Ablation Failure - Time to Schedule Another

I had an ablation done at UPenn about 16 weeks ago; the first 30 days my heart was quiet, but since then I've been having afib weekly or more. At week 8, I started taking nightly 50mg flecainide again, but that hasn't helped like it did prior to the ablation when I'd have afib on average every 10 weeks - so my afib has gotten worse post-ablation.

Tomorrow I have an appointment with my EP to discuss scheduling another ablation since my quality of life has taken a nosedive since the last one. One thing I want to bring up with him is that previously his PA told me to only stop the flecainide the night before, which calls into question how effective any pacing / mapping would have been. I want to ensure this time he thorougly performs the necessary pacing to identity and ablate all ectopic sources. Is there anything else I should discuss regarding a 2nd ablation?

I imagine some people might wonder why I'm sticking with my EP if there's any question about the prior procedure, but he's supposed to be one of the best. Also, my case is supposed to be a "simple" one; I'm fairly young, previously my afib was relatively infrequent, there are no complications with my heart, etc.

Thanks for the feedback.

Mark

Hi Mark,

Well, that sucks. The good news is even top EPs often need two procedures to get it done.

I would definitely bring up the question of stopping the flecainide just the night before. I've never heard of such a practice. The usual practice is to stop all antiarrhythmics at least five half-lives before the procedure. Flecainide has a half-life of 12-27 hours, so you probably should have been told to stop the flecainide at least 5 days prior. I always was.

Quote
MarkF786
(...) Also, my case is supposed to be a "simple" one; I'm fairly young, previously my afib was relatively infrequent, there are no complications with my heart, etc. (...)

"Simple" cases are only simple statistically. Their success rate is statistically high (70% and even 85-90% after a second procedure), but that doesn't prevent you unhappily fall in the 30% or 10-15% for whom it fails.

Sorry for the double post - not sure how that happened and cannot figure out how to delete this one.



Edited 1 time(s). Last edit at 12/13/2018 12:06PM by Jons.

Hey Mark - you are the reason I found this forum! I was looking for accounts of those that had experienced coming off of flecainide and other similar meds before an ablation and found your earlier post.


I find it interesting that your afib has actually increased after the ablation. I cannot figure out how that would happen! How long did you have afib prior to the ablation, was it well controlled on the meds and did you always know when you were in it?


I am 50, had afib for 10 years before my ablation a little over a week ago at PennMed (UPenn) with Dr. D'Souza, and thought my afib was very well controlled on flecainide and metoprolol. Interestingly, I learned that I may not have been as sensitive to feeling afib as I once was. I was in full blown afib the morning of my ablation and did not even feel it at first. I did after a while but not immediately. I think the metoprolol and flecainide may actually make your heart beat weaker and because of that it is not always felt. I don't know - just guessing at this point!

I've heard of touch-up ablations - is that what they are talking about with you or did they completely miss something and need to do a full blown ablation again?

Jon

Hi Jons,

Yeah, I agree it’s strange my afib has increased post-ablation and don’t understand why; it could be just the normal evolution of things, or a change in the electrical conduction of my heart, or some unknown factor I haven’t accounted for. I will say that my lifestyle has been the same, continuing with the same supplements (as recommended here in the forum) as before.

Yes, I’l be discussing a ‘touch-up’ of the pulmonary vein isolation with my EP today (Dr. Garcia @ UPenn), though from what I understand the best practice is to also do “pacing” to identify any other hotspots of activity.

I’m a few years younger than you, at 46, and have had afib for about 7 years now; it’s seems to be genetically inherited for me since my father, aunt, and grandmother all have it (though they were in permanent afib before realizing it). I’m very aware when I go into afib, even with it waking me up in the night; I largely attribute this awareness to various meditation-like practices I’ve done over the years with a focus on awareness of the sensation of the heart, prior to my afib, My family members on the other hand are oblivious to being in afib.

My afib is vagal, so I mostly get it while sleeping or while waking, and I only used a pill-in-pocket approach for the first 5 years. The frequency started to increase, so I began taking flecainide nightly which reduced the incidence again though the medicine made me feel like crap in the morning. Pre-abalation, the frequency of afib started creeping up again, so I decided to try to solve it with an ablation.

Hope that info helps.

Mark

I had the appointment with my EP. From what I can tell, UPenn's (or at least my EP's) protocol is to do an index PVI, with another small ablation if needed to eliminate indications of atrial flutter, for first-time ablations; this is based on various statements from my EP and his PAs, though I don't know they'd officially state this. Showing me the images from the procedure, the PVI did seem thorough with a double row of ablations in most areas, and he was able to induce afib several times during the procedure to to validate the pulmonary veins were a source of afib, and that they were isolated after the ablation, but I don't think he performed any pacing in other areas of the heart.

This time he wants to check if there is any reconduction of the pulmonary veins, and also do further pacing to identify any other sources of afib (this last point, I stressed the need for several times). His recommendation is to keep me awake during the induction of afib and mapping, and then to put me under while doing the ablation; this concern is that general anesthesia may interfere with identifying all the sources.

I'm curious, does Dr. Natale's team at St. David’s also follow the protocol of doing an index PVI for initial basic ablations or is pacing for other ectopic sources a standard in all procedures? It might be a good differentiator for people to know when deciding where to get it done.

Thanks.

Are you sure what you're experiencing since the ablation is afib and not flutter? Flutter following an ablation is common.

If I use the following definition I quickly found - "In atrial fibrillation, the atria beat irregularly. In atrial flutter, the atria beat regularly, but faster than usual and more often than the ventricles, so you may have four atrial beats to every one ventricular beat" - then I'd say I'm pretty sure it's afib. Only the first post-ablation incident was caught on the monitor, but symptomatically all experiences are the same.

Usually it starts with a low heart rate, then my heart rhythm goes off for a few beats (it's hard to say if a beat is missing or added) - and sometimes I can coax it back into rhythm through intentional rhythmic breathing (something learned during HRV training pre-afib) - but often it then goes wildly off rhythm, and the rate increases (maybe up to 110 bpm, though more usually around 90 bpm). If I then monitor my heart rate (using either a Heartmath finger or ear sensor, or a Polar chest strap), I can see the great variations in rhythm - and later use the same method to validate when my heart is back in NSR after taking the PIP.

Does that sound like afib or flutter?

P.S. Tone in email is easy to misinterpret, but no negativity was intended above, though as I read it I can 'hear' that possible misreading.

Cheers.

For folks like us, flutter can feel like afib, especially in the blanking period. For me, I look for the patterns to see if I'm in rhythm with some PAC disruptions, vs. afib which means I can't find a lot of organization to the rhythm. PAC's and flutter are disruptions that very briefly interrupt a normal an organized rhythm. Afib tends to be really disorganized, and that's the distinction I try to look for.

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MarkF786
Does that sound like afib or flutter?

I can't really tell from your description. The key difference between the two is afib is a very irregular rhythm but flutter is very regular. You don't need fancy tools to know the difference. Just feel your pulse at your wrist or neck for 30 seconds. Is it a regular drumbeat? If so, it's flutter. Otherwise it's afib.

Yup, it's afib.

I had what was supposed to be a touch-up ablation done in January. My affib had returned after several years of sporatic affib following an ablation in 2009. The January ablation only lasted a couple months and my affib returned worse than it was before. Flecanide would no longer keep me in rythm and Ticosyn only kind of worked.

I had my third ablation done by Dr. Natale on July 20th 2018. I stopped the ticosyn a week prior to my ablation. I did a taper and took the last pill the morning of Friday July 13th. Dr. Natales office said I could stay on the Ticosyn until Sunday July 15th but I wanted to be sure it was out of my system. I stopped metoprolol a day or two before.

Hi Mark,

I totally agree with Carey that it’s highly unusual to only stop FLEC the day or night before an ablation! And it’s not at all
unusual to need a second ablation as noted above, even with a top EP and even if the first ABL was done essentially perfectly. that’s why I tell everyone to expect two procedures to be truly done with this business, regardless of the operator, and be happy as a clam if you wind up in long term ddurable NSR after an index Ablation which happens often enough.

If you’d like, please send me your cell and time zone and perhaps I can shed some additional insights along with the very good excellent replies from Carey above. I need to know some more details of your case first to, perhaps, be able to shed some additional light reqarding who at Penn did your index ABL, plus a few more questions about your overall case. Once I know more about your scenario and your index ABL at Univ of Penn, which is truly a fine ABL Ablation and education center, it may bring out some more points it would be good for you to know prior to your follow up ablation.

Penn has some excellent ablation EPs but like in most large centers (even top tier ones) there will be a fairly broad range of expertise and not every EP will be equally experienced in just what you are having done, and/or some of the more elite operators may take a more liberal approach to Non-PV-trigger detection and ablation than has been the more conservative published protocol by Penn using a more basic approach to Non-PV trigger technique, rather than the more advanced Non-PV trigger detection and ablation methods now done by many other elite EPs at various top centers. In other words, there can be a somewhat wider variability in the nuances of a given ablation performed by different EPs in a given center based on their overall experience as well as there chosen career focus.

And sometimes just based on their overall preferred focus as an ablationist ... i.e. does the EP do mostly PVI-only ablation for AFIB, yet is his primary love and focus on doing more on Ventricular tachycardia ablation etc etc?? But as implied above it could be that there were a few reminebt triggers that were just too immature and/ir were being suppressed just a but too much by the anesthesia to rear their head during the first typically busy and ‘noisy’ index ablation.

In any event, let’s talk via you sending me a PM link (private message) next to my name just above with your cell number and time zone and Ill try to get back to you in the next few days during normal day time hours and we can go from there. You or I can then update us all here afterward if there is anything additional that is worthwhile that comes from discussion in your case, and if you so wish too then update this thread.

Cheers!
Shannon



Edited 2 time(s). Last edit at 12/15/2018 11:37AM by Shannon.