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4th ablation procedure

Posted by Pompon 
4th ablation procedure
March 07, 2019 02:12PM
Hi everybody.
This post to share my experience about my last (to date) ablation procedure. I think it may be interesting, as it was performed under conscious sedation, Nov 27.

4 weeks before the date, I did start taking dabigatran.
Stress test and echocardiography performed by my cardiologist 3 weeks before the procedure: everything was fine.
Bisoprolol and PIP flecainide stopped one week before the procedure.

Nov 27 :
3 hours driving my car to the hospital, but not too tired at the arrival.
Lots of questions by the nurses, and not always easy to answer because they’re Dutch speaking in this hospital, and I'm not (apart some politenesses). Using my French and a little English, I manage to answer the best I can.

Blood test and some other controls; then, at 3PM, I’m in the operating room.

It's a very quiet atmosphere in there (some music playing in the background), and just two nurses and the EP (Dr K) around me. The nurses are experienced, and I would be proud speaking Dutch only half as well as they speak French! Large electrodes are positioned on my back before I lay down on the table. Then, lots of smaller ones are sticked on my chest for heart monitoring.

Two drips must be placed. The first one in my left arm, the second one more deeply in my left wrist, to reach an artery (around the place where one usually check the pulse).
While the nurses make the preparations for the procedure, afib suddenly starts! I’m clearly feeling it and the monitoring machine starts beeping accordingly. It’s my usual “unsustained” afib: out of rhythm most of the time, avg 115-140 BPM, but with some normal beats (clear P-waves) here and there, and, from time to time, one minute or two in NSR.

I ask if I’ve been injected a drug to induce afib, but the EP says “no, not yet”. He adds it’s rare seeing someone going spontaneously in and out of afib just like I do; but that it’s fine for the procedure, since the ectopic points triggering afib will be more easily visible.

Dr K generously “paints” my right groin (and everything all around) with disinfectant and makes injections for local anesthesia. Little cuts are made, and three catheter sheaths are placed in the femoral vein. I don't feel any pain. I’m just feeling the EP’s hands touching me, their movements and the catheter tubes pushed into the vein. Strong painkillling drugs have been injected, of course, and I’m quiet. I’m a little “floating”, but fully conscious of my body, from head to toes.

Dr K says he’s doing the transseptal puncture, but I’m barely feeling something.
There’s an appliance (resembling those used for radiography) above my chest, so I can’t see a lot in front of me towards my feet, but on my front left, I can look at a couple of screens. There’s an impressive one where my atrium is pictured in 3D, in bright colours, numbers appearing here and there while the picture rotates and changes.

Dr K says that PVs are still electrically disconnected. He then makes some burns in the rear wall of the LA. He asks me to tell if I’m not OK, but there’s no real pain to feel. The drugs are strong! Nevertheless, it’s strange feeling my heart changing rhythm, going in afib then back to SR.

At a moment, I feel some strong bumps in my chest. Dr K says he’s checking the exact position of my phrenic nerve. It’s the nerve controlling the movements of the diaphragm. It’s crucial keeping it safe from the burns.
Dr K says he’s going to make some other burns in the RA, near the superior vena cava. He says it'll make some pain towards my right shoulder. I feel it, but it’s easily bearable.
My heart is now beating in NSR. I can’t see the numbers on the screen, but I guess it’s somewhere between 80-90 bpm.

A drug named isuprel is used to stress my heart. I’m feeling it racing for some long minutes. Then, we must wait to see if other ectopics show up. Everything is normal. Another dose of isuprel is used, another race, but no afib. Not even a single ectopic while we’re waiting.

Suddenly, I feel some strange beats, out of my regular rhythm, like strong ectopics. Dr K says: “don’t worry, I'm doing this”. He’s trying to induce arrhythmia with some impulses, but I don't know how he does it.

He then tells me not to be afraid, since I’m going to have a shot of adenosine; which guarantees some awful seconds to live. I confirm it’s a really scaring sensation, but, happily, it’s short.

As nothing seems able to disturb my NSR, the catheters are pulled out. Then I’ve to slide laterally on my bed, keeping my leg straight, the big pads are removed from my back and I’m rolled out of the room by another team of nurses.
Three hours have passed since I entered the operating room.

I’ve to wait about 15 minutes in another room; then everything is removed from my right groin and compression is manually applied on the insertion site. Then, a compression bandage is placed, and, after another 15-minute wait, I’m rolled to my room. It’s not a “regular” room. It’s an “intensive care” room, close to the nurses’s office. I’m continuously monitored, drugs are instilled in my arm and nurses come see me very often.

I’m offered a light meal around 7:30 PM, then begins some of the most awful nights in my life. I must lay down on my back the whole night (I can’t sleep this way), keeping my right leg fully straight. It does not take me long to have a completely sore back! Regularly, the nurse comes to check the screens, appliances and IVs.

Dr K comes see me around 9 AM. I’m OK (except for my sore back!), in NSR with some PVCs from time to time. I say it’s the first time I’m still in NSR more than 8h after an ablation (now 15h), so it’s probably a good sign.
He replies: “Maybe… But with you, I don’t make previsions…”

In the afternoon, I leave the hospital (my wife driving the car). I've been prescribed omeprazole (1 month) and Pradaxa (3 months). I'll take some bisoprolol (2,5 mg in the evening) and flecainide (2x 50mg).

During the following days, no afib but some ectopics. On the fifth day, at 3 AM, afib is back for 55 minutes.
On the 7th day, afib starts at 0:25. As it doesn't stops spontaneously, at 6:00 I take 100mg flecainide. Bad idea. Around 10:00, my heart starts racing in a-flutter (+/- 125 bpm). It'll last the whole day (despite taking a little more bisoprolol), only slightly slowing down in the evening. It's near midnight (I'm in bed, trying to sleep) when my heart goes back to NSR.
No more flecainide for me!

Since then, I'm back to my usual pattern: short “unsustained” afib episodes (less than 2h), every 8-10 days. In between, I may have ectopics apparently linked to digestive issues – but not always. Supplementing with Mg helps reducing ectopics; adding C, D3 and K2 vitamins + some silicium (equisetum arvense) seems to be a good idea (better magnesium assimilation). I've reduced my calcium consumption too.

My CHADS score is 0, so I've stopped my OAC.

We're all different. Both my cardiologist and my EP (it's the third I see) say I'm a rare case...
Re: 4th ablation procedure
March 17, 2019 03:38AM
Thanks Pompon for the very thorough report on your latest ablatioof 4 total ablations. conscious sedation (CS) is not often used in the US any longer for AF ablations for a variety of reasons including greater assurance of catheter stability under GA as well as undying no sudden big moans, groans or movements which can definitely happen involuntarily during CS and can even cause the catheter to skip across the interior of the atria which is obviously an unwanted occurance.

They still use CS in some E.U. hospitals mostly as a cost control measure in single pay or health systems.

Hopefully, your blanking period activity is only just that and will quiet down before the end of your eighth week. Please keep us posted with your progress and if there is any continued atrial arrhythmia activity past the eight full week which is the end of the actual blanking period, after which you hope things to be as quiet as a church mouse.

Where did you have the ABL done, in Antwerp? You said they were Dutch speaking in the hospital and it seems you are located in Belgium so a hospital in Antwerp is a likely Dutch speaking but perhaps you may have been at a Dutch facility in Brussels, if not Antwerp?

I lived in Amsterdam from 2006 to 2010 and have spent a good deal of time in Belgium as well.

Best wishes to you,
Re: 4th ablation procedure
March 17, 2019 04:22AM
Hi, Shannon. Thanks for your answer.
I've been ablated in Brugge.
The EP speaks very good French but, as most EPs, he's very busy and don't have a lot of time to talk with me.
The hospital sent me an account of the procedure, but everything is in Dutch, and as it's very technical, I can't understand everything.
I'm now more than 3 months post ablation and feeling better. I've stopped all my meds, only supplementing with magnesium and vitamins (D3, K2 and C).
I've recently realized I had really bad breathing habits since my first procedure (cryo ablation). I've no sleep apnea, but daytime apnea causing ectopics. When I just care breathing deeply and slowly, ectopics disappear. It's amazing to think it took me more than two years to find my main trigger. I must learn to breathe efficiently without holding my breath more than now and again.
We should'nt have to learn such a thing, we should'nt even have to think about it, but afib can drive us nuts...

Edit :
About the CS against GA to save on costs, I've to say it isn't the case here in Belgium. We have a national health insurance (obligatory) for which our wages are heavily taxed. In three years, I've had 5 ablation procedures (counting the first one, which was a simple CTI ablation for RA flutter), and never been asked to have a CS instead of a GA. Above this, our national health insurance administration never argued against my repeated procedures.
GA is commonly used here for AF ablation procedures. I know most patients favour a GA, for they are not keen being conscious while burns are made in their heart. And I'm sure most EPs ask for a GA not only because they want to be sure the patient stays perfectly quiet during the procedure, but because they feel more comfortable ablating in those conditions too. When a patient asks for a CS, the usual answer is: "you have to stay perfectly still, so we'll make a GA". I've been told this and, IMO, it's a poor argument. The whole time for a procedure may be 3 hours and more, but it's not such a long time without moving. Burning time is short, especially for a touch-up procedure. While the EP is making the TS puncture or burns in the atrium, I wouldn't move a fingertip. I wouldn't want nor need moving. Sedatives and painkillers are strong drugs. If I say it's a poor argument, it's because I'm sure there are better reasons to make a GA, but they are much more difficult to speak about: don't they require speaking about the risks for the patient's life?
For myself, I dislike GA because I've a really hard time eliminating the drugs. My first three procedures were under GA, and each time, this gave me three following days of unbearable headache.
I think it's a choice to make, and both the EP and the patient have to be comfortable with this choice.

Edited 1 time(s). Last edit at 03/17/2019 12:48PM by Pompon.
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