Post ablation - blood in lungs - coughing up blood - hemoptysis?

Has anyone else here had this complication after an ablation? Rates are between 1-4% according to research I've found.

Schedule was about like this - ablation Friday AM. Friday evening, having troubles breathing, Saturday got worse, gurgling sounds with every breath, bad coughing attacks began Saturday afternoon, had the feeling I needed to cough up phlegm from lungs but it turns out to be a mix of blood and clear fluid.

Ended up coughing up about a coke can worth of blood over next 24 hours. Extreme near death like feelings Saturday night.

They were treating me for 'pneumonia' (or pneumonia like symptoms) as well as trying to remove excess fluid with lasix. How does one that is not sick prior to an abalation get 'pneumonia' from the ablation itself?

Is it possible that debris from the work done on right atrium went to my lungs and caused this?

Is it possible that having an ablation (for me) produced much more of this debris than the normal person resulting in hemoptysis?

If so - why? Softer heart tissue?

I don't know where you found the 1-4% number, but that's higher than the total for all possible complications.

Pneumonia doesn't happen due to some transfer of material from the atria to the lungs. That's not even physiologically possible. It happens due to the introduction of bacteria into the lungs during intubation. It was probably aspirational pneumonia, which means you inhaled saliva during the introduction or removal of the intubation tube. It could also have been due to bacteria/virus/fungi being introduced by the tube itself since that tube has to pass through your mouth, pharynx, and esophagus, all of which are teeming with nasties.

Been there, done that, spent a night in the hospital on IV antibiotics to show for it. All I experienced was fluid buildup and fever, so I got off easier than you.

Carey thanks for answering and considering what happened here. I find it remarkable that pneumonia develops in hours without exposure unless it was from the inside out - meaning, saline, heparin and ablation debris ended up in lungs. What accounts for 12 oz + of blood being coughed up? BTW this is what they measured. I filled several towels and coffee cups with blood that wasn't accounted for.

The study that showed 4% was for cryoablation.

Other research I've found shows that debris is created in 100% of ablations - whether it ends up causing complications like blood in lungs or stroke is another story.

I'm wondering if I am a uniquely prolific creator of debris. And could it have been caused by supplements which I stopped 2 weeks prior to procedure but maybe should have been off longer? Things like coq10, fish oil, fisetin, or other items which I was not taking but would act similarly; eg serrapeptase or nattokinase

NLAMA-I feel bad for what you went through. I hope you never had to go through that again. I was hospitalized once for over two to three weeks for a staphylococcus wound infection I got from GI surgery. Same concept—where did that come from? What was the origin? Wasn’t the surgeon wearing sterile gloves and the operating room clean?

Anesthesia causes me to get lung liquid buildup in general. Have you ever had general anesthesia before and experienced pneumonia? It didn’t happen with the two ablations but did with over a dozen prior surgeries. I was told it was caused by the anesthesia and each time I was given antibiotics.

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NotLyingAboutMyAfib
Carey thanks for answering and considering what happened here. I find it remarkable that pneumonia develops in hours without exposure unless it was from the inside out - meaning, saline, heparin and ablation debris ended up in lungs. What accounts for 12 oz + of blood being coughed up? BTW this is what they measured. I filled several towels and coffee cups with blood that wasn't accounted for.

Pneumonia can definitely develop in hours. I don't know why you think it can't, but you are wrong.

The so-called "debris" from the ablation did not cause your pneumonia. That's physiologically and anatomically impossible. That debris is really just micro-clots that form when the burns are made. During work in the right atrium those micro-clots would travel to the lungs where they would be trapped and filtered out by the capillary bed. There aren't enough of them and they're too small to do any harm to your lungs, and they absolutely cannot travel beyond the lungs to reach any other part of your body. They are stopped cold in their tracks in the lungs, and then your body dissolves them and removes them the way it does millions of times per day throughout your body every day of your life.

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The study that showed 4% was for cryoablation.

That's the rate for all complications, and cryo does tend to have higher complication rates mainly due to splenic nerve injury (and that almost always heals quickly). Serious complications in a center like St. David's are generally less than 1%, and I'm sure Natale's rates are well under that.

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Other research I've found shows that debris is created in 100% of ablations - whether it ends up causing complications like blood in lungs or stroke is another story.

The only other story is that your pneumonia was almost certainly aspirational. The ablation itself did not cause it. Strokes are a rare complication of ablation, but this "debris" you're focusing on isn't the cause. When a stroke occurs from an ablation, it's usually either a preexisting clot that was dislodged, or a new clot that formed during/after the procedure in the left atrium.

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I'm wondering if I am a uniquely prolific creator of debris. And could it have been caused by supplements which I stopped 2 weeks prior to procedure but maybe should have been off longer? Things like coq10, fish oil, fisetin, or other items which I was not taking but would act similarly; eg serrapeptase or nattokinase

No and no. Really, get off this idea about debris.

Carey, where does all of the blood in lungs come from? I was definitely coughing it out of my lungs. Because of the volume, hospital believed it was in GI tract and put me under to do a probe only to find nothing.

Wouldn't debris (small particles) go from right atrium into lungs and cause those complications?

Here's the research on VT ablations where a Cerebral Protection System was used but of course acute thrombus created in the atrium would be the same.

The placement of the CPS was conducted before the ablation procedure via the right radial artery. The VT ablation procedure was performed via a combined transaortic and transseptal approach. All VTs were successfully ablated. Placement and retrieval of the CPS was successful and safe in all cases. No periprocedural complications related to the CPS were observed and no periprocedural transient ischemic attack or stroke occurred. Debris captured by the CPS was detected in all patients. Histology revealed that acute thrombus was the most common type of debris (91%), followed by arterial wall tissue (73%) and foreign material (55%). Less frequently found were myocardium (27%), calcification (9%), necrotic core (9%), and valve tissue (9%).

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NotLyingAboutMyAfib
Carey, where does all of the blood in lungs come from?

Bleeding caused by the pneumonia. Blood from your atria cannot enter the airways and be coughed out. It's anatomically impossible.

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Wouldn't debris (small particles) go from right atrium into lungs and cause those complications?

No, pneumonia caused those complications. Anything that left your right atrium and ended up inside the capillaries of the lungs would be sterile and simply can't cause pneumonia or bleeding.

You had a decidedly non-sterile tube inserted in your trachea. When that tube went in and came out, you had no gag reflex. Saliva on the tube itself or saliva you inhaled during intubation or extubation were the source of the pneumonia. Your mouth and throat are full of bacteria that can cause pneumonia if saliva gets into your lungs. That's what happened to me and it's what happened to you. You just got a more virulent strain than I did.

I'm sitting here reading through this thread with my wife. She is a DED,MSN,BSN,RN and she and I both agree with Carey here.

There is no way the debris could have entered into your lungs giving the symptoms your describing. They were definitely a side affect of the intubation. Now weather it is a sterilization, aspirasion or present bacteria picked up along the way such as strep by the intubation tube who knows.



Edited 2 time(s). Last edit at 11/10/2020 10:24PM by rocketritch.

OK - I'll go with dirty intubation tube. What caused the blood in lungs?

Why wouldn't they have someone gargle with mouthwash before they put them under and inserted tube? Seems like it could cut down on bacteria.

The blood in your lungs was caused by the pneumonia. Pneumonia can cause bleeding in the lungs.

Any mouthwash strong enough to sterilize your mouth and throat would probably kill you. It's just not possible to sterilize that area.

With being a patient veteran unfortunately with surgeries, I always ask for a spirometer to use after surgery. Did you ask or offered one?

[www.google.com]

[www.healthline.com]
[www.healthline.com]?-

Helps clear your lungs and lowers risk for pneumonia. I got one from my RN in September’s ablation. My index I brought my own.

Yes - I had one. Normally hit 5000 with a thump but only managed 2000 initially and it went up by about 500 a day starting day 3.

Mouthwashes have some use - [www.healio.com]

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NotLyingAboutMyAfib
Mouthwashes have some use - [www.healio.com]

I didn't say they were useless, but that article is about COVID-19, an extremely fragile, easily killed virus. Killing all the much, MUCH hardier bacteria in your mouth and throat can't be accomplished with anything safe to put in your mouth. And even if you could, it would regrow promptly, just like the bacteria that inhabit your skin, GI tract, etc. We evolved to live in harmony with these critters, and killing them is usually futile, temporary at best, and sometimes harmful.

It's tempting to second-guess doctors and say, "Hey, why aren't they doing this simple thing? Did they overlook the obvious?" The answer to that in virtually all cases is no. You don't spend 12 years in training just to be outsmarted by a patient who consulted Dr. Google. If anesthesiologists thought they could safely sterilize your oral cavity before/during intubation with a simple mouthwash, they would be doing so. It's also a low-risk consequence. Aspirational pneumonia from surgical procedures is relatively uncommon, and almost always easily treated since you're already in the hospital where it can be recognized and treated quickly before it gets out of hand. It's just not a big priority.

Carey:

You put a lot more faith in doctors than I do.

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Elizabeth
Carey:

You put a lot more faith in doctors than I do.

My guess it has less to do with faith and more to do with being educated in the processes. Along with the variability of possible complications.

Couple that with a good rapport with your caregiver and those variabilities become less of a concern.

I am here because primary MD failed to ever suggest over a decade 'low carb' as a way of controlling diabetes and hypertension and led to multiple causes for AFIB. Dr. Google and low carb reversed my type 2 in 10 days - what my MD, 2 RDs and 5 drugs + the threat of insulin couldn't do in a decade +.

Cardiologists failed to discuss what could be done about CAC score of 250 or even discuss it at all - while it went up the next 5 years. Took multiple appointments and requests to a 2nd CAC which showed how bad they did their jobs and then suggested to my horror to prescribe statins which would increase my CAC by 50% or more a year while increasing my chances of diabetes, cognitive issues, myopathy etc for a useless unproven strategy of reducing LDL vs focusing on the health of my LDL which is essential for immunity and energy delivery.

Most MDs are practicing the science they learned in school 20-30 years ago taught by professors that learned their science 40-50 years ago.

While I have a lot to learn, I'll take Dr. Google and nurse PubMed and learn as much as I can to keep these standard of don't care professionals from harming me.

If MDs knew WTF they were doing, this forum wouldn't even exist.

Agree with that Elizabeth - I thought a Dr was good if they listened to me and I left with some prescriptions. Turns out they were just listening in order to code into insurance for billing and collect more income for their practice.

Good MDs listen and test and teach. That's what I have now. If I had this Dr. 10 years ago I would have been great.

I suppose I'm fortunate. My PCP always seemed to be utd on all the most recent treatments and testing. It was a rare occasion for him to send me off with a script. Unless it was for something common like a sinus infection or a preemptive cycle of doxycycline if he was suspect of Lyme's.

All of my other doctors are affiliated with UPMC. Which is not only a teaching hospital but also a magnet hospital. This also forces other local hospitals to up their game.

I do agree with NLAMA. As I have mentioned before on threads I have tossed many doctors to the curb because of exactly what he described. However, there are allot of good doctors out there. I am also fortunate to have my own in-house health advocate.

I finally found a good one and had a not too bad one before that but the fact that I'm here asking questions that should have been explained to me in the hospital when an ablation turned from an overnight affair into a 6 day brush with death with very little answers indicates the pros aren't doing their job. I shouldn't be looking for explanation and understandings on the interwebs - no one should - yet here we are.

NLAMAF - I am very sorry you had such a traumatic experience with your recent ablation and I wish you will with your recovery process.

I can truly appreciate your situation regarding being prescribed meds instead of managing the root cause of the ailment as I have experienced three separate cases of mis-treatment due to the fact that the doctors were unaware of the fundamental underlying 'root-cause' of my ailments which were nutrition-based. I won't go into the details but I know full-well your 'after the-fact' frustration. One of my cases had a dreadful result which was totally unavoidable if the doctors I consulted had a clue about fundamental nutrition.

You're correct, too, that with the advent of online research resources, we can research symptoms and causes and we can learn to advocate for ourselves in finding an appropriate physician to oversee our health...especially now that there are medical organizations that focus on holistic and functional medicine with programs for certification which includes what was not covered in medical school. Once I became a patient of my board-certified, Family Practice, MD... who is also certified by the Institute for Functional Medicine, my life took a distinct 180° positive improvement. I still see a D.O. for routine visits covered under my insurance and she cooperates with my FP MD to make sure that in my 'senior years,' I'm tested to maintain systemic nutritional levels that influence my health and longevity. If it weren't for my LAA being isolated, I would not be taking Eliquis, which is my only medication. I do take abundant nutritional supplements based on NutrEval results from Genova Diagnostics and other routine labs from Lab Corp.

With the onset of Afib 25 years ago, I also learned more about nutritional requirements for heart health. I was also very fortunate to be in the care of a cardiologist at the Cleveland Clinic who eventually helped me connect with Dr. Natale.
My first ablation was 8 years after the AF onset...that lasted for 11 years before the Aflutter surfaced and I had no hesitation to follow Dr. Natale to Texas for the 2nd which isolated the LAA and then, 7 mos. later... a touchup. All has been very calm since, thanks to Dr. Natale, but I have never slacked off on my protocols for overall nutritional support including cardiac.

Be well and stay safe,
Jackie

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NotLyingAboutMyAfib
If MDs knew WTF they were doing, this forum wouldn't even exist.

Sigh... I should have known I had to be more specific.

I was talking specifically about anesthesiologists and intubation. Anesthesiologists don't and can't practice on what they learned 30 years ago, and they don't engage in fuzzy medicine that's in danger of being found wrong by your google search or personal experiences. If they did that, they would be killing patients. Keeping you alive is their absolute first job. It's not the surgeon who does that -- it's the anesthesiologist. And the basics of doing that aren't fuzzy and don't change. In EMS we had a saying:

The blood goes round and round
The air goes in and out
Any deviation from that is a bad thing

That's the mantra an anesthesiologist lives by, and all the anecdotes of foolish and misguided cardiologists and PCPs you can think of won't change the fact that either that doctor behind your head while you're on that table knows what they're doing and is fully up to date on their training, or you will soon be dead.

Carey wanted me to mention that my experience was unique. I am still reading papers to find out how unique and get a real handle on the risks.

Carey - "Aspirational pneumonia from surgical procedures is relatively uncommon"

Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs 48-72 hours or thereafter follow¬ing endotracheal intubation, characterized by the pre¬sence of a new or progressive infiltrate, signs of systemic infection (fever, altered white blood cell count), changes in sputum characteristics, and detection of a causative agent [1]. VAP contributes to approximately half of all cases of hospital-acquired pneumonia [1], [2]. VAP is estimated to occur in 9-27 % of all mechanically ventilated patients, with the highest risk being early in the course of hospitalization

So I agree that it was the intubation that caused it but in no way is it rare. But everything I've read doesn't account for the amount of blood I coughed up - even the hospital was confused enough by the volume and purity of it and put me under sedation to do another procedure where they looked in my GI tract to see if the blood was coming from there.

Given the possibility (remote) of atrial-esophageal fistula post ablation, I’m shocked that they scoped you. They should not have and you should have refused the procedure. At a bare minimum a CT scan should’ve been done first to look for an AEF.

Sorry it happened but it was a pneumonia from the intubation. Your lungs are a perfect breeding ground for bacteria. Warm, moist and oxygenated. Petri dishes can’t grow stuff faster. And every ounce of your body’s blood volume goes through them.

Glad you made it through all of that!

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wolfpack
Given the possibility (remote) of atrial-esophageal fistula post ablation,

Too soon for that. AEFs typically occur 2-6 weeks out because it takes time for the fistula to erode its way through two layers of tissue.

Why do they even do this in the first place? Can't they just push O2 in through a mask?

AFAIK they didn't do this for any ECVs, colonoscopy's I've had. But hell who knows? I was off in propofol dreamland the whole time. Easy to understand why Michael Jackson loved the stuff.

Maybe a short 'touch up' ablation can be conducted w/o intubation? It was the worst of the 'at that time' complications because I was gurgling with every breath, felt like I was drowning and coughing up all of this blood - and to be clear bright red fresh blood - not clear fluid with a bloody tinge, nor reddish brown sputum - just blood with a small amount of clear fluid that remained separate (layered) in the vessels they had me collect it in.

Because during a prolonged procedure using general anesthesia, definitive airway control is essential to keeping you alive. If something goes south, they can't be taking time to scramble to establish an airway, a feat that's not guaranteed to be possible. Your life depends on that airway -- within just seconds or a handful of minutes -- so having it established before you run into trouble is the standard of care. Another reason during ablations (and chest surgery) is that it gives the EP the ability to control your breathing. The operator can tell the anesthesiologist to hold your breathing for a few moments, make it deeper, shallower, faster, slower. They have total control. This goes to what I said earlier about anesthesiologists and how they're not doctors who can get by on what they learned 30 years ago.

As for other, shorter procedures using light anesthesia or conscious sedation, they can wake you back up quickly if needed, and you don't have catheters (or surgical tools) inside you that can't be immediately removed. As for colonoscopies, you're probably unaware but during a colonoscopy you probably have another airway device in your throat known as a Laryngeal Mask Airway (LMA). An LMA is like an endotracheal tube except that it covers the opening of your trachea instead of actually going inside it. They can use this device for a colonoscopy because it's a short procedure and the colonoscope can be removed immediately and you can be awakened very quickly if needed. So it's less invasive but it still isn't a guarantee against aspiration. As long as you're "under" and have no gag reflex, nothing can guarantee that.

There are EPs who will do ablations without general anesthesia, and therefore without intubation, but they are few and far between in the US. I would never agree to such a procedure. I don't know if you could talk Natale into doing that, but I doubt it.

Don't just focus on the one unlikely thing that happened to you. Consider the entire risk profile, and the lack of definitive airway control during general anesthesia is a far more serious risk than what happened to you.

Thanks for the overview and understanding. I'm not trying to talk anyone (yet alone Dr N into how they run their procedures)

But my mouthwash idea ain't so bad after all

In total, 14.7% patients of the HP group and 38.2% patients of the NS group contracted VAP. The risk of VAP in the NS group was 2.60 times greater than that in the HP group (RR = 2.60, 95% CI: 1.04–6.49, p = 0.0279). The mean ± SD MCPIS was calculated as 3.91 ± 1.35 in the HP group and 4.65 ± 1.55 in the NS group, a difference statistically significant (p = 0.042). There were no significant differences in the risk factors for VAP between the two groups.

Conclusion

HP mouthwash was found more effective than NS in reducing VAP. HP mouthwash can therefore be used in routine nursing care for reducing VAP.

[www.scielo.br]

Others -

VAP incidence was significantly lower in the povidone-iodine rinse recipients than in either the saline-rinse or the standard-care recipients (8% vs. 39% vs. 42%). No differences were noted in ICU length of stay or mortality rate, or in the incidence of infections at other sites.

[www.jwatch.org]

[www.ncbi.nlm.nih.gov]

I convinced two surgeons to give me a spinal instead of a general. I didn’t move a bit. I’m a seasoned patient. I asked for an overhead mirror on my side of the sterile blue barrier and I enjoyed watching the whole thing from initial scalpel cut to sewing up in the end. I wasn’t nervous and the next major surgery I had I also asked for a spinal. The hardest part for me was being as mute as I could be (I’m chatty) and not to ask too many questions and let the surgeon concentrate and do his thing. I convinced my daughter to try a spinal and actually got permission to be in the operating room to hold her hand.

I did well but Carey is right, in case of an emergency it would not be to my benefit.

I'm going to ask (demand) the oral rinse if I should decide to have a touch up -. BTW - one of my very intelligent friends that ended up with covid used povidone iodine 0.2-1.0% gargle 4x a day as part of his protocol - knocked covid out in 4 days.

A very long time ago, January 2003, in Bordeaux, I had an ablation and touch up under sedation rather than anaesthetic. It was very comfortable, no problems, and I quite enjoyed sleepily watching the flickering wires on the monitor above my head.

Don’t know what the current practice is in Bordeaux.

Still in nsr after almost 18 years. Most EPs in those days wouldn’t even try to ablate longterm persistent AF, which I had had for 18 months. Think I hit the jackpot!!

Gill

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Gill
A very long time ago, January 2003, in Bordeaux, I had an ablation and touch up under sedation rather than anaesthetic. It was very comfortable, no problems, and I quite enjoyed sleepily watching the flickering wires on the monitor above my head.

Don’t know what the current practice is in Bordeaux.

Still in nsr after almost 18 years. Most EPs in those days wouldn’t even try to ablate longterm persistent AF, which I had had for 18 months. Think I hit the jackpot!!

Gill

May you remain successful in living in nsr your entire long life. I’m happy for you.

Hi Gill - So good to see you continue to do so well.
You certainly did hit the jackpot and I'm so pleased for you.

I'm so glad you continue to check in periodically.
Thank you.

Kind regards,
Jackie