This section of the af-ideas.com  web site will help you to choose a treatment for Atrial Fibrillation (or "AF"). It will describe factors that can affect your choice, and it will help you to gather and organize information you obtain about different treatments and about the doctors who perform them.

Conclusions from research and experience will change over time. Treatment for AF is a rapidly developing field – a “moving target”, as some have called it.   

Two implications of this inevitable and rapid change are:

1) Research or other materials that are as little as a year old or less may be out-of-date (see Resources  for ways to get the latest information);

2) Waiting for techniques to improve or for doctors to get more practice in performing a new technique may be a reasonable option.

In what follows, I am assuming that you have a general familiarity with the causes, symptoms, and treatment of AF (see Resources for help with this).

Abbreviations

•  AF = atrial fibrillation;

•  LA/RA = left atrium/right atrium;

•  EP= short for  "electrophysiologist", who is doctor who specializes in catheter ablation of arrhythmias;

•  CA = catheter-approach ablation;

•  PVI = pulmonary vein isolation;

•  NSR = normal sinus rhythm (no AF or other arrhythmia is present);

•  CV=cardioversion (converting a heart that is in arrhythmia into NSR, using electric shock or medication).

•  LAA = Left Atrial Appendage (a small extension of the LA that is the location of the great majority of blood clots that can form during AF)

• PP=prospective patient

Here is the latest (2007) in the evolving process of determining the most useful classification scheme for AF:

The only distinction with implications for treatment, according to  Dr James Cox, is between AF that is intermittent -- “Paroxysmal” --, and AF that is present all the time -- “Continuous”.  I will use "Paroxysmal" and "Continuous" throughout this presentation.

Treatment of Continuous AF -- especially it has lasted for a long time (>2 years? over 5 years?) --  has a lower success rate and requires a particular lesion set that is relatively straightforward in the case of Maze surgery, but that can be difficult to do in the case of CA (see the Audience and Panel Discussion section  of the Report of the 2006 Boston Symposium). 

AF that is of whose total duration is of great length has also been related to a poorer outcome, and some EPs or surgeons will not treat a PP whose total duration is over whatever period of years they think will reduce their level of success below what they consider to be acceptable (this limit will vary widely, but we are talking on the order of 5-10 years).

The Role of Individual Preferences

Personal preferences or other individual differences may affect your attitude towards various treatments for AF.

You may want to sort through the possibilities in the above link and see how they apply to you. You can then decide which of your reactions are truly significant. 

For example, paying too much attention to the length and discomfort of the recovery period of more invasive surgical approaches at the expense of the success rate for your type of AF may be trading short-term comfort for long-term gain. In other words, Maze surgery -- or any other treatment-- should not be rejected on the basis of its longer and more uncomfortable recovery period alone.

Some Assumptions about Treatment for Atrial Fibrillation

The ideas presented below draw on the conclusions presented in several important articles.

Assumption #1: It is not healthy to remain in continuous AF or to endure frequently occurring Paroxysmal AF.

For more information, see the above articles. You should read these articles if someone has told you either that AF is a benign condition or that medication is an effective long-term treatment for it.

Assumption #2: Medication is not a long-lasting solution for most people who suffer from AF.

An exception would be the person who is rarely in AF (say, once a month or several times a year), and whose ventricular heart rate and other unpleasant symptoms are controlled by a rate-limiting medication. Such a person might be waiting: 1) until AF becomes more frequent and his symptoms more unpleasant or, 2) until new, more effective treatments are developed and doctors have time to become proficient in them. (He should not wait until the total time in AF are likely to cause changes in his heart that will make treatment more difficult.)

Another exception would be a person whose rare occurrences of AF are converted to NSR with a "pill in the pocket" approach; that is, by taking a high dose of an AR medication such as flecainide (Tambocor) or propofanone (Rhythmol) when AF occurs, perhaps preceded by- or in combination with a beta blocker. 

The problem with both these scenarios is that AF can occur without the person's being aware of it ("silent AF"). Such asymptomatic AF carries the same risk of blood clots and and changes in the electrical and physical characteristics of the heart as does symptomatic AF.

Silent AF can also occur in patients who have been "cured" (see the remarks of Drs Calkins and Kottcamp in the Report of the 2006 Boston Symposium .

There is ongoing discussion and research into the question of the clinical significance of silent AF. For example, if such episodes are of short duration they are unlikely to give the blood enough pooling time to create clots that can cause stroke.

Types of medication

>> Rate-control medications (for example, beta-blockers and calcium-channel blockers) can control the rapid ventricular heart rate that results from AF and will reduce the strain on the ventricles. For some, they also reduce symptoms to a tolerable level; however, they leave AF and its consequences -- such as stroke risk from clotting of the blood in the atria and electrical and physical remodeling -- untouched. And, remaining on warfarin (Coumadin) or aspirin to reduce this possibility presents a risk of hemorrhagic stroke or other uncontrolled bleeding (see "Books" in the Resource Section for more on stroke risk and Coumadin use).

>> Rhythm control medications can prevent AF, as long as they remain effective; however,  there is a 20-60% rate of AF recurrence at one year. The real recurrence rate is undoubtedly higher because an unknown amount of  AF is asymptomatic and undetected. Also, anti-arrhythmia medications can have serious toxic and unpleasant side effects. (This is especially true of amiodarone (Cordarone) , which is also the most effective.)

Several studies have reported that rate control medications are just as effective as anti-arrhythmia medications with regard to mortality and quality of life.

This does not mean that both are effective in an absolute sense, or better than being in NSR without taking these medications.  

Rate-control medication does not control the fibrillation of the atria, and therefore would not be expected to prevent the formation of clots or other consequences besides a high ventricular rate. So, the problems created by an irregular fast atrial beat and inadequate filling remain.

Rhythm control medications can stop AF, but in many cases, they lose their effectiveness in a couple of years or so, and may increase mortality by being toxic over the long term.  

Here is the way the Bordeaux EPs put it in the introduction to one of their 2005 studies:

"Antiarrhythmic drugs have been the mainstay of maintaining sinus rhythm for many patients with persistent atrial fibrillation (AF). However, their limited efficacy and potential for significant adverse effects has led to renewed interest in rate control measures. This concept has been strengthened by the publication of the "Atrial Fibrillation Follow-Up Investigation of Rhythm Management" (AFFIRM),^] the "Rate Control versus Electrical Cardioversion" (RACE),^] and the "Pharmacological Intervention in Atrial Fibrillation" (PIAF) trials,^] which suggested an equivalent outcome for pharmacological rhythm and rate-control strategies. However, emerging evidence suggests that these findings merely highlighted the fact that the benefits of sinus rhythm can be negated by the deleterious effects of antiarrhythmic drugs. Indeed, a further analysis of the AFFIRM results demonstrated that sinus rhythm was associated with a 47% lower risk of death, while the use of antiarrhythmic drugs significantly increased mortality risk by 49%. Thus, the restoration and maintenance of sinus rhythm is of potential benefit if it can be achieved without the use of antiarrhythmic drugs."

Since all current medications have serious drawbacks, it is no surprise that many have concluded that the use of medication is inferior to other procedures that return the heart to NSR.

Coumadin (warfarin) is worth special mention as a medication to avoid if possible, even though it has made a huge difference to those who must be on it. This includes people with AF that meet certain criteria (please see the a report and comment on current guidelines here). Many people with AF will meet these criteria, and there is anecdotal evidence that many who do not will be placed on warfarin anyway.

Problems presented by using warfarin include risk of internal bleeding and the encouragement of artery calcification, which is an important risk factor for heart attack.

The best compilation of information for sophisticated lay people on their options for dealing with their risk of stroke and the negative effects of warfarin (if they must take it) is found in two references listed in the Resource section.

Drug companies and researchers are working hard to develop new medications that more accurately target the causes of different types of AF without short-term unpleasant- and long-term toxic side effects. Motivation for developing such medications is provided by the fact that the whichever pharmaceutical company develops them is assured of huge profits because of the large number of AF cases (estimated to be 3-5 million).

Watch out for premature announcements of effectiveness and safety of new medications. This has already occurred in the cases of more benign substitutes for amiodarone and warfarin.

Choosing a treatment: The decision-making process

So, you have decided to find out about treatments that may cure your AF. What do you do next?

The short answer is this:

Find out the success- and complication rates for your type of AF for the EPs or surgeons that you are considering. They should have done at least 200 cases (the best known have done one-to-several thousand). Success rate should be 85-95%; complication rate resulting from his technique (that are his fault and the not the result of a patient condition), <1%. You should also find out how he defines success.

Find out these statistics by calling or emailing several on the Doctors' List. See Questions for Doctors for suggestions on what to ask them.

Decide if an EP or surgeon's rates are acceptable to you by comparing his rates to those of others and by thinking about the risks you are willing to take. Decide if the risks of failure or complications are better than the risks of waiting for new approaches to develop. If you think you may proceed, then get on the waiting list. You can always cancel if you change your mind.

Seriously consider getting on the waiting list for one of the top people from the Doctors List.  There is significant difference between the rates of the top practitioners and those who are less experienced or skillful. There may be a waiting list of a year or more, but this  should not ordinarily affect your decision. I know it is difficult to wait ...  Getting a consultation shouldn't take as long, and having a plan can make the wait easier to bear.

Whom to choose? For CA, the stock answer is relatively easy: Dr Andrea Natale at wherever he ends up practicing (as of October 2007 his contract with the CCF was terminated but he may still be practicing at the Marin County Hospital) or Dr Jais or Haissaguerre at Bordeaux France. EPs Marchlinski and Morady are also high on the list. This answer will change as more EPs create good records and technology shortens the learning curve. For surgery, the answer is not so clear, but more about this later...

There are important details, of course. How do you choose between CA and surgery? What are the criteria that different doctors use for success? Exactly what complications can occur? What are the characteristics of a good procedure? ...and so on.  The rest of the article will cover these topics.

Choosing between CA and Maze Surgery

The short answer is this:

If you have Paroxysmal AF, you can expect good results from CA. And because CA for this type of AF is relatively straightforward (a PVI will do in many cases), the success rates among expert EPs (i.e. those on the List) will not differ a great deal (or will be within the margin of error).

Paroxysmal AFers can also consider the Wolf Mini-Maze and the Saltman Micromaze surgeries. They are mainly PVIs with some additional features, and with some advantages and disadvantages when compared to CA.

If you have Continuous AF, I believe you must think about on Maze or Modified Maze surgery

or a CA procedure in which the EP can make lesions that are Maze-like, if necessary. Not every EP will do this because doing so takes more skill than doing only a PVI. This is especially so in the case of one of the lesions. So, the choice for those with Continuous AF is more complicated, as we shall see later on.

In the discussion that follows, it is important to note that, the probability of the occurrence of some complications  will depend how the skill and experience of the doctor. Some problems that can occur with CA may be virtually absent from the records of some expert EPs; the same goes for surgeons. The success rates of such practitioners will be higher than that for those of the procedure as a whole, and the complication rates, lower.

But the even the expert can do a limited amount about some potential long-term negative effects. Their risk is unknown because the necessary outcome studies have not been done, so we must depend on educated guesses based on the process. Examples would be the effects of extensive scarring in the case of CA, and problems resulting from the patient's time on the heart-lung machine in most Maze surgeries. 

The effects of certain procedures will also depend on the your physical robustness. For example, having a more procedure that is more invasive or traumatic physically may not be a concern if you are young and strong.

You should always ask a doctor questions that about complications that can occur with his procedure and the rate these occur in his own pracice. The way he is doing the procedure or the technology he is using may take care of something  that can be a problem in other centers. Examples are: Using an approach with robotic arms that permits smaller incisions and more precise placement lesions or ablations, using an energy source that reduces device-tip temperature or one that permits targeting LA areas ordinarily blocked by blood vessels, or using an imaging system that gives a 3-D image of the inside of the heart and of catheter placement. 

Positive and Negative Features of Catheter Ablation and Surgery  

Success Rates

It is difficult to evaluate success rates because follow-up assessments are not standardized. Some doctors define a patient who is in NSR and on medication as a success (for more discussion of criteria for success, see Curative procedures for AF and Success rates, competition ... ).  The duration of follow-up is often short: Six months to at most a year or two. As noted above, success rates will differ a great deal depending on the skill of the individual doctor. And rates do not mean much if they are based on a small number of cases.

Remember, then, that you must ask the EP or surgeon whom you are considering for

• ... his success and complication rates for your type of AF

• ... the number of cases on which these rates are based,

• ... his definition of success and length of follow-up.

Generally speaking, these days (2007), you should be considering practitioners with success rates in the 85-90+% range. The figures for Paroxysmal AF will be higher than those for Continuous AF. Success should be defined as off all medications and follow-up should be at least a year.

Going to a reputable medical center is no guarantee of success because the records of different doctors at the same center will vary. So ask! The best doctors will give you their success and complication rates.

Catheter Ablation: Some Advantages

CA is less invasive than Maze approaches. The incisions through the skin are less extensive; the heart is not opened, and the heart-lung machine is not used.

If a CA is not successful, another can be done (a "touch-up" ablation), which will significantly affect the success rate. (In a report by the Bordeaux group, the success rate for CA of 60 patients with Continuous AF went from 87% to 95%.). Surgery can also be performed on a patient who has had a CA. But only one surgery can be performed, although a touch-up CA can follow. So, in many cases -- especially of Paroxysmal AF-- it makes sense to begin with CA and then to proceed with additional CAs or perhaps surgery if necessary.

CA can be tailored to individual differences in the location of circuits contributing to AF (“mapping”), as opposed to surgical lesion sets which are, for the most part, “one size fits all”; however, the lesion set is designed to prevent future AF, whereas the goal of CA must be to ablate or "maze off" areas that are currently causing AF.

Catheter ablation: complications and other disadvantages

The tools an EP uses are designed to ablate a point or small area from which is contributing to a patient's AF. Making lesion lines that completely block an electrical current from passing though must be done by burning a series of dots without a break. The latter is especially difficult to do, especially on a beating heart, without being able to see directly what you are doing; however, whether a complete conduction block is necessary for a successful outcome is debatable.

There is a slight risk of stroke from clots broken loose by the procedure. This is prevented by making sure that any clots are detected and dissolved previous to the procedure. 

There is a risk of PV stenosis, which narrows or closes off the affected vein to the heart.

There is a low but dangerous risk of an esophageal fistula (making a hole in the esophogus) and  phrenic nerve paralysis. 

Stenosis and other negative effects caused by misplacement of energy are more probable in CA than in current Maze surgeries because the energy source is directed from the inside of the heart out into structures outside the heart (an “endocardial” approach) rather then from the outside in ("epicardial" approach). Also, the EP does not have a direct view of the operating field, as is the case with many Maze surgeries.

As noted above, these complications are all but absent from the records of the top EPs. Improvements in imaging and the use of robotic techniques can help, as can the use of energy sources which are more focused or which do their work with less heat.

CA may create negative long-term effects, such as loss of function from scarring that results from extensive high-temperature ablation and de-bulking of the wall of the LA. No one knows for sure. EPs will try to ablate only those areas necessary to prevent them from being able to induce AF at the end of the procedure. They will also try to use tools and energy sources to reduce tip temperatures.

CA can be long -- from 3-9 hours. Exposure to radiation (if flouroscopy is used) will be much less but some believe is it significant. Any improvement in technique that makes CA faster -- such as the use of robotic arms -- will help, as will improvements in imaging.

The LA appendage – a small bit of elongated tissue extending from the LA that encourages clot formation on its surface -- is not removed (but there is controversy about doing so). There have been efforts to design devices that can occlude the LAA, but these have not yet been successful.

Surgery: The Cox Maze (Versions I-IV, and the Modified Cox Maze), the Wolf "Mini-Maze, and the Saltman Micromaze  

The goal of the Cox Maze surgeries is to wall off or channel aberrant electrical impulses -- wherever they might originate -- and whenever they might occur. This is done by making lesions using a a variety of energy sources on the inside of the heart. The scar tissue formed when these lesions heal blocks electrical conduction.

Through the years, the lesion set has been reduced in the hope that the relatively good results of the original maze. The location and number of incisions has also evolved in the form of versions II-IV.

The Wolf and Saltman procedures are not really maze surgeries since they are PVIs with some added features (as described here).

For additional descriptions of these surgeries and how they differ from one-another, click here.

Surgery vs. Catheter Ablation: Additional features and comparisons

The major differences between CA and surgery used to be that surgery had a higher success rate, but the fact that the operation involved spitting the sternum, working on the open heart and putting the patient on the heart-lung machine ("on-pump") meant that there was the possibility of serious complications, as well as a longer recovery. This kept doctors from recommending the operation.

The initial apparent difference in success rates have been somewhat narrowed by current techniques in both surgery and CA.

1) The short- and medium term success rate for Paroxysmal AF would be expected to be about the same, since all that is usually needed is a PVI. The higher success rate for Continuous AF enjoyed by the Maze procedure would be reduced by CA procedures that do Maze-like lesions.

I think that, at the present time, the burden would be on the surgeon to describe the advantages of surgery over CA with both types of AF. He could hypothesize that the long-term effects of extensive ablation are more harmful than the scarring created by his simplified Maze. He could say that his lesions will prevent future AF from occurring better than a CA. He could also point out the he will remove the LAA appendage, which is the source of the great majority of the blood clots that can occur as the result of AF, but whether this should be done is the subject of controversy.

2) The rate of complications in CA are probably higher, but those that may occur with surgery are more serious and irreversible (see the Table below). On the other hand, no one really knows the long-term (10-20 years) effects of either procedure.

And remember, skill and experience will increase success rates and reduce complication rates for each approach so that the rates for the best EP and the best surgeons will differ very little from each other.

Complications of Maze surgery for AF

Complications of the Wolf "Minimaze" and Saltman Micromaze procedures

(Remember that these are PVI-centered procedures, making lesions that do not replicate those of regular Maze operations.)

Both these procedures are less invasive than regular Maze surgeries because they are completely endoscopic. The surgeon works on the outside of the beating heart and uses tools for viewing the operating fields and for making the lesions that fit through small 1-2" incisions in the sides of the rib cage. The recovery time, therefore, is shorter (however, the discomfort during recovery from the incisions through the rib cage may actually be greater than the splitting of the sternum which may be done for a regular Maze operation). In Saltman’s Micromaze  procedure the patient  is released the next day and is cleared to do whatever he wants after about six days. Compare this to up to 12 days in the hospital and weeks or months of being off work (depending on what kind of work you do and your pre-operative physical condition). In the case of the Wolf Mini-maze, there is usually a 2-3 day stay in the hospital and about a two-week period before a you can do what you consider prudent or possible with regard to exercise.

Possible complications include pneumonia (from pushing the lungs to the side); pericarditis  (from opening up the pericardium to expose the outside surface of the heart), as well as those arising from making incisions (see above).

BE SURE to ask your surgeon what his complication risk is for patients with your type of AF and your state of physical health. You can also ask him how he prevents these problems, and how he deals with them when they occur.

As mentioned previously, complication rates should be essentially zero in the records of expert practitioners.

>>> The next two sections that may be useful background if an EP or surgeon you are considering discusses his technique.

Energy sources and device characteristics

A variety of devices using different energy sources have been used to make the lesions that isolate or otherwise deactivate the electrical sources of AF: bipolar radio frequency energy(“RF” energy); microwave (used in the Saltman Micromaze procedure); HIFU (high-frequency focused ultrasound), and cryo-ablation (freezing the troublesome areas as in the “Cryomaze”  or the Cryosurgical Maze procedures).  

Several characteristics of the device are may be important:

The Lesion Sets of Surgeons and of some EPs

Catheter-ablation lesions sets

Actual lesions where an instrument is drawn across heart tissue (as opposed to ablating a small spot or making lines of burn dots), creating scars that block wayward electrical impulses, used to be the province of the surgeon. Recently, EPs have begun to do Maze-like lesions in the hopes of increasing their success rates while retaining the advantages of their less invasive procedure . (I must hasten to add that the long-term effects of catheter ablation beyond one or two years is not known. Finding these out will be especially crucial for the ablations that include Maze-like lesions, because these procedures tend to be longer and to affect more cardiac tissue.)

The best way to find out what well-known EPs are doing in this area is to check the section in the latest Reports of the Boston Symposia where they talk about their approaches to Paroxysmal and Continuous AF.
 

Pulmonary Veins are isolated, as they are by all EPs. Only those additional areas that are causing problems are dealt with. They find that 85% of Continuous AF require a  Mitral Isthmus line (a lesion), which can involve work near or in the Coronary Sinus, which apparently can be difficult to do safely and effectively.

The lesion sets for Maze and PVI-Centered surgeries

Click here for the lesion sets performed by several well-known surgeons from the Doctor List

Surgeons typically remove the LAA. Since there is controversy over doing this (click here), you will have a choice as to whether you want this done or not. 

The significance of the differences between the different sets remains a subject of discussion and research. Dr Cox says that the PV to mitral valve annulus (or "ring")  is necessary to successfully treat Continuous AF, while the PVI-Centered approaches of Drs Wolf and Saltman may well be sufficient for Paroxysmal AF.

So, if you decide on surgery, whom should you choose?

First, let me say that, if your AF is Paroxysmal, either CA or PVI-Centered surgery is a valid choice.

For Continuous AF, especially if its duration is over a year, it would be difficult for me to choose between a CA that can include Maze-like lesions when the patients need them, or Maze surgery, assuming that one can go to one of the top practitioners in the field.

The short answer to the above question is this:

For Paroxysmal AF, the relatively less invasive Wolf Minimaze or the Saltman Micromaze are worth considering. (Be sure to insist of success rates for your type of AF. At this time (2/2007) Dr Wolf's statistics are quite old and based on very few patients). If one of them doesn't work, you can have a "touch-up" ablation; however, you may not be able to have any version of the regular Maze -- something that you can do after a CA. (I have heard different reports on this...)

For Continuous AF, I would be looking at the Bordeaux group who has had such good results with their CA approach, and any of the Maze surgeons on the Doctors List.  With regard to the latter, Dr Geiss is of special interest because I had heard that his success rate was 100% -- possibly because of the lesion he added to the Cox set -- but I have not been able to find out how or what he is doing at present (he has not published results or answered emails; however, I have not called his office).

The best answers will come from your looking over the Checklist that follows, and then asking the Questions for Doctors.

What to do when you can't go to a top EP or surgeon

Not everyone can go to the best, as defined by reliable estimates of success-  and complication rates.

First of all,  there are not enough slots in the top centers to accommodate all those who need treatment. The wait-lists will get longer as people realize that they don't have to settle for a life on rate-limiting or AR medication, and that they can choose the treatment procedure and the doctor to do it.

Not all practitioners collect the data necessary to make these estimates because doing so takes resources that are most readily supplied by an institution who will use the results in journal articles or in reports at conferences.

There are presumably many potentially excellent EPs and surgeons who have not done enough cases on which to base these estimates.

Many patients will  be restricted by insurance or travel requirements or other practical considerations.

So, here are some things to consider when reliable estimates or success- and complication rates are not forthcoming from the practitioners from whom you must choose:

Let me repeat that going to the best --or as close to the best that you can manage-- is more crucial in the case of Continuous AF.

>> Look at the doctor's training. It will be in his favor if he has trained with one of the top people, or, better yet, if he has a recommendation from a top person. I believe that the Cleveland Clinic will give such recommendations; perhaps other doctors on the List  will, too.

>>Look at the technology the doctor is using. Certain energy sources may increase the effectiveness of ablations or lesions and reduce complications. Other technology (e.g. robotics) can increase safety and reduce the effects of operator experience by making it easier to make precise lesions in just the right places with just the right pressure.

>>Other characteristics of the procedure will also become relatively more important when success and complication rates are not available. For example, you can make sure that the lesion set is appropriate for your type of AF. Your cardiologist may be able to help you with this, but finding this out may be mainly up to you.

>>If possible, you should schedule a consultation with the EPs or surgeons whom you are considering and take a list of questions with you. It can also help to have someone else there who can help you make sure that you ask everything you need to, that you get clear answers and that you remember everything the doctor says.

Remember that the doctor may feel pressed for time. He is one-up on you by virtue of his expertise and status. He may be trying to sell his approach so that he can gain experience or for other reasons. Of course you want to find a person you can trust, but I do not believe that bed-side manner should be a critical factor.

The Checklist below and the list of Questions for Doctors* that is based on it can be used:  a) to collect information to use in making your choice of a  procedure and EP or surgeon; b) to report what you have learned about doctors and  procedures to others; and, c) to describe your experience of after undergoing a procedure.

* See the a-fib.com site for another list of questions to ask doctors .

Most of the most important questions in the Doctor’s level of experience and his success rates and Characteristics of the procedure sections. Questions in bold face should have priority.

Most questions are relevant to both catheter-approach ablation and surgery. Those that are not are so indicated.

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CA vs. Surgery *

* You may want to wait to make a final decision on this until after you consider questions in the Doctor’s level of experience and success rates and Characteristics of the procedure sections below.

Contact Information

Waiting List

Type of Patient Accepted or Preferred*

* It is my impression that the criteria that follow are becoming less and less likely to be relevant, although doctors may decide to accept only those who need their help the most or with they are most likely to be successful.
 

The Doctor’s Level of Experience & His Success Rates

Characteristics of the Procedure