When to Stop Flecainide before Ablation

I'm currently on 25 mg Flecainide twice a day. I'm going to Bordeaux for an Ablation on 11th June.

The Check List they send to tick and return just before the operation date says to stop antiarrhythmics 48 hours before the operation. That seems quite clear but the details they send when you initially contact them says 5 days. Yes, I have tried to get clarification on the difference and failed.

Could anyone who's had an ablation, preferably in Bordeaux but anywhere else too tell me when they had to stop.

Thanks

Depending on the EP... and the patient.

- Before my 1st procedure (PVI), EP said "three days without rhythm drugs".It was OK.
- Before my 2nd procedure (touch-up), EP said "three days without rhythm drugs". I've had a terrible afib attack (4h with lots of PVCs and nearly 1hr at 120-140bpm) the evening before the procedure. Because of this, next day EP failed getting me out of SR, and nothing could be ablated.
- For my 3rd procedure (touch-up, nearly two months ago), EP asked me to stop the drugs only 24h before the ablation. This was apparently enough...

Edit: maybe they only say 48h because you're taking a very low dose?



Edited 1 time(s). Last edit at 05/22/2018 01:07PM by Pompon.

It depends on the drug's serum half-life. The EP needs to be able to induce AF in order to ablate AF. If you still have high-enough blood concentrations of an AAR drug, then that could "mask" areas of electrical activity in the LA and cause the operator to miss them. The median half-life for flec is about 20 hours, so after 48 hours you're going to have a little less than 25% of the blood concentration that you had while taking it regularly. At 25mg BID that's probably getting low enough to be out of the therapeutic range and not cause any problems during the procedure. I'd still double check that with the staff at Bordeaux. IMO, if you are also rate controlled and anti-coagulated then stopping it 3 or even 5 days in advance wouldn't be a problem unless your AF is very debilitating and you're quite keen to avoid any episodes.

Always a trade-off!

I was told to stop a week before every time

I've had two ablations while I was on flecainide and both times they had me stop it 5 days in advance. That makes sense because the usual rule is 5 half-lives, and flecainide's half-life is about 20 hours, so that works out to just under 5 days. I think 48 hours would definitely be inadequate. In any case, you want to err on the side of stopping sooner rather than later.



Edited 1 time(s). Last edit at 05/22/2018 06:26PM by Carey.

I was not on any antirhythmic drugs before my first ablation and it was successful.
I was on flecanide up until the day of my second. My second ablation failed miserabley and I can't help but think that is the reason why.
I would make sure the check exactly what they want you to do.



Edited 1 time(s). Last edit at 05/22/2018 03:16PM by rocketritch.

I stopped propafenone about 2 months before my Dr. Natale ablation because the conversion pauses were so lengthy. The AFIB essentially grew persistent as tachycardia also emerged soon after a failed marathon FIRM ablation. While waiting for Dr. Natale's expertise I was absolutely miserable, going from AFIB to pretty high rate tachycardia to occasional NSR and back again. All the AA's I tried caused conversion pauses, and they're frightening in their own right. I'm no expert, but Carey's suggestion of sooner than later is best in my view. Assuming you're taking an anti-coagulant you should should be fine. Miserable perhaps, but safe, and presenting to the EP in a way that gives him or her the best opportunity for success.

Sam,

I too understood it to be 5 days from the preliminary info I was sent. Interesting that you are now being told it's 2 days instead. Would be good to firm up on that one way or another and I'd appreciate it if you'd keep me posted in that regard.

As an aside, when I saw Sabine Ernst a month or so ago she told me it would be OK to stop the Flec the day before.... but then again what one would be getting first go around with Ernst (and Schilling and pretty much every EP in the UK) is a PVI end of. I've got to say that whilst being off AAR meds for 5 days doesn't exactly appeal to me for obvious reasons, I still much prefer the Bordeaux approach of having your heart as 'twitchy' as possible for when they go looking for other non-PV triggers as part of the first procedure rather than leaving that for the second procedure. This arguably being especially important for those like me who whilst still paroxysmal are long term paroxysmal - in my case coming up 20 years.

Regards,

Mike

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Carey
I've had two ablations while I was on flecainide and both times they had me stop it 5 days in advance. That makes sense because the usual rule is 5 half-lives, and flecainide's half-life is about 20 hours, so that works out to just under 5 days. I think 48 hours would definitely be inadequate. In any case, you want to err on the side of stopping sooner rather than later.

Carey, there are things I’d like to understand…
Some afibbers taking a rhythm drug stay in SR for weeks or months between two (possible long) afib episodes. On the opposite, other afibbers have very frequent (and likely short) afib episodes despite taking a rhythm drug. Should they follow the same rule before a procedure?
Another point is many afibbers can’t have afib in the hours or days immediately following the end of an afib episode. So, stopping the meds too soon may trigger an unwanted afib episode a short time before the procedure and make it fail (this happened to me last year).
May we generalize? In some cases, 5 days make sense; but in others, can’t 48h or even 24h be enough?

Many thanks for all your replies! My feeling was that 5 days to be sure was the one to go with.

That's what most of you said and that's what I'll do.

Thanks again

Sam

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Pompon
Some afibbers taking a rhythm drug stay in SR for weeks or months between two (possible long) afib episodes. On the opposite, other afibbers have very frequent (and likely short) afib episodes despite taking a rhythm drug. Should they follow the same rule before a procedure?

Yes, because the reason for stopping is to prevent the drug from masking afib during the procedure. EPs generally want it completely out of your system, hence the 5 half-lives guideline. It doesn't matter much what pattern your afib follows.

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Another point is many afibbers can’t have afib in the hours or days immediately following the end of an afib episode. So, stopping the meds too soon may trigger an unwanted afib episode a short time before the procedure and make it fail (this happened to me last year).
May we generalize? In some cases, 5 days make sense; but in others, can’t 48h or even 24h be enough?

I'm one of those people who never had episodes shortly after a previous episode, and I had that same concern with my previous ablations, but my EP didn't care. Not having the drug onboard is more important. I think you'd get the same answer from any EP.



Edited 1 time(s). Last edit at 05/24/2018 10:40AM by Carey.

Definitely the concesus recommendation among vast majority of high volume EPs is stopping most AAR drugs like FLEC, Propafenone, Sotalol, Multaq etc 5 days prior to an expert Ablation.

Not so with AMIO where typically a bare minimum is Two weeks stoppage and that only the patient has been on lower dose AMIO (200md/day or less) for no more than 1 to 2 months.

For folks on normal dose AMIO for 6 months or longer the weight can be from ‘minimum 2 months to 3 months abd for higher dose (400mg/day) long term AMIO 4 months can be minimum time off the drug prior to Ablation for persistent or LSPAF.

Any EP that said they could not perform any ablation due to FLEC being on discontinued for just three days suggests choosing a more experienced EP next time. I agree 5 days is the option for Flec to insure minimal masking effect on triggers, but total Inability to perform any ablation at all should be a deal breaker!

Shannon

Well... Considering the answers here above, may I think I've been unlucky having afib 12hrs before my procedure ? Is it part of the risks?

A good EP (edit - one of the elite EPs) wouldn’t be phased by someone being in AF at the time of the ablation procedure - quite the opposite as they’d relish being able to terminate it.



Edited 1 time(s). Last edit at 05/24/2018 04:31PM by mwcf.

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Pompon
Well... Considering the answers here above, may I think I've been unlucky having afib 12hrs before my procedure ? Is it part of the risks?

It's fine to be in AF going in to the procedure. They were going to induce it anyway.

My rhythm on the morning of my ablation was AF with 55bpm average ventricular rate.

Wolfpack, my afib did last 4h, stopping 12h before the last year procedure. They tried having me in afib again, but in vain. So nothing could be ablated.
I guess it's why my EP asked me to stop the flecainide only 24h before my recent touch up ablation, and it went fine. I must add that, before this last procedure, I spent the second part of the night sitting on my bed, because I was beginning having PACs.
That's why I tend to think the 5 days rule may have some exceptions, particularly for patients like me, who use to go in and out of afib very often and for whom rhythm drugs are poorly effective, the on/off pattern being prevalent.
I'm no expert but, again, before changing something prescribed by the EP, I'd cautious asking him if it's a good idea.

Pompon, you need to go read Shannon's post again, in particular his last paragraph. An EP who couldn't do an ablation at all because he couldn't induce afib isn't who you should be seeing.

Carey, that's why, for my recent touch up, I've seen another one and all went well. Things are slowly settling down and I'm now afib free for two weeks, which is the longest period I've had for a long time. I've still lots of ectopics and some periods of SVT, but no afib.
I get it : there are better EPs than others. But I'm suspicious about the fact that afib may be induced artificially, while its natural triggers stay a mystery. And EPs use to stop it the hard way: electric shock or ablation. With the latter, they close the doors, but the beast is still waiting outside.

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Pompon
But I'm suspicious about the fact that afib may be induced artificially, while its natural triggers stay a mystery.

It is done by isoproteranol (fake adrenaline) injection into the left atrium via the catheter. That'll induce a-fib even in the healthiest of hearts - just won't sustain very long. In our cases, it will and then the EP can map out areas of errant electrical activity.

If an EP says he or she can't induce AF in a heart that has been diagnosed with AF in a symptomatic patient, then that EP should not be doing complex left atrial ablations.

Thanks, Wolfpack, it's clear. So, obviously, the EP was not skilled enough to perform the touch up.
The other EP I've been recently referred to got me easily in afib, despite I was taking flec two days before... During the procedure, I was feeling all the changes in HR. The EP explained what he was doing, the areas he ablated...
The first EP said he only saw ectopics appearing briefly here and there, so he could not ablate anything. I don't know what really happened, as I was on full anaesthesia (likely another mistake), but I'm now understanding this doc was only competent to perform a PVI (what he did correctly, according to the second EP). As I read elsewhere on this forum, when doing the cryo ablation, most EPs don't try checking other ectopics, because it would require using RF catheters after having removed the cryo catheter.
I guess the first EP thought I was an "easy" patient and, seeing it wasn't the case, decided to cheat when justifying the failing of the touch up.
(I hope I've been clear, English is not my usual language...)

Clear enough.

Yes, the cryo-balloon can only perform PVI. It’s very likely inferior to RF, but a lot of that is going to depend on the skill of the operator.

My first Doc told me three days. With Dr. Natale I was told five, but I bargained for four and went to Austin after the first day without since I didn't want to get on a plane unmedicated. I also looked up pressurepoints for anxiety and heart rhythm (I had taken a class in the past) and used them when I felt a premonition about rhythm issues. This worked well for me. I was shocked I didn't go into a-fib before the ablation as at times I had short episodes nightly even on meds.