AFib & AFlutter Alternating

I have some questions and asking for suggestions. My situation in a nutshell is that at the beginning of last year I had robotic mitral valve surgery, my LAA sutured/closed and a Cryo-Maze. I was in NSR for 5 consecutive days when all of a sudden I went into Atrial Flutter. I was told this was a good possibility as mitral surgery and heart surgery in general can cause Atrial Flutter, so I wasn't surprised, just disappointed. I stayed in Flutter 100% of the time, until I had an ablation with a local, top EP in September of last year. The EP said I had a very small area on the right side that he used RF on and I immediately went into NSR. He said no other arrhythmias showed.

I was discharged hours later and maintained NSR for over 3 weeks. I was excited but out of nowhere I had an episode where my heart rate went up to 145bpm or so at rest. My Kardia showed AFIB and I was immediately concerned as It wouldn't seem as though a "blanking period" would apply here as it was only 3 weeks post-ablation, but it was "AFIB" and not "FLUTTER", so that would likely mean the LEFT side of my heart, not the right side which was ablated. I actually went to the ER and was still in AFIB which was caught on their 12 lead EKG in the ER. Shortly after getting to the ER I converted on my own to NSR. When I spoke to my EP the next day he said to continue to monitor it and not start any anti-arrhythmic at the time, just stay on Metoprolol.

I did this and for most of 7 consecutive months, I was in NSR any time I checked. A few weeks ago, out of nowhere, I went into AFIB and have STAYED in AFIB any time i've checked. I let my EP know and he said that I may need a touch up ablation from the Maze on the left side. What concerns me most is about 70% of my EKG's shows AFLUTTER, about 30% show AFIB. I had a follow up appt at my cardiologist 2 weeks ago and the 12 lead sure enough reflected Atrial Flutter at 110BPM. My Flutter heart rate seems to never get over 117bpm, but it is usually around 108bpm. When I go back to AFIB, the rate is typically around 85-95bpm and I can clearly see the irregular rhythm on the EKG.

When I had the ablation for Flutter my EP said he thought I would have a 90-95% chance to completely rid the Flutter. He was right....for 7 months, and now both AFIB and AFLUTTER are alternating. Most days when I wake up I am in AFIB with a HR around 90bpm. During the day I get into FLUTTER where I stay either until the next morning or consecutive days until AFIB comes back. I am Asymptomatic to BOTH thankfully.
I am baffled that 7 straight months i'm in NSR, and out of nowhere I just go into PERSISTENT AFIB/FLUTTER with no natural conversion to NSR?

My EP prescribed Sotalol which I am going to start in the next few days, but I'm thinking I may need another ablation. Because I am alternating between AFIB and AFLUTTER, if i'm understanding correctly, I would need BOTH the right and left sides ablated? Any suggestions or ideas on any of this?

Yeah, you need a touch-up ablation. Until an EP is in there and able to see what's going on, you won't know if it's all right sided or not. Afib can originate in the right atrium too.

Thanks, Carey. Is it possible for FLUTTER to come from the Left Atrium or Flutter definitively and always comes from the right side?

If Afib can come from the right side I guess I would hope both the Flutter and Afib are coming from the right side as from my understanding it's an easier procedure and less dangerous away from the Esophagus, etc, right? If the Afib were to be coming from the left side and the flutter the right side they'd have to go through the septum during the ablation to ablate both sides, correct?

Definitely possible. Both can come from either side. My flutter originated in the LAA on the left. My other flutter originated on the right side. Yes, you can have more than one source of flutter just like you can have more than one source of afib.

Both AF and AFl can happen in either upper chamber. I know, it's almost beyond belief, but it's true. The expectation, on the basis of probability, is that AFl will be found and corrected in the right atrium, most often peritricuspidal, and that AF will be found in the left. AF in the right usually near the coronary sinus, AFl in the left atrium is likely to be from a rotor around the mitral valve (annulus often), but not always. Some patients have flutter originating near or in the PV, as is usually the case with AF.

[www.ahajournals.org]

The septum is punctured on the catheter's way to the left atrium where the PV ostia are located if it's AF we're talking about. If the right atrium if affected and is the target vessel, then the septum need not be punctured. The septum is a divider between the two upper chambers, and extends to perform the same function in the two larger lower chambers. So, if AF, most likely a puncture on the way from the insertion into the heart, which is via the femoral vein and into the right atrium. Puncture the septum, slid into the left atrium, and from there the mapping and lesions can be generated.

Thank you Gloaming and Carey once again for all the great info. It's very helpful. My EP made two comments post-ablation, one saying my Left Atria reduced in size greatly which is was happy to say, and he also mentioned my Maze looked great. He said he has a device that shows amazing views of the heart and those are the two things he mentioned, both of which I was obviously very happy to hear. I have 2 questions.

1) Do you think because I have a Maze, it's less likely either Afib or Aflutter or coming from the left side and more likely both are coming from the right size? 2) When I had the Maze, it was Cryo and only on the left side. I've read places like Cleveland Clinic try do a Maze on the right side as well when they do a Maze. They try to ablate around the Tricuspid annulus, etc. After my Maze, I asked my EP and they said at that time they only saw Afib on the left side and because I was on Lung Bypass, they were most concerned with getting me off of that after the Mitral Valve Repair and LAA closure. I certainly would agree with that. But do you think that HAD THEY done a Maze on the right side, that I never would of had Flutter or needed an ablation on the right side to begin with? And assuming one or both of the AFIB/AFLUTTER now is right sided, do you think the likelihood would be far less there'd be any arrhythmia at all as BOTH sides would of had a Maze?

I would be pure guesswork to say. There's just no way to know until an EP gets in there and finds out.

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I would be pure guesswork to say. There's just no way to know until an EP gets in there and finds out.

I May go to Dr. Natale on this one. At the end of the day, if I go with another ablation I seriously doubt I would do another one again. If it's going to be an endless cycle and my echos continue to improve and my HR is around 100-105bpm with no symptoms, I think i'd just stick with the Metoprolol as long as I can. If I go with Natale on this one, at least I can say i've gone to the best of the best.

With that said, do you think I should start Sotalol at all if my RHR is around 100-105bpm with no symptoms? I am on 50mg of Metoprolol 2x a day now with no anti-arrhythymiac. Do you see any benefit prior to a month's long wait with Dr. Natale to even start Sotalol in my case with no symptoms and not too bad a RHR?



Edited 1 time(s). Last edit at 05/21/2025 08:25PM by cornerbax.

Probably not. And he'll have you stop it about 5 days before the procedure anyway. But it would be better if you could get that HR under 100. Maybe try 75 mg metoprolol?

I can definitely try that Carey. I know 100mg 2x daily is usually the max limit so I have room. I think the only reason I would even remotely want to try the sotalol is to see if it will put me back in NSR. I have been persistent Afib/Flutter for about 3 weeks. Last question I have for you is IF I were to start the sotalol how long do you think it should take to restore NSR? If say after 3 days to 2 weeks and NSR isn't restored, would it be safe to say the sotalol isn't going to restore NSR?

I read that up to 200 mg BID can be administered to those in acute heart failure. Sounds horrible all around, but I was careful to reread to make sure I had it right. These sites both say 200 BID for hypertension, but I'm darned certain I found an article two years ago saying 400 mg total per diem for HF.

[www.drugs.com]

[www.ncbi.nlm.nih.gov]

I doubt the sotalol will put you back in NSR by itself, but if you were cardioverted a day or two after starting it, that's likely to work. If it doesn't, then the sotalol definitely isn't working.

Thanks, Carey. I may not start the sotalol at all.



Edited 1 time(s). Last edit at 05/22/2025 01:04AM by cornerbax.