Two Ablations Now Afib Again

It has been awhile since I've made a post. After two ablations by Dr. Natale in 2014 and 2015 for persistent afib, I've been afib free for 5 years. My left atrial appendage is non-functioning after last very extensive ablation; only Rx I've been on for 5 years is Xarelto daily.

Well- the beast arose again after working outdoors in the heat and probably got dehydrated.

This time the afib is paroxysmal rather than persistent- at this point. But I actually feel worse this time around than I did with previous bouts of afib.

I used propaferone to get back to NSR, then had another 2 day flare up a few days ago. I'm now taking propaferone 3 times a day. My current EP at Vanderbilt recommended 150 mg of propaferone 3 days a day and Metoprolol 25ER once a day, however just the propaferone lowered by heart rate significantly and I started taking just half a tablet (75mg) and my heart rate is below 60 most of the time. I did not want to lower it more than that by adding the Metoprolol - so I have not taken it.

I've been back in NSR for 2 days, but feel fatigued. I'm not sure if it is the propaferone or due to having a low heart rate or ???. Even if I do light exercise my heart rate doesn't get above 80. As I said, I actually feel worse this time around than when I had persistent afib before.

My health- I'm 65 yrs old, active (exercise regular basis, run 2-3 miles a few times a week), not over weight, no other significant health concerns. I take supplements- potassium, mag, COq10, Taurine, Vit D, Red Yeast Rice.
I really felt pretty good until afib arose again a couple weeks ago.
I know at some point I was wanting to close off the left atrial appendage- probably with a Watchman Flx (Vanderbilt EP active in using this device). So, Iooks like I will probably need more ablation in the future too.

Anyone had experience with course of action after already having 2 ablations?
Thanks!



Edited 1 time(s). Last edit at 09/11/2020 09:58PM by KenKY.

I'm no expert but I've read several times taking a beta blocker is not required when taking propafenone as it is with flecainide.
A BB, even at low dose, prevents my heart from reaching 100 bpm even while exercising. I'd say it's the same for you. Just my own experience as afibber. I may be wrong.

Hey KenKy,

Please send me your cell number and time zone (I assume it is Kentucky and thus EST time zone I believe?) and let's discuss this by phone so I'm
clear whether or not Dr Natale did the LAA isolation in your index procedure and then did a touch up of the LAA in second ablation? After I have a more complete overview of exactly what was done in each of your two Natale ABLs we can zero in quickly on your next best step to restore durable NSR.

When Dr Natale does an index ablation on a patient in confirmed persistent who is ~ age 60 or above, it is not uncommon for him to have to isolate the LAA and CS (coronary sinus) in that index procedure. If he did perform LAA isolation in your first ablation with him, then I suspect he had to revisit the LAA and possibly CS too, in the following second ablation to touch-up the LAA isolation a second time.

Dr Natale and his staff no doubt told you that since the LAA structural morphology is a bit different from the other target areas in which most baseline ablation takes place (i.e. such as the PVI, Left Posterior Wall-Iso and SVC-Iso.), that the odds of needing to revisit the LAA for a touch up procedure to insure really buttoning the LAA down for good at least one more time, is approx. 25% odds of needing that second zap of the LAA ostium.

When the second LAA-Iso ablation is completed, typically that results in approximately just over 90% odds of long term freedom from all
atrial arrhythmia!

You have noted in your thread above that you had around 5 years of steady NSR since the second ablation ... and assuming, for the moment, until you confirm for me one way or the other that your first LAA-Iso was done during your index Natale ABL, or did he not have to touch the LAA until as part of your second ABL??

If Dr N did isolate your LAA in your first ABL, and you then subsequently required a touch up re-isolation of your LAA in round two, then I suspect this late recurrence after 5 yrs of solid NSR may be atypical left atrial flutter rather than strictly AFIB. In addition, while the vast majority of LAA-isolations are solid by end of the second procedure, there can be a much more rare 3rd brief revisit to zap the LAA ostium once and for all!

Out of all the many many hundreds of Dr. Natale LAA-Iso patients I have followed over the years, the vast majority have remained in durable long term NSR after 1 to 2 Natale ablations. Again the vast majority needing an LAA-Isolation are in persistent or LSPAF, though occasionally longer term paroxysmal Afibbers who have more ads an ed structural remodeling can also require LAA-iso in and index ABL
or second procedure.

And only ~ 14 persistent/LSPAF patients who I've followed, and who started and completed their ablation process with Dr N, who then went on to require a first, second and finally a more rare third LAA touch-up ablation with Dr Natale, have not required any additional ablation work, to-date, beyond these relatively rare 3rd LAA touch-ups. There may be a few who required a 4th LAA touch up but I do not recall any from our long forum history who needed a 4th visit to his EP-Lab to restore durable lasting NSR.

So KenKy, you may be one of these more rare folks for whom the third zap proves to be the final charm.

Keep in mind though too, that if you did not require that first LAA Isolation until your second touch-up with Natale, then you may need only one last visit to his EP-Lab but that's would only be your second LAA touch-up.

Bottom line, your odds are extremely high that should you need one final LAA button down, it should truly be your last visit and when it comes to LAA-isolation, if you need a third one, the overall amount of ablation work required will be a very modest touch-up, typically requiring just a handful of RF lesions to finish the job.


Hope that helps Kenky, and we can discuss by phone any further questions you may have.

I suggest calling your prior NP at St Davids and send them an ECG or KARDIA of your current arrhythmia ... if you are still
out of rhythm then it is probably worth doing an ECV to see if this might be just a one or two off fluke after 5 yrs of silence. If you have more than three new episodes of AFIB/Flutter/ATachy then a final touch-up is no doubt in the cards to restore lasting NSR.

This coming Wednesday through Friday, I'll be down in Phoenix for my right hand surgery (Thursday early at 5:00am) ... my left hand was done this past February ..: and thus my typing will be on hiatus for a while so I'll be limited to cell phone communication for several months.

Cheers!
Shannon



Edited 3 time(s). Last edit at 09/12/2020 10:43AM by Shannon.

Sorry Ken, I guess 5 yrs is good though. Shan will give good advice.