP ‘contrarian’ and ‘provocative’ because he doesn’t happen to share your views is more than sad: I’m glad there are professionals like him who keep an open mind and are willing to share their valued opinion.
Dr. John Mandrola is a distinguished cardiac electrophysiologist. He specializes in diagnosing and treating heart rhythm disorders, particularly atrial fibrillation, and is proficient in procedures such as catheter ablation and the implantation of cardiac devices like pacemakers .
Dr. Mandrola earned his medical degree from the University of Connecticut School of Medicine. He completed his residency, fellowship, and electrophysiology training at Indiana University School of Medicine, where he was honored with the Outstanding Fellow Award. He is board-certified in Clinical Cardiac Electrophysiology by the American Board of Internal Medicine and is a Fellow of the American College of Cardiology .
Beyond his clinical practice, Dr. Mandrola is a prominent medical communicator. He writes a regular column for theHeart.org | Medscape Cardiology and hosts the podcast “This Week in Cardiology.” His writings have also appeared in publications such as the Journal of the American Medical Association-Internal Medicine, The Atlantic, and the Louisville Courier-Journal . He is known for advocating evidence-based medicine and patient-centered care.
An avid endurance athlete, Dr. Mandrola has competed in triathlons, marathons, masters swimming, and cyclocross.
Dr. Mandrola’s multifaceted career bridges clinical excellence, medical journalism, and patient advocacy, making him a respected voice in cardiology and healthcare communication.
Abbbyroza: And calling (Dr.,Mandrola) contrarian’ and ‘provocative’ because he doesn’t happen to share your views is more than sad:
"I have sometimes been called a contrarian. This can be both a positive and negative label."
Or maybe you missed his 2019 article titled,
"A Contrarian View of Digital Health
So yes, Dr. John Mandrola is indeed a contrarian. And calling him that is not."sad", it's an apt description that both himself and others use to describe his way of thinking.
I doubt that it will be possible to prevent AF in the foreseeable future because as others have said many of us are born with a pre disposition which probably the majority of people don’t understand until the condition hits them . The majority of people in ICU go into AF because of the drugs they are given . All hearts have the ability to fibrillate . How could you remove al triggers ? Mine started with a couple of capsules of Celecoxib for a back injury . In a small minority of people this inhibits the potassium channels in the heart triggering AF . You can’t predict who those people will be and there are people crippled with arthritis who wouldn’t be able to move without those drugs. They aren’t going to ban alcohol sales because it causes AF in some people if they haven’t banned it for causing liver disease . Etc etc . Currently one AF pathways are triggered it’s either managed with drugs or effectively stopped at least temporarily by ablation . Pragmatically do you put most money into what will help the most people , we know there are vast numbers of people with AF right now , or looking to prevent something when we know vast swathes of the population are not compliant with lifestyle measures to prevent disease and there isn’t any other clear path to prevention ? Personally I have always tried to live a healthy life before AF but that didn’t stop me developing it. I have implemented more lifestyle measures since AF started . I am 100% wishing AF could be prevented but can’t practically see how it would be done in my lifetime . Still thank you for the information, an interesting read
My AFib started when I caught a very nasty coughing virus at my sons wedding in 2014, which put me in hospital. I also had SVT since my 20’s. I had an ablation for both AFib and SVT in Sept 2023. I just hope it holds and the nasty AFib doesn’t come back, but reading about peoples experiences on here, I just don’t know. It will always be on the back of my mind. I’d like to know how many people have had a successful ablation and never had a recurrence of AFib. I believe that SVT ablations are more successful, so hopefully that will have been eliminated.
I am not overweight, I don’t drink or smoke and try and eat healthily and also do exercise, so do all I can to stay healthy, but I still got AFib. When I got Covid in March 2023, it started my AFib, but sometimes it started for no reason, so cannot say what caused my AFib to start. My mother had AFib, when she was in her 80’s, but wouldn’t take Warfarin, which was the only anti- coagulant they gave people then and she had 2 mini strokes, but lived to 93.She wouldn’t take Warfarin because my Dad was taking it for a DVT in his leg and died from a brain haemorrhage at 69.
You would think with all the millions of people around the world that suffer with AFib, that scientists would do a lot more research into finding some form of treatment that would eliminate this horrible condition for good. We would all be so very very grateful if they did.!
Scientists need money. Medical research can only happen if it’s supported. Governments around the world place different importance on different diseases, mostly weighing up the cost to public health and its impact on their coffers.
I have what is strongly believed to be a genetic condition which will ultimately see me die earlier than I would like. Genetic testing is inconclusive simply because there isn’t enough research done yet on cardiac diseases for them to be able to identify what I have. I have two children and two grandchildren who also have a chance of having the same condition.
I support cardiac research in any way I can. Cancer research is by far the highest funded - we need to push more to get more support for cardiac research to equal that of cancer.
thanks for sharing that and very interesting. I have always been concerned about the accuracy of ablations and the need to in for 'top up' ablations 2 and 3 times. I am hoping my AF stays calm as it is at the moment until things improve and we can be offered a far more accurate system to ablate so that possibly only 1 ablation is needed as all targets can be identified.
There is one company Imracor in Trials at the moment, for AFlutter and just commencing for VT and i understand they will be looking at AF in the future. They have developed a real time MRI system guided catheter. They say they will have a higher success rate with faster and safer treatments compared to conventional treatments which use Xray guided Catheters.
If all this is true then there will be less tissue disturbed in the heart and the need to have multiple ablations will lessen. Though this sounds exciting it still has to be confirmed with Trials.
It would be great if you had an ablation that they could guarantee to be 100% effective. We’d all be so so happy to know that when you go through this, you’ll only need it doing once. I just hope I’m in the 60% or so people who have had a successful ablation and don’t have to have another one. I had mine in Sept 2023
Yes it would make life a lot easier. I don’t think 100% can be assured though with the accuracy of this new technology maybe it can go from 60% to 80%. The EP I saw suggested it’s about 60-70% success for the first 12 months. I forgot to ask him what the success rate is for 3 years and longer. Well done on 2 years, may you enjoy continued success
that’s a long post and the theoretical chat coming out of the woodwork 😂. It’s so far away from where we are now it’s almost fanciful. Life’s too short. So I’ll do what BobD says. ‘ keep taking the tablets and enjoy life ‘
But it’s worth while drawing the attention to the existing discrepancy in investments between ‘novelty hi-tech (catheters)’ and ‘thorough research into the causes’.
I am on the mailing list of catheter manufacturers like ‘Boston Scientific ‘ and the avalanche of advertising for their new ‘toys’ is just overwhelming. They suffer from commercially driven tunnel vision, and do not spend one dollar on the research of other possible, less invasive solutions.
‘Burn, baby, burn’… that’s all they know. Sad, really.
We must consider that everyone's daily journey of living with AF is very different, and it is unlikely that anyone will experience exactly same journey.
As it stands there is no permanent cure for AF at this time, therefore finding the most effective methods of treating and managing symptoms are vital.
Therefore, we are aware the medical experts will present the best possible treatment for a patient with AF based upon their individual needs, this may include medication, procedures to more long term treatment options such as an ablation or pace and ablate to provide a good quality of life.
The Charity continue to raise awareness about AF to ensure everyone recognises the early warning signs to gain a swift diagnosis and ensure treatment is immediately provided.
May I take this opportunity to invite you to attend our Patients Day on Sunday 05 October, ICC, Birmingham, UK.. We are currently offering an early-bird price to attend! To take advantage of this one-off opportunity, visit: heartrhythmalliance.org/afa...
Alternatively, if you prefer, please contact our Patient Services Team via our dedicated Patient Helpline; +44(0)1789 867502 or via email: heartrhythmalliance.org/afa...
I’m almost certain the cure lies in the management of the subtle balance of the parasympathetic nervous system and the activity of the vagus nerve. There is some research going in that direction, but there should be much, much more. As dr. Mandrola says: the key lies in the research lab, not the cathlab.
So do I can be agreed on vague nerve symptoms. I have paroxysmal AF for many years and with more often episodes now. On Bisoprolol ,Eliquis and Flecainide as PILL IN A POCKET I able to stop arrhythmia .Never wanted to go the ablation path ( I am old for it)
The parasympathetic vague nerve effect on Afib’ onset well described by dr Sanja Gupta. yorkcardiology.co.
I think you are right for many, with the proviso of my theory that for most people the cause of AF is not one factor alone but usually a number of factors go into the pot and, to continue the analogy, we are individuals with pots of different sizes so when they overflow (ie AF starts) is a combination of factors.
I think the cure will occur over time but you could do a lot worse than improving lifestyle and reading this Forum every day.
In the last 2 years I have seen 3 cardiologist (apart from my best friend, who is a retired cardiologist) and they all mentioned ablation as their first choice of treatment. For my very asymptomatic paroxysmal AF that occurs every two or three months. I discussed this with my good friend and he called their suggestion ‘crazy’. (I won’t repeat his other remarks).
I think their attitude has to do with what dr. Mandrola writes: “The main factor driving early acceptance of PFA relates to basic human nature. It is the fear of missing out. Marketing works on consumers, and it surely works on doctors. Companies that make PFA systems sponsor key opinion leaders to discuss PFA. These companies have beautiful booths in the expo of our meetings; they host dinners and talks”.
The video, explaining ablation in colourful detail, that one of the cardiologists very proudly showed me on his desk computer had cost a fortune to produce. I have been in the advertising business myself and I must admit it was one of the most convincing commercials that I had ever seen. No wonder the man in front of me was so enthusiastic!
That is the ‘bias’ I worry about. These professionals loose some of their professionalism out of sheer bewilderment for the ‘miracles of state-of-the-art catheter technology’. They did not even mention lifestyle, meds, or any other solution. Ablation it had to be.
I agree with the sympathetic and parasympathetic nervous system being involved. I have PAF, with definite triggers - inflammation from covid, exhaustion, dehydration, high humidity/heat, extreme anxiety. I have episodes rarely and in batches over a couple of months, then nothing for 6 months - my first with covid in 2022, then nothing for 18months, 1 a month for 4 months (lasting 1-2hrs), nothing for 8 months, one in December 2024 and nothing since. I have been able to stop a few from taking off by taking a big breath in and holding and slowly breathing out. Are you on heart meds at all? I am not at this stage, but I do take heart-healthy supplements.
The Thyroid problems doesn't feature in your studies.
But after 5 years since Thyroidectomy my AF hasn't left me.
Mind you only follow up for this Thyroid cancer and no follow up of med Metopolol for Heart Effects of rapid and Persistent AF. These weren't addressed by my request for a Heart Specialist at 1 year 5 months a 24hr Heart Monitor Metopolol proved taking it did not control my Day Heart Rate avg 186 no exerting and 47avg bpm Night WITH 2 SEC PAUSES cause for alarm. But hearing me about uncontrollable sweating with no energy and sleeping turned a deaf ear in my endeavours of changing med!
Then the change to another Beta Blocker Bisoprolol showed 156 avg Day, with Night the same but taking away breathlessness and pauses at night.
But left there.
9 months later my Locum Dr advises me to attend a private Heart Specialist. Introduction CCB Calcium Channel Blocker. Within 2 hours on 1/2 dose Diltiazem the 156 down to 51! H/Rate Day and left notmal 47avg bpm Night.
Private to Public H/Specialist another 24hr Heart Monitor with reduced Bisoprolol and reduced Diltiazem 120mg CD early morning.
Given No to other procedures due to showing an ECHO with Heart Structural damage.
So for me spending monies on procedures is a waste of time and meds for advancement in meds or to end AF more be most helpful. All that radiation used during ablations for patients and surgeons is eliminated.
Just saying.
Control of BP improved and stopped Bisoprolol. Control of Rapid and Persistent H/Rate Day 80s without a BB.
I've often thought about a day in August 1947. I was just over 2 months old. I had a brother and a sister, both older than me, but between my sister being born and I being born was just 30 month. We lived with both parents in a 19th century terraced house. It did not have a bathroom so we were washed in the kitchen, and the toilet was at the bottom of the garden.I had pneumonia. Why and how did my brother aged just over 3 catch poliomyelitis. Why didn't I catch it, or our sister?
Fast forward 77 years and our sister has type 1 diabetes with complications to one leg, my brother is fit and well, and I am asthmatic, have permanent though asymptomatic AF, after 20+ years of paroxysmal AF, have lymphoedema in my lower legs, BPH, and a week ago diagnosed with trigeminal neuralgia. Why me?
I get around okay and don't consider myself to be unwell, though the trigeminal neuralgia is the worst pain there is, now replaced with a twice daily tablet and a daily headache.
So this is a more recent September 24 position from Dr Mandrola where he states that he may have been wrong regarding PFA and states "Now I have used PFA. And. It is somewhat amazing. It ablates cardiac tissue quickly and easily. Patients hardly feel chest pain after the procedure". He still doesn't see it as a panecea and like anti arrhythmic medications or simply living with the condition and letting it take its course, all three approaches to treatment have particular disadvantages. Each of us on here grapples with making the best choices given their unique circumstances and preferences.
I had read Mandrola’s new stance. But even then he calls ablation ‘guesswork’. Not for me, thank you, I’m not the gambling type. Certainly not when my heart is at stake. I only have one, that should keep going. 😉
The excellent Dr Mandrola has - I guess you know - revised his opinion of PFA? He recognises its relative safety compared with all other ablation methods. That is extremely important and places PFA firmly as a major advance in therapy.
Here is what he said:
"In sum: I might have been too sceptical of PFA. There is a high probability that it will make current modes of AF ablation easier, and avoidance of a catastrophic but rare complication is a positive. Future generations of the technology will improve it further...".
As for the originating cause of atrial conductivity issues including AF, I suspect Mandrola knows how much genetics are at the heart (!) of this, and just how very much, given the right genetic background, behavioural lifestyle effects are the "cause", i.e. nature + nurture.
The behavioural lifestyle red flags that we must change if we are to reduce the burden of heart diseases:
- we eat too much;
- we eat the wrong foods;
- we exercise too little;
- we get too fat;
- we have too much sleep apnoea;
- we have too high BP;
- we have too much free cholesterol and triglycerides in our bloodstream;
- we have too much calcified atheroma in our arteries;
- we have too much diabetes and pre-diabetes...
and the list goes on.
I wish it were easier to live healthily!
The study below, although now almost a decade old, contains much truly valuable information and has not yet become outdated to my knowledge:
"Atrial Fibrillation: The Science behind Its Defiance by Czick, Shapter & Silverman"
Sure, I have read Mandrola’s revised stance on PFA and as a result I would certainly insist on having an ablation done with these new catheters instead of heat or cryo, because of the considerable lower risk of (potential deadly) esophageal damage . But even then Mandrola keeps calling any type of ablation ‘guesswork’, because he admits that they do not exactly how and why it works.
Now that’s not for me. I’m not the gambling type. Certainly not when my heart is at stake. I only have one, and I would like that to keep going as long as feasible. 😬
Indeed - I am on your side. I have always said that one day in the not too distant future, two things will be said, one by us all and one by cardiologists:
1. It's not a myth: Donald Trump really did exist and lots of Americans really did vote for him
Only thing I can add to all the above is that the autonomic nervous system inputs to the heart receive way too little examination - almost none. Prof Phillippe Coumel was on the right lines. But see the snippet I have put, in the image below (in the reply to this post).
My own AF has always been vagal, many people are classically adrenergic, one paper I saw shows a U-shaped relationship between resting heart rate and tendency to AF - low rate provokes AF (probably vagal), as does high rate (adrenergic).
My latest Wellue, post-ablation and on Flecainide (no other rate limiters), showed a max daytime rate of 110 bpm as a short tachy run, average 60, nightime low of 35, and try as I might whilst swimming I could not get it above 76 bpm. Same heart, same meds, same genetics, yet vastly different rates, far more so than normal variation, (except maybe for those who can exercise into the 140's.) So if that is not autonomic, I am stumped.
Coumel's work states that the acetylcholine released by the sinus node to slow the heart acts very fast (of the order of a second) whereas the noradrenaline to speed up the is slower acting - 15 seconds or so. These chemicals alter the refractoriness of the heart and can lead towards electrically heterogeneous cardiac muscle and hence arrhythmias. Mandrola said in a blog comment a long while back that there are a couple of US specialists working on the autonomic system (names escape me). But they are exceptions.
The root cause of the current thinking on AF is of course money, in that drugs and physical procedures will only get developed if there's a profit to be made at the end of the day. There's precious little commercial interest in really finding out what electrolyte levels, other nutrients, etc etc., contribute to AF and its prevention. Sorry if this sounds too cynical, but it is by and large true, save for a small and often suppressed minority.
Exactly. My friend (retired) cardiologist calls cathlabs ‘the cash cows of the hospitals’. Hence the lack of real interest in finding the root causes of AF.
My own AF is mainly vagally triggered, and I read a promising paper about anti-cholinergic meds to influence the outcome. But I cannot find it anymore. I do remember that Disopyramide works rather well for vagal AF, because of its (secondary) anti-cholinergic properties.
Disopyramide was a wonder drug for me, before my first ablation. For about 2 weeks, then it completely stopped working. I've noticed this with almost any intervention for AF, save perhaps a really successful ablation - that something works great for a short while, then the heart seems to say "ha ha fooled you, let's do something to counter that..."
There are so many documented triggers so it's a bit like peeing in the wind to know which one may set off AF for the first time, so not sure of what use a study into this would beObviously, if there's a family history of it, then there's a chance you'll get it, same as other maladies.
I have no trigger that I'm aware of, as mine just randomly kicks in.
what a interesting article and I congratulate you to ease the issue . We the suffers feel helpless . Medical industry are mainly like the life long medications as we become their permanent costumers
I agree with you regarding the PFA. It is pushed very hard by the industery. Though you are right in saying it is fast and save time I did have a discussion with one of the EP in the UK about this. He told me in terms of of success rate there is no difference between RFA and P FA, but one interesting thing he said that they concern regarding the ablation with PRA is the re growth of the ablated area
He said it require more data and yet it is not available .
I'm glad for the few who mentioned genetics and I think it's very relevant in the discussion on prevention. What shall we do, we who have never been overweight, never drank or smoked and who have multiple relatives who had AF? What kind of prevention is there for that?
I am one who takes a dim of view of being on Rx meds for life. I think Pharma is too prone to treat rather than cure. I'm interested in a minimaze procedure, something that would allow me to live med-free. After all, anticoagulants can be life-threatening too,
I gather from your comments you are an EP. I am a clinical immunologist with a history of long standing persistent AF for 2 years and developed a protocol that has converted my AF to SR for the past 19 months. I am not an integrative physician despite my protocol uses a combination of select Mg supplements, potassium supplements, focused on hydration, adding foods fortified in Mg and K and the need for daily self monitoring EKGs 3-4 times a day ( 30 sec for 2 minutes a day).,A statistician corroborated my meticulous accumulated data demonstrating comparison of AF burden before and after conversion is p=< 0.002. It took 24 weeks to convert which correlates with underappreciated data that for someone in balance with Mg has a half life of Mg for 6 weeks. But data shows many AF patients have more pre-existing Mg deficiency in their cardiomyoctes. Consequently, it likely will take many 6 week half lives of Mg to replenish Mg in cardiomyocytes in AF patients. There is more to my story which I have published recently in a book on Amazon. Title
ATRIAL FIBRILLATION: How a Physician Converted his Atrial Fibrillation to Normal Heart Rhythm with a Low-Risk, Low-Cost Protocol.
I have hit a wall trying to publish my data in 10 journals including cardiac and EP journals. What is not appreciated is if my protocol were published by a peer review journal it could be tested with RCTs and might prevent AF recurrences after cardiac ablation. The book includes my hypothesis that AF is caused by the following:
1. Activation of the NLRP-3 inflammasome by danger associated molecular patterns derived from unhealthy lifestyles ( e.g. cholesterol plus rate ester crystals; ROS; l) which cause secretion of pro- inflammatory cytokines IL-1 beta and IL-18 initiating and enhancing inflammation.
2. IL-1Beta has been demonstrated in vitro inhibiting ATPase in cardiomyocytes. Result is likely an energy deficit in cardiomyocytes needed for electrolyte pumps for SR.
3. Mg is important to combine with ATP for a conformational change in ATP that allows ATPase to recognize and hydrolyze ATP . Result of Mg deficiency is an energy deficit in cardiomyocytes that could cause electrolyte pumps to fail required for genesis of action potentials for SR.
4. The combination of #2 and #3 combined can lead to energy deficit in pacemaker. Replenishing Mg over requisite time could reverse Mg induced energy deficit.
5. My protocol ( n= 1 ) may provide a breakthrough option hconverting AF to SR and could be a complementary not disruptive and could be administered electively to prevent AF post ablation and cardiac surgery.
If any of this is of interest you can contact me at
Well, reading your post & only a few weeks away from facing an ablation does nothing to ease my worried mind. Having experienced PAF for almost 20 years (probably hereditary as mother & brother had/have it) and, it seems, coming to the end of the road with medication options, I have agreed to undergo the procedure. The ideal for me is an holistic approach to health, avoiding invasive treatment as far as possible. With that phylosophy in mind I'm, at the very least, nervous that the years of taking anti arrhythmic meds will have taken their toll, despite having appeared to have tolerated them well and an invasive ablation is by no means ideal. However, in my world meds or ablation are the only options available for reducing my increased risk of heart attack or stroke - the devil you do, the devil you don't. The ideal of alternative research into preventing AF altogether may well offer better alternatives one day but the reality for me in the present is to face an ablation, so I'll finish this post as I started - there's no doubt, I'm concerned.
The “medical community” have looked after us well! They have done everything possible to stop AF in its tracks because there is no way they can prevent it.! To date there is no cure. I don’t for one minute think they have not tried to find a cure do you? How could you treat something without trying to prevent it in the first place? It would not be logical to me.
Treatments are improving all the time for us, so we gratefully accept their help in giving us as good quality of life as possible.
SpeckledCoast, you will be in safe hands. 100’s of ablations have been performed and been successful. You have got to the stage where it will be beneficial for your well being and to go forwards with this horrible thing. I am nearly at that stage and catching you up and l know in the future l will be following in your footsteps, Take the bull by the horns and go for it. Keep positive it is a path that has been taken by many.
With all good wishes for the days ahead. Let us know how you get on and how much better you are!
AF does certainly not cause heart attacks. Rather on the contrary: my heart attack 7 years ago caused AF, as a result of the damaged heart tissue during the attack.
And AF is only the culprit for strokes if anti-coagulation is not well under control.
In any case, all the best with the ablation that will hopefully keep your heart in sinus rhythm forever!
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75 in February and looking for walking holiday recommendations?
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Hematoma in the foot
Head in the sand!....
Ablation in the morning !!
