Cath Ablation in Two Weeks...

Hello everyone.

I am seeking any information, advice, or thoughts related to what is coming for me.

I am a 39 y.o. male, 6'2", 185, very fit and athletically active my entire life. When I was about 23, I noted that during periods of really intense exercise (typically hockey or basketball), there were times my heart would race and I would get a little faint, having to back off. It also occurred sometimes during road races (5k/10k). I went to my doctor at the time and she said that I was "Just getting older" and would "need to have reduced expectations."

Fast forward sixteen years, still active, still occasionally experiencing this, and I had a routine physical with my current doctor. He caught me in a period of a-fib on an EKG check. That led to a 24 hour monitor which showed me in and out of a-fib all day long and especially while sleeping. My resting heart rate has always been in the 40's, and he said there were times during the a-fib where it would swing to as low as 30 and as high as 70. My echocardiogram, thyroid, and other data have led to me being diagnosed with lone a-fib.

I met with the best cath EP Dr. in my region, and liked him. He set me up with my coming surgery. I really understand this stuff because I have a biology degree with physiology as well.

The only issue I have now is that I had a stress test last week in preparation for the surgery (along with the echocardiogram, which was all good). I knocked the stress test out of the park but right before the tech stopped the monitor (after I stepped off the treadmill) I felt that twinge of faintness that I would sometimes get in basketball or hockey during an intense period....and when he saw it on the screen (a-fib kicked in, then v-tach at 260 beats a minute) he raced out to get the cardiologist. Next thing I know I'm hooked to an IV for heart rate decreasing medication

It was a real good thing they caught this, but the cardiologist did not feel comfortable getting in depth about it and wanted me to have a brief consult with the EP surgeon (Tuesday). He did say that it was aberrent v-tach and could be fixed with the a-fib.

Is there anyone here who had a similar diagnosis? I am happy they found it (v-tach can lead to v-fib and sudden death) but I am concerned my case just got a lot more complicated and difficult to treat with cath ablation. I know my surgeon is the best in the area but I wonder if I need to go see someone who is the best with this type of complicating factor. Any input?

Thanks!

Ryan

I should also add that I don't really notice if I am in a-fib...I suspect I have had it so long that I don't know what it feels like to not have it. I get some chest tightness and fluttery nervous feelings in my heart area that is uncomfortable but I can't be certain that it is a-fib. I also wonder if this surgery will make me feel.....better, as if I didn't know what I was missing all these years. I read that many people are very symptomatic, but when I suspect I am feeling this, I have in the past written it off as "nerves." That has led me to believe myself a "high strung" person....but I suspect now that stress was simply a trigger for a-fib for me, leading me to feel like crap when I was stressed out, which is often.

Ryan,

Any possibility of WPW (wolff parkinson white) syndrome, too. WPW's are prone to afib but they also have multiple pathways through the AV node which can lead to the high rates.

Also, you may want to tone back the "very fit and athletically active my entire life" part. Good for the heart plumbing but not for the electrical circuits. I know, chronic fitness was my ticket to afib. I'm still fit and active but have eliminated steady state cardio training and/or competition from what I do. I also limit everything to what my nose will allow - breathing always with mouth closed, even HIIT Tabatas.

George

Thank you for the quick reply, George, and thank you for your knowledge. I just read about WPW, and perhaps it is a possibility (however rare). I am guessing that at this point, the EP surgeon is going to tell me on Tuesday that he can't tell for sure until he gets in there and does the EP study pre-ablation, right?

As I said, the two cardiologists who were attending when I had the V-tach episode were extremely interested in it, until they carefully read the event onscreen and mutually diagnosed it as aberrent vt.

As for your comment about fitness getting us into electrical trouble: I don't think I'm being modest when I say that I just prefer an active lifestyle with light running and sports. I'm not anywhere near a triathlete; I hurt my back at age 29 and typically only run twice a week max in warm months, limiting my mileage to about 5-7k so as to help my back and hips that don't respond to high-mileage sciatica

That said, if the cardiologists tell me that seriously backing down my exercise intensity for the rest of my life is in the best interest of longevity, I'll do it. If not, I'll keep having fun.

Hi Ryan,

Not sure the cardios will tell you. This was a flag for me: "My resting heart rate has always been in the 40's"

A lot of guys who regularly exercise and have afib have a "vagal" trigger for afib <[www.afibbers.org]
<[www.afibbers.org]

The arial effective refractory period (AERP){more here: <[www.afibbers.org]} is essentially the "reset" time for the pacing cells in the atria. The slower your heart rate the more time there is for something to go wrong. I used to have a resting heart rate in the high 40's (dropping into the 30's on a recording heart rate monitor during sleep). Now it is more in the high 50's dropping into the low 50's or high 40's during sleep. I wasn't that much of a manic on exercise.

The question I always ask myself is "how much is too much?" I like to be very active and I am compared to many my age (60). I always think (and others here probably think) I err on the too much side. But I've been able to keep myself in rhythm and remission for very long stretches of time for 11 1/2 years (currently 1 hour of afib in 32 months). I'm sure the answer to this question is specific to an individual.

So where I've come down to is to limit cardio. As I said, I do HIIT, bodyweight training, alpine skiing, rock climbing & so forth. I don't exactly sit at home. When I am doing activities that resemble steady state cardio (like breaking trail in 2' snow on snowshoes), I don't push myself hard (again keeping my mouth shut and using nasal breathing). The pushing myself hard for extended periods of time is, for me, a potential trigger of a vagal episode. Thirty one months ago, I was with a group on a couloir climb to 13,000'. This was certainly violating this rule for me. So I took buckets of magnesium to offset the stress (I currently take 5.2g/day of mag, just on a normal day). This worked and I did not have a delayed vagal trigger.

Our prior moderator, Hans Larsen, wrote this on exercise: <[www.afibbers.org]

As to an EP for an ablation. Most here would encourage you to select the best possible EP IN THE WORLD, not just in your area. There is a fairly short list to choose from. The success stats fall off dramatically and the nasty complications likewise increase dramatically.

I would bring up the WPW question with the EP's. A WPW ablation is very easy compared to an afib ablation and requires much less skill. Your tachy history with exercise over time sounds similar to those I know with WPW.

George

Thank you George....I really like the information you are giving me about this.

Are there any top EP surgeons in the southern Great Lakes Region? (UM Hospital, Cleveland Clinic, etc?)

Rylar - As for referrals in the Great Lakes Region... consider Robert A. Schweikert, MD in Akron, Ohio - Heart Rhythm Associates which is now part of the Cleveland Clinic, as one of the top-tier ablationists. Several of our members have had safe and successful ablations with him. I've consulted with him when I had need for electrocardioversions. [www.healthcare4ppl.com]

While you are waiting and after the procedure, you should take the time to read more at this website about the importance of optimizing the critical minerals (electrolytes) that help stabilize heart cells so that the electrical conduction signals can function as normal... especially with your athletic exertional history. Exercise is a stress and stress (of all types) depletes these important nutrients. In some people, the resulting manifestation is arrhythmia. We call this the "canary in the coal mine" warning that something in the body is amiss. George has offered you excellent advice. Take the time to learn more because at your young age, you have a lot of years ahead to cope with the ramifications of developing Afib.

Check out some of the topics at this link: [www.afibbers.org]

We are all here to help so, welcome to the group.

Jackie

"Take the time to learn more because at your young age, you have a lot of years ahead to cope with the ramifications of developing Afib."

Jackie-Thanks for the info. Can I ask you what you probably think is a simple question: If I have a "successful" ablation under current standards, what exactly are the lifetime ramifications for me? I was told that without ablation, his job was to keep me off a pace maker for as many years as possible. I understand this has only been around for about 18 years....so there isn't a lot of long-term data on stability....... The doctors have been unable to offer a lot of information and I am pretty unhappy with that. That is why I am here, I suppose.

Rylar,

There are some long-term success stories with ablations on this forum, and those with more experience can fill you in.

I'm echoing Jackie's recommendation about Dr. Schweikert. I traveled from Pittsburgh to see him and he performed an ablation on me in September after my long-term use of propafenone (over 6 years) failed. So far, so good and I have a blessed normal heartbeat. Dr. Schweikert gives you as much time as you need during your appointment and is very thorough and knowledgeable.

Best wishes to you.

Doreen

Rylar said:

Jackie-Thanks for the info. Can I ask you what you probably think is a simple question: If I have a "successful" ablation under current standards, what exactly are the lifetime ramifications for me? I was told that without ablation, his job was to keep me off a pace maker for as many years as possible. I understand this has only been around for about 18 years....so there isn't a lot of long-term data on stability......sad smiley. The doctors have been unable to offer a lot of information and I am pretty unhappy with that. That is why I am here, I suppose.

The fact that you haven't received much useful information from your consults thus far is often not uncommon, unfortunately. Most of us can relate to our own initial contacts with cardiologists who are often not well-versed in the current ablation methods. The best approach is to consult with whom we term, top-tier Electrophysiologists... those who do the ablation procedures and have done thousands of successful procedures. The good news is that when you are healthy and young and your heart is healthy, the outcomes with the top EPs are most likely to be easy and successful.

My first ablation (age 67 - by Dr. Natale) lasted 11 years... then I had some trouble areas crop up so I had I two more procedures after that to manage those.

My point to you in my initial response is that from our research and anecdotal testimonies, many of us have found that the imbalances or deficiencies in the core electrolytes are essential to identify and correct to help insure that the heart has what it needs to function...with or without the ablation procedure. We have a small group of people who have managed to correct those deficiencies and have not needed to have the ablation. Our 'star' member (Erling) in that group is now 87 and after dealing with debilitating Afib for 8 years or so (I've forgotten the exact number), managed to balance his electrolytes so afib was no longer an issue. Several others have posted their non-surgical successes as well.

So to help insure that an ablation is successful for the long term, it's helpful to be mindful of what depletes electrolytes and then work to optimize and maintain levels that help the entire body function as intended. Today, we have many influences that enter into this depletion issue including dietary choices, lifestyle, genetics, stress levels, environmental toxicities and more. No two people are identical in needs or responses, but with time and dedication, one can typically restore those areas to ranges that promote overall homeostatic balances. Endurance athletes are highly prone to the consequences of electrolyte imbalances which is why I initially commented to you as I did. With or without an ablation, the electrolyte balance is imperative.

You should work on the electrolyte issues, do the ExaTest if you can so you know your baseline, and consider making the Schweikert contact in Akron sooner rather than later. He has a busy schedule... and as Doreen says.. takes plenty of time for the consult and is a genuinely nice person. He also had the tremendous advantage of working with Dr. Natale when they were both at the Cleveland Clinic main campus.

Let me know if I can help direct you to more info on the various topics.

Best to you,
Jackie

Thanks for your info Jackie. Regardless of outcome, I will be looking at the Magnesium issue along with other electrolytes.

Today I had my second meeting with my EP Surgeon. He pulled my stress test chart, looked at the end where I went into V-tach, and said it wasn't v-tach per se. He strongly believes I either have WPW syndrome or have perimitral tachycardia of some type. As I am sure you learned folks know, he told me WPW would be a wonderfully easy fix in the absence of other problems, but the perimitral problem could be a real PIA to find and ablate. His plan is to take this slowly and simply go in for an hour long procedure on my cath day to look for the WPW site, ablate it if it is found, then back out. If he doesn't find the WPW area, he has to back out and we will later start looking at structures around the mitral area using cardiac MRI before taking any action as it is hard to find (electrical study will not show it).

I did get hooked up today with University of Michigan's top ablation EP Doctor for a second consult. I am fine having the current surgeon do the WPW search if the UM guy agrees on the plan; if my current guy says no WPW found, I am going to need someone really experienced with the perimitral issue.

Ryan,

"I was told that without ablation, his job was to keep me off a pace maker for as many years as possible. "

This is BS. There is a procedure where they destroy the AV node (AV node ablation) and then put you on a pacemaker, for the rest of your life. This is rarely done anymore. For one thing you now need a pacemaker to stay alive...

Essentially, afib can be fatal in two cases. 1) you stroke out due to a clot forming. This is why anticoagulation is used. A metric CHA2DS2-VASc is usually used to decide whether it is needed. It is not typically prescribed with a score of 0. <[en.wikipedia.org] 2) you get heart failure due to uncontrolled high rate during afib. Rate control drugs can be prescribed if this is an issue. During my initial 4 months of afib, I had a 2 1/2 month episode. The rate never went over 100 BPM, so not an issue for me then.

If you stay in NSR these are not a worry. For an afibber, NSR can be created by an ablation, rhythm control meds or sometimes through other strategies like trigger avoidance or electrolyte supplementation as Jackie describes.

Given that you are in and out of afib all day, you might try rhythm control meds, but an ablation is likely warranted.

George

Hi Ryan,

Am joining in late here as I only have a short while to check in with the board and then back to the grind on the next issue of The AFIB Report that I'm deep into at the moment and and shooting to have done by end of next week ...

Although as a diehard Denver Broncos fan for a full 50 years now, I am going to reward my own long support for the team by taking Sunday off and just watch the whole show from beginning to end ... win or lose ... it's great they made it all the way this year!

In any event Ryan, good to hear you got a clarification on the 'Aberrant VT' diagnosis ... By the way, how many PVC beats in a row did you experience in each run that led to the diagnosis of Aberrant VT?? Usually, if its three to five PVC in a row it is often seen as 'Aberrant AFIB' which is what your Cardio's may have been referring to anyway as Aberrant AFIB like that includes such modest short runs of PVCs. When the run is made of more than 9 consecutive PVCs in a row it's more often just called real VT.

In any event, ruling in or out WPW certainly makes sense, but with the long-term AFIB issue as well, this is where you may well have been in LSPAF (long-standing persistent afib). That likelihood, and your EPs comment about feeling a bit edgy and uncertain about dealing with a possible perimitral flutter/tachy ... otherwise known as mitral isthmus flutter ... are both good indications for a guy like you with your described history that youwould be well served by going to the very best persisent/ LSPAF ablatonist you possibly can arrange for yourself, regardless oof how far you might need to travel to do so.

Dr. Schwiekert is a truly wonderful EP and doctor and excellent choice for many situations, but for a situation where LSPAF may well be involved and perimitral flutter (though the latter issue I'm sure Dr S. can certainly deal with. However, with that combination of likely issues I would look to travel to Austin for Dr. Natale in your case with you possibly having had many years now of mostly ongoing largely asymptomatic AFIB along with the potential complexity of the WPW thrown in.

It often pays big long time dividends to demand for yourself the most experienced operator you can find in such cases. And with at, or around, 8,000+ AFIB ablation under his belt, Dr. Natale is the most experienced ablationist on the planet. Also, over 75% of his cases are of the most challenging kind, very often referred to him at St Davids Med Center in Austin (which is his prime center and the largest AFIB ablation research center in the world) by other experienced EPs to handle their most difficult cases.

A case like yours, were I in your shoes which I more or less have been in the past, ... I'd hold out for the best and not worry about having to fly down to Austin for 5 days including initial consult followed by ablation and three recovery days in town before returning home, to make that happen.

You have enough markers for a challenging case at your age to strongly recommend that course for you... You could have your local guy deal with the WPW if you wish too now. Especially since he confirmed that should he find that you did not have WPW, he said he would not address the perimitral tachy/flutter in any event, without planning it out first.

I respect your EP for saying that. The issue with mitral isthmus flutter is the difficulty for less experienced operators, in particular, in delivering a truly unbroken continuous line of ablation lesions across the full mitral isthmus line. And thus, his wanting to go through such a planning stage to think it all through.

Dr. Natale does these things all the time and it is quite routine for him. But it's very good of your EP to honestly share his reservation about taking that on and I highly respect that honesty and approach with you.

In any event, we can talk about this too on the phone if you wish and can wait until I have some time and can talk around Feb 12 or shortly thereafter, once I've sent the next issue of the newsletter out.

You definitely came to the right place here Ryan, with a lot of good advice some wonderful folks have shared with you above, as usual from some of our stalwart old timers here.

Be well,
Shannon

Ryan,

Everyone else on the forum has wealths of knowledge around this subject that I don't have, but I just wanted to add my support. I am 37 y.o. 6'5" afibber. Diagnosed at 35, I share some of the same long term concerns as you. I wish we had good long term studies on how ablated hearts fare over time (I'm talking 50+ years, since thats how much longer we probably have).

For what it's worth, I was able to go from weekly episodes to episodes 3+ months (and counting) by changing my diet, reducing stress and supplementing magnesium. I am really hoping I can stay relatively afib free for another 10+ years so that when I do eventually need an ablation hopefully we will have improved techniques and better "long term" data.

Welcome to the under 40 afib club.

-Eric

Shannon, congrats on the Broncos. I'm a lifelong Lions fan (ugh).

Erich, thanks for your input. I will say that my EP told me that the technical equipment brought into this field in the past two years have added another 10-15% success rate to the average. He said it takes some of the subjective human decision making out and replaces it with objective computer data. I think that will only continue to get better.

You are both right however in that this type of work is subjective in many ways....and it pays to have the most experienced person.

I am however ready for ablation and I don't want to wait. I prefer the risk of surgery over a stroke or sudden cardiac arrest. I really want to stay active, but this has made me consciously decide to slow everything down permanently. I'm done with competitive sports, distance running and will be replacing it with activities that don't demand high output or constant cardiac stress. I am definitely going to try to put together a Mg plan.

Ryan - Sounds like a smart plan. Keep in mind that it's about more than just magnesium but that's a critically important start.

Wishing for you the best and successful outcome with the ablation and your new lifestyle strategy.

Jackie

I had a bad spell of a-fib which caused my heart rate to go up into the mid-100s, occasionally touching 200 last Saturday. I felt bad, but otherwise it did not present with any obvious symptoms. The halter monitor company called U-M and they asked me to admit myself.

I went to our local hospital Saturday afternoon, got stuck there for three days, then UM opened a bed and advised that they wanted to do the surgery ASAP. My selected EP doctor who thought I had an accessory pathway was on vacation this week, but he had one of the EP doctors with 15 years experience collect more data over the course of five days. From this, he determined that I likely had a-fib with aberrant tachycardia, not an accessory pathway. When he went in yesterday for the EP study, he confirmed this--and found that I also had a bad case of right atrial flutter. He advised that I had very easily excitable cells and that he had to perform a lot of ablation. It took over five hours and he said it was one of his more challenging cases in a while.

Last night in recovery I experienced a lot of chest discomfort, pain when breathing in past 2/3, and went into the same pattern of a-fib that I had been suffering for several days at around midnight. I converted for a brief period this morning and was set free with two rhythm drugs, anticoagulant, and Prilosec (they had to perform a TEE). I went back into afib but I am very slowly feeling better as I type this.

I was very disappointed that I had a bad case of a-fib and tachy today, but I'm just trying to stay calm and see what happens. The EP did say that my heart muscle was pretty thick from working out and I'm not sure if he meant that might have made his job harder.....he said I may very well need a touch-up but that my heart is stirred up like a hornet's nest right now. I agree....it isn't happy

Quote
Rylar


I did get hooked up today with University of Michigan's top ablation EP Doctor for a second consult. I am fine having the current surgeon do the WPW search if the UM guy agrees on the plan; if my current guy says no WPW found, I am going to need someone really experienced with the perimitral issue.

Rylan can you tell me which doc you saw? thanks.

Quote
bettylou4488



I did get hooked up today with University of Michigan's top ablation EP Doctor for a second consult. I am fine having the current surgeon do the WPW search if the UM guy agrees on the plan; if my current guy says no WPW found, I am going to need someone really experienced with the perimitral issue.

Rylan can you tell me which doc you saw? thanks.

i would like to know which doc as well. thanks.