Flutter after ablation and Titrating off propafenone - ideas please.

I had my ablation for afib and aflutter at Southlake in Ontario in December. I was on 150 mg propafenone b.i.d. and 12.5 mg metoprolol b.i.d. for three months afterwards. After my three-month followup, I started to reduce the meds. I started propafenone 75 mg b.i.d for a week and then reduced it again to 37.5 mg b.i.d. and then the troubles started. I got bouts of atrial flutter - sometimes lasting for only a few minutes, sometimes an hour. My heart rate would go up to 120, even though I was still on the metoprolol. It was not afib, it was steady - sinus tachycardia. I had a Holter monitor on for two days and it showed flutter. When I go back on the propafenone, the episodes stop. I saw the EP again last week and he said so little showed on the monitor that if he went in to ablate more, he would not be able to find where to ablate. Right now I am off the propafenone entirely while I wear a two week event monitor to see what it is like without the propafenone. I am getting several episodes a day.

Has anyone had something like this happen after an ablation?

I wonder whether this is just the result of me going off the propafenone too quickly. I see many who titrated down with good results. I did try shaving off a little, but it is very difficult to shave accurate amounts off a half-pill. I remember someone - Gill? talking about titrating down by putting the pill in water, measuring and taking a little less each day or week. I have tried to find that post but haven't been successful yet. Can anyone help?

Thanks,

Marg

Sorry, it wasn't me Marg! Wonder if it was PeggyM.

Gill

Hi Marq.

The fact that your flutter is starting and stopping on its own and is paroxysmal 'may' indicate it is a typical right atrial flutter in origin. More often when flutter happens some months after AFIB ablation it is atypical left atrial flutter and is hard to stop on its own and then you typically need to be cardioverted while setting up a left flutter ablation as soon as possible.

The thing is, chasing down an atypical left flutter circuit is more challenging than a simple PVI anatomical ablation, so make sure your EP is highly experienced in dealing with more complex ablations and atypical left flutter in particular.

If it is likely only right atrial flutter, then most any experienced ablationist should be able to handle it. The caveat is that sometime an atypical flutter will stop and start on its own for a while before becoming persistent, so its only a rule of thumb that when it still stops it is likely to be typical right flutter and not an absolute certainty.

It is possible the flutter is triggers by Propafenone, so if it stops for the long haul after titrating off then you will know that was the culprit and you might not have any more issues with the flutter going forward.

If you start having more consistent breakthroughs though and especially if and when it become persistent flutter then its time for sure for a follow up ablation with a very experienced operator. If you EP is hesitant to do it, then that is a good tip that it may be over his head.

Shannon



Edited 1 time(s). Last edit at 06/16/2013 07:51PM by Shannon.

Marg - What are you doing to ensure that your electrolytes...especially magnesium and potassium are optimized? If you were using them previously, then you should continue. As I just responded to AFhound in another post, I've had excellent success in weaning down and off drugs by optimizing the essential nutrients the heart needs to facilitate electrical signal transmissions...

When you wean down, plan to spend enough time at each diminished dose... like 5 - 7 days and let your body acclimate. I was once told that when the doses become just 'crumbs,' they have no efficacy, but I persisted and thought of it as the power of positive thinking even if it was considered a placebo type dose.

I widh you success.
Jackie


Re: Lower resting heart rate increased incidence of AF
June 16, 2013 06:51AM

The heart meds/drugs I used definitely lowered my HR which was never high to begin with unless during an event.

It has been my experience with using heart meds for AF that until I put back into the cells what was missing… (nutrients versus drugs), I did not measurably or consistently improve.... plus the drugs made me feel awful.

When I reached nutrient optimization or repletion, then I could eliminate the drugs. Even post-ablation and off drugs, if my levels of the electrolytes and other nutrients responsible for the heart energy (voltage) became insufficient, that would trigger an event. I also stepped up proteolytic enzyme intake to help assist magnesium in getting rid of cardiac fibrosis which interferes with the cell signaling and optimal electrical conduction.

This will all be covered (eventually) in my revised version of The Strategy that is on the workbench undergoing a complete overhaul. There are several other very important factors that need to be added. Now that it’s summer and I’m enjoying the luxury of great weather (mostly), I’m not spending as much time at the computer so it's a work in progress. Stay tuned.

Jackie

Hi, Marg, I do believe that it was me.

[www.afibbers.org]

That is one of the times I have explained it, but the idea isn't mine (I'm not that clever). There are more of my posts where I explain it, but that was the first one I came across on a search of my posts.

I hope that was helpful.

lisa
__________________________

So much of medicine is looking solely down the wrong end of the gun barrel, and that is really a pity for all of us---Shannon

Thanks, Lisa, that's what I was looking for. It sounded so simple but I had forgotten the details. I will try that. So basically, I would take about eight weeks to fully titrate down. Does that sound right or should I go slower?

Jackie, Thanks, I do make sure that I have the potassium and magnesium in the right amounts every day and have done so before and after the ablation. I will continue to take them when I start titrating down. And I intend to follow your advice and go very slowly when titrating down. I read your posts faithfully and appreciate all the sound advice you give.

Shannon, Thanks, I also think it is the propafenone that caused the flutter in the first place. My EP is very knowledgeable, I think the best in Canada, studied with Natale at the Cleveland Clinic. He is on Hans' list of the best of the best. I do trust him with this, but at the moment he says that my flutter is not noticeable enough. Granted, when I wore the Holter monitor three months ago for him to look at, I had only gone off the propafenone for two days, and I see that it takes about four or five days for the symptoms to really kick in. So this time, I will give him a lot more to work with and hopefully he will be able to ablate again, if that is what is needed. So right now, I am off the propafenone for two weeks while I wear this event monitor and record my events, and then if I am still having episodes, I will go back on it until I stabilize and then try titrating off. If (fingers crossed) after two weeks I stabilize on my own, so much the better.

Thanks again, everyone, for your responses.

Marg

Marg, this is just my opinion, but unless there is some sort of urgency (beyond just wanting it over with), taking more time will not hurt, and certainly will help avoiding any "shock" to the system. Taking it more slowly, in smaller steps, may also make it easier to judge exactly how far you can go without going too far (if that made sense).

It will also help in discovering when during the day you still need some med (or less).

For me, slowly reducing and tinkering with timing, I have been able to reduce my propafenone (Rythmol SR) by half and my atenolol to 1/16th of its highest dose prescribed to me. At the same time, my episodes went from a high of 2-3 times a week (12-24 hrs duration) to about 1-2 a year (2-6 hrs duration) right now. Keep in mind that I take Mg and K as well as D, a few other supplements as well, so it wasn't solely a case of reducing my meds, but more a case of being able to do so because of the supplements.

lisa
__________________________

So much of medicine is looking solely down the wrong end of the gun barrel, and that is really a pity for all of us---Shannon



Edited 1 time(s). Last edit at 06/16/2013 10:16PM by lisa s.

I guess I should also add this disclaimer : I've not had an ablation, so I can't speak to the aftermath of that , and how it may be different when it comes to getting off the meds without upsetting the apple cart. Logic says that slower, smaller steps would still be the way to go.

lisa
__________________________

So much of medicine is looking solely down the wrong end of the gun barrel, and that is really a pity for all of us---Shannon

If necessary, dilute the propafenone with water or have it compounded into a liquid and use an oral syringe to titrate off by a fraction of a milligram at a time. Some people are very sensitive to dosage decreases of neuro-active drugs.

______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.