Posted by Sarah on January 27, 2004 at 01:26:04:
In Reply to: BORDEAUX posted by GEORGE on January 26, 2004 at 15:44:45:
I'VE FOUND IT!!!! I got this from Jacques Clementy back in March 2003, and I thought it was lost forever! (John, please put this somewhere where it won't get lost again, because you don't know how many requests I've gotten from this board during the last year for this!!!) SARAH
I'm sending you the document that explains how to get apointment with Dr. Haissaguerre, or Dr. Jais. Their e-mail, and fax is on the third page.
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CATHETER ABLATION OF ATRIAL FIBRILLATIONSurgical or catheter ablation of atrial tissue are the only curative treatments for atrial fibrillation (AF). The major goal of catheter ablation of AF is restoration of normal sinus rhythm to relieve symptoms associated with AF, and minimization or suppression of the associated risks of blood clot formation, cardiac failure and increased mortality.
Radiofrequency energy is delivered via intracardiac catheter to create lesions that eliminate the sources (ectopic foci) triggering/initiating the episodes of AF, usually in the pulmonary veins and/or segment the atrial tissue by linear barriers interrupting the errant electrical wavelets responsible for maintenance of AF.
Ablation of the triggers alone cures the paroxysmal (intermittent) form of AF in 70% of patients (without any medication) and improves an additional 15% (with an antiarrhythmic drug but without need for anticoagulants) whereas it cures 30 - 50% of patients with the persistent form of AF.
Linear ablation if combined with trigger ablation, increases the success rate of treatment in paroxysmal and persistent AF to 85 and 78% respectively (without any medication). The success is dependent on the feasibility of achieving continuous & coalescent cauterizing points to create a complete barrier.
Preablation management
For safety reasons (avoiding embolization of clot during catheter manipulation) the patient should take oral anticoagulation (coumadin, not aspirin) at an optimal therapeutic range (INR 2-3) for at least 1-2 months before the procedure to minimize the risk of clot formation. In addition a transoesophageal echocardiogramm should be performed a few days before hospitalization to confirm the absence of a clot, notably in the left atrial appendage which would postpone the date of intervention.
Anticoagulants should be interrupted 48 hours before the operative day, anti-arrhythmic drugs will be stopped on admission.
Catheter approaches
General anesthesia is rarely performed in adult patients to minimize the associated risks of infused drugs. Under slight sedation and local groin anesthesia, 3 catheters are typically introduced through one or two femoral veins for mapping and ablation. In the absence of patent foramen ovale (interatrial septal hole creating a pathway between the heart chambers, found in 20% of patients), a transseptal puncture is required to access the left atrium. Then pulmonary vein angiography is performed to outline venous size and anatomy.
Two or three physicians are involved during the procedure : for catheter positioning and for collection, analysis and interpretation of intracardiac signals obtained during conventional or computerized mapping.
RF ablation is performed at the orifice of pulmonary veins with a low level of energy to avoid narrowing of the vessel. In our experience, 100% of PV can be electrically isolated/disconnected from the left atrium. Then linear ablation is performed from the left inferior vein to the mitral annulus : this isthmus can be interrupted in 92% of cases but is incompletely blocked in 8% mainly because of local atrial tissue thickness (this cannot be anticipated from preoperative examinations).
Then provocative manoeuvers are performed to assess the presence of other extrapulmonary vein foci which will require additional radiofrequency applications.
Additional ablation of the appropriate site (cavotricuspid isthmus) is also performed in the right atrium to prevent the occurrence of right atrial flutter (complete linear block achieved in 99% of cases).
Pain or discomfort associated with cauterization are controlled by Midazolam & Nalbuphine.
Duration of operation and hospital stay
The procedure duration varies from one to four hours depending on individual conditions :
- the uncertain or elusive manifestation of ectopic foci notably those outside the pulmonary veins which require more mapping time ;
- completeness of linear alteration of atrial tissue substrate depends on local atrial tissue thickness.
The end-point of the procedure is an inability to induce spontaneous AF despite multiple pacing manoeuvers and provocative pharmacologic drugs.
A second procedure may be needed within 3-5 days in 25% of subjects for complementary ablation : either due to partial recovery of ablated tissue or secondary revealed foci.
Patients are hospitalized 4 to 6 days depending on the number of procedures required. Typically they return to the normal care unit after ablation and are ambulatory 12 to 24 hours later. They are monitored by telemetry during the next 3 days when any recurrence of arrhythmia is most likely to occur. The likelihood of recurrence decreases over the next month.
The patients are usually admitted on Monday and can leave the hospital for the week-end, if there is no complication. They may return the following Monday for outpatient evaluation which could result in rehospitalisation if needed (20% of cases).
In the absence of arrhythmia recurrence, patients can return home and resume normal activities thereafter. Anticoagulants are recommended for at least one month after ablation and then can be interrupted in the absence of AF and other risk factors.
Population of patients
Catheter ablation of AF is performed since 1994 in Bordeaux. As of November 2002, over 1200 patients have been treated and at least ten cases of atrial flutter or fibrillation are programmed every week. The clinical characteristics of patients cover a wide spectrum of age (15-82 years average 52) with 78 % male and 22 % female and 90 % of paroxysmal versus 10 % of persistent AF. All patients were resistant or intolerant to an average of 4 antiarrhythmic drugs and experienced at least weekly episodes of AF at their referral.
Some patients have documented sinus pauses following AF paroxysms and were cured by AF ablation thus avoiding pacemaker implantation.
Twelve per cent report a previous embolic event, most in the brain circulation.
Risks associated with AF catheter ablation
Although the operative mortality is presently 0 % in our department, 0.1 % risk is a reasonable estimation by analogy to other catheter procedures.The other risks of catheter ablation of AF are : bleeding in the pericardial bag surrounding the heart and requiring drainage (~ 1%), embolic event (0.5%) and groin access hematoma (4%). There is no risk of sinus node or AV node damage caused by ablation which would require pacemaker implantation.
In your experience, there is less than 1% risk of pulmonary vein narrowing which if it did occur would not usually cause symptoms. A single patient has required angioplasty and stent implantation of a PV.The above risks compare very favourably to the reported complication rates associated with AF, and inherent use of antiarrhythmic drug and anticoagulants.
Procedure cost
The total cost of AF catheter ablation depends on the duration of hospital stay according to the following rate : 583 euros per day, 3000 euros for the catheters (single use catheters).
The extracost for a private service (operators : Dr M. Haïssaguerre and P. Jaïs) is 3000 euros (hospital and physician charges).
For example a hospital stay of 5 days with a single ablation session costs 9313.77 euros. This provisional cost is asked at the hospital admission date.
For patients accompanied by a family member and without local accomodation, a bed and breakfast is provided in the same room (42 euros/day).
Patients should come with personal clothes as it is possible to walk outside and patients are expected to generally wear their own clothes including pyjamas. As the hospital only provides small towels, you may wish to bring your own towels.
Information about the hospital
Cardiologic Hospital of Haut-Leveque is a 300 bed hospital which is enterily devoted to cardiology. It is located in Pessac, at 10-15 minutes drive with a taxi from the airport and 20-30 minutes from the center of Bordeaux and TGV station.
Additional information can be obtained on request- by faxing at n° 33 5 57 65 65 09
- or e-mailing to Dr M. Haïssaguerre and Dr P. Jaïs :
jacques.clementy@pu.u-bordeaux2.fr