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Convergent Ablation vs Traditional Ablation


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  • Convergent Ablation vs Traditional Ablation

    So. Hey guys. I'm a 37 M. I have paroxysmal Afib with rvr. I have HCM and a family history of HCM thus i also have an ICD.

    My Afib has gotten progressively more frequent last few years. Last year I had 5 cardioversions with the last one failing. Scheduled a emergency ablation at the local hospital but i converted chemically with amiordrone in the ICU. I've been back home now for 5 months. Afib free so far. Back on my sotalol. I just got insurance back so yesterday I spent all day at Emory Hospital talking to my EP and heart doctors.

    The hospital and EPs, Thorasic Surgeon Im seeing are located at Emory Hospital in Atlanta Georgia. I go in thinking standard ablation. They drops the bomb that instead of traditional RF ablation I should get a "Convergent" hybrid ablation. Due my HCM (IHSS) and what he said the stiffening of my heart. The hybrid approach has a 70% of success and freeing me afib compared to the 40% of a single traditional RF ablation.

    Instead of 2 days at the hospital, its going to be 4. I'll need general anesthesia instead of conscious sedation and there's more risk involved due to cutting thru my stomach into my heart from a 1inch incision. This approach includes needing a chest drain tube for 2 to 3 days as well..

    I'm scared to death. The thought of RF ablation was already a terrible thought but now they want to literally cut into my heart.

    Anyone had this done? Is this a drastic first approach to HCM afib ablation? I'm on my max solotal dosage. When im in sinus Im perfectly healthy aside form SOB due to my high sotalol dose and HCM. That said. My Afib with RVR is completely unbearable when it does happen.

    I'm signed up for the convergent procedure now. They are calling monday to schedule preop labs and to make a date. They said 2 to 3 weeks out. Is this a good choice? The increase risk for increase chance of success? Fear and the undue stress I'll be putting on my wife and kids with such a procedure is more than a regular ablation. From what I read. The recovery is a bit harder than traditional ablation. I've heard a lot more chest pain and I wont be able to lift more than 10lbs for the first month. The flip side is the success rates seem to be higher for people with structural heart diesease as myself. I find myself wanting to trust my EP but I know Covergent is a brand name and a technique being push by a pharmaceutical medical manufacturers that sell the actual tool used to make the lesions/ablations. I'm just scared I'm going to make a life altering decision I could later regret.

    The cardioversions are bad. I definitely need an ablation. The EP tells me he thinks the risk are worth it. 40% success with a traditional ablation. With HCM. I'll likely need a repeat. Compared to the 70% success rate of this single convergent proceedure.

    I just need some insight. I have to trust my EP right? He knows more than I do, right? He wouldn't suggest this if he didnt think it was the best approach, right? Basically two ablations at once with the intent of not needing a second separate procedure..

    If anyone could offer any additional insight or even experience on the procedure. Please post or done hesitate to email or call me. My contact info can be found @ clemsonwebdesign.com

  • #2
    I don't know much about this procedure, but I do know this: afib ablation success in HCM is substantially lower than it is in other people. That is, HCM patients are more likely to need repeat ablations, and to have shorter periods that are afib-free. That raises two thoughts in my mind:
    • I would guess that the success rate they're quoting you is for the procedure in general, not for HCM patients. It wouldn't be surprising if it's not as good for us.
    • But - precisely because we are more likely to have recurrent afib, it *might* be the case that this at least improves your chances.
    Both points are guesses; I really don't know. I would suggest doing a couple of things. Call the HCMA office and see if they have any insight on this, or can point you in the right direction. If it were me, I'd also see what's being done in the high-volume HCM centers (Cleveland Clinic, Mayo Clinic, Tufts), where they see a lot more HCM patients. When I had a PVI ablation (at Cleveland Clinic) the EP told me that afib ablation in general involves a considerable amount of art as well as science, and that this is especially true in HCM. Knowing something about whether this procedure is done much at these centers (with HCM patients, in particular) might help you make a decision. I'll be interested to know if you learn much about this.

    Myectomy on Feb. 5, 2007.


    • #3
      Alright. I spent the last day reading everything I could find. The "Covergent Ablation" is really just a brand name for a "Hybrid Ablation". Its literally a trademarked name from atricure/nCure, A medical manufacturer who manufacturers the ablation tool used in the procedure. Its only considered minimally invasive when you compared it to the open chest procedures like the Maze/Cox. The procedure is normally only reserved for people who have failed multiple past traditional afib ablations who want surgical results with*out the complete sternotomy.

      You are right. The 70% number I was quoted is the standard success after 1 years of people without underlying structural heart disease. Success is measured apparently by less than 30 seconds of Afib. There honestly isn't much data, if any, on the hybrid "converge" ablation procedure on patients with HCM. Not that I have found anyway.

      Which leads me to this. RF Ablation is decently studied and well cited in HCM patients. HCM patients like myself, with occasional paroxysmal afib, tend to do much better with traditional cath ablation than HCM patients with persistent or long standing afib. 1 year sucess rates, off of AAD's for HCM paroxysmal afib patients after 2 ablations are comparable to the general population in the (60% to 75%).

      After doing my research, which includes over 20 cited government and medical reports, and spending time with my family. I decided I have too much to lose to be letting people cut into heart. I'm fairly young, 37, Take care of myself and hopefully have many years of life left. If a traditional ablation with a touch up ablation 6 months later can allow me to at least reduce my ER trips, cardioversions and maybe reduce my sotalol dosage - then the reduced complication rates, reduced mortality risk, reduced hospital stay, reduce cost and overall stress, makes the traditional cath ablation a no brainer for me.

      I can always do the tradtional cath. If the attempts fail. The hybrid procedure isnt going anywhere and maybe in a few years the technology will improve even more.

      On that note. I'm disappointed with Emorys physicians lack of ability to convey the Convergent Hybrid Procedure to me. Granted my normal EP was out of the office that day. It was his recommendation that drove me down this path in the first place. When I asked for details on the procedure. The NP literally gave me a print out with 2 paragraphs of text. When I asked the PA about statistics, her response was "its a routine procedure". When I asked the thorasic surgeon about the hybrid/surgical portion of the procedure. His response was "left your shirt". It points at my chest and goes "boop". Right there, I'll make a one inch incision. Thats really the extent of the information I left the hospital with. I get it. They likely dumb things down for most patients. I understand these are truly great people, real life super heros that save lives. Some of these people have lived lives I can only dream about. I just feel like they really, really need to work on their patient skills. =-)

      I'm calling Emory first thing in the morning. Letting them know I dont want to schedule that hybrid procedure but instead the traditional cath.
      Last edited by fiftycal; 01-27-2019, 10:33 AM.


      • #4
        I think you have made a wise and informed choice. As an RN with a Master's degree....I have distanced myself from any physicians or surgeons who talk down time or pat me on the head and tell me not to worry....I usually let any doctor know up front that I am a nurse and I research all my healthcare decisions thoroughly so feel free to use medical language and I will stop you if I don't understand.
        If it were me, and I need RA for Afib .... I might still look at who does the most RAs on HCM patients with the best success rate. Because, as Gordon said:
        " Routine" RA is not necessarily " routine" for an HCM. My understanding is that Each HCM Center of Excellence has all the components of a well rounded program available... like RA. However, there will always be centers that are stronger in one area than another A call to HCMA might give you a perspective on this also.... You should be able to feel totally confident in your choice of procedure and the practitioner who is doing it.
        After years of symptoms:
        Officially Diagnosed HOCM 2006
        Myectomy 3/11/13 at non-COE
        Extended Myectomy 7/23/14
        At Mayo with Dr. Joseph Dearani


        • #5
          So my nurse is now telling me there really is no other option. That the Dr. said a traditional RF ablation wont help me. Thats left me panicing. Friday i was under the impression I had a choice. The EP told me 40/70. 70. same Dr. was ready to schedule a ablation last year but I put it off because I lost my insurance for a few months. Now they are telling me this Hybrid Convergent is my only choice that will be beneficial due to my HCM.

          Everything I read only tells me otherwise. I cant find one single instance of this procedure being used as a first line invasive treat for paroxysmal afib in a HCM patient.

          Dont know what to do now. Ive waited on this for years and now im scrambling for a second opinion. To go from RF ablation to cutting into my ueart is a pretty drastic leap for me. Everything I read states RA is a effective and safe proceedure to treat paroxysmal Afib in HCM patients.

          They're suppose to call me back on Wednesday and Im hoping my actual Doctor calls me. I have yet to speak with him (only his colleagues) about this Hybrid Ablation. I'm nor really sure why they would tell me its my only option. Theres plenty of documentation of RA helping HCM patients a lot worse off than what I am. I'm not even persistent afib. I'm in sinus with sotalol 99% of the year.
          Last edited by fiftycal; 01-28-2019, 05:20 PM.


          • #6
            Wow! I can understand how disconcerting this must be for you. Just remember this is not an emergency at this point....do not feel rushed into making a decision you are not comfortable with. I support you in your premise that this is not a first line procedure. The fact that they are telling you there is no choice seems very fishy to me....and even if they backed down and said they would do the RA...I don’t know if I would feel comfortable having them do it. Have you tried talking to Lisa at the HCMA office possibly she has Some current information on this procedure for you.
            After years of symptoms:
            Officially Diagnosed HOCM 2006
            Myectomy 3/11/13 at non-COE
            Extended Myectomy 7/23/14
            At Mayo with Dr. Joseph Dearani


            • #7
              Oh I agree with you on if they back down and do offer me a RF ablation. The disinformation, or lack of information they have given me up to this point is even making me question my ICD implant. They cant seem to "converge" on their communication with me. I literally spent two sleepless days choosing between the "Convergence Hybrid Ablation" and RF ablation because they told me I had the choice on Friday.

              HCM interns have my info and stated they would call me back in the next couple days. I know I should be going to Cleveland or Mayo but honestly i doubt I have those financial means. I've been going to Emory for 10 years and from what I understand they are a high volume center and maybe even a HCM center.

              My wife advises me to not panic, wait to hear back from Emory on Wednesday. I know at this point I need a second opinion. I have a referral to Dr Sturdivant at MUSC that i need to setup (will be a two day car ride) and can likely see some local EPs at Greenville Hospital System here in upstate South Carolina.

              I dont know. I just wanted to get cardioverted less, a little less burden and less stress on my family. I mean. I literally had to get cardioverted on our beach vacation last year. That entire experience alone aged me and my wife like 5 years haha.

              I expected and been told I need a RF ablation for years. I dont know if the stress, the ptsd and cost of cardioversions is worth heart surgery, all that pain and the door that type of proceedure opens up.

              My locals tell me I cant keep up my current life of getting cardioverted multiple times a year. Everyone, even my local cardiologist has been pushing me to get the ablation for years. I dont know what i should do at this point. I dont want to let people cut into me unless i really have no choice.
              Last edited by fiftycal; 01-29-2019, 07:45 AM.


              • #8

                Here's the conclusion section of a analysis of hybrid ablation techniques. One of many I used to make my choice that this hybrid proceedure might not be a great choice.


                ​Given that there are no published studies to date comparing hybrid ablation to catheter ablation, definitive conclusions about hybrid AF ablation cannot be made. Several different methods have been shown to be effective, however the relative efficacy compared to catheter ablation or surgical ablation alone has not been sufficiently studied for paroxysmal, persistent, or long-standing persistent AF. However, considering the advantages and disadvantages we feel that currently there are several clinical situations in which a hybrid approach should be considered; first, as adjunctive therapy for patients with symptomatic AF undergoing cardiac surgery. In this setting epicardial ablation adds little additional operative risk and can offer provide optimal access for PVI and additional anatomically guided substrate ablation as indicated. Indeed, animal studies have consistently shown the greatest degree of transmurality for epicardial RF ablation with cardioplegia. Second, hybrid ablation should be considered in patients with persistent AF who have failed catheter ablation, particularly those in whom endocardial PVI has failed because of risk to surrounding structures including phrenic nerve or esophageal injury. Hybrid approaches also would offer potential advantages for additional substrate modification including possibly posterior wall debulking, homogenization of fibrosed/scarred atrium, and atrial denervation. Efforts to elucidate non-invasive and invasive targets are ongoing and will require further study. Finally, hybrid ablation may be considered in patients with persistent and long-standing persistent AF who are not optimal candidates for catheter ablation or who prefer a thoracoscopic approach. Such situations include patients with advanced LA structural remodeling such as in valvular AF, patients following atrial septal defect closure, or patients with challenging venous access.

                In conclusion hybrid epicardial and endocardial ablation for AF is promising. Further careful study of techniques and patient selection will be necessary to optimize outcomes, especially a direct comparison to catheter ablation alone.
                There's just nothing I've read that even hints at something this invasive as a first line treatment for paroxysmal afib. Granted I'm very symptomatic when in afib. I dont see why a RF ablation with a touch up down the road wouldnt significantly reduce my afib burden and improve my quality of life. HCM patients have a higher chance of needing a repeat proceedure but those with paroxysmal afib seem to have pretty good outcomes compared to those in the general population.

                Just one of many publications detailing ablation outcomes in HCM patients.

                RESULTS:At 12 months, stable sinus rhythm (SR) was present in 16 (53%) patients, significantly more frequently in patients with paroxysmal AF (71% in SR) compared to those with persistent (57.1% in SR) or long-persistent (22% in SR) AF. A significant reduction of AF burden was observed in 85.7% of patients with paroxysmal AF, 71.4% of patients with persistent AF, and 55.5% of patients with long-persistent AF. Single procedure success rate was 33% (10 patients), and repeat ablation procedures were performed in 13 patients.

                CONCLUSIONS:Catheter ablation of AF in patients with HCM is an effective and safe therapeutic option, particularly in patients with paroxysmal AF. Effectiveness of ablation is significantly smaller in patients with persistent AF and even more so in those with long-persistent AF. Repeated procedures were often necessary. Continued antiarrhythmic drug therapy is often required due to a significant degree of atrial remodelling.
                So I know Im not crazy for going against the grain here. Theres just so much information out there that shows RF ablation can be a effective approach in treating paroxysmal AF with HCM patients. Emory claiming my only choice is a procedure with higher risk that has no documented use (none that I have found) in HCM patients. Its just blowing my mind.
                Last edited by fiftycal; 01-29-2019, 09:49 AM.


                • #9
                  Absolutely you are at the point that a second opinion is critical to your decision making...I don’t know that MUSC is going to provide you with the consult you need. I might suggest driving 4 hrs instead of 2hrs and getting a second opinion at the HCM Specialty Clinic at Duke University it is a designated Center of Excellence and Dr. Wang is very well respected in the HCM community.
                  Duke University Medical Center
                  Jennifer Whitaker

                  DUMC 3428/2301 Erwin Road
                  Durham, NC 27710
                  United States

                  Phone: (919) 681-5816
                  • Andrew Wang, MD- Director
                  • James Daubert, MD- Electrophysiology
                  It’s important in a large University to make sure you get into the HCM Specialty clinic.....not general Cardiology. Emory is on the list of HCM Centers of Excellence also. I assume that at Emory you are being seen in the HCM Specialty Clinic and not general Cardiology?. I have a Dr. Robbie Williams listed as the director.
                  You are not crazy.... I agree with your wife, don’t panic... You have done your research and it is difficult after being somewhere for 10 years to need to look for a second opinion..... but it’s OK. Put this on your list of “All things happen for a reason”” and move forward one step at a time.
                  After years of symptoms:
                  Officially Diagnosed HOCM 2006
                  Myectomy 3/11/13 at non-COE
                  Extended Myectomy 7/23/14
                  At Mayo with Dr. Joseph Dearani


                  • #10
                    I dont think I'm seeing the Emory HCM clinic. Just the general cardiology department at Midtown Emory. I had no idea they had a separate HCM clinic.

                    This is who I see and who implanted my ICD https://www.emoryhealthcare.org/phys...eon-angel.html, https://news.emory.edu/tags/expert/a...eon/index.html

                    Dr Leons nurse just called. Shes telling me Dr Leon states he wouldnt do anything other than the hybrid convergent proceedure. Tells me even with that, given my HCM - it has a low chance of working. Which is kind of devastating and a brick wall. Im going on 5 months of sinus rhythm. Just a matter of time before my next episode. =-(

                    It doesnt sound like my specific case of HCM. Just because I have HCM in general. That this is my only choice with Emory.
                    Last edited by fiftycal; 01-30-2019, 10:45 AM.


                    • #11
                      Thank you Jill. I've requested the referral from Emory to Dr Wang at Duke. He can see me two weeks sooner than MUSC can, so thats good. Its a little further than Charleston but its reassuring to know he runs one of the top HCM programs. MUSC isnt a HCM center. They are just a recommendation to me from Emory.

                      If what Emory is telling me is true then it sounds like its this hybrid convergent procedure or a pacemaker. I hope I'm making the right choice in delaying and getting second opinions. I'd feel like a moron if I end up having to get a emergency ablation locally while waiting on the second opinions/consults.


                      • #12
                        Take a deep breath.....the more you allow yourself to be stressed....the more your body creates chemistry that is not healthy
                        for you or your heart. Use the next two weeks to get what medical records you can for your appointment and what I found helpful for myself ....maybe more than for the doctors, I wrote out an event time line of my adventures in HCM so I could give a good concise history to my new doctors.
                        I also understand you have an appt to talk to Lisa at HCMA. She is the key person in reviewing HCM Centers of Excellence and has a wealth of experience and compassion. You will learn a lot.
                        You are making good choices.... relax and have confidence in what you are doing.
                        Jill C.
                        After years of symptoms:
                        Officially Diagnosed HOCM 2006
                        Myectomy 3/11/13 at non-COE
                        Extended Myectomy 7/23/14
                        At Mayo with Dr. Joseph Dearani


                        • #13
                          A couple of things I was told may be helpful.

                          First, I was told by a couple of people who are real HCM experts that I'd do much better at a center that does ablations for a lot of HCM patients. So I chose to go to Cleveland Clinic, where my HCM specialist is and where I'd had a myectomy. My local EP at the time (in Tampa) actually agreed with this: he said that afib ablations are chancy for everyone (in the sense that repeat ablations aren't rare) and more so for HCM patients, and, while he'd done quite a few in HCM patients, he was sure they had a lot more experience in Cleveland. Second, the Cleveland EP - he's the head of their afib clinic or something like that - told me that the realistic goal nowadays with all afib ablations is to reduce the frequency of afib episodes, as well as their intensity, not to cure you of afib for all time. It's important to know that going in! As it happens, I've now gone almost 3 years without any afib, or none that's been noticed, anyway.

                          So my general recommendation is to consider the possibility of traveling even farther and going to one of the centers that has even more experience than the Duke people do.
                          Myectomy on Feb. 5, 2007.


                          • #14
                            Just an update here. I'm meeting with Dr Wang tomorrow at Duke for a second opinion. Still in sinus rhythm going on 6 months! Been walking/jogging a mile or so every day, watching what I eat and keeping my stress low. Seems to be working. Feeling great. I'll post back in a couple days with what Dr Wangs opinion is.


                            • #15
                              So. We drove down the 5 hours to see Dr. Wang at Duke. Ironically enough. I woke up at 2:30 last night. In Afib.. LOL. Drove to Dukes ER. They cardioverted me. Made Dr. Wangs appointment right on time at 8am. Was still a little out of it from the cardio-version. Dr Wang has instructed me to start taking a low dose of Verapamil along side of my Sotalol. Said he wants to see if my bad symptoms are from rate control vs rhythm control.

                              I think the goal with Verapamil is - the next time I go into afib. Maybe my heart rate will hopefully stay low (no RVR) and I can manage the symptoms at home and hopefully self convert (sotalol). Reducing the need to go to the ER. Dr Wang says if it doesnt help me - We can talk AF Ablation. Then if a AF Ablation or two doesnt help. I might consider the Convergent Procedure. He agreed the Convergent Procedure seems like a drastic first step.

                              So. I guess I'm going to give Verapamil a try and put off the Convergent /Ablation procedures.