4 month after second Natale ablation.

Hello everyone,
It has been 4+ month after my second ablation with Dr. Natale in Austin (first one was March 2008 also with Natale in San Francisco). I am happily report that I am in NSR since the ablation. Still on blood thinner(Eliquis). Have to schedule follow up visit sometime in February or March. One thing that worries me is that in those 4 month I had 3 -4 times short episodes (around 20 seconds each) which looked like afib or may be it was "atrial run". One was recently, and i even thought that afib returned, but they self terminate quickly ( as I say 15 - 20 sec). My question if this means that most likely Afib soon comes back or should i not worry about it because I am still not out of the blanking period ?

Deniss



Edited 1 time(s). Last edit at 01/07/2019 12:42PM by dartisskis.

It means the ablation was a success. First, episodes of afib during the first 3 months are common, expected, and don't mean the procedure failed. Second, any arrhythmia lasting less than 30 seconds doesn't really count, so to speak. It's not considered an actual episode. What you've experienced sounds like a pretty calm, perfectly normal blanking period. Don't sweat it. You're doing fine and it's very unlikely your afib will return.

30 second rule. The short ones don't count.

Carey/wolfpack, thanks for your answers.

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Carey
It means the ablation was a success. First, episodes of afib during the first 3 months are common, expected, and don't mean the procedure failed. Second, any arrhythmia lasting less than 30 seconds doesn't really count, so to speak. It's not considered an actual episode. What you've experienced sounds like a pretty calm, perfectly normal blanking period. Don't sweat it. You're doing fine and it's very unlikely your afib will return.

I had to be cardioverted twice following my ablation with Natale in July. The third time I went out of rhythm I converted back on my own. All three events happened within the first three months following my ablation.

I have been off of anti-arrhythmic drugs now for over 3 months only remaining on elequis and metoporlol. I too will be returning to Austin sometime within the next few months for a TEE to see if I can come off of the elequis. I also suspect that at some point soon he will be taking me off of the metoprolol and will also be sending me an event recorder to wear for a while.

So don't worry yourself.

Deniss

An EP here in London once told me that ablation might not prevent AF from starting, but should stop it from sustaining itself. Sounds to me just like what is happening to you - the lines are doing exactly what they are supposed to do.

I have experienced this many times. I have been in nsr since ablation in Bordeaux in January 2003, (will be 16 year anniversary tomorrow!) and that remark by the EP has reassured me every time.

Gill (pronounced 'Jill' and female)



Edited 1 time(s). Last edit at 01/08/2019 07:00PM by Gill.

Congrats on your anniversary Gill!

The EP comment you refer to is a bit odd given that an ablation is more typically supposed to prevent AF by blocking errant signals from the PVs. I’ve always suspected that there’s a lot more to it than that with my guess being that the truth is that most if not EPs aren’t 100% sure precisely just how an ablation works! My take is that preventing ectopics isn’t even the half of it.

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mwcf
The EP comment you refer to is a bit odd given that an ablation is more typically supposed to prevent AF by blocking errant signals from the PVs.

I think what he probably meant was an ablation doesn't stop the errant cells causing the afib from firing. It just prevents those signals from going anywhere. I'm sure the cells in my PVs are blazing away with random, afib-inducing signals at this moment, along with some cells in the posterior wall, my coronary sinus, and my LAA. But they're all encircled by dead scar tissue now, which doesn't conduct signals, so those errant signals go nowhere. That's how ablations work. No mystery about that.

I think what he probably meant was an ablation doesn't stop the errant cells causing the afib from firing. It just prevents those signals from going anywhere. I'm sure the cells in my PVs are blazing away with random, afib-inducing signals at this moment, along with some cells in the posterior wall, my coronary sinus, and my LAA. But they're all encircled by dead scar tissue now, which doesn't conduct signals, so those errant signals go nowhere. ""


So without having an ablation and cells not encircled by dead scar tissue what stops these cells from "blazing away with random" in someone who hasn't had an ablation?

liz

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Elizabeth
So without having an ablation and cells not encircled by dead scar tissue what stops these cells from "blazing away with random" in someone who hasn't had an ablation?

You said it yourself in another post: it's probably genetic.

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Carey

The EP comment you refer to is a bit odd given that an ablation is more typically supposed to prevent AF by blocking errant signals from the PVs.

I think what he probably meant was an ablation doesn't stop the errant cells causing the afib from firing. It just prevents those signals from going anywhere. I'm sure the cells in my PVs are blazing away with random, afib-inducing signals at this moment, along with some cells in the posterior wall, my coronary sinus, and my LAA. But they're all encircled by dead scar tissue now, which doesn't conduct signals, so those errant signals go nowhere. That's how ablations work. No mystery about that.

The mystery is this.

OK so a few lucky individuals like you have been successfully ablated to the point where - if I recall correctly - you don't even feel a single ectopic. That said, many other Natale ablatees do continue to notice PACs and short runs of PACs etc.

That said, the wider consensus here is that most folks with successful ablations still get ectopics and often a lot of them at that (Gill here in the UK for example still gets many many ectopics but no AF for 15 years post-Bordeaux)..... as well as sub-30 second runs of various atrial ectopics/'arrhythmias'. So 'successful' (i.e. preventing the reoccurrence of AF) ablations in such cases clearly don't prevent ectopics: this being - I suspect - including completely from the PVs, and definitely not from elsewhere in the atria. MAybe ablations that stop AF but not PACs are at least partly successful because they modify the substrate enough to stop AF getting established enough to last more than a couple of seconds.

Maybe AF for a lot of folks is precipitated by a combination of ectopics from the PVs AND elsewhere in the atria - including the LAA(maybe what it took to stop you having any PACS after your last Natale ablation). Maybe isolating the PVs and stopping all or at least the majority of the signals coming down from the PVs is - along to some degree or other with the collateral damage caused to the upper atria - is enough to stop AF in many people.

It certainly does not present as an exact science to me, and I doubt very much I'm alone in that regard.



Edited 3 time(s). Last edit at 01/09/2019 07:53AM by mwcf.

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mwcf
OK so a few lucky individuals like you have been successfully ablated to the point where - if I recall correctly - you don't even feel a single ectopic. That said, many other Natale ablatees do continue to notice PACs and short runs of PACs etc.

It's a lot more than "a few." Keep in mind that people who undergo successful ablations don't tend to follow forums like this. They just get on with their lives and never show up here. Those people are, in fact, the majority of ablation patients.

Having had multiple ablations I certainly understand the issue of PACs and ectopics. I dealt with them for years. Prior to my Natale ablation I often experienced bigeminal PACs that went non-stop for weeks at a time. No drug we tried would stop them, which would be everything except for amiodarone. Why do PACs happen? Because it's very difficult to find and ablate every single ectopic source. Aside from the usual suspects in places like the PVs, there can be many single point sources spread around the atria and finding every one of them is extremely difficult because they don't cooperate and fire while you're in the lab with mapping catheters in place to locate them. So quite often the result is the worst offenders are found and isolated, which stops your afib, but a few more remain hidden and still fire on occasion, resulting in the PACs that bother so many of us. How did I get so lucky not to experience them anymore? Well, as my local EP remarked after reading Natale's ablation report, "There's not much left of your atria that hasn't been ablated." (I've got very small P waves as evidence of that.) So yes, PACs can be eliminated, but the amount of work it takes to achieve that might not be something most people are willing to undergo. I don't count the first three of my ablations as having happened at all (and neither does my EP who did the fourth), but there were three more after that by competent EPs. That's what it took to achieve complete remission.

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mwcf
OK so a few lucky individuals like you have been successfully ablated to the point where - if I recall correctly - you don't even feel a single ectopic. That said, many other Natale ablatees do continue to notice PACs and short runs of PACs etc.

I'm not a Natale ablate, but I do get ectopics frequently. It all depends on hydration levels and how I've been doing with electrolyte supplementation. I'd say PACs post ablation are more the rule than the exception.

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Carey
Keep in mind that people who undergo successful ablations don't tend to follow forums like this. They just get on with their lives and never show up here. Those people are, in fact, the majority of ablation patients.

I would be, too, except I know that having been ablated at age 41 the chances of that index ablation lasting another 40 or so years (knock on wood) are just about zero. So I'll have to revisit surgical AF management at some point in the future, and I'm doing my level best to stay on top of the science and where it's headed. And if I can take advantage of this community's experience with risk factor management and thoughtful supplementation protocols then that's what I'm going to do to stretch that interval between my visits with the catheters as much as possible. And, I'll share my own experiences along the way as some meager means of payback.

Knowledge is power, folks. You'll get way more here than you ever will in a 15-minute office visit with an EP (or cardiologist, or any doctor for that matter).

wolfpack, PEF ablation looks very promising indeed but remains several years off yet for the likes of us. Take a look at:
[www.dicardiology.com]
Also see [farapulse.com]
(Prof Jais who did my ablation at Bordeaux last year is heavily involved with this new technique and is very excited about it. He has confirmed to me that PEF ablation can be undertaken on folks who've already had RF ablations.)



Edited 1 time(s). Last edit at 01/09/2019 12:36PM by mwcf.

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wolfpack
Knowledge is power, folks. You'll get way more here than you ever will in a 15-minute office visit with an EP (or cardiologist, or any doctor for that matter).

Well said!

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mwcf
wolfpack, PEF ablation looks very promising indeed but remains several years off yet for the likes of us. Take a look at:

Also see
(Prof Jais who did my ablation at Bordeaux last year is heavily involved with this new technique and is very excited about it. He has confirmed to me that PEF ablation can be undertaken on folks who've already had RF ablations.)

How far out until this could become the norm? Something worth waiting for maybe? I'm on the list with Dr. Natale for this summer. Meds work well for me, but I'm wanting a long term solution.

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Kleinkp

wolfpack, PEF ablation looks very promising indeed but remains several years off yet for the likes of us. Take a look at:

Also see
(Prof Jais who did my ablation at Bordeaux last year is heavily involved with this new technique and is very excited about it. He has confirmed to me that PEF ablation can be undertaken on folks who've already had RF ablations.)

How far out until this could become the norm? Something worth waiting for maybe? I'm on the list with Dr. Natale for this summer. Meds work well for me, but I'm wanting a long term solution.

Kleinkp, please see the thread I started above:

[www.afibbers.org]

and particularly Shannon's two posts third last and last (as I write).

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wolfpack

Knowledge is power, folks. You'll get way more here than you ever will in a 15-minute office visit with an EP (or cardiologist, or any doctor for that matter).

Never been a truer statement.

And as Carey said there are many folks that have had successful ablations that never visit sites or this one in particular. And those that have visited here, then having had successful ablations, disappear. I am one of the later that visited early on, had a successful ablation that put my afib into remission so I quit posting. Then it came back and so did I. Same goes for the friend of mine that guided me here way back then. His first ablation is still keeping him in rhythm.

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Carey

Why do PACs happen? Because it's very difficult to find and ablate every single ectopic source. Aside from the usual suspects in places like the PVs, there can be many single point sources spread around the atria and finding every one of them is extremely difficult because they don't cooperate and fire while you're in the lab with mapping catheters in place to locate them. So quite often the result is the worst offenders are found and isolated, which stops your afib, but a few more remain hidden and still fire on occasion, resulting in the PACs that bother so many of us.

I've had four procedures and I still experiment PACs and, sometimes, short runs of afib. Of course, I'm still in my blanking period and things may improve in the near future, but I know I've got the bad genes and I'm far from being an 'easy' patient.