Ablation on Monday - and was only told to stop Flecainide the night before

I have my first ablation scheduled for Monday morning at University of Penn's EP lab, and tonight I was reading some older posts in the Affiber's forum and saw that the standard time to stop Flecainide before the ablation is 5 days, whereas I was told only to stop it the night before... but there's more to the story.

My EP and his staff have been very sparse on the details on the upcoming procedure, and what little information I’ve been given has only been from me asking questions. I was told the Monday before the procedure someone would call me to review my medications, tell me what to stop, and give further details on the procedure. When I hadn't heard from anyone by midday on Monday, I called the EP's office since I was traveling Tues-Thurs and they assured me "Trevor" would call me that day. Monday came & went without hearing from anyone, then my business trip took my focus (with long days from 7am to 11pm). On Thursday morning when I hadn't heard from anyone, I called the EP's office again and was told "Trevor" would call me. Late that afternoon around 4pm, a physician's assistant called (not "Trevor") and seemed very nonchalant and offered scant details, just telling me not to eat after midnight the night before. When I asked him if I should stop taking any medication or supplements, he said that wasn't necessary since “you're not on any medications". When I corrected him and said I take 50mg Flecainide nightly, he said to not take it the night before. So here I am on Saturday night, having already taken my nightly meds, and in about 36 hours I’ll be getting the ablation done.

On a somewhat unrelated note, the EP's office called me Friday afternoon asking if I could reschedule! I said that I had scheduled this six weeks in advance, and had planned my work schedule around it, and it would probably be another couple months until I'd be able to take the time off again. Luckily they then called back and said I was still on the schedule, but bumped to the afternoon.

I've always considered the University of Penn to be the best hospital with the best doctor's in the area, but this really seems amateurish and even negligent.

I guess I have limited options now, either asking to reschedule the procedure for a couple months from now, or to go ahead and hope for the best. I’m sure they plan to do a standard PVI, but they also planned to induce afib to look for any ‘hot spots’, and if the Flecainide lowers their chances, then I’m not really getting the most out of the procedure (and it ain’t cheap)!

I don't know if it's worth calling the doctor's office in the morning. I imagine if I raise the issue, they'll just try to sweep it under the rug, rather than admitting the mistake.

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MarkF786
I have my first ablation scheduled for Monday morning at University of Penn's EP lab, and tonight I was reading some older posts in the Affiber's forum and saw that the standard time to stop Flecainide before the ablation is 5 days, whereas I was told only to stop it the night before... but there's more to the story.

I was off diltiazem three days prior to an ablation. It doesn't sound like you are overly confident about your EP....besides the fact that you are paying for it. Personally, the only reason I chose to have an ablation is believing I found someone uniquely gifted to perform it. I've read too many horror stories. Your choice.

It's not much my EP I'm concerned with but his supporting staff.

University of Penn is supposed to be one of the best EP labs in the country, and my EP is also supposed to be one of the best. Shannon has had many good things to say about him in these forums.

In my search for info now tonight, the only reassuring information I've found so far is Shannon mentioning Dr. Natale only requiring he stop Flecainide 24 hours before getting a circumferential PVI done.

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MarkF786
It's not much my EP I'm concerned with but his supporting staff.

It's like that at UCSF also. They have some great doctors, but it's a nightmare sometimes getting through triage.
Guess just overly busy.

The easy conclusion is indeed that they’re just thinking of doing an index PVI for you (as indeed every centre here in the U.K. will do first procedure for PAF - e.g. Sabine Ernst in London told me likewise stop AAR med the night before). But that said, at 50mg Flecainide once per day only, after one half life of 12-27hrs (let’s average that and say 20hrs) you’d only have 25mg in your system anyway and IMO FWIW that’s pretty much sub-therapeutic. Most folks taking Flecainide will be on 200mg/day (i.e. 100mg twice a day). Maybe only 25mg Flecainide in yoursystem come Monday morning won’t interfere very much if at all with them pacing for other sites if and as required.

I've always been told to stop the antiarrhythmic I was taking 5 half lives before a procedure, and that includes Natale. I'm not sure why Penn would say otherwise, but they are one of the top centers in the country for ablations. I very much doubt they'll do a simple PVI and not do any mapping or trying to provoke the arrhythmia. Penn is better than that.

At this point, it's hard to say if it was a mistake of my EP's staff or standard operating procedure. I guess I won't know until I ask tomorrow.

Doing some research, I see my EP and the team at UPenn have published some recent studies on the topic of the "Lack of prognostic value of atrial arrhythmia inducibility..."

Lack of prognostic value of atrial arrhythmia inducibility and change in inducibility status after catheter ablation of atrial fibrillation (May 2018)

Conclusion: Noninducibility of atrial arrhythmia or change in inducibility status after PV isolation and non-PV trigger ablation is not associated with long-term freedom from recurrent arrhythmia and should not be used as an ablation endpoint or to support the appropriateness of additional ablation lesion sets.

Inducibility of atrial fibrillation and flutter following pulmonary vein ablation (June 2013)

Conclusion: ...inducibility did not predict clinical recurrence in follow-up. Distinguishing organized atrial arrhythmias from AF did not yield any further prognostic information. The utility of aggressive stimulation protocols after AF ablation for prognosis and to guide therapy appears limited.

Or another recent study by another group of EPs:

Utility of acute arrhythmia termination as an ablation endpoint for induced atrial tachyarrhythmia after complete pulmonary vein isolation during catheter ablation for persistent atrial fibrillation (August 2018)

Conclusion: Acute termination of induced rhythm is not a reliable ablation endpoint during substrate modification in patients with inducible arrhythmia after PVI.

When I joked with my EP that I heard he's one of the best, but that Dr. Natale was the best, he laughed and said they were friends, but that the did do some things differently. I asked what he did differently, and he said that in advanced cases they had different approaches, but in simple cases like mine they generally did things the same - FWIW.

Maybe my case is indeed simple, and with a basic first-time PVI it's not considered critical to induce afib, which seems to align with Shannon's first PVI with Dr. Natale. In some other research I found, even in follow-up ablations, non-PV triggers accounted for less than 10% of afib, and the recurrent afib was due to conduction having returned across the PV. Maybe if a doctor is very good at the PVI, inducing afib is less critical.

Inducing afib during an ablation has important utilitarian purposes for the procedure itself. It's used to locate ectopic sources and to confirm conduction block. Whether it has predictive value is a minor side issue.

The first study states that that only 65% of patients were inducible at all, so obviously a skilled EP can perform the procedure without inducing afib.

There's little value arguing the topic any further, and it only serves to get me more worked-up the day before my ablation. Time will tell if it's my EP's staff's mistake or his protocol.

Considering my EP has been published 116 times, is the Director of Penn's EP lab, and come's highly recommended by Shannon, I can only assume he knows what he's doing.

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MarkF786
The first study states that that only 65% of patients were inducible at all, so obviously a skilled EP can perform the procedure without inducing afib.

Yes, they can, and only about 65-70% of index ablations succeed. I doubt those numbers are complete coincidences.

I'm not arguing anything nor am I questioning your EP's abilities. Not at all! I agree that you're in excellent hands at Penn. I just know that top EPs will almost always attempt to induce afib in the lab and will usually also give isoproterenol to make it even more likely. I'd be surprised if Penn doesn't do that too since it's really rather standard procedure. Sometimes they can't, and that's just the way it goes. It doesn't mean the ablation will be a failure, but it may mean they miss ectopic sources that would have been apparent had they been able to.



Edited 1 time(s). Last edit at 08/27/2018 10:49AM by Carey.

Chiming in late.

Based on conversations with Shannon you are in excelent hands. Also, during one of our conversations I had mentioned that one of the reasons I thought that my ablation in January failed was because I was on flecanide right up to the day of the proceedure. Shannon stated that any reputable EP should still be able to perform a successful ablation even under those circumstances. Keeping in minde that even under perfect conditions, there may still be a need for a touchup procedure or even 2 depending on the complexity of the case.

During my ablation in July they had to induce affib as my heart decided to be quiet that day. However, my arrhythmia did organize organically later during the proceedure. Even at that, Dr. Natale and I discussed the fact there is still always the possibility that I will need a touchup proceedure.

Best of luck to you. I am looking forward to seeing how you progress.

The ablation seems to have been a success. When I asked my EP about stopping the Flecainide only the night before, he almost scoffed at it, saying he'll easily be able to induce afib in me. Also he said that my afib was "bread and butter" and that he expected only a PVI would be necessary, but he'd look for other non-PV triggers.

Post-procedure, he said that he induced afib, and saw I had "angry" pulmonary veins (ie. they were the obvious source of my afib), which he then ablated. During the procedure, I went into afib four times total, and after the PVI was complete he couldn't induce it again. He said though that during the procedure he saw signs of atrial flutter, so he ablated a spot to prevent that in the future.

So far so good. My heart feels great, though I've had some other minor complications with the procedure. It was done on Monday, and today I'm starting to feel better.

Thankfully, he said I can stop taking Flecainide (just keep some on hand for 'pill in pocket'), though I need to take a blood thinner, Eliquis for a few months and Prevacid for a month or two.



Edited 2 time(s). Last edit at 08/29/2018 11:47AM by MarkF786.

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MarkF786
The ablation seems to have been a success. When I asked my EP about stopping the Flecainide only the night before, he almost scoffed at it, saying he'll easily be able to induce afib in me. Also he said that my afib was "bread and butter" and that he expected only a PVI would be necessary, but he'd look for other non-PV triggers.

Congratulations! Once again, it all comes down to the correct choice of EP.

Great news!!

Sounds good!!