Typical flutter after successful flutter ablation?!?

Okay... so this was somewhat unexpected, and wondering if anyone here has heard of this happening before?

I’m in Austin for my ablation with Natale (tomorrow). I’ve been going in and out of rhythm for several days now - hasn’t been awful, but I’m very aware of it.

When they did an EKG before the consult today, I could feel that I was in and out of rhythm during the few minutes I had the leads on, and the EKG captured it as expected.

What surprised me was that the nurse practitioner noted typical (right-sided) flutter (Natale confirmed when he came in later) - but I had a successful CTI ablation about a year ago (successful, meaning they achieved bidirectional block). I hadn’t realized this was possible! The NP said that sometimes the inflammation from the procedure can play a part in suppressing the conduction, and that once it heals, the conductivity of the tissue returns. Why have I never heard of this?!? Why didn’t the EP I was seeing in Chicago mention this possibility when problems resurfaced and flecainide dosage needed to be jacked up multiple times?!?

Hi Karen,

While you would hope more CTI flutter ablations were as durable as they are typically advertised to be ... Nevertheless, I can tell I’ve seen a bunch of CTI failures!

The premise that they should be ‘relatively’ easy is based on the fact that both a CTI Flutter circuit and an AVNRT Supraventricular Tachycardia circuit are well-defined straightforward ‘cookie-cutter’ ablation lesion sets in the right atria. These two right Atrial ablations are protocols that every EP knows how to do, and they are not typicaly fraught with anything close to the greater complexity that Left Atrial AFIB ablation demands on the skill of the EP.

Acheiving a “bi-directional block”, whether that is achieved at the end of a PVI lesion set when isolating all four PVs, or whether the EP achieves a bi-directional block across the CTI line, this term ‘bi-directional’ block ... as an end point at the end of any procedure ... ONLY defines an ACUTE block and it says absolutely nothing certain at all about whether or not one can expect a lasting bi-directional block to occur ... though one would hope for that outcome, no doubt.

The Nurse Practitioner at St David’s gave you a fine explanation for one of the prime reasons so many ‘bi-directional ablation blocks’ fail to
last and her answer is true whether this long term failure of the bi-directional block occurred during a CTI-Flutter ablation, or during a bi-directional block during a PV isolation?

During a PVI, even the most average ablation EPs achieve a “bi-directorial block” across the PVI encircling lesions around all 4 PVs in nearly Every single AFIB ablation they perform! However, inspite of this reality, the vast majority of these EPs fail to achieve better than a 55% to 60% success rate defined by total freedom from AFIB alone at 12 months post ablation!

The same is true overall with CTI Flutter ablation, although you would certainly hope for a much higher long term success rate from a CTI Flutter ablation. And with the most experienced and truly capable ablation EPs you can, indeed, get around 90% long term CTI-Flutter ABL success rate ... provided you use tough discrimination in your choice of ablation EP to perform even a relatively straight-forward right Atrial CTI Flutter ablation!

There just is no substitute for demanding the most experienced operator you can find when it comes to consistent success in the least amount of total work required within your one and only heart! Regardless of type of ABL procedure(s) you require.

I have seen at least 100 folks who Dr Natale had to perform a repeat CTI-Flutter ablation on after a different EP had done the first CTI-Flutter ABL for all these patients. Almost invariably, Dr. Natale discovers the need to perform a repeat CTI-Flutter during one of his AFIB ablations in much the same way he discovered the need to do so in your ablation tomorrow Karen. No worries though, I can almost guarantee you will not have to have a third CTI-Flutter ABL going forward after tomorrow’s procedure!

Every one of these CTI-Flutter ablation failures occurred even though the EP who performed the Initial CTI Flutter ABL literally ALWAYS achieved an ‘Acute’ Bi-Directional block across the Cavo-Tricuspid-Isthmus line of block! In every single case in which those same Afibbers are then requiring a repeat CTI Flutter ablation as part of their AFIB ABL being done by Dr Natale, their initial EP also got a Bi-Directional block that did NOT confirm anything beyond a transient acute block during the first CTI Flutter procedure.

Dr Natale will also achieve an acute bi-directional block across your CTI line tomorrow as well ... but the difference is the Dr Natale’s CTI block will be durable and lasting, while obviously your initial flutter Ablation was not durable. Consistent success in cardiac ablation is what separates the men from the boys, especially so when we are talking about a relatively easy and straight-forward CTI-Flutter ablation in particular.

It happens WAY more frequently than it should Karen! And, no doubt, I see a greater percentage of these follow-up CTI Flutter ablations being needed due to a failure of the initial flutter procedure performed by another EP. I’ve seen this too often being needed during a Natale AFIB procedure simply because so many people referred to Dr Natale have already had several failures of their prior ablations, regardless of type of ablations they had had previously ... including CTI-Flutter ablation failures.

Best wishes tomorrow Karen, but you won’t need it ... You are in the best possible hands in this field world-wide and that is a fact!

Sleep well,
Shannon



Edited 2 time(s). Last edit at 02/21/2019 08:24AM by Shannon.

Thanks, Shannon. All this makes sense of course.

Dr. Natale’s nurse practitioner, by the way, was very knowledgeable and helpful. My long conversation with her saved a lot of time (as yours with me did too).

I had wondered about whether the prior CTI ablation was done well - but didn’t expect an answer before he even got inside my heart!

So, looks like he might end up with a little “extra” work tomorrow, but he seemed entirely unfazed (consistent with your information that this is more common than one might wish)...