MedPage: Ablation for Afib Dogged by Complications

April 29, 2013

Action Points

  • This study found that catheter ablation for atrial fibrillation — with its promise of drug-free symptom relief and long-term outcome benefits — thus far has been hindered by high rates of periprocedural complications and a frequent need for rehospitalization.
  • Older age, female sex, prior hospitalization for atrial fibrillation, and recent hospital procedure experience were all associated with a higher risk of complications and/or 30-day readmission after ablation

 

http://www.medpagetoday.com/Cardiology/Arrhythmias/30461


What they won’t tell you at a teaching hospital…

May 2, 2012

Originally posted on Collateral Damage: A Patient, a New Procedure and the Learning Curve:

This post from an atrial fibrillation support group:

“I had an ablation at Johns Hopkins this past week and am very upset at the outcome. I haven’t had any [afib] symptoms but experienced severe shortness of breath.  After xrays and tests it was discovered that the phrenic nerve was damaged and I now have parylasis of the right diaphragm. I have a continuous dry cough and such SOB I can’t lay down to sleep. I can’t even sniffle.

“I’m told if it doesn’t resolve in 24-48 hrs [which it didn’t] that it may take 3 months to a year to recover and that is not guaranteed.. I’m very dissappointed and confused. I’m also on amiodarone and worry about lung involvement with a weakened respiratory system. I was released after 4 days and an appointment for 3 months from now. I don’t know where to start to figure out what I need to do now…

View original 366 more words


What they won’t tell you at a teaching hospital…

February 9, 2012

This post from an atrial fibrillation support group:

“I had an ablation at Johns Hopkins this past week and am very upset at the outcome. I haven’t had any [afib] symptoms but experienced severe shortness of breath.  After xrays and tests it was discovered that the phrenic nerve was damaged and I now have parylasis of the right diaphragm. I have a continuous dry cough and such SOB I can’t lay down to sleep. I can’t even sniffle.

“I’m told if it doesn’t resolve in 24-48 hrs [which it didn’t] that it may take 3 months to a year to recover and that is not guaranteed.. I’m very dissappointed and confused. I’m also on amiodarone and worry about lung involvement with a weakened respiratory system. I was released after 4 days and an appointment for 3 months from now. I don’t know where to start to figure out what I need to do now to make this better.”

That’s what happens when you get clipped at a teaching hospital—the bum’s rush. This was supposed to be a safe and minimally invasive outpatient sort of procedure, and here you are at home after an unexpected 4 day stay at the hospital; wounded, scared and confused, with more questions than answers and hardly able to breath.

The person who caused this situation is Dr. Hugh Grosvenor Calkins, who is,  according to the victim of this story,  the best doctor at the best facility in the land. That is what they would have you believe, and that is what most of us do believe. People want to believe it, and once you’ve put your life into the doc’s hands, you have got to believe it.

As for the complication, Dr. Calkins has reassured you that he himself did the procedure and that it was a very rare thing that happened in your case, so rare that he didn’t think it worth mentioning. And actually, when you think about it, it’s sort of your fault because your anatomy is different than everyone else’s. Your atrium is smaller than a normal person’s, or the walls of your heart are thinner.

“I was informed of many side effects but not that one. When I asked why I wasn’t informed I was told it is rare.

“Also talking to the radiologist and Drs. and looking at the ct scans and TEE results I have an abnormal heart anatomy. Things are not where they are supposed to be. "

It makes you feel bad somehow, that America’s Best Hospital has deemed that you have odd body organs.

Maybe Hugh Calkins is behind in his journal reading, otherwise he would have seen that phrenic nerve injury is “a well-described complication of AF,” and he would have read about “currently available tools to avoid the complication.”  Or maybe a doctor who was training for his fellowship in electrophysiology did the job. After all, that’s what they do at a teaching hospital, and the head of the EP lab at Johns Hopkins is on record as saying that for ablation procedures at Hopkins, “the attending shows up to be there during the burn.”

What did you expect?


Hugh Calkins on Death by Ablation

November 26, 2011


“Just another risk to put on the consent form.”- Hugh Calkins

_________________________________________

A typical case is someone who had pulmonary vein ablation shows up in the ER with three pulmonary veins completely blocked and the fourth one 90% blocked,” Calkins relates. “The patient gets emergency heart surgery and dies. Another person gets an A-Fib ablation, you get a call, the patient has been diagnosed with lung cancer, well it wasn’t lung cancer, it was an occluded pulmonary vein that appeared to be lung cancer, but the patient got a lung removed. There was this iatrogenic epidemic of pulmonary vein stenosis…”

… And the complications kept on coming, each one unexpected, and each one unprecedented. There were four reported cases of “gastric hypomotility and pyloric spasm.” The victims suffered terrible bloating of their stomach and vicious bouts vomiting because their stomachs had become permanently paralyzed.  He wrote in 2006 about what was “perhaps the most feared and most lethal of the many complications,” the atrio-esophageal fistula. They probably call it The Widow Maker back in the doctor’s lounge. “Among patients who do not exsanguinate from upper gastrointestinal tract bleeding,” a surgeon writes, “presentation includes sepsis and embolic cerebrovascular disease.”

That is to say that they’ve burned a hole through your heart into your esophagus and if you don’t drown  in your own blood right then and there, you’ll die very soon in some equally grisly manner.

“Just another risk to put on the consent form,” said Hugh Calkins.

 ****

Results: Thirty-two deaths (0.98 per 1,000 patients) were reported during 45,115 procedures in 32,569 patients. Causes of deaths included tamponade in 8 patients (1 later than 30 days), stroke in 5 patients (2 later than 30 days), atrioesophageal fistula in 5 patients, and massive pneumonia in 2 patients. Myocardialinfarction, intractable torsades de pointes, septicemia, sudden respiratory arrest, extrapericardial pulmonary vein (PV) perforation, occlusion of both lateral PVs, hemothorax, and anaphylaxis werereported to be responsible for 1 death each, while asphyxia from tracheal compression secondary to subclavian hematoma, intracranial bleeding, acute respiratory distress syndrome, and esophageal perforation from an intraoperative transesophageal echocardiographic probe were causes of 1 late death each….

devastating complications may occasionally occur, some of them ultimately leading to death of the patient (5,7). Systematic assessment of death rates and precipitating causes is difficult, because of the rare occurrence of death, making its description anecdotal in single-center reports (8–10), and because of reluctance to publicize this information (7). As a consequence, physicians performing CA of AF sometimes discuss this complication, but a clear picture about its incidence in the real-world practice is lacking. http://content.onlinejacc.org/cgi/content/full/53/19/1798

During the presentation, Calkins said the two current treatment options for AF, including conventional radiofrequency ablation catheters, are not designed well enough to treat persistent AF, given that persistent patients often have multiple triggers, rotors, and drivers of the arrhythmia within the atrium. These catheters are time-consuming to use, as physicians create lesions in different areas, but the Medtronic catheter system is a multielectrode device, so they are able to ablate multiple areas of the left atrium much more easily.

Wrapping up the panel meeting, Yancy said that despite the negative vote on risks and benefits, it simply can’t be approved “yet.” Better safety results, as well as possible technical tweaks to the catheter, are needed, he said.

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Complications of Atrial Fibrillation Ablation When Prevention Is Better Than Cure

http://www.medscape.com/viewarticle/752625?src=nl_topic

Orginal Front Page Chapter One

March 5, 2008

A Work in Progress …

Hugh Calkins Johns Hopkins Cardiology

PreviewCHAPTER ONE:

“A Mitral Valve, Flapping in the Breeze, Prolapsed into the Atrium …”

Johns Hopkins Medicine has a long tradition of prioritizing patients, and striving for the bottom rung are the anonymous poor.

If, for example, you catch a bullet on a Baltimore street corner, or your mother presents you at the ER as a feverish welfare child, then it’s open season for the med students, well meaning as they may be. They can practice on you because if  their actions result in an adverse outcome—which is to say that if you are mangled or killed—nobody will question said outcome, precisely because… you are a nobody.

At the other end of the spectrum are wealthy and prominent patients, who get treated by doctors who have already learned what not to do from the mistakes inflicted upon the lower classes.

My wife landed somewhere in the middle. We got snookered by all the hype from US News into thinking that she was going Hugh Calkins Johns Hopkins Cardiology to be treated by the best doctor at “The Best Hospital in America.”

Hugh Calkins, MD was to maneuver tiny wires around in my wife’s heart and burn scar tissue in the wall of the atrium to stop atrial fibrillation.

The job required someone with a cool head and a keen eye, and Hugh Grosvenor Calkins, MD, FACC, FAHA, FHRS, Professor of Medicine, Director of the Electrophysiology Lab at Johns Hopkins University School of Medicineand graduate of Harvard Medical School—assured us that he had done plenty of these procedures, and, he said, “experience counts.”  So we knew we were in the best of hands. What we didn’t know is that Professor Calkins—according to what he later told colleaguesfollows the practice at most teaching hospitals wherein “the attending shows up to be there during the burn.”

What he meant by that was this:

The patient is etherised upon a table, and wheeled into the laboratory.  A student of the  treatment  performs and is responsible for routine aspects of the procedure.  According to the rules, all this is to be done under close supervision.  With blue vinyl fingertips feeling their way under bright white light, the trainee practices finding the femoral vein in the patient’s groin, high up inside the thigh, pressing and probing and picking a spot and then pushing the point  of a large needle into the flesh until it punctures and there is blood.

The trainee then inserts the sheath for the catheter into the vein and snakes it up into the pumping heart. Then he inserts the catheter wire up into the sheath, and here is where one would expect the experienced attending physician to step in because it is a very tricky business to navigate a thin wire around in a beating heart guided by cloudy X-Ray imagery, even if you know what you’re doing.

But since he only “shows up to be there during the burn,” Hugh Calkins was presumably relaxing with colleagues down in the doctor’s lounge or out selling TASER guns while a young cardiology trainee by the name of Richard Wu—whom we’d never met—was sweating out a decision in the lab. He had a stranger laid out on the table before him and a new type of catheter in his hand.

It appears that young Wu wasn’t sure into which chamber of the heart the catheter was to be inserted.

Richard Wu Cardiology

He went for the left ventricle (it says right on the box to not do that) and the catheter got tangled in the muscles of her mitral valve. Her chart read: “only the first 50% of the circular portion of the catheter tip could be withdrawn into the sheath and pulsatile motion could be appreciated.”

Pulsatile motion.

They were trying to cajole the catheter back into its sheath, but it was tugging right back, like they’d hooked a five pound bass. A nurse noted here that the “patient is waking and moving around, with chest pain @ 7/10.”

Imagine that.



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