OBSTRUCTIVE SLEEP APNEA & ABLATION FAILURE part2

OBSTRUCTIVE SLEEP APNEA & ABLATION FAILURE part2

August 15, 2019 5 By Bertrand Dibbert


This is the second in a series on
obstructive sleep apnea and failed ablation. Now, what is ablation? Why does
all this matter? I’ll go into some detail on that in just a minute. This image, by
the way, is the internal image of an ablation. Basically your cauter- the – the
cardiologist cauterizes two rings around the area of the left atria where the
pulmonary arteries come in. Again, why does all this matter? It’s a major cause
of disability. What is atrial fib? and how does
it cause that? By stroke. Stroke is the number one cause of disability in this
country. You have people that are built – that have wheelchair ramps built in
their homes. My – I mentioned in the previous video, my brother’s personally
involved in building these. He’s been involved in building over 300 of them. You start looking and there are a lot of
people whose lives have been – had major impact. You don’t tend to see them so
much because they don’t get out. It is not easy to go – to a restaurant or church
or anywhere else, if you’re in a wheelchair; and, again, the number one
cause of that is stroke. The number one cause of stroke is hypertension. We’re
beginning to manage that better over the past generation but the number of
strokes associated with atrial fib is growing dramatically so typically of –
typical of what we do in high-dollar US medicine, we tend to throw a lot of money
and procedures at it. The procedure that we tend to – to use for this and I – I have
atrial fib, I went to a doc. He recommended this as well. It’s called
ablation. Now, what is an ablation? You go in with a – a catheter that has electrodes on it and you burn the heart tissue in the atria –
in the atria, right around these areas where the pulmonary veins come in. The
pulmonary veins are bringing blood from the lungs so they are the only veins in
the body with oxygenated blood. Now, why is that where this aberrant conduction –
this short circuit in the heart’s conduction system; why does it come from there? That’s not too clear but we do know that it does come from there and
that’s what an ablation does. Basically, just burning these areas. So to get back
to that image, that’s what they do. Now, in the previous video and in several others,
I’ve talked a little bit more about atrial fib and how it works. Usually, the
the heart has a conduction system – that conduction system is made up of muscle
cells that have evolved heart muscle cells that have evolved into more of a
conduction cell so people like me, who have the genetics – 4q25 risk gene, it
appears that our heart muscle cells evolve quicker into a conduction cell
and that is, again, what causes failure for people like me with 4q25 post
ablation. You – you’ll quite often get an effective ablation at first but within a
year, the – the aberrant pathways (aberrant meaning the unusual – the rogue pathways have grown back in and you’ve got another short-circuit) and instead of
having a coordinated beat, you’ve got this circular chaotic beat, again, up in
the atria. How does that cause stroke? Well, it appears that the pooling of
blood in here may result in formation of clots. These clots, when they are pumped
out through the ventricles, then go to – can go to tissue like the brain
and cause what’s called an infarct or a stroke. Now, enough of that – the basic
information. I mentioned that people like me with 4q25 chromosome have
recurrence after catheter ablation. That’s – that was this study. I’ve covered
that in previous studies. Also, what we found – begun to find is that obstructive
sleep apnea patients also have a significant failure rate in ablation. I
covered this in part one on obstructive sleep apnea and failure but that was
just a small study with about a hundred and fifty patients. This is a
meta-analysis so there have been several studies which now cover this and the
evidence is really clear that if you’ve got significant obstructive sleep apnea,
you should really think two or three times before you agree to have an
ablation. This was in the American Journal of Cardiology, 2011. So, again, this is not new data. Its information, though, that my cardiologist certainly didn’t
mention to me. Anyway, American Journal of – and for those of you who don’t
know, I’m a physician. I started off as an ER doc; got very frustrated by the – the
vast majority of things bringing people into an ER are preventable, like this – 80%
of strokes are preventable. So rather than wait for a cure that is not so good,
focus on prevention and we’ll talk about that a little bit later. Again, CDC’s
estimate – it’s not my estimate – CDC’s estimate is 80% of strokes are
preventable. As with most CDC things, I think they’re
way conservative. I think its higher than that. So, back to this article – American
Journal of Cardiology, 2011: Meta-analysis – meta-analysis means you’ve taken a bunch of studies, all the studies that you could find in the literature that you –
that are on a specific topic. This topic, for example, failure of
of ablation with patients with sleep apnea. So, let’s go basically to the – we’re
not gonna go through the whole study – again, I’ve found youtubers don’t want to
take that kind of time and I have too many long videos on my channel, anyway.
Let’s just go through the – the basics here. They looked – they noted that the
association between OSA or obstructive sleep apnea and a-fib is strong and now
very well established. However, at that point in time, the role of OSA and
recurrence of atrial fib after catheter ablation had, at best, conflicting results.
So what they did was – they did a meta-analysis. They looked in PubMed; They looked in web of science; They looked in the Cochrane databases – you know the
Cochrane databases are the ones that are the standard for meta-analysis; They
looked at all studies up through August 2010. In addition, they manually searched – this was – you don’t see this in a lot of these meta analyses. They manually
searched the Proceedings of – of meetings: the European Society of Cardiology,
the American College of Cardiology, and the American Heart Association for
related abstracts and presentations. Initial research showed a 402 reports
but you have to – in a Cochrane analysis, you have very strict criteria on what
you can – what you leave in and what you leave out. They identified 6 studies
that met all the criteria but that went from a typical study of 150 up to almost 4000 patients; 3995 patients that met
the – met the inclusion criteria. Overall, patients with OSA (obstructive sleep
apnea) had a 25% greater risk of afib recurrence after catheter ablation than
those without OSA. Now – and so the risk would be 1.25. 1 would be
the exact ratio. The .25 is an additional 25% risk. The confident – 95% confidence intervals were pointed 1.08 to 1.45, P
equals 3 out of 1000; so what that means is – they’ve got a 3 out of
1000 probability of the actual increase in risk, statistically being
between 1.08 and 1.45 so there’s clearly increased
risk for recurrence if you have OSA. Now, here’s another point. When I covered the
last video on this topic, the study was basically just using the
Berlin questionnaire. There was not a complete polysomnography or sleep study on these individuals; so in this meta-analysis, they pointed out – when OSA was diagnosed using the Berlin questionnaire, the confidence intervals
were not as good as when they actually did sleep studies. So, bottom line is – go
ahead, get a sleep study, and if you do have significant sleep apnea, just
realize (that) if you’re gonna get the ablation, you’re much more likely to have a
failure. Again, trying to keep these short. I hope you’ve been – I hope you’ve learned
something from this; increased your awareness and I hope it helps you from
becoming one of these people that’s creating business opportunities for
folks like start-up jungle, in terms of how to start an adult daycare business.
Well, you know what my business is to – how to decrease demand for that. Thank you
very much for your interest.