Intro and my AF experience pre and post ablation

First I want to thank everyone on this forum for sharing their experiences, asking great questions and just providing support for those with AF. Many read the forums before posting and this forum has been a great resource through my post ablation healing process. I thought it was time I shared my own experience and get some feedback from the forum. Hopefully this will also help someone else down the road.

My Afib history and road to ablation
I started having afib episodes back in 2011 around the age of 36 (I didn’t know it then but in hindsight I now know they were short afib events) and have had 2-3 a year since, each lasting 1-2 hours at most until 2 years ago. In 2016 I had 3 episodes total, each lasting between 7 and 24 hours. During the second episode I decided to stop by the ER to get checked out as I had not yet been officially diagnosed. My cardiologist had suggested a trip to the ER the next episode so we can see what was really going on via EKG. My ER visit confirmed AF and they ended up electro cardioverting me.

Once afib was confirmed my cardiologist started me on Metroprolol 25mg. I had another 3 episodes over the next 4 months and started to seriously consider having an ablation. I went to several seminars and studied ablation online and was convinced cryoablation was right for me – the uniform contact around the pulmonary vein made more sense to me than 50-100 individual burns which seemed more likely to result in reconnection. Several months later I went about interviewing a few EPs based on referrals all of whom agreed an ablation was a good option given my age (42 at the time), health, lifestyle, etc. I was committed to getting an ablation at this stage as it made more sense than a lifetime of medication. Two months later, in September of 2017 I had a cryoablation. My EP said I had a time to effect of 30 seconds which studies suggest results in a high probability of PVI durability. The voltage map pre and post ablation looked perfect to me and the EP had suggested it was exactly what you want to see. I asked if he found any other areas of activity and he said no. He seemed to suggest that he doesn’t like staying in the heart long and doing excessive pacing trying to find every possible errant signal though. He stated he takes a conservative approach so as not to cause other issues. After reading these forums I understand the importance (from Shannon in particular) of ablating other areas in addition to the PVs in the index ablation. So how did I fare after the ablation?

Post ablation
The procedure went smoothly and I was back at home the next day, tired but otherwise ok. I was put on Flecanide 50mg 2x daily and Xarelto. By the third day I felt great and returned to work the following day. I of course took it easy as recommended. The first 9 days were event free. On the evening of day 10 I had my first breakthrough event. It lasted about an hour, then went back to NSR for 10 minutes and then started again for another hour or so. Maybe worth noting – I had just gone from sea level to 5500’ of elevation that day visiting the in-laws in the local mountains. Not sure if this impacted my heart given the thinner air. In any case, for the next few days I had at least one episode a day and sometimes up to 4 or 5. Most episodes were under 30 minutes. As the days went by they started to reduce in duration and eventually in frequency as well.

About 4 weeks out from my ablation all went quiet aside from daily ectopics which I could feel more prominently than before my ablation. All the normal triggers like stress and positional triggers did nothing to start an episode. 2 months later however (3 months post ablation) I had another episode. This one lasted 25 minutes. It was around this time that I stopped Xarelto and Flecanide under direction of my doctor. I had another episode a month later (4.5 months post ablation) which lasted about 1.5 hrs. Then all was good for another month until I had my most significant episode post ablation which lasted about 6 hrs (not sure exactly b/c I went into NSR while sleeping – I took 300mg flecanide after not converting on my own in 3 hours). I was then good for another 3 months until my next episode. This one however was 3-4 short one minute episodes while terribly sick and traveling. It’s now been almost 4 months since my last episode and 1 year since my ablation.

The overall patterns post ablation seems to have been quiet for the first 10 days, daily activity for days 10-30, quiet for second and third month post ablation, singular events months 4 and 5, nothing for 3 months, a few clustered super short events over 30 minutes and then nothing again for another 4 months and going. So overall it seems it has been getting less frequent the longer I have healed. However, since I did have episodes in the post blanking period it sounds like I may need a touch up at some point from everything I have read. My doctor suggests holding off to see how often I have episodes before recommending any touch ups. He has had a few patients with similar patterns end up having no issue after a year or so post ablation. As well, nearly all my episodes post ablation have been much shorter than the last few years before the ablation suggesting there has at least been improvement. Of course, with the strong ectopics, and given the last two episodes were ~3 months apart, I am sometimes concerned the next one is coming but I generally try not to think about it and just live my life. I mountain bike and hike regularly and figure I can always push through an episode as I have in the past. I have found that continuing my exercise will often revert me and if not I have PIP flecanide to fall back on. I feel like I have it under control and have a solid plan for dealing with it should AF arise again. I am hoping of course, that my heart is just slow to heal fully. 

If I do need a touch up then I will certainly look into seeing Dr. Natale. I have been trying to find patient accounts of interactions with Dr. Natale to glean whether he would even recommend a touch up himself at this point. I read one account that suggested he may opt to wait for more frequent activity before going back in. I would love to hear from folks here whether anyone has had similar post ablation experiences and if it was suggested you get a 2nd ablation or wait for more activity. I am particularly interested in Shannon’s opinion given all of his experience in the field.

Thanks for reading.
afdude



Edited 1 time(s). Last edit at 09/10/2018 03:00PM by afdude.

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afdude
I went to several seminars and studied ablation online and was convinced cryoablation was right for me – the uniform contact around the pulmonary vein made more sense to me than 50-100 individual burns which seemed more likely to result in reconnection.

Expect to hear a few skeptics on that one

Cryo works great for about 65% of the patients who receive it, which is on par with RF ablation performed by average EPs. It's quicker than RF ablation and can be performed by EPs with far less training and experience, so it has merits. As a first procedure I would not tell someone to avoid it, and if their EP was less than highly experienced and they insisted on seeing them anyway, I would recommend it over RF ablation. But if you're not one of the lucky 65%, that's the end of cryo's usefulness for you. It's a one-shot deal. It's also mostly useless for persistent afib since that's rarely limited to the pulmonary veins and the PVs are all cryo can address.

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Carey
Cryo works great for about 65% of the patients who receive it, which is on par with RF ablation performed by average EPs.

Hongo felt that lines were more susceptable to breakthroughs than points over the long term.

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jpeters
Hongo felt that lines were more susceptable to breakthroughs than points over the long term.

The lines will obviously work great if they're continuous as they're hypothetically supposed to be. Problem is, everyone is different and so are the insides ('architecture/topography'-wise) of their LAs and the point by point approach can be adjusted to accommodate this better. Plus the energy output with point by point can be modulated for different LA thickness more precisely. All that said I understand some of the newer balloons (cryo and RF) are making progress in this regard - although any balloon is going to struggle IMO to be as individually 'tailorable' as point by point RF. As Carey says, for point by point you do need a very experienced AP above all else.

My first ablation was done by a local EP and he used RF. He did a touchup last January Using Cryo. My third abalation was done in July using RF. In the report it was stated that the PVI leisions were solid meannig that the Cryo touchup was successful. Even at that, Dr. Natale took a spin around the PVI anyway.

However, with Cryo an EP is limited in the scope to which issues can be addressed.

Thanks for everyone's responses thus far. I didn't think this would morph into a cryo discussion but appreciate the insight. It's actually quite helpful.

I would really love to hear everyone's thoughts around my post ablation experience. I am trying to decide if I should pursue a touch up or wait to see how I do over the next year or so first. Thx

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jpeters
Hongo felt that lines were more susceptable to breakthroughs than points over the long term.

Natale agrees, which is why he makes lines, not points. Experienced, well-trained ablationists make lines with RF.

What cryo can't do is anything other than isolate the pulmonary veins. That makes it effective for simple cases, which apparently comprise about 65%, but if there are sources outside the PVs then RF is the only way to fix them, and that's apparently about 35% of patients.

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Carey

Hongo felt that lines were more susceptable to breakthroughs than points over the long term.

Natale agrees, which is why he makes lines, not points. Experienced, well-trained ablationists make lines with RF.

Probably semantics, since Hongo trained under Natale.

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Carey

Hongo felt that lines were more susceptable to breakthroughs than points over the long term.

Natale agrees, which is why he makes lines, not points. Experienced, well-trained ablationists make lines with RF.

What cryo can't do is anything other than isolate the pulmonary veins. That makes it effective for simple cases, which apparently comprise about 65%, but if there are sources outside the PVs then RF is the only way to fix them, and that's apparently about 35% of patients.

You’ve lost me there. So Hongo feels lines are more susceptible to breakthroughs (as in PV reconnection presumably) than points and Natale agrees but does lines?!



Edited 1 time(s). Last edit at 09/11/2018 06:34PM by mwcf.

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mwcf


Hongo felt that lines were more susceptable to breakthroughs than points over the long term.

Natale agrees, which is why he makes lines, not points. Experienced, well-trained ablationists make lines with RF.

What cryo can't do is anything other than isolate the pulmonary veins. That makes it effective for simple cases, which apparently comprise about 65%, but if there are sources outside the PVs then RF is the only way to fix them, and that's apparently about 35% of patients.

You’ve lost me there. So Hongo feels lines are more susceptible to breakthroughs (as in PV reconnection presumably) than points and Natale agrees but does lines?!

Think he may be referring to dragging technique, which is different then cyro.

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jpeters
Think he may be referring to dragging technique, which is different then cyro.

That's exactly what I'm referring to. Natale makes lines with RF. It's not unique to cryo. Cryo just makes it easier and faster at the expense of being rather limited in where it can make lines.

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Carey

Think he may be referring to dragging technique, which is different then cyro.

That's exactly what I'm referring to. Natale makes lines with RF. It's not unique to cryo. Cryo just makes it easier and faster at the expense of being rather limited in where it can make lines.

Thanks for validating that No, they're not the same thing (unless, of course, Hongo doesn't know the difference and likes to contradict himself).


Comparison study (although I think Hongo had other concerns):

"Nevertheless, there was a trend for slightly lower acute and long-term success rate for patients underwent cryoablation ablation compared with radiofrequency ablation. Following factors might be responsible for this phenomenon: cryoablation ablation was applied by using focal “point by point” method, whereas radiofrequency ablation created consistent ablation lines by using “drag and burn” method across the cavotricuspid valve isthmus"

[www.ncbi.nlm.nih.gov]



Edited 3 time(s). Last edit at 09/12/2018 12:42AM by jpeters.

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Carey
Experienced, well-trained ablationists make lines with RF.

Presumably when you refer to lines you are talking about Natale's 'gliding catheter' technique yes?

So do Natale and DiBiasi use point-by-point as well as lines or just lines?

And by implication are all ablationists who don't make lines inexperienced and inadequately trained?? Does anyone here know whether making lines or 'gliding' is actually used by any ablationists other than Natale and his proteges??

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mwcf


And by implication are all ablationists who don't make lines inexperienced and inadequately trained??

Obviously not.


Published:
20 June 2017

both strategies were shown to be similarly effective for primary outcome. However, ablation and fluoroscopic time in group D were significantly shorter than those of group P. (42.9 min vs. 57.9 min, p=0.040 and 11.2 min vs. 20.4 min, p=0.009, respectively).

Conclusion: For radiofrequency catheter-based PV isolation, contiguous dragging catheter ablation targeting low FTI could create comparable lesion in a shorter time compared with point by point ablation with high FTI target.

[academic.oup.com]

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mwcf
So do Natale and DiBiasi use point-by-point as well as lines or just lines?

I'm sure they do both as the situation calls for it. For example, ablating a single focal source of ectopy probably requires individual burns rather than a line.

Natale and his proteges aren't the only ones capable of the technique but I do believe he pioneered it.

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Carey



Natale and his proteges aren't the only ones capable of the technique but I do believe he pioneered it.

Hongo noted that techniques were being presented in workshops that they had been doing for 10 years.