Touch-up ablation - foreign travel and CV-19

Hi all,

26 months out from my PVI, on 20th Oct I had a 13 hour episode of a focal atrial tachycardia - 105 BPM and regular as clockwork - not too unpleasant but not exactly fun either. It felt a bit like AF when it started (6-15am) for a minute or two but I couldn't be sure - it could just as easily have been a run of ectopics. It seemed to go back into lumpy ectopics for a minute or two before it converted back to NSR at 60 BPM at around 7-30pm after dinner.

Professor Jais at Bordeaux feels that a second touch-up ablation is required - an opinion with which I entirely agree. As I understand it the majority of post-PVI atrial tachycardias are the result of PV reconnections. Shannon always told me to expect to need two procedures to beat this thing so I've always pretty much expected to go back to Bordeaux sooner rather than later and am psychologically fully prepared to do just that!

Prof Jais has put me back on Flec 100mg BID in the meantime. I've also started Apixaban 5mg BID too.

So I'm keen to go and on 26th Oct I was offered 24th Nov 2020. The problem obviously is CV-19. Since I was offered 24th Nov on 26th Oct France has gone into lockdown 2 and England is about to the day after tomorrow. My wife and mother (even my brilliant doc of the last 30 years) really don't want me to travel - risk of getting stuck in France if borders close, risk of CV-19, need for 14 days self-isolation on my return, risk of over-run hospitals here in UK not being able to deal with any post ablation adverse issues (unlikely but not impossible) I might have etc.

I'm agonising over things. Do you guys think I should wait 2 or 3 months in the hope that things will have settled CV-19-wise by then?? Or do I chance it??

Cheers,

Mike F

Even without the COVID issues I wouldn't seek a second ablation based on a single episode in 26 months. In fact, I wouldn't take the flecainide either. Since it was a regular rhythm it probably wasn't afib, so could have been flutter or atrial tachycardia, but either way a single episode doesn't justify intervention in my mind, especially since it was a fairly tolerable rate and rhythm. I would wait and see what happens. What if you have an episode like this only every two years or so? Personally, I'd find that more tolerable than a repeat procedure and the risk of being stranded in another country, possibly for months.

Yes, going into an ablation one should be prepared for the possibility of needing a second procedure, but it's not a guaranteed thing by any means so I just don't think a single episode justifies intervention. Remember, any intervention can make things worse, so I would wait and make sure the risk is worth it.

That's just my 2 cents and how I would handle it if I were in your shoes.

Like you Mike I had an episode 13 months after the first op. As Carey said I waited to see if it was a one off. 7 months later I had another. 3weeks later another and one a week later quickly followed by two more. I knew then I really needed a second procedure. I wish I'd gone earlier because by now lockdown was just about to start.

I asked my cardiologist for a prescription for Flecainide and have been on 50 mg twice a day for over 7 months. It has kept the heart in NSR but I don't don't like it.

However my decision is to wait until Covid 19 settles before booking another op.

Sam

Mike,

I second Carey's advise. I certainly wouldn't go based on one episode. Question, would PIP (vs chronic) flec work? I recall you took flec for a long time, pre ablation.

I'd list out pros and cons of going now and waiting to get a sense of what to do. Personally, I don't see any real advantage to rush it.

Cheers,

George



Edited 1 time(s). Last edit at 11/03/2020 02:42PM by GeorgeN.

I agree with Carey. Waiting at this juncture is not going to create any real issues for you. However, traveling for you at this particular time could.

Also, stressing over the decision isn't going to be any good for you either.

I would not go for the 2nd. I would try George's anti-afib concoction. I notice on the days I take it (now every day) I have a lot more good readings. Or could be I am finally settling down int he blanking period in the 9th week.

Many thanks guys.

I'm very much leaning towards postponing for the time being, waiting to see what happens and rescheduling as and if necessary.

I did post at the time but should have reiterated/added in my first post that I have had 2 other multi-hour episodes of ectopics (no AF on ECG but bigeminy, trigeminy etc.)since my Aug 18 PVI i.e. in Sept 19 and June 20 prior to this latest atrial tachycardia. And this latest incident did feel quite a bit like AF when it first started (but then so do some runs of ectopics) - thinking back it also similarly felt quite a bit like AF for a minute or two before converting back to NSR too. Hence why Prof Jais and I were of the same mind that a touch-up ablation is likely required - and why I was thinking OK let's just get it done. But that said, this really isn't the best set of circumstances in which to be having it done! At least this latest episode didn't feel anywhere near as unpleasant as the previous two as aforementioned: as Carey says, regular and not too fast. And as I said PV reconnection does frequently give rise to atrial tachycardias after segmental/antral PVI. I've always felt that my PVI did and still does do a good job in the sense that it has stopped my heart from being as easily able to go into and maintain AF than was the case previously. But reconnections do so frequently happen in addition to which new ectopic-inducing sites develop in the heart as we who are prone to such things get older.

Cheers again guys,

Mike F

Quote
GeorgeN
Mike,
Question, would PIP (vs chronic) flec work?
George

Just want to mention if one plans on a PIP flecainide approach —the dosing recommendation is 200mg in a 24 hour period if they weigh less than 154 pounds and those who weigh more than 154 pounds, then 300mg is the maximum flecainide dose within a 24 hour period.

Here is a recent flecainide toxicity thread for those who are interested:
[www.afibbers.org]



Edited 1 time(s). Last edit at 11/04/2020 12:19PM by susan.d.

Well that's it postponed - the folks at Bordeaux were totally understanding about the situation as one would expect,

I had two ablations in Bordeaux. Second one touch up, required because AF came back after 9 months. I decided to have it done as my episodes were very frequent and long. After touch up I was AF free for 12 years. AF reappeared in past year. Getting very frequent and long episodes. I was considering traveling to Bordeaux but because of pandemic decided against it. But.. by being not able to live with very symptomatic and debilitating episodes I will have ablation in my country.
I think your decision is good. It's too much risk during pandemic, anyway organism/ immune system/ is compromised after invasive procedure. If no pandemic I would go to Bordeaux in a hear beat. 😀