Afib Journey/Ablation Update

I recently passed my one year post-ablation anniversary and wanted to offer an update to my fellow afibbers. I have documented my journey leading up to my decision to seek an ablation in my previous postings on this forum so anyone interested can look that up. I’ll focus here mostly on the new stuff with just a bit of background.

After 20 years of paroxysmal afib I (63 year old male) finally decided to seek an ablation in late 2022. The combination of flecainide, metoprolol and, more recently, Eliquis, worked well for many years but I began having breakthrough episodes every few days. I was still paroxysmal and would usually convert using the flec and met in less than 48 hours. Thanks to the advice and experiences from people on this forum I chose TCAI in Austin. I had my PVAI index ablation with Dr. Rodney Horton in November of 2022. After an afib/flutter episode with RVR about 10 days after the ablation that lasted about 90 hours and converted just hours before a scheduled cardioversion, I have been afib/flutter-free since then!

I have been off flecainide since late January of 2023, which was eight weeks after the ablation. Based on results from a 7 day VitalConnect (Holter) monitor in early April of 2023, five months post-ablation, I was found to have no afib and allowed to discontinue the Eliquis. The extended holter did show about 4,500 ectopics over the one week cycle, most concentrated in one 24 hour period.

I just completed a second 7 day holter monitor 14 months post-ablation and was again found to have no afib/flutter. Dr. Horton’s PA discussed the findings with me over the phone and gave me the good news, with the understanding that it may not last forever. I hope I am one of the lucky “one and done” ablation patients.

I am currently on 12.5 metoprolol BID (25mg daily total) which is the only afib related drug I am taking. I also take 400mg’s of chelated magnesium glycinate. I still have occasional ectopics, sometimes several in a row which is disconcerting and causes me to quickly reach for my wrist to check my pulse. My most recent holter also showed four counts of VT, with the longest episode being 14 beats at a max HR of 131. My TCAI PA was not concerned and, based on my most recent 2D echo, did not believe I was at risk of the non-sustained VT transitioning into sustained VT due to any heart abnormalities. The echo showed only a mild dilation of the LA (4.3cm). I don’t experience any dizziness or breathlessness during ectopic episodes. My holter showed an ectopic burden of less than .3% over the monitoring period.

My ectopics during the day feel like afib is trying to start. But to this point it never has and my heart rate returns to sinus within a few seconds. I do have a Kardia monitor that still gets a good bit of use, despite my last documented afib/flutter episode having been 14 months ago.

I feel I’m ready to take some extended trips again. We are planning to go out of the country soon, which is something I never felt comfortable doing in the few years of increased episodes leading up to my ablation. I had one bad episode during a visit to L.A. in 2018 which brought me to the ER there (NO FUN) since I was not yet taking an anticoagulant. That led to another cardioversion (I’ve had three). Fears of winding up in the ER in a small town in a foreign country hoping they wouldn’t think I was having a heart attack or needing emergency surgery kept me close to home or at least inside the U.S. I now carry a month-supply of Eliquis, Flecainide, and metoprolol along with my Kardia monitor whenever I’m away from home. My TCAI PA said having that toolkit on hand should cover me if an episode happens. I would only go to the ER if I faint, or start having chest pains or shortness of breath. Managing the anxiety, however, will be a challenge! He told me to take 200 mg’s of flec in one dose and an extra metoprolol and also restart the Eliquis in the event of an episode. He said sometimes flecainide will convert an episode for an afib patient AFTER an ablation even though it had mostly stopped working BEFORE the procedure.

I did try to get off metoprolol a few weeks ago with the permission of a TCAI nurse. I’ve tolerated it very well over the past 15 years but I was eager to see how I’d feel without it. I planned to taper off of it by first reducing my dose to 12.5mg once a day. But after a few days, I began to have bouts of resting tachycardia with rates around 100-110 bpm and more ectopics. I also already take blood pressure medication and the metoprolol was also helping keep my BP to a normal-ish range. So, after consulting my TCAI PA, I decided to go back to the full 25mg dose twice a day.

I realize there is no cure for afib and that reconnections through the pulmonary veins may occur. Also, new afib sources may emerge which may require a follow-up ablation. My research showed about a 60% chance of freedom from recurrences after 5 years. But even if I’m back on this board seeking advice after a recurrence in the future, I consider my ablation a success and I am grateful every day to have maintained sinus rhythm continuously for over a year.

I would encourage anyone considering an ablation to follow the research and the advice of the many forum contributors and seek out a highly experienced EP at a high-volume center like Texas Cardiac Arrhythmia in Austin. It may cost more if you have to go out-of-network for insurance coverage, but you are much more likely to get a good result.

Glad you're doing so well.

If I understand you correctly you went directly from metoprolol 25mg bid to 12.5 mg, once a day?
If so, I wouldn't call that "tapering", It's really closer to going cold turkey You might want to try again with a
much more conservative tapering schedule.

Jim

Tapering off metoprolol can be tricky, sometimes. If you want to taper off, I would cut the night down to 12.5 for about 3 days and see how it goes. If all is good, drop the morning dose for 3 days. Then, if good, take one away and see how it goes. It might seem like a small dose, but the body can become dependent on it. Way back when, I was on 100 mg twice a day and took a bit to wean off of it. Recently I was on 50 mg twice a day, and we switched medicines and had problems with the fast change. It was not fun at all!

Good luck with your success, may it last long.

It's good to see the occasional success story. Most of us have a storied life during the progression of the disorder, and beyond. I hope yours is one and done.

I jinxed myself! Just hours after posting my afib-free update I'm pretty sure I had a 4-5 minute afib episode. I had been having an unusually large number of ectopics throughout the day which isn't unusual. But in the early evening as I was eating, I noticed that dreaded flopping sensation. Usually, with ectopics, it dissapates after a few extra or skipped beats. But this time it continued. I immediately got up and walked around the room. It went back to NSR before I could find my Kardia device or track down my flecainide.

I haven't been eating very well lately, lots of sugar and processed meats and cheeses and not enough fruits and vegetables. I also had several drinks one day two weeks ago. Even though I was, and continue to be in NSR (Kardia confirmed) since yesterday's episode, I continued to have lots of ectopics, (PAC'S I think) which continue at this hour.

So, is my ablation failing? Are lots of ectopics a signal that afib/flutter is looming? Have new pathways to conduct the afib signals formed? I'm holding onto the slim hope that this episode was a jumble of ectopics or NSVT which can feel like afib. I'm immediately rethinking travel plans and looking ahead to possible re-ablation scheduling and whether to restart the flecainide and/or Eliquis. Of course, I'll contact my local EP and Dr. Horton's office before doing either. I think I'll just hold the line for now and see what happens in the next few days/weeks.


I'm still grateful for the 14 months of NSR since the ablation and am happy to have options to try to get this resolved again, but this is a bummer!
To answer Jim's comment to my previous post; I may have written my metoprolol dose wrong. When I tried to wean off of it I began cutting my dose in half. From 12.5mg twice a day for a total of 25 mg daily to just one 12.5 mg dose. But, as I said, I have returned to my original twice a day dose.

So sorry this happened. I can feel you frustration as am in the similar situation. Trying to stay positive and optimize what you can - diet, exercise, sleep, stress relief...

Quote
hacksman
I jinxed myself! Just hours after posting my afib-free update I'm pretty sure I had a 4-5 minute afib episode. I had been having an unusually large number of ectopics throughout the day which isn't unusual. ..

I think you have suspected as much for some time, and your subconscious mind was working on the likelihood that the last procedure had indeed failed. You came here and tried to do a conscious 'propping-up' post to boost your confidence, but you had that dreaded feeling that all was not well. You didn't jinx yourself...the suspected recurrent AF and PACs just came to the fore, and it happened to be a few hours after your post.

You knew this all along. I'm sorry that this has happened, but you can look forward to another attempt at remediation. If it worked once, and you're not the first to have to go back for a touchup, that is probably all that's required. Get the best EP there is on your side, have him read in if needs be, and then consult to see if he feels that you're fixable.

hacksman, as I remember your ablation was only pulmonary veins? If so, a touchup should be able to deal with any other areas that are acting up. Your nurse navigator could give you input on this I’d think.

I think it's premature to consider the ablation a failure, based on what you think was an afib episode so short that it resolved before you could find your Kardia. My motto has always been that if things resolve before I can record it (usually within 2 minutes) it didn't happen The other thing is what is the definition of "success".

Prior to my ablation, one ep told me that if I counted success as no afib episodes lasting over 30 seconds after six months, then I could expect around a 60% chance of success. However, if I was content with a 90-95% reduction in afib burden, with perhaps a very occasional short and self terminating episode, then he gave me 80-90%. So, by his second definition -- the one he uses with most patients and the one I find the most realistic and prudent -- your ablation so far is a success.

It sounded like a lot of the new activity started after you reduced your beta blocker dose. Hopefully, now back on the original dose, things will start to calm down again and when/if you decide to again go off beta blockers, definitely consider a much more conservative weaning schedule.

After my ablation, I've also had periods of ectopics which in the past have led to afib episodes. So what I do now is take some Flecainide prophylactically, rather than just wait for the afib. For me, it's 50mg bid and usually things calm down in 1-3 days and then I go off of it. I take Something you may want to consider, because as your doc said, the Flec may be more effective post ablation than it was prior.

Jim

I went 4 1/2 years after my second ablation with absolutely no problems when in fall of 2021 during an echo in preparation for my annual appointment with my cardiologist I was diagnosed again with afib. I was totally asymptomatic, did not know when I went out of NSR. My daily routine included 30-45 min of vigorous cardio exercise. Dr. Natale had warned me in 2017 after my second ablation TEE that I could go out of rhythm again and If I do so, it might be time for a Watchman. Two years ago today I had third ablation and Watchman implant. Who knows what's going to happen next? I don't think or worry about it. As long as I'm not on fire and am not getting shot at, life is mighty good.

Quote
JayBros
As long as I'm not on fire and am not getting shot at, life is mighty good.

There was a guy on another afib forum who liked to say that.

Quote
Carey

As long as I'm not on fire and am not getting shot at, life is mighty good.

There was a guy on another afib forum who liked to say that.

LOL. This applies actually to me too. :-)

Thanks for the responses to my rambling post. I appreciate the no-nonsense insight from Gloaming and the words of optimism from Mjamesone.

I wanted to wait a few days to see if the PAC'S calmed down and if the afib returned before posting an update. The answer to both is no (at least so far). I've had probably 1500-2000 PAC'S during the day for the past four days. Usually two or three per minute. They go away when I lie down, and I sleep well. Not life altering, just troubling since I fear they will spark afib. I'm pretty sure these are PAC's because I've had both PAC's and PVC's and the Kardia tracing is easy to distinguish. My Kardia is getting a good workout this week.

I was not aware that flecainide could treat PAC'S (Thanks Jim). I thought they were solely for afib/flutter. If the PACS continue I will take 50mg's to see if it helps. My EP is on board with PIP flec for afib so I don't feel I need to contact him to get approval. I am also continuing the 25 mg metoprolol split into two doses. I guess I could take an extra half-dose of that as well.

These PAC'S and PVC's are weird. As I mentioned, my last two 7-day holter's showed nearly 4000 total PSVC (PACS) last April but only 58 PVC's. Then, in December, the holter showed nearly 2000 total PVC's but only 365 PSVC's. Why the discrepancy? I used to have only PVC's and very few PAC's before the ablation. Now, it's both.

[...Managing the anxiety, however, will be a challenge! He told me to take 200 mg’s of flec in one dose and an extra metoprolol and also restart the Eliquis in the event of an episode. He said sometimes flecainide will convert an episode for an afib patient AFTER an ablation even though it had mostly stopped working BEFORE the procedure...]

I reread your OP, often a wise thing to do for a guy my age. The text I've quoted stands out. I'll explain:

I had a similar experience to yours in that, days after both of my ablations, I had the dreaded run of ectopics. The first was deemed a failure, and I went on amiodarone right away. Ten pound sledge, no hammers need apply. I had the second ablation seven months later, and again, at the two week mark, I was in the ER with a runaway heart. I was very discouraged. They didn't offer to cardiovert me because three previous attempts, seven weeks earlier when I had another bad night or three near New Years, had not worked. I got more metoprolol.

I related this to my outreach nurse from the AF clinic in Victoria, British Columbia. She immediately said that each procedure gives you a new or different heart, so-to-speak, and that cardioversion was absolutely THE first thing I should have been offered, my recent failures notwithstanding. In fact, she very emphatically said, "You do NOT have AF any more. Your heart is just cranky and needs a cardioversion, and what they said to you was the wrong thing." And, bless her, she was absolutely right. I haven't had a lick of trouble since converting on my own later that night, and I just celebrated my first anniversary on Wednesday.

Cheers to you, and to your continued time in blissful NSR.