Dr. Natale - Questions

OK here goes . . . After February appt with EP I had about decided to go the PVI Ablation route. Said they were scheduled out to June but would call 2 months prior. Well they called in April, day of the "co-worker died" thread + I had episode early that morning + I was with the 1 & 3 year old when the phone call came they had an opening on May 5th so barely 2 weeks notice. That was just too much too soon and husband, 7 years my junior, had just had back surgery (lifelong problem).

Now I'm thinking since the vitamin, healthier lifestyle, etc doesn't seem to be as successful as I'd hoped . . .

That I'm thinking of seeking care from the Best of the Best in Dr. Natale. I'm from Texas so a trip to TX is no biggie and could stay however long I need to.

Questions:

1. How long is the wait?

2. How on earth do I prepare for a telemed appt with him? Tests? Records? Submit electronically? Some or all? I do have a IHLM since Sept 2022 so all those monthly reports.

3. I can navigate the insurance, out of pocket, hotels etc fairly easy.

4. 2 Echo's one said "mildly" enlarged Left Atrium and most recent "marked" enlargement but no measurements. I've read that Echo's can be rather subjective depending on who is reading them. Also have Hashimoto's (thyroid and have read it too affects the LA. Also sleep study indicated "mild" sleep apnea, breathing has been better past 2 years with Flonase though.

5. I take Eliquis. Couldn't really tolerate the Metoprolol / Flec with the Brady. Only other meds Armour Thyroid and 40 mg Cholesterol med.

6. My regular Cardiologist and the EP met prior to my Feb appt and came to the conclusion I "needed" an ablation when all I had done was inquire about my hiatal hernia via message before regular annual appt with Cardio doc.

7. What else should I do prior to attempting this? Drop 10 pounds get BMI down a little? Continue Mg and Taurine and get cellular level of Mg up?

8. Restrictions afterwards, Lifting etc. so wondering how much of getting my "affairs in order" I should do prior. We've been trying to find a house, only 30 minutes away, to be closer to the kids and grandkids, but IF I find the right one a BIG move would be in store.

IF I'm going to do this I might as well go for the best although I'm already a bit intimidated when I go to my local "heart center" that going to someone else and then continue future appts with them and say "hey I went somewhere else". Awkward.

I've never navigated such complex medical waters until AF and I've read here and elsewhere until I'm mentally exhausted reading about it. Having PAC's all this past week to 10 days hasn't helped either, stubborn and haven't gone away, paused supplements for about a week - 10 days for some blood work and they reared up. Argh. Sorry for rambling.

Thanks in advance for any tips or advice in navigating how to become a patient of Dr. Natale.



Edited 1 time(s). Last edit at 05/20/2025 05:22PM by Qwackertoo.

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Qwackertoo
1. How long is the wait?

Probably a couple of months. If you want it sooner, ask to be put on the wait list for cancellations.

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2. How on earth do I prepare for a telemed appt with him? Tests? Records? Submit electronically? Some or all? I do have a IHLM since Sept 2022 so all those monthly reports.

Simple: sign the release. Natale can then get them electronically. If your doctors use Epic (most do), he won't even have to request them. They'll be immediately available online.

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4. 2 Echo's one said "mildly" enlarged Left Atrium and most recent "marked" enlargement but no measurements.

Yes, it is subjective. So there's some degree of enlargement. No surprise there.

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7. What else should I do prior to attempting this? Drop 10 pounds get BMI down a little? Continue Mg and Taurine and get cellular level of Mg up?

That's about all you can do.

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8. Restrictions afterwards, Lifting etc. so wondering how much of getting my "affairs in order" I should do prior. We've been trying to find a house, only 30 minutes away, to be closer to the kids and grandkids, but IF I find the right one a BIG move would be in store.

No lifting anything over 10 lbs for 1 week. That's it. I don't think you need to be "getting your affairs in order" any more than they probably already are.

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IF I'm going to do this I might as well go for the best although I'm already a bit intimidated when I go to my local "heart center" that going to someone else and then continue future appts with them and say "hey I went somewhere else". Awkward.

That shouldn't be an issue at all, and definitely not awkward. If it is then you need to find an EP with a less fragile ego.

Good luck and I think you're making the right decision. To get started, call the Texas Cardiac Arrhythmia Institute and ask to speak to Norma. She's Natale's scheduler and she can get you started.

Thanks so much Carey. I will definitely give Norma a call and get things started.

Not sure IF it is Epic but IF not I'll just sign the release. I'm 1K miles away so cancellation list might not be workable and a couple of months more won't be bad IF things stay about the same.

15#'s would be better and my goal but 10 is pretty easy and doable plus it would build up my stamina a bit prior to procedure since I've been on eggshells and not faithfully exercising much these days.

Thanks Again~!

Message left for Norma. First Big Step!!!

Thanks!

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Qwackertoo
Message left for Norma. First Big Step!!!

Thanks!

Good going! Norma will guide you through the whole process and be the intermediary with Dr. Natale, getting you ready for a telemedicine appointment, which usually happens about a month before your scheduled ablation. They will handle the insurance – they actually make everything very easy and basically all you have to do is show up! I know I’ve done it too! And by the way, when I got on the table, I needed a lot more than a PVI and was very thankful to be in Natale‘s hands.

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Daisy

Message left for Norma. First Big Step!!!

Thanks!

Good going! Norma will guide you through the whole process and be the intermediary with Dr. Natale.

Thanks Daisy~! Glad to hear you were in Dr. Natale's skilled care~!

I am hoping that all I need is the PVI. After my First Big Step yesterday, haven't heard back from Norma, there is always the possibility he'll look at my test results and information and say Sorry, Can't help ya. After deciding yesterday to Begin the Journey then after last nights episode I'm feeling a bit apprehensive IF they'll accept me, maybe this is normal to feel at this point. AF is such a "quality of life sucker" that I came to the it is time and bypass local and get best care I can find & afford.



Edited 1 time(s). Last edit at 05/21/2025 03:01PM by Qwackertoo.

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After my First Big Step yesterday, haven't heard back from Norma,

You can always call her on her direct line if you wish. With Natale, he will do whatever necessary to resolve your problems, but he won’t know ahead of time as he will do a lot of testing during the ablation. Note: he won’t do more than is necessary, however!

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Daisy
After my First Big Step yesterday, haven't heard back from Norma,

You can always call her on her direct line if you wish. With Natale, he will do whatever necessary to resolve your problems, but he won’t know ahead of time as he will do a lot of testing during the ablation. Note: he won’t do more than is necessary, however!

Hi Daisy

I've sent my new patient forms so in the "wait & see" once he looks at all my tests and records.

I'm not even sure IF I'd be an ideal candidate. Local EP wants to do an ablation thus my seeking Dr. Natale for the "best of the best". Local EP wanted to do a pacemaker back in Jan of 2023 but I declined at the time due to everything that was going on with "testing" out the medications which were awful for me, 2 re-infected old root canals, steroids from knee/ankle issues after 3 week trip to the Alps, and lastly a 5 yr (although 7 elapsed due to Covid crisis) colonoscopy that left me passed out on the floor after 2nd morning dose and a phone call from EP's NP due to alert from my heart loop monitor.

I'm still reading more and now worried/wary of the Bradycardia + AF combo that IF Dr. Natale would want to do the Pacemaker plus Ablation or just one of the two or simply outright reject me as a patient. Thankfully the notification for low heart rate notifications from Apple Watch (10 minute algorithm based) have ceased since last October although I know they are still happening with both FitBit and Apple Watch, yes I wear both for different reasons/features, from the beat-to-beat on Apple or just watching real-time heart rate on FitBit. Although my Monthly Report usually shows 50 for night time low and 58 for daytime, I think that is only for the 24 hrs before the read out/report for the month, even though I get lower numbers on my wearable devices

IF they also do a Pacemaker for the Brady, do they always destroy the AV Node? My heart loop monitor is nearing its expected battery life of 3 years and Norma said he'd just replace it or remove it then rely on Kardia testing going forward.

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IF they also do a Pacemaker for the Brady, do they always destroy the AV Node?

No, they would not destroy the AV node—that is an extreme measure used by some people as a last resort when no other treatments for arrhythmia have worked. I have a pacemaker and there are several indications for one, but your heart rate really doesn’t seem low enough to need a pacemaker. I have sick sinus syndrome (Tachy-Brady syndrome) and that got me a pacemaker. Pacemakers don’t do a lot for Afib, except that they can be set to outpace the arrhythmia and that sometimes stop it.

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Daisy
Pacemakers don’t do a lot for Afib, except that they can be set to outpace the arrhythmia and that sometimes stop it.

I don't know if anyone is still doing that. I asked my EP about it 10 years ago and he just shook his head and said it was a nice idea but it just doesn't work.

Pacing is not all it's cracked up to be. I just read an article saying it can actually hasten a patient's demise. I think I posted it on Mayo Connect community forums a week or so back...don't remember. (Reminds me, must take Omega 3 fish oil capsule today).

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Qwackertoo
IF they also do a Pacemaker for the Brady, do they always destroy the AV Node? My heart loop monitor is nearing its expected battery life of 3 years and Norma said he'd just replace it or remove it then rely on Kardia testing going forward.

There is no reason to destroy the AV node for a PM. IF they ablate the AV node, which is a last resort and very uncommon today (though member susan.d had this done because of her very complex situation), THEN a PM is required.

As an aside, my heart rate minimum was 39 BPM last night with an average of 46 BPM. This was with an ECG grade chest strap. It is normal for me (and I'm completely asymptomatic) and no intervention is required.

Yuck. I don’t want to know this gloaming :-(. I just got my echo back today and my EF slipped a bit to 50-55 from 55-60. Pacemakers can for some cause ventricular pacing cardiomyopathy so I was encouraged to get scheduled echos. Unfortunately I’m in PVCs so echo and the one before 6 months ago was incomplete due to my arrhythmias.,

Yes if one doesn’t have a 1:1, Metronics told me they can pacemaker convert me. I visited the ER twice where the ER called up a Metronics tech who converted me in the waiting room. Once I was converted from afib and once it was aborted for flutter so I got ecv.

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Metronics told me they can pacemaker convert me

Yes, my EP converted me out of Afib in her office, using my pacemaker, but this human intervention using the pacemaker seems to work much better than the pacemaker’s built in “outpace” algorithm.

Well I went thru all my Patient Summaries this afternoon while I wait for an appointment or rejection . . .

Originally said Brady way back in 09/2019 with a stress test - This was my first visit after Abnormal EKG at regular doc checkup

then Nothing until almost 2 whole years later due to Covid and maybe had a few episodes in the wee night/morning hours
06/21 with encounter notes as "palpitations"
07/21 encounter notes Tachycardia - tachy, PVC snoring ??? I guess I did a sketchy sleep study that month
also a Holter Monitor that month and nothing after 30 days

10/21 ER visit via Ambulance due to syncope episode . . . electrolytes were LOW then released to home

8/22 more PAC's in encounter notes from 30 day Holter Monitor - Metoprolol 12.5 x 2 Started then HLM implanted
the next month
11/22 more notes of palpitations
12/22 FINALLY visit to discuss AF, First time this was ever mentioned so a little over 2 years to get here after 3 months with the implanted HLM.

Then all my issues with steroids after big 3 week trip for knee/ankle, somewhere around here EP added Flec plus the 2 tooth infections and colonoscopy And the holidays

1/23 During all this chaos SSS and Acute Diastolic HF showed up . . . maybe with passing out on floor and HLM Alert

Later in 1/23 BOTH SSS gone from "list of problems" and Acute Diastolic HF gone too . .. no one every even mentioned either

1/25 all of a sudden SSS showed back up in Problem / Encounter lists and I hadn't even had a Clinic visit just the Echo so did someone who was looking at old record add that? It wasn't mentioned @ Feb 2025 visit either.

So I guess either I do or don't have a SSS and diastolic issues but my BP is usually very normal to the low side.

EP recommended a PM during all that chaos of stuff that happened in about 30-45 day time frame and I declined and wanted to let everything settle & calm back down . . . which I have been pretty much same as I was before with random AF episodes in the middle of the night which now, almost 5+ years later since my very first visit and very first middle of the night, they do make me feel a little bad the next day for sure.

I guess I'm just "all over the map" with What IF's right now, after finally deciding to go for an ablation in Texas with Natale or not being a suitable candidate. Hard to interpret all the Visit Summaries and test results and again Echo's can be subjective and that is when the SSS magically showed back up on that "summary" of Problem List/Encounter.

I feel like it is gonna be a worry worry worry long wait for evaluation & appointment & procedure. Eeeek Right now I only take the Eliquis no other heart related meds and seem to manage for the most part. For the most part not that many visits to the Cardiologist OR the EP, just the monthly HLM reports. I'd guess less than 10 total Cardiologist/EP visits plus a few heart test days, maybe 3-4 of those . . . over almost going on 6 years.



Edited 2 time(s). Last edit at 05/23/2025 11:14PM by Qwackertoo.

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Qwackertoo
07/21 encounter notes Tachycardia - tachy, PVC snoring ??? I guess I did a sketchy sleep study that month
also a Holter Monitor that month and nothing after 30 days

If you are having some sleep apnea (and/or snoring), you could try taping your mouth at night to encourage nasal breathing. I have a post here on it. In my case it eliminates apnea. Doesn't work for everyone, but is a low effort (in my opinion) solution. Nasal breathing also encourages better CO2 tolerance. Though people aren't commonly aware of this, sufficient CO2 is required for O2 delivery to the cells because of the "Bohr" effect (discovered by Christian Bohr in 1904 - father of Neils Bohr). In layman's terms, the Bohr effect loosens hemoglobin's hold on O2 so delivery to the cells is better.

50 BPM seems like a high cutoff for SSS, but I'm not an EP or cardio.



Edited 1 time(s). Last edit at 05/24/2025 10:38AM by GeorgeN.

George,

I think the SSS showed up in the Visit Summary & Problem list then disappeared just as fast . . . Next Summary . . . right after/during that 30-45 days crazy period and with the Met & Flec added into the mix and with everything else going on with big time infection + other 2 issues, steroid pack & colonoscopy . . . After Flec was added and going to the Endodontist .so prob 2 rounds of strong antibiotics If I recall . . I was getting hundreds upon hundreds of low heart rate notifications on my Apple Watch for several days so I stopped both Met & Flec on my own before my return appt a day or so later. Haven’t taken either since.

Then when I was in waiting room, right during that time I mentioned how just sitting there my heart rate on my wearables was all over and he dismissed it as normal and that happens even when you are sitting there just thinking of stuff . . .and at one point, maybe next visit . . . He said he wasn’t worried about my Low heart rate so much unless it was really low like low 30’s which seems strange thing to say for somebody with Bradycardia diagnosis whom you are wanting to implant a Pacemaker.

I’m hopeful Dr. Natale will accept me for an ablation and lately with PAC’s I hope sooner than later because this is now increasingly affecting my QoL. Both the sense of dread of next episode and next day feeling bad.

I’ll try the tape again. I did it 2 nights maybe 6 weeks ago and felt pretty good the next day! Thanks for the reminder!



Edited 1 time(s). Last edit at 05/24/2025 02:20AM by Qwackertoo.

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Qwackertoo

I’ll try the tape again. I did it 2 nights maybe 6 weeks ago and felt pretty good the next day! Thanks for the reminder!

I also have taped my mouth and over the past 2 - 3 months my wife has noted a significant decrease in my snoring.