Urgent question for the veteran afibers here

My brother in law (50 yo), was admitted into the hospital this past Monday with uncontrollable heartbeat. They later in the evening diagnosed him with atrial flutter. They recommended he have an ablation yesterday and he is scheduled for tomorrow morning. He has a history of alcoholism, high anxiety, high blood pressure and sleep apnea. He is also suffering from congestive heart failure. They have tried cardioverting him with cartizem and lopressors to no avail at this point. He has no real history with either of the doctors he is dealing with. The cardiologist that recommended ablation he has only seen once before and he just met the electrophysiologist yesterday.

From my ablation experience and from others I have read and followed here, this seems a drastic measure at this time. Especially with all the other issues he is currently facing. I personally think that the other issues should be addressed first as that in and of itself may be the cure. Thoughts?

Also, when he first arrived at the ER his bp was 150/150 and his heart rate was 150.



Edited 4 time(s). Last edit at 02/14/2019 07:49PM by rocketritch.

So they didn't Convert him to NSR, I take it they are controlling his rate with Drugs? Have they succeeded? What is his HR right now? If controlled well, it would seem that that would allow more time to think about this. You may be right, I wouldn't want to do anything that short notice, unless I had to. I believe however that most Ablations for Flutter entail a relatively simple procedure compared AFIB Ablations. Also the success rate for Flutter Ablations is much higher than AFIB Ablations. Is there a reason they don't want to Electrocardiovert him? It usually only takes 50-100J for Flutter ECV's, less than AFIB ECV's. Also Flecainide has caused many of us AFibbers to have issues with Flutter, if he was taking that.

You might try to get a hold of Shannon, he knows the most about Flutter and Ablations.



Edited 1 time(s). Last edit at 02/14/2019 07:34PM by The Anti-Fib.

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The Anti-Fib
So they didn't Convert him to NSR, I take it they are controlling his rate with Drugs? Have they succeeded? What is his HR right now? If controlled well, it would seem that that would allow more time to think about this. You may be right, I wouldn't want to do anything that short notice, unless I had to. I believe however that most Ablations for Flutter entail a relatively simple procedure compared AFIB Ablations. Also the success rate for Flutter Ablations is much higher than AFIB Ablations. Is there a reason they don't want to Electrocardiovert him? It usually only takes 50-100J for Flutter ECV's, less than AFIB ECV's. You might try to get a hold of Shannon, he knows the most about Flutter and Ablations.

They currently have his rate controlled @75 bpm which seems reasonable to me. I am also aware that flutter ablations have a higher success rate as well as being a less complicated procedure. I am unclear as to why they have not tried to electocardivert him. Cartizem and labetalol are the only medication they have tried. He is also on heparin drip and adovan for the alcohol. To me it seems they have not exhausted all of their options.

I thought about calling Shannon but I just showed up to this rodeo and I’m still trying to gather all the information.



Edited 2 time(s). Last edit at 02/14/2019 07:54PM by rocketritch.

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From my ablation experience and from others I have read and followed here, this seems a drastic measure at this time time. Especially with all the other issues he is currently facing. I personally think that the other issues should be addressed first as that in and of itself may be the cure. Thoughts?

Also my thoughts. The doctor must be able to give a very good reason for going for an ablation at this stage. The cynic in me makes me think - if your only tool is a hammer.....

Full stop. That's messed up. Heparin?! WTF are they doing?

Flutter is usually easy to ablate, but considering that three EPs failed to ablate mine in four attempts I wouldn't be so sanguine about it.

They need to cardiovert him, give him rate control meds and an anticoagulant, send him home, and then let him choose an EP if he wants to pursue ablation. A rate of 150 isn't that bad, especially since it can be rate controlled (mine couldn't).

However, with the alcoholism is he going to be reliable about taking meds?

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Carey
Full stop. That's messed up. Heparin?! WTF are they doing?

Flutter is usually easy to ablate, but considering that three EPs failed to ablate mine in four attempts I wouldn't be so sanguine about it.

They need to cardiovert him, give him rate control meds and an anticoagulant, send him home, and then let him choose an EP if he wants to pursue ablation. A rate of 150 isn't that bad, especially since it can be rate controlled (mine couldn't).

However, with the alcoholism is he going to be reliable about taking meds?

What’s your concern with the heparin at this juncture? I also think the alcohol is playing a part is decision but I can’t seem to get any clarification on that. I do know that last year he was to have back surgery. During the procedure he woke up and bucked the vent. So they aborted that procedure. This is also a concern my wife and I have concerning tomorrow’s scheduled events.



Edited 1 time(s). Last edit at 02/14/2019 08:30PM by rocketritch.

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rocketritch
What’s your concern with the heparin at this juncture?

It's just an unusual solution to a common problem and seems like overtreatment. Maybe there are issues I don't know about, but I would sure question why he's not simply been put on a NOAC, rate control meds, and sent home. It seems like a lot of hospital treatment and a rush to a procedure.

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Carey

What’s your concern with the heparin at this juncture?

It's just an unusual solution to a common problem and seems like overtreatment. Maybe there are issues I don't know about, but I would sure question why he's not simply been put on a NOAC, rate control meds, and sent home. It seems like a lot of hospital treatment and a rush to a procedure.

I agree. Their arseanl appears to be limited for some reason and what that reason might be I don’t know. All they have basically done to get his heart rate under control is continue to give the same medications in greater amounts. The only other issue he has that I was just made aware of is liver function. According to my wife it’s not terrible but then again I don’t know for sure. I realize that many meds are metabolized by the liver. However, all that should affect is dosing.

I agree that they should send him home and give him some time to think things through.

Stomp on the brakes.

Beware anyone who says they can do an ablation tomorrow. What about the anticoagulation protocol? Heparin is really short-lived. You need to be on Eliquis for a month at least before anyone sticks a catheter in your heart. OK, so it’s a right-atrial flutter ablation. So he dies of a pulmonary embolism instead of severe brain damage.

I’m sorry but this sounds nuts to me. Get the rate under control, ger anticoagulated and go see an EP who isn’t trigger-happy.

Sorry to hear about your BiL's troubles. Ditto what Carey and wolfpack say above. Hoping you get a handle on all of this soon.

Agree with the consensus of our forum members on this.

/L

Thanks all. My wife expressed our concerns last night so it's out of our hands now. He is scheduled for this afternoon so we will see what his final decision is.

First off I questioned continuing this as I don't want to instill any unwarranted fears into those who may be embarking on or considering an ablation. However, I think we are all already aware of the possibilities of issues that can arise from any medical procedure. Also, there are a huge amount of success stories to be found within this site that show that by following a certain protocol, good outcomes can and should be expected. None of which were followed in this particular situation. Red flags abounded. And good solid advice to not proceed so hurriedly was given by myself, an ablation veteran, and my wife who is finishing up her Doctoral in Nursing.

Well, after having the doctors convince him that the ablation was his only option that would definitely cure him he decided to go for it. (one of many red flags).

Unfortunately he never made it past the TEE. He had a mucus block from his years of smoking and sleep apnea that created complications with the TEE. Not sure of the extent but they did damage to his esophagus/throat as a bleed developed so they had to bring in a second specialist from another hospital to address the bleeding. In the end they got the bleeding controlled and he spent most of yesterday into this morning in the ICU fully incubated and fully sedated. They brought him out of sedation this am and slowly weaned him from the breathing machine. However, the tube remained for a while because they wanted to be sure the bleeding was under control.So he had to be restrained for a time until they removed the tube. What a cluster.

IMHO this is why you need to take the time to find a reputable EP that will take the time to learn of you history so that he will be able to make good decisions and have some inclination as to possible roadblocks he or she may run into. Also, that experience will ensure that if there are obstacles they will be able to address them immediately.

They did end up electro-cardioverting him at some point during all of this so he is in sinus rhythm now.

There are a lot of posts on here that are giving very good outcomes after having an ablation and apparently with Dr. Natalie that is so. Even with Dr. Natalie many have had to get 2 and 3 ablations then some have to have their LAA worked on and then are on blood thinners for life, either that or have a Watchman installed. There have been problems with that device also, perhaps this new watchman device will solve everything.

We need to know all sides good and bad, hopefully the medical profession can figure this out.

Liz

Rocketritch - I am so very sorry for your extended worry and for the trauma your brother-in-law is enduring.
You offer an important reminder to take time with major decisions and often, when possible and practical, get second opinions.

Your concluding statement is compelling. Thank you.

Kind thoughts to you all.
Jackie

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rocketritch
Unfortunately he never made it past the TEE. He had a mucus block from his years of smoking and sleep apnea that created complications with the TEE. Not sure of the extent but they did damage to his esophagus/throat as a bleed developed so they had to bring in a second specialist from another hospital to address the bleeding. In the end they got the bleeding controlled and he spent most of yesterday into this morning in the ICU fully incubated and fully sedated. They brought him out of sedation this am and slowly weaned him from the breathing machine. However, the tube remained for a while because they wanted to be sure the bleeding was under control.So he had to be restrained for a time until they removed the tube. What a cluster.

Cluster is right. Everything you've told us about these guys completely vaporizes any confidence I might have had in them. A long-term alcoholic suffered esophageal injury from a TEE. Well, gosh, who could have imagined that? Who knew that alcoholics often have varicose veins in their esophagus that are prone to bleeding? They could have just put him on Eliquis, a beta blocker, sent him home for three weeks, then done the cardioversion without a TEE if he didn't convert during that time, which he probably would have. Those guys are procedure happy.

My advice to him would be to check his ass out of there as soon as possible and go see a qualified EP.

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Carey
Those guys are procedure happy.

My advice to him would be to check his ass out of there as soon as possible and go see a qualified EP.

Now that he has survived all of that and he is back in sinus rhythm they want to try again Monday. They are procedure happy. My wife again advised him to get out ASAP and take a pass on the ablation for now and focus on addressing his other issues for now.

Your brother-in-law is being used as a pincushion. Get him out of there, before he becomes a permanent resident.

If it was me, and I just endured that, and on the positive side, I am now in NSR, I would get the Hell out of there, let my esophagus heal up, and get on with normal life. He has had only one Flutter episode? Why is it urgent to get Ablated? He is in NSR. We obviously don't know everything about this case, mainly the urgency to Ablate.

Wow. I am so sorry that this is happening. Your brother-in-law must be overwhelmed and confused by so much happening in such a short time. It’s awfully hard to do nothing/wait when you’ve just been diagnosed with (and are experiencing) a heart arrhythmia for the first time and a specialist is infusing the situation with a sense of urgency.

It sounds like he desperately needs a second opinion from a well-qualified EP who has no connection to the first one - someone who believes and can convince him that he no longer has to remain committed to this path just because he’s begun down it...

I so hope something will occur to turn this around for him. He’s fortunate to have your experience and caring in his corner.

The saga continues. They have convinced him that the only reason he is in rhythm is due to the metoprolol and the hospital gods and if he goes home he will go out of rhythm. They are also saying that following the ablation there is no chance of reoccurrence and won't be sending him home on any meds including blood thinners.

They , not sure who they are, also said they want to use the echo they have as it showed the pathway that was creating his arrhythmia. LOL .That probably Deservs a ROFLMAO instead.

They are also saying that if he leaves without the ablation he's going against medical advice,. Uterly ridiculous and underhanded and seams as if they are trying to cover themselves in some fashion or reason.



Edited 2 time(s). Last edit at 02/17/2019 02:47PM by rocketritch.

As if he can't take metoprolol at home? This is outrageous. They're flat out lying. There's no way an echo showed a pathway causing the arrhythmia. That's just nonsense and I can't believe they said it. And so what if he's going against medical advice? Their advice is absolute rubbish. I've never seen or heard of a hospital behaving like this. Is this some small community hospital?

This is a pretty reputable hospital near Pittsburgh. And if I wasn't seeing all of this first hand I would think I was making it all up. Its been a real comedy of errors.

My wife is headed back right now but for what reason I don't know. Her brother and sister have rolled over on the plan and there seems to be no changing their minds at this point. I'm steering clear as I'm pretty sure at the very least I would just make everyone uncomfortable. I can't keep my mouth shut and I'm sure I would end up offending someone.

Document all of this and consult an attorney. I’d ask your wife, if she’s willing, to ask her brother for a medical power of attorney. Those forms are readily available at any hospital and there should be a notary on hand. It takes only a few minutes.

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Carey
And so what if he's going against medical advice?

I agree completely. What is the penalty for non-compliance anyway? You get a better doctor? I was accused of it years ago when trying to find a cardiologist I could work with. When confronted with it by my PCP at the time I told them to find me a Cardiologist that listened to me the same way that they did and it wouldn't be an issue. The very next cardiologist and I had a 20+ year relationship.

So if he goes home and does go back into Flutter, it shouldn't that much of a big deal. Take the Metropolol or Cartizem to control the rate. He can schedule Ablation without a rush. At only one episode thus far, how do they know he wouldn't self-convert after a short while?

That's only one part of what is so crazy about all of this. What kind of EP stakes their reputation on such a situation as this. Or a hospital for that matter.

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rocketritch
What kind of EP stakes their reputation on such a situation as this. Or a hospital for that matter.

One that’s facing closure or buyout. Ablations are $50,000+ procedures and, if I may entertain a bit of cynicism, a 50 year old, alcoholic tobacco user “explains away” a lot of complication risk that might otherwise be attributable to shoddy procedures. I said before that I thought they were using him as a pincushion. Perhaps “blank check” would be a better choice of words.

I suppose that's a possibility. The Hospital is a flagship for Highmark so I doubt buyout is a driving force. Blank check maybe. This is also what's so troubling about the whole thing.

Well my BIL ended up going through with the ablation and survived. They have him on elequis for 1 month and I am guessing that he is still on metoprolol. The doctor showed him the burns that he did and I guess he said he had to do a couple others as well.My wife said that he seamed pretty proud of himself and my BIL was satisfied. Time will tell the outcome.

I'm glad he went through without complications so far. I don't know how much esophageal risk there is in a right-sided flutter ablation, but it's probably not zero. Given the fact that alcoholics' esophagi (?) are often in bad shape, I'd recommend keeping careful watch for signs of any complications there over the next few weeks. You mentioned your wife is a nurse or studying to be a nurse so I'm sure she would be knowledgeable about it.

For our newer folks, what rocketritch has gifted us here by his careful and thoughtful anecdote is a textbook example of HOW NOT TO HAVE AN ABLATION. Ever.

Thanks, rocketritch, for sharing and we're all keeping our fingers crossed for your extended family.