Can catheter ablation of AF ever be compatible with a less-is-more approach?

Here's a challenge: Pick up a cardiology or electrophysiology journal and show me a negative piece about catheter ablation of atrial fibrillation. It's true; our world is mostly free of doubters.

Then there is the real world, one populated with other medical specialties, and those daring enough to ask, "What, exactly, are you ablating?" As it turns out, not all doctors think so highly of the notion of ablating a disease that we do not fully understand.

Dr Rita Redberg, influential cardiologist and editor of the JAMA Internal Medicine "Less is More" series, said this about ablating AF:

"Because ablation has never been studied in a randomized blinded fashion, we cannot know whether patients experience fewer symptoms after ablation because subjective symptoms frequently decrease following a procedure or whether the ablation itself was beneficial.

Furthermore, the clinical benefit on survival and morbidity of this invasive procedure, which has substantial procedural risks, remains to be established."

Ouch!

As one who makes a living burning and freezing in the left atrium, these are stirring words. An attached electrophysiologist might even get mad. That sort of reaction, however, could lead to inflammation, a potential cause of AF. Perhaps a more useful approach would be to consider such critique as a challenge—a call to explain what we are up to behind those leaded walls. I have about 800 words.

Let's start by setting out two points of agreement (always lead with the positive). First, I am a strong believer in the less-is-more philosophy. Cardiologists have too often strayed from this guiding principle. Second, it is also true that few large randomized controlled trials of AF ablation have been done. The CABANA trial is enrolling now, but the answers are many years away, and surely, the ablation procedure tested will be obsolete by then.

In the meantime, more than a million humans seek advice for their fibrillating atria. Grinning and bearing the disease surely adheres to a less-is-more philosophy, but that treatment is neither fair nor compassionate. Antiarrhythmic drugs are also a deeply flawed therapy. And what of that time penalty: the longer one stays in AF, the harder it is to treat.

And this is the point. Patients with AF that persists despite lifestyle maneuvers face tough choices: They can live with their disease, take drugs, or have an ablation. ( I can attest that having AF changes your view of treatment options. Perchance the critics of AF ablation haven't had to call their wife to come pick them up from a bike ride because they were too weak to go on?)

Enter pragmatism. We know rhythm-control drugs for AF are terrible. They lack efficacy, cause side effects, and most important, confer real risk. The default thinking—that taking a pill is less risky than a procedure—does not apply to rhythm-control drugs for AF. Prolongation of the QT interval, 1:1 atrial flutter, and postconversion pauses present clear and present dangers.

An image might help: picture the sun-worn 65-year-old triathlete pedaling himself through the pain threshold up a big climb. Now picture him doing the same on propafenone or flecainide. That's risk.

Do not misunderstand; AF ablation isn't free of risk. Tamponade, stroke, esophageal damage, vascular complications, and phrenic nerve injury, among others, are serious issues. That said, however, in 2013, at least in my laboratory, the risk of major complications is less than 1%. (Yes, we have [our] data.) Most EP centers have similar numbers, especially if one looks at results from the past two to three years. The procedure is safer now. Don't take my word, though; in the MANTRA-PAF trial (NEJM), major adverse events did not differ between ablation and drug arms.

AF ablation in 2013 has come a long way. Due to technological advances (low-flow irrigated ablation catheters and 3D mapping systems), learning curves (the human component), and establishment of standardized approaches (durable pulmonary vein isolation in all), AF ablation has been transformed. The 2013 procedure is low in radiation exposure, well-practiced, and mainstream. Gone is mystique and magic. Ablation cowboys have been domesticated. Most of us drive minivans.

Now let's talk about outcomes

As a given, let's agree that quality of life and exercise capacity are important patient outcomes. In this category, AF ablation is superior to drugs. Although there will be quarrels about the word "success" and "cure," it is clear that most patients who are able to endure multiple ablation procedures end up feeling better than those who stay on drugs. Feeling better is an important end point, isn't it?

On the matter of hard end points (or long-term outcomes), like stroke and mortality, the picture is cloudy. The AFFIRM trial taught us that employing a rhythm-control strategy with AF drugs does not lower stroke or death rates. Being in sinus rhythm is good, but not so much if you get there with AF drugs. Will it be the same story for ablation? Optimists argue that since the procedure is more successful than drugs, it stands to reason long-term outcomes will follow. We shall see, but it's going to take years to know. While we wait for randomized controlled trials there are preliminary data worthy of a look.

During this session of the American College of Cardiology 2013 Scientific Sessions, two abstracts compared populations of AF patients who had or did not have ablation. Although these sorts of studies are nonrandomized and retrospective and therefore limited in power and scope, they are all that we have until CABANA is available.

In the larger of the two abstracts, University of Utah investigators studied a database of 13 751 AF patients, 1099 of whom had catheter ablation between 2006 and 2012. The incidence of stroke was 4% in the ablation group and 12.8% in the nonablation group. This led to a highly significant hazard ratio of 0.29. The problem with saying too much about these data was that the catheter-ablation cohort was younger and more likely to be on warfarin. Was the lower stroke incidence due to the ablation or just that the ablation cohort was at lower risk?

In the second poster right next door, South Korean investigators performed a similar look-back population analysis. They took 586 patients with AF who had AF ablation (2003–2009) and compared them with matched controls. Again, patients who underwent ablation enjoyed a 61% lower risk of stroke.

These are not the only trials that have looked at the long-term results of AF ablation. This one from Beth Israel investigators found similar reductions in stroke in those who had prior AF ablation. And this trial from the Intermountain group in Utah showed that AF ablation might confer a lower risk of developing dementia.

Taken together, association trials at least hint at the possibility of long-term benefit from AF ablation. Association never means causation, but my conflicted eye has trouble seeing any signal for harm.

My one-paragraph summary response to Dr Redberg

I hear you about AF ablation. It is a big hammer. It bothers me doing all those burns and freezes. But the disease sucks. And so do the supposedly safer medical options. So far, I see four themes of AF ablation:

1. There is a (strong) hypothesis that AF ablation improves long-term outcomes.

2. When done skillfully, there is little signal of long-term harm.

3. There is a high likelihood of symptom relief.

4. There is a dearth of other good alternatives.

So yes, I think AF ablation is an especially reasonable and compassionate therapy to discuss with patients.

JMM

Your comments

	Can catheter ablation of AF ever be compatible with a less-is-more approach?
	# 1 of 17	March 18, 2013 05:25 (EDT)
	don kaplan	cardioversion if cardioversion is working,why go for the more intrusive procedure? Author's disclosure (Mar 18, 2013) I have htc and recently had cardioverion which is ,so far, working.
	# 2 of 17	March 19, 2013 08:30 (EDT)
	Ken Grauer	Great Summary of Practical State of the Art of AFib Ablation GREAT post John! Your 1 paragraph summary at the end is perfect. As a noncardiologist - I agree totally with your last sentence: "AF ablation is a reasonable and compassionate therapy to discuss with patients". Ablation isn't perfect - but nothing is for AFib. Ablation has as much potential (if not more) for as-best-as-can-be-hoped-for outcome with AFib as any other therapy - so clearly MORE than reasonable to discuss with the patient in 2013! Author's disclosure (Mar 19, 2013) I have no relevant disclosures to make in connection with this topic.
	# 3 of 17	March 20, 2013 08:24 (EDT)
	David Ward	Excellent results with ablation I have commented on a similar Dr JM topic (10 facts about AF ablation) recently but I can't find the blog - so sorry if I am repeating myself. I entirely agree with DrJM. Medicines are not only ineffective but dangerous. Ablation is a mechanistic way of curing the AF disorder provided it is done early enough in the natural history to prevent deterioration in "left atrial health" which ineluctably occurs during persistent AF. I now use this phrase to illustrate to patients and physicians alike the perils of leaving PAF to evolve into persistent AF. With the cryoballoon PVI I am quoting a 90% success rate for PAF with one procedure (my own experience is over 4 years. My first case, a colleague (so good follow-up!)in 2009 was crippled with PAF (and medicines) and is literally cured. I now offer cryo PVI as a first line treatment in simple PAF (obviously depending on the clinical circumstances) rather than drugs. Cardioversion is good as a holding procedure but does nothing to modify the basic cause. Failure to offer ablation as a treatment option for PAF would in my view be a breach of duty.We must "get in" early to allow simple procedures (PVI) to work rather than deal later with persistent AF and all the bad procedures we do in attempting to get rid of that (eg, linear ablation , WACA, isthmus lines, CFAEs, DFA, ganglia etc). We can avoid these extensive procedures by ablating the veins early in the disease course. Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 4 of 17	March 20, 2013 08:58 (EDT)
	Blanca Turcott	Not a cardiologist. A year ago I had an AF ablation. My life has completely changed since then. I am back feeling the same than I did before I was diagnosed with AF. Will always be grateful to my doctor for suggesting it within 6 months of the diagnosis. Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 5 of 17	March 20, 2013 09:41 (EDT)
	Anne Bance	New Life After Ablation (Patient Report) After nearly 19 years of Paroxysmal AF, with epsodes latterly lasting for anything up to 48 hours, and at the rate of 2 or 3 a week, I had PVI done at The Heart Hospital in May 2011. It was only a partial success (shorter episodes but no fewer). I had a repeat procedure in February 2012, during which it was discovered I had had slight re-growth in 3 pulmonary veins, and a lot of activity still going on in the 4th. Thirteen months after the second procedure I am still AF free and off Warfarin and all anticoagulants/anti platelet drugs. The drug comparison is dismal indeed. Bisoprolol temporarily reduced episodes for a short while, and sent me into energyless torpor, Flecainide gave me terrifying nightmares and hallucinations, and I asked to be excused from trying Propafenone. I am now on just one blood pressure lowering drug only (aside from Thyroxine for hypothyroid). Apart from the odd random beat (ectopics) my pulse is as steady as a drum. I wish I could have had Ablation years before. I should like to have the procedure shouted from the house tops, but I think that patients will find that they have to do their homework and ask for Ablation because, in most cases, it will not be offered. I entirely agree about the 'compassionate' aspect. It is cruel to leave patients living in this kind of nightmare, and often just as cruel to fill them up with drugs, which may help AF in some, but will very likely be causing harm in other areas. Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 6 of 17	March 20, 2013 10:36 (EDT)
	elaine knapp	Ablation versus medication I have AFIB and am on meds. Have thought about an ablation, but the medical community(both cardiologists and EPs) make it difficult to make an informed decision. Your success rates are all over the board, there is no good place to get side by side analysis of ablaton versus meds. Both sides paint a glowing picture, neither side presents a comprehensive comparison. You are not helping us make decisions. Enough said Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 7 of 17	March 20, 2013 11:39 (EDT)
	Rusty Etheredge	Ablation Merits Interesting is the fact that you did not address the issue concerning "subjective symptoms" that Dr. Rita Redberg, influential cardiologist and editor, left like a dangling participle. Atrial fibrillation is a hammer, a very physical phenomenon in the closed definition of phenomenon. I found little need for subjectivity in discussing AF with anybody. Subjectivity might have been important as a vehicle for empathy for somebody else regaling me with his own AF had I no personal experience with AF. In as much as I myself fought AF with a very limp and short stick from first event in fall 2006 to November 9, 2012, I don't know what subjective symptoms are. Post ablation on November 9, 2012, I still have no indication of what subjective symptoms might or might not be, but I do know that the hammer Dr. Whelan applied to my AF at Baylor Heart Hospital has sufficed to silence the hammer AF afflicted me with all those years. Especially intriguing is the pattern of the final two years of that AF, in which cardiologists in Amarillo, Texas persisted in drug therapy in the face of increasing frequency, increasing intensity and increasing duration of AF events under their care, without the mention, much less discussion, of ablation. My own research into my condition, and my own research into the medications prescribed by that bunch of charlatans, chased me out of their clinic and into the electrophysiology lab at Baylor. The time factor is incredibly important, since AF begets AF, because the symptoms that drove me there were by no means subjective. There is a huge built database of ad hoc evidence indicating the efficacy of ablation as first line treatment of AF, a database that is accreting by the day, a database consisting of objective empiric information from patients like myself who have very little time for academic debate on the clinical benefit on survival and morbidity of this invasive procedure. Us ad hoc evidenciaries constitute the establishment of the benefit of ablation as curative for AF. Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 8 of 17	March 20, 2013 05:00 (EDT)
	Bill Van Haren	holding out I'm 62, have had AF since at least 2009, probably before. I've had an active life and otherwise good health. This is a very useful website, thanks. I am one of those old tri-guys going up the hill on flecainide. Is there a risk to that? Flec 50BID, hasn't really had many side effects for me and I often go months between AF events. Those usually resolve in 12 hours or so with the addition of 100 mg flec and diltiazim. To me, as long as I have few events that convert without CV I'll wait for the ablation. The outcomes are better than they were 4 years ago and it looks like there are more improvements evolving. At times I have had events weekly for a few weeks, then I start thinking of the procedure, but these periods still come and go for me. So, if i am in nsr 97% of the time the ablation seems like the higher risk. Like others have said, our local EP's are not that hot on ablations and pooh pooh the risks and side effects of the meds.(Except for the 1:1 problem) I have AF on my mom's side and was a more serious endurance athlete for about 15 years, but only as an adult. Now I keep my hours quite low, maybe 3 per week and compete the best I can. Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 9 of 17	March 22, 2013 12:09 (EDT)
	Brin Cous	Question re: AF events. I have had AF for 11 yrs. now and I do not know what you mean by an AF event...? I take Diltiazem, Allopurinol and Warfarin and have always felt fine. When I first was diagnosed I could feel my heart beating irregularly and would tire easily but that feeling left immediately after being treated with the above meds...I never am aware of my heart beat and it is regularly irregular when I take my pulse and quite often it is completely regular. My heart rate is right at 60 bpm. So again my question is , what is an AF event ? Is that when you are short of breath and feel your heart beat ? If so I don't ever have those... Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 10 of 17	March 22, 2013 04:58 (EDT)
	Sheri Margulies-Semel	ABLATION or NO LIFE I began suffering with Afib at the age of 47...19 years ago. My life was reduced to being almost a total invalid by 2001 when I had my first of 3 ablations, performed by Dr. Andrea Natale at the Cleveland Clinic. The first ablation was not much of a success and I had another one 3 months later. I was FINE for 9 years and had my 3rd ablation 3 years ago...again by Dr. Natale. To me he is close to a GOD! I would not be here now if it were not for him and for his FAITH in the idea of helping me...even totally curing me. How can ANYONE doubt the efficacy of the ablation procedure when people like me would have never made it without the procedure? My life was not only worthless to me, it was UNLIVABLE. I was sick all the time with a paroxysmal situation that I hoped would finally become permanent because THE DOCTORS told me it would be easier on me. Drugs failed me, and those drugs that I DID take made a zombie out of me without helping much. 2 years of Amiodarone nearly destroyed my thyroid and did NOT prevent the FIBS after the first 5 months yet the DOCTORS insisted that I keep taking it. I was going to have a MAZE procedure but my thyroid was so HYPER by then that it was postponed, and in the interval Dr. Cox at Georgetown University had retired. That brought me to Cleveland and while there I inquired about other procedures and was directed to Dr. Natale. I do not OVERSTATE my case to say that he saved my life. I have lived for 12 years now in relatively good rhythm with occasional bouts of ectopic beats. We decided upon the 3rd ablation because some afib was returning but it was more aflutter than afib. In the last 3 years I have experienced very little in the way of arrhythmias and NO ONE can ever tell me that there is ANY QUESTION if the procedure is OVERKILL. My LIFE was in total ruins at the time that i had the first procedure and I went into the operating room thinking that it was worth dying to try to find a cure. So NO ONE should judge the idea that it might be overkill unless they HAVE AFIB and know what life is like under that curse. I know pain...I suffer from terrible pain in my back...but PAIN is just PAIN. When your HEART is beating totally out of rhythm and you can hardly walk or talk or think straight and you have lost the CENTER of your LIFE...then you can determine whether a patient is taking too big a risk to have an ablation. I think NOTHING could be too big a risk to END the AFIB. But taking drugs that make you even MORE debilitated and can kill you slowly but surely is NOT the answer for most of us, I dare say. I sure know it was not the answer for me. I think the pioneers of the PVA are the real heroes of the medical world...well...for me! And I and MY HEART will be thankful to Dr. Natale and his courage and foresight for the rest of my life! I hope to remain well from now on ...(maybe with help from my ARB's which I now take for B/P but which I have learned here can help prevent AFIB too). Some lucky people have AFIB and don't even KNOW it...I can't imagine that but so I'm told. Well...many of us are so symptomatic that life becomes impossible to live. And for US there is the miracle of PVA. THANK YOU to the pioneers who invented it and the bold E/P's who really save the lives of their AFIB patients every day. Life is not just how many days you live...it's HOW you live! To live in total misery with no hope of a moment's peace..well...I, for one, say no thanks to that kind of life. Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 11 of 17	March 23, 2013 10:29 (EDT)
	Jeffrey Patten	I'm good with mine I concur with Dr John right down the line. I did a great deal of research before my cryoablation four months ago. Still recuperating. It is indeed a "hammer". Not as easy as I was led to believe. But the alternatives - dangerous drugs that work for a while - maybe - or fibrillations getting worse, perhaps irreversible - are not viable options! (I can live much more comfortably now with half a working diaphragm than I could with fibrillations!) But what about avoiding it altogether, before it strikes first or before getting it AGAIN after ablation? Dr Seward of Mayo thinks it can be done. ?? Interview from theheart.org : http://www.theheart.org/columns/mayo-talks/24-preventing-af-the-role-of-ace-inhibitors-and-arbs.do?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%253A+BlogsTheheartorg+%2528Blogs+%2540+theheart.orgENGLiSH%2529 Author's disclosure (Mar 23, 2013) I have no relevant disclosures to make in connection with this topic.
	# 12 of 17	April 11, 2013 04:15 (EDT)
	Gerard Muller	Past performance does not guarantee future results The title of my comment is, to me, one of the essential problems with ablation. While often billed as a "minimally invasive procedure", the fact remains that regardless of how well a particular ablation team has recently performed, on any given day it can be "off its game" during the many hour it takes to do this which can cause irreversible damage and even death. Yet, some electrophysiologists are now promoting ablation as the first course of treatment for arrhythmias! That is why Dr. Redberg's view that "the clinical benefit on survival and morbidity of this invasive procedure, which has substantial procedural risks, remains to be established" strikes a particular chord with me, since I have vagal associated PAF but have symptoms that are tolerable and not limiting particularly since they infrequently occur, almost always at night and are gone by morning. Beyond the concerns I've cited, the one that bothers me most is that Afib is treated as if it were the disease when in reality it is a consequence of something else which is not only not being treated but has not even been identified. It strikes me as being akin to the time long ago when people who had sustained gaping wounds would be taken to the blacksmith who would then place a glowing rod next to the wound thereby cauterizing it. This "medieval ablation" process did destroy whatever bacteria was around but if not properly done destroyed a lot more. Later, of course, when we learned about the causes of infection, a course of washing and keeping the wound clean proved a much better approach for all concerned. In much the same way, burning the nerve endings can stop the nerve signals causing the irregular heart pumping but the nerve endings can generate new paths and the return of the irregular pumping. Meanwhile whatever has been causing all this is free to continue to do whatever it is doing of which arrhythmias may be only one manifestation of the possible conditions it produces. That's why Dr. Redberg's message should be seriously considered. Settling on ablation as the "cure" for Afib strikes me as more opportunistic than scientifically supportable. Author's disclosure (Apr 11, 2013) I have no relevant disclosures to make in connection with this topic.
	# 13 of 17	April 14, 2013 07:47 (EDT)
	Graham Palmer	Ablation Personally I have had, initially, two cardioversion attempts (1998), in both cases AF returned within a few days, since then until 2009 I have been tried on a number of drugs including beta-blockers all of these did nothing for my AF - not only that but the side effects were most unpleasant. I was then referred to Papworth the world famous UK heart hospital who tried another drug I was not familiar with - Flecainide 50 mg 3 times a day and the AF cleared within a few days - I was delighted, however there were unpleasant side effects. The Consultant Electro-cardiologist then decided on ablation which was carried out but although the frequency of AF was reduced I still had to take Flecainide although at lower dosage. Another ablation was performed and this time it was successful after which I had almost 2 years AF free. Then, in 2011 my wife had a massive stroke and the stress of all this, including her death brought back my AF. I have just undergone, at Papworth, another ablation which seems at the moment to have worked well. I hope that this experience of mine will help towards stopping patients from being afraid of invasive procedures and achieve real relief from what is a debilitating and dangerous condition. Author's disclosure (Apr 14, 2013) I have no relevant disclosures to make in connection with this topic.
	# 14 of 17	April 14, 2013 11:02 (EDT)
	James J. King	Unfortunately Atrial modification has risks. 1. Ablation can lead to Atypical Atrial Flutter, and repeat interventions. Unfortunately eventual Sinus Arrest could lead to a Pacemaker Placement. 2. Surgical and catheter-based therapies may be used to prevent recurrence of AF in certain individuals. Depending on the risk of stroke and systemic embolism, people with AF may use anticoagulants such as warfarin, which substantially reduces the risk but may increase the risk of major bleeding, mainly in geriatric patients. The prevalence of AF in a population increases with age, with 8% of people over 80 having AF. Chronic AF leads to a small increase in the risk. 3. Minerals like to be in certain cases helpful. 4. Potassium from fresh green leafy food, as well as calcium, can make all the difference in the world to heart function. 5. Magnesium best absorbed in a regular Epsom Salt baths. 6. Vitamin D is beat from the sun, if not then a tanning light will raise serum levels. Vitamin D pills are not helpful for immunity or arrhythmias. 7. Free electrons, obtained by contact with the Earth by walking barefoot and sleeping on ‘Grounding Sheets’. This will thin the blood as measured by the profound effects on the autonomic nervous system (ANS), heart rate variability (HRV) and blood viscosity/zeta potential. 8. Cells stick together when they lack enough negative surface charge with which to repel each other. 9. Zeta potential describes the relative surface charge of red blood cells. Increased zeta potential indicates thinner blood and greater negative charge of red blood cells. As electrons are negatively charged, absorbing them by Earthing may increase the negative surface charge of our red blood cells, and thus decrease blood viscosity and increase zeta potential. Author's disclosure (Apr 14, 2013) I have no relevant disclosures to make in connection with this topic.
	# 15 of 17	April 16, 2013 01:13 (EDT)
	Cletus  Bodensteiner	Doubt is alive and all about Doubt is alive and about inside busy taverns where people gather together and discuss current events that directly impact on their romantic or financial interests. Not much else really matters; and no one cares too much about atrial fibrillation / tachycardia / or flutter unless they wake up at night with rebellious palpitations and night sweats mixed with shortness of breath and panic attacks. Atrial fibrillation patients need not be afraid of migraine headaches or mitral valve prolapse syndrome because specialists console them with idiopathic diagnoses. Electrophysiologists recommend ablation therapy that is experimental and mostly ineffective except that it improves the quality of life by reducing bad sensations of palpitations that inflict emotional distress. Anti-coagulation is the only therapy that has been proven to reduce the mortality of atrial fibrillation. About 25,000 cardiologists and curious healthcare workers attended the American Cardiology College 2013 Scientific Sessions that were held at the Mosconi Center in San Francisco, California, March 9 – 11, 2013. Two distinct camps presented their innovative thoughts about diagnosis and therapy. First, the North Mosconi Center was full of intelligent gladiators that presented interventional therapies, stints, pacemakers, and catheter cryo-ablation for atrial fibrillation. Next, the South Mosconi Center overflowed with imaginative pharmaceutical companies, not for profit educational organizations, publishers, and sponsors of AED defibrillator monitors. A massive quantity of EKG and pulse oximetry data was presented by thousands of scientists who dissected thousands of research papers during poster sessions. Computer analysis is frequently flawed with incorrect conclusions about associations, cause and effects. Cardiac scientists are so close to understanding how the heart skips a beat and yet so far away from the truth about the ‘long QT’ of the EKG. A new concept called Thrombocardia is emerging that believes that bloody clots get stuck in heart valves and cause sick sinus syndrome. New catheter cameras videotape tiny purple blood clots inside cusps of tricuspid valves of patients with atrial flutter / fibrillation. After the lectures were finished, learned men and women of the medical profession wandered through the streets of San Francisco until they gathered inside the ‘W’ tavern where they munched vegetables, sipped wine and beers, and freely discussed their deep and darkest fears about hospital administrators and managed care. Some of my best research is completed by listening carefully to my colleagues as they express their doubts about new therapies. Author's disclosure (Apr 16, 2013) I have no relevant disclosures to make in connection with this topic.
	# 16 of 17	May 5, 2013 04:17 (EDT)
	d Walter	A corporate-driven procedure .... I thought you'd be interested in this patient safety post by Dr. David Mayer: "A deeply researched, remarkably well-written account of the cardiac catheter ablation business. Mr. Walter holds nothing back. Not only does he name names, but he includes pictures of physicians and others...” Dr. Mayer has made it required reading for his medical students. Author's disclosure (May 5, 2013) I have no relevant disclosures to make in connection with this topic.
	# 17 of 17	May 5, 2013 09:17 (EDT)
	Melissa Walton-Shirley	Cletus Love your Hemingway-esque turn of phrase. Interesting read. Melissa Author's disclosure (May 5, 2013) I have no relevant disclosures to make in connection with this topic.

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