Post Natale ablation

To Jackie and others from the old days of Han's AfibForum,:

Having had an ablation with Dr. Natale at the Cleveland Clinic in September of 2007 and living blissfully free of afib for the last twelve years, I'm back into occasional runs of Flutter and PC's.

Needless to say, having thought that the ablation would hold through my old age, I am discouraged. ( A nurse in my cardiologist's office said that most ablations last only ten years at the most and that I should consider myself lucky that mine lasted as long as it did.)

(1) How long do ablations usually last? - even having been carried out by someone as truly excellent as Dr. Natale? What are other Natale patients experiencing? What has Natale himself said? Should I have another ablation? I am now 83, but doctors say that my heart is strong and that is just the "wiring" that is malfunctioning.

(2) For the last three weeks I have been taking Eliquis (5mg.) prescribed by my cardiologist, but I am experiencing bouts of diarrhea. Has anyone else taking Eliquis had this symptom?

Oh yes, forgot to mention that I need to be free of afib,and side effects of drugs,.because I am trying to finish a scholarly "breakthrough" book about Emily Dickinson.

Thanks for your help.



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Carola
(1) How long do ablations usually last? - even having been carried out by someone as truly excellent as Dr. Natale? What are other Natale patients experiencing?

Jackie is a similar age to you. She had her index Natale ablation in 2003. She needed another a couple of years ago. I'm sure if you do an advanced search, you can find some of her posts. Ken recently posted he's having some issues on the 13th anniversary of his index ablation with Dr. Kevin Wheelan in Dallas. <[www.afibbers.org], Gill (from the UK) got her index ablation around 2002 or 2003 in Bordeaux, She's maybe a couple of years younger than you. She's still going strong.

My understanding is that the issue with these obviously good ablations is that the illness continued to progress, not because there was a flaw in the original ablation. Jackie said as much. The ablation techniques have improved dramatically since '03. MikeF from Scotland had a Bordeaux ablation in the last year or so and as I recall, he said Dr. Jais kind of cringed at what they did then.

PC, (Dr. Pat Chambers) had a Bordeaux ablation in 05 or 06 and went back some years later, and is doing well now. I spent some time with Hans in April and he got his Bordeaux ablations around the same time as PC. He is now on flec to control his afib, but is doing well. Hans is in his mid 80's.

In your shoes, I'd probably go back to Dr. N and have it fixed.

George

Yep, gotta agree with George. It's not that your ablation failed. It's that your afib progressed, which is what afib does. The good news is that a second touch up should be much easier. Stick with Natale.

If you need to be free of afib, as you said, then your choices are ablation or antiarrhythmic drugs. A mild antiarrhythmic like Multaq that's usually pretty free of side effects might work for you, but if it doesn't, all the others are full of side effects. Multaq might be worth a try but if it doesn't work then I think your only realistic choice is another ablation.

Never heard of diarrhea from Eliquis but anything's possible. If it keeps up I would ask the doc to switch you to Xarelto.

Hello Carola,

As stated your afibs return is more likely a progression of the beast than anything else. Sometimes there is a chance of PVI scarring re-connection, but with someone like Natale doing your index that is highly unlikely. What is more likely is that some outlying trigger points have developed as Afib is a progressive issue.

As Carey stated, if ablation is your chosen route I would go back to Natale for a touch-up.

Carola,
Sorry to hear that you are having issues. 12 years is good going keeping AF at bay though. When you say PCs you mean PACs, right? How long are the 'runs' you are experiencing? A few seconds? Or longer? But no AF so far as you're aware?? If you are returning to runs of flutter/AF longer than a few seconds, then I absolutely second the excellent advice from George, Carey and rocketritch above.

Hi Carola,

As George and Carey noted above, it is not that your trusty ablation failed, once ablation lesion lines hold up with zero recurrence for at least a full year and a half, it's highly unlikely for those scar lines to ever fail, and thus allow AFIB/aflutter to trigger again from the same previously ablated spots that were solid so long. The old adage that AFIB can't cross a durable mature scar is still very much valid.

What can happen, especially for people who had a very successful Natale (or any other operators successful PVI-only ablation) that are usually now well over a decade ago, is that the progression eventually can move on well past the PVI antrum/Posterior wall isolation areas of the left atria that typically defined the limits of ablation target zones up until roughly late 2007 into 2008 when Dr Natale began pioneering expansion of more advanced ablation techniques to include ablating all of those much further out frontier areas of both the left and right atria located beyond the usual initially ablated PVAI antrum areas of the left atria that defined the maximum extension of early stage PVI/PVAI ablation target zones.

Want we have seen frequently over the last 10 plus years (again as noted above), is that eventually the underlying progression of AFIB outstrips the range of the initial standard PVI anatomical-only ablation protocol's sphere of effect within the atria.

AFIB generally, and in the vast majority of cases, begins its progression close to and around the four pulmonary veins, including the antral area immediately surrounding the four PVs, and begins to fan out, roughly analogous to the spread of a brush fire in the open prairie. The leading edge of this 'brush fire' is where the crux of the arrthymogenic triggering tends to manifest as it spreads further away from the origins of AFIB, in or around the PV zone. This leading edge 'hot zone' largely defines the active triggering at any point in the progression of AFIB as it gradually spreads eventually reaching the far frontier areas of both the left and right atria represented by the Coronary Sinus (CS) in the right atria, and left atrial appendage (LAA) in the frontier anterior part of the left atria.

A well done truly durable 'old school' PVI-only ablation, which even today is the limit to which at least 80% of EPs who offer an AFIB ablation to their patients will actually ablate too, and most still don't even look for any real time unique triggers beyond the anatomically described PVI region, we have found such relatively limited initial ablations will typically keep AFIB at bay for 10 to 11 years once they have been recurrence-free for at least 1.5 years or so.

More rarely such a limited anatomical PVI can last indefinitely, but usually this occurs only in those lucky folks who show very little, to no, progression of the disease beyond their PV antrum/posterior atrial wall zone where the disease initially manifests and was successfully buttoned down during what was, way back then before 2008 or so, the limits of AFIB ablation effect.

From the advent of the PVI first described in the seminal Bordeaux study published in October 1998 to the present, the majority of AFIB ablations still deal only with PVI or PVI plus posterior LA wall... some add the SVC too and all three zones are purely anatomical targets that don't require much, if any, real time electrophysiological sleuthing during the ablation to ferret out other Non-PV triggers where-ever such active triggers can be found.

The CS and LAA represent the furthest out structures in the both right and left atria with a similar enough morphology to the PV antrum area that they can sustain any atrial arrhythmia, be it AFIB, AFlutter or ATachycardia.

The evidence we have so far, is that once all the usual target zones around the PV antrum/LAPW/SVC plus active non-PV triggers spreading outward toward these last two structures of CS and LAA that can sustain atrial triggering, are all durably ablated/isolated, then there is no solid rationale for any more recurrence of any form of atrial arrhythmia to occur.

So, again Carola, it's not that your expert Extended Natale PVI with LAPW-iso ablation from 2007 has failed, but that your AFIB/aflutter progression has simply outstripped the limitations of what marked the limit of PVI type ablations from the early years of ablation technology.

Those lesions that Natale made in your left atria are still holding fast, but it appears your Arrhythmia has moved on to greener pastures with a very high likelihood that by now CS and/or LAA involvement may well be driving your recurrence.

No worries though, since Natale’s method and skills have also greatly evolved since the early generation PVAI that gave you a long and welcomed respite from the beast.

Your two choices now are, as Carey noted, either try an AAR drug since one of the benefits of having had a solid ablation originally is that often times AAR drugs that did fail before your index ablation, often now work much better and may be enough for you, at least for the time being.

The second, and in my view much preferred next step, is to revisit Dr Natale’s new state of the art EPLab at St Davids and begin what should certainly be the final leg of your AF experience once he can durably isolate these last few remaining structures in the RA and LA, such that no further battles with the beast should ever be expected.

While all of our current evidence with over 12 years of LAA isolation by Dr Natale to-date, strongly support the rationale that complete isolation of the LAA and CS (on top of previously successful extended Natale PVAI), should mark the end of all this gedoe once and for all. Nevertheless formal confirmation of that fact will require another decade or so of direct evidence.

I am on my 12th year + 4 months with not a single beat of AFIB since my index ABL with Dr Natale after having had AFIB/Flutter gradually progress to a highly aggressive persistent AFIB over 16 years before I, very thankfully, found my way to Natale’s table!

Thus, it's no surprise why I strongly recommend letting Dr Natale complete his Hat trick in your heart to restore the great result of durable NSR restored for the long term.

Finally, for some folks in your shoes, depending on one's age and overall health, there is a potential role for adopting an AAR drug like Flecanide (if you tolerate it well) and see if that is sufficient for you going forward. I still prefer the full fix ... but some scenarios, including in ones more advanced older age, can make the drug route worth considering too.

Cheers!
Shannon

As George mentioned, I had ablation in Bordeaux in early January 2003 after many years of paroxysmal AF and 18 months of long-term persistent AF with rapid ventricular response.

AF recurred two days later so they did an immediate touch up. Prof. Haïssaguerre thought there might be a gap in one of the lines but this was not the case. He found a very toxic focus in the coronary sinus which he said was extremely difficult to find and ablate, and he was not sure that he had got all of it, so prescribed flecainide and bisoprolol for a few months.

Mine was not just a standard PVI ablation. It also included the roof line and a line from the LIPV to the Mitral Annulus, plus the usual flutter line in the right atrium 'on the way out'. At that time Prof. H. said he had done everything that was known to work, although several years later Prof. Hocini told BarryG that they cringe when they think of what they were doing in those long ago days. (BarryG labelled mine a “cringe ablation”!)

Since then I have been in sinus rhythm, it will be 17 wonderful years in January 2020. I get many ectopic beats which were uncomfortable until I started taking magnesium, potassium and taurine - they still happen but I hardly feel them. Prof. H. told me that they are a nuisance but not a problem and that it they bothered me I should take bisoprolol.

I’ve had a few bumps along the road. After knee surgery 5 years ago I was given Tramadol for pain relief, felt nauseous and had a strange heart rhythm. I thought I might be in AF. The ER Doctors did an ECG and said yes, it was AF so I was devastated. However when the EP looked at it later he said it was runs of many ectopics and not AF. I now avoid Tramadol.

More recently I had two strange incidents. The first happened on October 23rd this year as I was boarding a plane to fly to the Canary Islands. I have no idea if it was AF or just more runs of ectopics because I was on a very small island with limited medical facilities. Heart rate was normal, I took bisoprolol which didn’t seem to help so I sat it out. It lasted for 3½ days then stopped during the night.

November 13th the same thing happened again when I was back home in London. Heart rate was normal, Bisoprolol seemed to work this time and it stopped after 3 hours. Again I don’t know if was AF or just runs of many ectopics. Since then my heart has been quietly ticking in sinus rhythm.

Is my AF progressing? I shall have to wait and see. I am now 82 years old but very fit and active. I take no prescribed medication and would like that to continue so if Bordeaux would be willing to do it I would certainly consider another ablation.

Gill (pronounced 'Jill' and female)

Hello Carola - As noted, my first Natale ablation (Cleveland) in 2003 lasted for 11 years. I didn't consider it a 'failure' and as Shannon so aptly explains, back then, those ablations didn't check for other potential trouble areas compared to the current practices. My second ablation with Dr. Natale was in 2014 in Texas followed by another 'touchup' about 7 months later, also in Texas. The 2014 procedure isolated the left atrial appendage and was no surprise since that area had become a common 'problem target' as a result of advancement in procedural techniques. My heart has been very calm since then.

I'm now 83 and if I needed to have yet another procedure, I would not hesitate to see Dr. Natale again as I am active and in good health but I fully understand the risks that are inevitable with 'aging tissue.'

Because of my age and also the LAA isolation procedure (even though my clearance velocity is in acceptable range), Dr. N. felt it is best to remain on Eliquis so I have continued with the recommended half-dose daily. I don't have major side effect issues but there are some that are annoying. However, all things considered, it's a relatively minor concern. I don't take any other meds and am on a broad spectrum of targeted nutritional supplements (directed by my FM MD) that focus on support for healthy aging. I never did well with the meds for Afib so the procedural approach was my best option and I have no regrets.

I wish you well and would encourage you to at least consider an assessment consultation with Dr. Natale.

Kind regards,
Jackie