two Natale ablations, then cardiomyopathy, now tachycardia?

Hello, I don't post here often, but I value the opinions.


In 2014 I had an ablation with Dr. Natale in Austin. I return to Austin in 2015 for a 2nd ablation which isolated my LAA. 2016 I was hospitalized for cardiomyopathy for three days due to the sudden death of my son. Who died due to an enlarged heart (unbeknownst to anyone). My fraction rate returned to normal after a few months.



Yesterday I had to go to the ER for a high heart rate of 190-200. I was diagnosed with tachycardia. I was given a dose of Adenosine and returned to a natural rhythm. Blood work and CT scans were normal. I was released and I have an appointment with my local cardiologist next week. I had an elevated blood pressure most of that week.

Questions are, what has caused this tachycardia? Will I need another ablation? I'm very concerned.

Thank you for any thoughts!

Jake



Edited 1 time(s). Last edit at 10/05/2017 11:50AM by Jake.

Tachycardia isn't really a diagnosis; it simply means a heart rate over 100, so the ER didn't really give you much useful information. There are several possible causes, but the fact that adenosine terminated it means it's almost certainly SVT (supraventricular tachycardia). SVT can often be terminated with vagal maneuvers, so if it happens again you should try that. Some techniques are described here (but avoid carotid massage).

That said, my recommendation is to get on the phone to Natale's office. In the meantime, your local cardiologist can do useful things like an echocardiogram, a stress test, and/or a monitor, but I wouldn't let anyone other than Natale do another ablation.



Edited 1 time(s). Last edit at 10/05/2017 02:46PM by Carey.

Thank you Carey,

I left the ER without discharge papers or further explanation . I was in a total brain fog & was discharged while the ER was dealing with a serious problem. I do recall them saying SVT. I have left a message with Dr Natales office. My local cardiologist has done all the mentioned testing due to presistent chest pain that has baffled him. The SVT is new. I also had elevated blood pressure all week.

The thought of another ablation is discouraging.

Carey:

I have been on this site for many years and have noticed that most people need a second and sometimes third Ablation, even if they had Dr. Natale do them. You also stated that after your first ablation and succeeding ones you went into flutter, you don't say that you had that problem before your ablation so the ablation brought that malady on?

I would think that after an ablation a person would not have to be on blood thinners yet many still are. Seems like these ablations still need more work and study.

Liz

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Elizabeth
I have been on this site for many years and have noticed that most people need a second and sometimes third Ablation, even if they had Dr. Natale do them.

Consider who comes to these forums. It's people new to afib and people who deal with it long-term. Folks who go to Dr. ____ and get a successful ablation get on with their lives and don't bother with afib forums. And sure, Natale has repeat customers too, but I have no doubt that if all EPs published their numbers, his numbers would dwarf all but a small handful worldwide. I've also noticed that the folks I see coming back after Natale ablations come back years later, not months or weeks.

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You also stated that after your first ablation and succeeding ones you went into flutter, you don't say that you had that problem before your ablation so the ablation brought that malady on?

Without question. It was another side effect of an EP with inadequate training and experience doing a procedure beyond his abilities. He should have referred me elsewhere when ablation #2 failed.

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I would think that after an ablation a person would not have to be on blood thinners yet many still are. Seems like these ablations still need more work and study.

The anticoagulants question is an interesting one and maybe not as simple as it seems. If you buy into the idea that afib is really just a symptom of a heart disease called atrial myopathy, then having that disease alone may be reason enough to remain on anticoagulants even if all the afib stops. Turns out a lot of strokes happen to people with a history of afib even when they haven't been in active afib for a long time. Why would that be if the arrhythmia is the cause?

Anyway, it's just another unanswered question we all have to deal with for now. My passion is cycling, so I'm at some risk of head injury. Not being on an anticoagulant is important to me, but I'll take that risk over afib any day.

No question that ablations need more work and study. I think mainly what needs to happen is fewer ablations by low-volume centers. It's a complex, delicate procedure that needs to be done in high-volume centers by EPs with a lot more training and experience than your average EP. Like I said, thousands of procedures, not hundreds.

Good questions Eliz and good answers Carey.

Thank you

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Elizabeth
I have been on this site for many years and have noticed that most people need a second and sometimes third Ablation, even if they had Dr. Natale do them.

I would think that after an ablation a person would not have to be on blood thinners yet many still are. Seems like these ablations still need more work and study.

Liz

Hey Liz,

Dr. Natale is conservative in that he usually stays away from ablating the left atrial appendage (LAA) on the first ablation. This is because ablating the LAA can result in low blood velocity through the LAA, which then requires a) lifetime anticoagulation or b) another procedure to isolate the LAA (Watchman and Atriclip devices are examples). So a person, such as myself, who is likely a "complex" case (since I had a 2 1/2 month episode 13 years ago that did not convert on its own) would likely need two procedures and possibly three. The first to do everything except extensive work on the LAA. If that did not keep afib at bay, then a second to deal with the LAA. Then, if the emptying velocity from the LAA was too low, a procedure to isolate the LAA or accept lifetime anticoagulation.

From my friends who have been through this with Natale, they say all of this is explained well before procedure number 1.

George

Liz - just a comment regarding the need for several ablations… You recall my history. #1 with Dr. Natale in 2003 when he was here in Cleveland. #2 with Dr. Natale in Texas as a result many a-flutter events. This involved the isolation of the Left Atrial Appendage… an area well known for causing ‘trouble’… but also an area where many if not the majority of EPs do not venture into. Thus, if that’s where the potentials are, but are not isolated, then arrhythmias persist and a 3rd o 4th ablation won’t conquer the problem if the EP doesn’t go beyond the traditional.

#3 Natale ablation in Texas was a ‘touch up’ to #2 because after 6 months, I was having some activity and he said to come in immediately to manage the ‘stragglers.’ It’s a delicate area and undoubtedly because of my age and the small female heart size, it’s better to be conservative with the burns and that makes perfect sense. Of course, it did mean procedure #3 which was short and highly effective so far… 2 years later.

Now, when the LAA is isolated, the concern becomes whether the appendage can effectively pump and clear blood so the clotting issue becomes very important, obviously. And while my clearance velocity was adequate, again, because of age, the conservative approach is to remain on anticoagulants for life so I’m on half dose… or eventually have the procedure to close or occlude the appendage. That certainly is a consideration as I’m not thrilled with taking Eliquis for life.

As Shannon emphasizes repeatedly is that it’s important for the EP to have the additional training and experience to know where to go beyond the traditional ablation areas.... Otherwise, while you do have the ablation, it’s often not effective for long because of the incomplete survey of drivers or potentials in more obscure areas were not investigated - especially important in the more complex/complicated cases.

Jackie



Edited 1 time(s). Last edit at 10/06/2017 02:06PM by Jackie.

George and Jackie:

Thank you for the clarification, it appears that people will probably have more than one ablation, then may have to be on lifelong blood thinners. I would think then that people who have AF and it doesn't appear to bother them and are on blood thinners then for them why go through ablations.

Liz

How about because if you don't your atria will remodel and enlarge?

Liz, I think your comment is very valid. My sister has AF & it doesn't bother her at all. Because of that she won't consider an ablation. I on the other hand just could not live with it for my rate was too high & it drove me nuts. Thats a good example of how we all are different. However Libby, Im very interested on the comment about remodeling and enlarging the atrium due to Afib... Plus, isn't there some remodeling going on after an ablation, which could have caused my break threw or just so to speak, another loose wire?



Edited 1 time(s). Last edit at 10/08/2017 07:58AM by Jake.

I don't know very much about remodeling after/from an ablation. I haven't thought about that. I'll have to look into it. I'm an echo tech and I just know it from that side. I see how the atria keep enlarging with chronic a-fib. and then one can't get out of it, has to worry about clots... I was hoping that taking care of things while my chamber sizes were normal would keep me from going down that road.
Is there real hope with ablation? I hate how I feel on the drugs. I don't really want to deal with this at all
#feeling crabby today

Libby, even though I had something every year, it was still worth it to me to get the ablations. My quality of life is so much better. To me once a year is well worth it. If I need a 3rd I will do it. Waiting for this monster to rule my life again is worth the effort to fix it.
Hope you feel better soon.

Libby:

My last Nuclear scan was 2 years ago, everything was good, I do have a one degree heart block which was due years ago from taking a beta blocker, taking it wiped me out. I trusted my doctor at that time, I will never take that drug again. I have episodes of AF once every two months or so I am not in AF all the time. I have had AF since around 1998 which was due to too much thyroid hormone.

The question about will there be re-modeling after ablations is a good one, I don't know the answer, hope someone will answer it.

Liz

Everyone is diffferent. I am wiped out in afib, large dose of beta blocker struggles to keep my heart rate down, I am out of breath, hot, generally miserable and overtime my ejection fraction is highly compromised.

Living with Afib is not an option for me as far as I am concerned. I am two weeks post Natale ablation #1, but on ablation #4. Might as well be the 1st one though as the 1st three were incompetent and useless.

2 weeks post I just has my first very short runs of something rapid or slightly afib like but only lasted maybe 10 seconds so could not catch them. Here's to hoping that was it, for reference these 2 weeks were the longest I went afib free for 2 years now.

Fibrillator:

I agree, everyone is different, and if I had Af often and had your kind of symptoms I would opt for an ablation as well. I hope you will now have a quiet heart.

Liz

Fibrillator,


You sound like me in Afib. Im pretty sure the 1st two ablations fix my Afib , but these PSVT are something else. Cant tell you which is worse. Just hope its ugly head stays down until I hear from Dr Natales office.

You will have some odd beats, it comes with the healing process.

Enjoy your NR & good luck!

An EP once told me that ablation might not prevent AF from starting, but would stop it sustaining itself. I found this very helpful.

In the 14½ years since my ablation and touch up three days later, in Bordeaux (for long term persistent AF) I have had occasional fluttery feelings but they have only lasted a very short time. At those moments I have always remembered what that EP said and assumed that the scars were doing exactly what they were intended for. Gave me peace of mind and stopped me worrying.

Gill

Gill, good to know. I have those same fluttery feelings. What still concerns me is the ache I get to the left of heart? I was on Bystolic & switched to a calcium blocker Lisinopril. Wonder if that had anything to do with it?