Arrhythmia Recurrence Post Ablation

Reading the recent discussion on the recurrence of arrhythmia after a successful ablation got my attention and generated some questions.

Bit of background..... had a successful Natale ablation in March 2011 and have been medication free since (per Natale recommendation take 83 mg aspirin daily). I am aware that an ablation is not a cure and the need of a second procedure is a possibility.

Early last year I had a routine check-up with my regular cardiologist and based on my Chads2 score suggested that I consider anticoagulant medication. I was extremely hesitant due to all the ramifications associated with the medication and decided to get an opinion from Natale. Because of the length of time since my ablation it required an office visit which was scheduled for three months later. I had previously established a relationship with a Houston EP cardiologist (recommended by Natale) for just this type situation and made an appointment with him immediately. During this appointment he reviewed my EKG and told me I was in arrhythmia!! I said "no I'm not.....I can tell when I am"..He then proceeded to show me on the EKG. After a lengthy discussion and the acquisition of several prior EKG readings (both pre and post ablatin) he agreed that I was not in arrhythmia and explained that my ablation had actually caused my reading to indicate arrhythmia (won't go into the details). When I eventually met with Natale discussed the EKG situation with him and he agreed.......stated that it was important for anyone reading my EKG to be very experienced.

Now the questions....

In the discussions it was stated that the possibility of a recurrence of arrhythmia due to new sites goes up after around ten years.....and I am near that time frame. Shannon stated that improved techniques would impact this situation. Would my procedure done in 2011 be classified as with the newer techniques and not be as high a probability for a new arrhythmia. Regardless, when I met with Natal told him "if it comes back plan to head to Austin".

In an effort to be proactive in monitoring any potential arrhythmia recurrence have considered a KardiaMobile Monitor. But based on my EKG situation would I get false positive readings from the monitor.

As always greatly appreciate the experiences and opinions from the people on this forum.


Steve
Spring, Tx.

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JAYHAWK
In the discussions it was stated that the possibility of a recurrence of arrhythmia due to new sites goes up after around ten years.....and I am near that time frame. Shannon stated that improved techniques would impact this situation. Would my procedure done in 2011 be classified as with the newer techniques and not be as high a probability for a new arrhythmia.

Hi Steve, my comment from the peanut gallery. If your ablation included LAA work or more generally outside the PV's, then yes newer techniques. Assume if no LAA or other non PV work, it was because it was not needed at the time. If the work was not done, of course it does not mean that the disease could not progress to the other areas.

Cheers,

George

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JAYHAWK
In an effort to be proactive in monitoring any potential arrhythmia recurrence have considered a KardiaMobile Monitor. But based on my EKG situation would I get false positive readings from the monitor.

I don't know what's unusual about your ECG, but afib is an unmistakable arrhythmia. You can spot it at a glance and minor details don't really matter. Will your ECG changes fool the device's detection algorithm? I doubt it, but possibly. I wouldn't rely on that anyway because the Kardia will label virtually anything that's the slightest bit irregular as "possible afib." Just look at R waves (the big peaks). Are they approximately evenly spaced? (Count the little boxes between them if you're not sure.) If they are, you're not in afib.

All in all I just don't think this is something you need to worry about. Your afib returning is a second thing you shouldn't worry about.

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Carey
Just look at R waves (the big peaks). Are they approximately evenly spaced? (Count the little boxes between them if you're not sure.) If they are, you're not in afib.

If Steve's ECG was that simple, it certainly should not have fooled an experienced EP or have Natale suggest that anybody looking at the ECG be very experienced.

There can be changes in post ablation EKGs for some Afibbers that can get misread by some docs and (even some EPs), and especially by ER docs, as indicating the post ablation patient has some 'ST elevation' when that is only a benign artifact and not at all related to actual ST elevation nor is it, in any way, related to a prior myocardial infarction finding. Hence the need for an experienced EKG reader to interpret the nuances correctly.

I have had this mistaken 'finding' printed out on some of my EKGs when I would go into the ER for a cardioversion back in the day when I was still prone to AFlutter between my index ablation with Natale and my LAA Isolation that occurred during my second, and so far last, ablation with him that ended all of my bouts of all atrial arrhythmia ... to-date!

Shannon

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GeorgeN
If Steve's ECG was that simple, it certainly should not have fooled an experienced EP or have Natale suggest that anybody looking at the ECG be very experienced.

I very much doubt he was fooled into thinking NSR was afib or vice versa. He may have seen diminished P waves or what appears to be an elevated ST segment like Shannon mentioned. Those are both common following ablation and yes, a doctor not experienced dealing with ablation patients could misinterpret them. But afib is just too blatantly obvious in its irregularity for anyone even modestly trained in ECG interpretation to not recognize. Heck, it can be diagnosed without an ECG at all. It's almost always obvious just from palpating a pulse.

It would be great if Steve would post an example.

Wasn't the case with me last year. The GP looked at the peaks' spacing between the Rs and told me that i was in afib. I saw a good P wave and thought that i was not in afib - just irregular. Anyhow, she prescribed Eliqus straight away.
Later that day she called back and told me that i was not in afib (pathologist or someone else who interprets ECGs agreed with me).
I had a cold virus at the time.

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Carey
But afib is just too blatantly obvious in its irregularity for anyone even modestly trained in ECG interpretation to not recognize. Heck, it can be diagnosed without an ECG at all. It's almost always obvious just from palpating a pulse.

I concur that is certainly true for me and for most I've palpated. I used to joke I could name that rhythm in 3 beats or less... The irregularity makes afib obvious on a tachogram (heart rate vs. time graph), which I used for many years prior to the availability of devices such as the Kardia.

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Joe
Wasn't the case with me last year. The GP looked at the peaks' spacing between the Rs and told me that i was in afib. I saw a good P wave and thought that i was not in afib - just irregular. Anyhow, she prescribed Eliqus straight away.
Later that day she called back and told me that i was not in afib (pathologist or someone else who interprets ECGs agreed with me).
I had a cold virus at the time.

There are other causes of irregular rhythms and you were right to doubt when you saw P waves (good eye!), but that's rare. If you see or feel an irregular rhythm, it's almost always afib.

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Carey

afib is just too blatantly obvious in its irregularity for anyone even modestly trained in ECG interpretation to not recognize. Heck, it can be diagnosed without an ECG at all. It's almost always obvious just from palpating a pulse.

Two ER doctors once told me that I was in AF after looking at my ECG. When my EP looked at it he said it was not AF but runs of many ectopics.

Gill

Yes indeed as Carey and George noted above, AFIB should still be clearly detectable on a 12 lead EKG. Keep in mind though, that with a KARDIA or other similar single lead EKGs, it is more likely for a moderately experienced EKG reader to not reach a clear determination or distinction between say ... AFIB and AFlutter ... especially when there is a mix of the two going on.

On rare occasions, even with Dr Natale, when I send him a KARDIA reading from a given Afibber, with only a single lead EKG I've seen noise artifact be enough to obscure the reading even giving Natale pause in these rare instances. In such cases, he will ask that the patient get a 12 lead to unequivocally confirm the proper DX (diagnosis).

Shannon

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Gill


afib is just too blatantly obvious in its irregularity for anyone even modestly trained in ECG interpretation to not recognize. Heck, it can be diagnosed without an ECG at all. It's almost always obvious just from palpating a pulse.



Two ER doctors once told me that I was in AF after looking at my ECG. When my EP looked at it he said it was not AF but runs of many ectopics.

Gill

Had a similar experience myself Gill 3 weeks and then 10 weeks after my Aug 18 Bordeaux ablation. I thought it was AF both times. My (excellent) GP wasn’t so sure. 12 lead ECGs couldn’t make their mind up but none of the traces were categorised as AF. Outcome both times when looked at by EP was actually runs of ectopics and bigeminy. Not AF but absolutely not pleasant at all either!



Edited 1 time(s). Last edit at 12/05/2019 06:30PM by mwcf.

I dealt with flutter as my primary problem for several years, and if you want to see a rhythm that will fool almost any doctor, even many EPs, it's flutter with a variable rate. Until that happened to me I didn't even know such a thing existed. The variable rate makes it look irregular, so it looks just like afib. It fools the Kardia too, and with only lead I on a Kardia it's impossible to distinguish from afib. The only way to identify it is with a 12-lead and look for flutter waves in aVF, or possibly if you're lucky you'll spot P waves.

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GeorgeN

Hi Steve, my comment from the peanut gallery. If your ablation included LAA work or more generally outside the PV's, then yes newer techniques. Assume if no LAA or other non PV work, it was because it was not needed at the time. If the work was not done, of course it does not mean that the disease could not progress to the other areas.

Cheers,

George

My ablation did not involve the LLA.
Appreciate the discussion

Steve

If you call PVC an arrhythmia then yes I never had it before my ablation but it’s my unwanted companion now. Carey suggested it would go away. I’m still waiting...2.5 months. Maybe lack of sleep is the trigger. It’s a catch 22. My pvc’s are violent in the evening and it keeps me awake. Pounding and vibrating chest. Like a caged animal. I was up 10 times (I counted) and my watch only showed 2am before I knew I wasn’t going to get much sleep. I would sleep for about 10-20 minutes with my mask and wake up from the force of the pounding, I flip to the other side and go back to sleep only to repeat until 5am when I have enough. Friday and Sunday night no sleep. I get Nsr at times but if I drink room temperature water, eat, sit the pvc returns. I have had it. I feel sorry for myself..something new for me because I never felt sorry when upon hearing of my aggressive cancer. It’s better HR wise. I had a 205 HR two weeks ago. 162 HR pvc 3 weeks ago. Yesterday it only went up to 122. Today 115 but it’s still early. The freak show will start soon.

I googled pvc and Mayo Clinic that gives natural treatments to rid pvc if one: Smoking-nope. Drinking-nope. The list goes on. Some days I may have an hour or so of nsr but then like now it’s all the time. Especially in the evening. Lisinopril? Crestor? I don’t do anything differently in the evening that could trigger it.

I don’t know if stress can cause it. A predictor(s) ate my koi fish during the night. I was upset this morning. Broken chewed plants floating in the pond and barely populated fishes. I handpicked them as babies and I fatten them up. I bought pretty exotic fish. It was my biofeedback if chilling out by my pond watching my fish. I raised them and bought imported koi food from Japan and pamper them so they get big. Who feeds their fish shrimp? Me. Healthy for them. I didn’t go into AFib today from my pets eaten..so that is good and a sign of a possible successful af ablation. Before my ablation I probably would had instant AF. Upon hearing the news of my mom,dad,brother’s death I had an AF beast marathon with each death. So far, the ablation stopped AF but I read If one gets majority pvcs, during a 24 hr day, then it weakens their heart. I’m wearing the last day of the 14 day zio patch ekg holter. I’ll find out soon enough. I couldn’t go on my treadmill since Friday because my hr would jump from the pvc and I would get lightheaded. One day on the treadmill (speed only a snail 1.2) I had to stop the treadmill and sit on the floor. I was so dizzy. So I am regressing and experiencing a lesser lifestyle. The dizziness from my hr jumping from the high 30s to one teens to 120s-130s has taken its toll. Sorry to vent. It’s my birthday and I don’t feel like celebrating and don’t know my future quality of life if I can’t do anything.