Dave Van Buren (DVB) Hi Jim.

Your note was not too long at all. True, my example was pretty simple and easy, but one f ... Read more

Dave Van Buren (DVB) Hi Jim.

Your note was not too long at all. True, my example was pretty simple and easy, but one faced commonly here by patients. That said...

I really appreciate what you wrote as it illustrates very nicely the kind of thinking needed for the best outcomes. You did exactly the right thing in your situation by removing known significant risk factors from the equation. In doing you accepted new, but smaller risks.

It is better to be in normal heart rhythm going in to surgery than being in atrial flutter. By undergoing ablation you could avoid the risk of entering surgery in atrial flutter completely, provided the ablation was successful. There was some small chance it wouldn't be successful, which you accepted as on that score you would be no worse off. So that was smart.

You picked up the risk of undergoing cardiac ablation, which was deemed significantly smaller than the risks you were avoiding. Average catheterization mortality risk by itself is on the low end of the 0.1% to 0.01% range. You could have fallen into atrial fibrillation (which has bad consequences) after the ablation. This risk is close to 0% for 4 months, but then is about 1-1/2% a month after that. So it is important to get the timing right.

Optimum timing would have been 4 months or less between ablation and surgery. Part of the point was to give enough time for remodeling to improve your ejection fraction, which is another risk factor for heart surgery. Remodeling happens pretty quickly (its like muscle conditioning / deconditioning). How long exactly was it between your diagnosis, ablation, and surgery? From what you wrote you had pretty close to optimal timing. Nice.

Having atrial flutter with low ejection fraction introduces a few percent per month risk of thromboembolism - a blocking blood clot - which if it happens in the wrong place can be fatal (heart attack, stroke). So you sidestepped most of that unhappy risk. I say most because you were exposed to it while awaiting ablation. Driving the thromboembolitic risk down to zero during the wait for ablation is done with anticoagulation therapy by my reading, so maybe you did that since it is so simple and effective. Or maybe you had the ablation immediately after diagnosis which would have been best of all.

I like your story because it shows how a way of thinking is important. Every patient is unique and has a set of medical circumstances that need to be thoroughly considered. A simple 4-step flow chart on the wall can't be used to make all the decisions for all patients. Having an experienced cardiac team that's been living day in and day out with these issues, and thinking about them deeply is huge. Part of the patient's job is to find just such a team.

Your last point I think is the most poignant. Everything comes at a cost, and most of it is borne by the various kinds of insurance that we carry - which we pay for one way or another - so ultimately this is a societal choice. The insurance carriers approve and disapprove various therapies based on medical need and their financial calculations. Minmax strategies would say that you should carry the best medical insurance you can bear, which most people don't, because quality of life is important too. Since everyone's insurance is not perfect there will be plenty of choices to make and opportunities to minimize risk within constraints. So I think there is a 3-part program to deal with this: (1) on a personal level think carefully about your insurance choices keeping in mind its the worst case you most want to insure against (2) on a social level act in favor of health care provider models that will provide you good medical choices when you need them and (3) when faced with dire medical circumstances make choices that optimize your survival chances with respect to the time & resources you have and don't optimize some other thing.

Wow, that was really thought-provoking, thanks Jim!

-- DVB