SHOILD I GET A REDO ABLATION

I had an ablation 11/7/24. I had no bouts of AFib during the 90 blanking period. Then out of the blue in April I had a short bout that resolved on its own within 30 minutes . Then night before last I went into AFib about 10pm and it was 730 am before it stoped. I think there were a couple possible triggers that caused it. 1) a medication, Flonase,that I’ve been taking for nasal congestion which presents a problem with my cpap therapy. Hard to breathe through a Cpap mask with a stopped up nose. Flonase is a topical corticosteroid which supposedly only 1% at most can enter systemic circulation and supposedly does not cause the usual problems associated with corticosteroids. But maybe even 1% is enough to trigger AFib ???? 2) I have a lot of trouble sleeping due to pain, struggles with Cpap, my garden variety anxieties. Wondering if poor sleep can trigger it. But I don’t go into AFib every time I don’t sleep well. I’ve not found a complete cure for my sleep issues, probably never will as I’m 76.

So I’ve had 2 bouts of AFib since my ablation 9 months ago. One bout was very short. The other about 9 hours long that I think was due to medication My EP wants to do a redo ablation. Does this sound like a reasonable thing to consider at this point??

I've suffered greatly from severe allergies all my life. During the past couple of years, it has been better using Arm & Hammer Saline Solution at night before bedtime. Spray a little each side then blow blow blow each side at bathroom sink. During the Covid years, I'd especially remember to do it after being out and about and around more germs and pretty much never caught it . . . had something earlier this year and but don't know IF it was the Flu or Covid. I get the 3 packs available @ both Costco and Sam's, Cheap. Feels so much better to breathe. Can't say it has greatly enhanced my sense of smell but maybe after a lifetime of allergies that ship has sailed.

Last year PCP pushed me to keep up the Flonase for at least a month during a bad cold or allergies, I stuck with it, thru the irritation phase to nose and now with the Flonase and A&H Saline, I've been breathing better than I have for pretty much my whole life, even overnight. My SpO2 levels are now usually 96 and 97 most nights vs before this routine I was regularly 95 with some 94's and 93's & a few 92's too. Miserable being so stuffy. I can still get a little stuffy by 5 a.m. or so but perhaps that is after being horizontal after 6-7 hours but still much better than before.

I'm no expert on the AF aspect of your break thru episodes, but I'd give the A&H a shot to use in combination with your Flonase. Maybe it would help you reduce your Flonase to 1 spray per side or even eliminate the Flonase depending on your congestion levels. Good Luck.



Edited 1 time(s). Last edit at 08/02/2025 03:07PM by Qwackertoo.

It doesn't matter what triggered it. A 9-hour episode of afib indicates the ablation wasn't fully successful, so a touch-up procedure is warranted.

On the subject of sinuses and nasal sprays .....

Flonase tends to be preserved with Benzalkonium Chloride. Benzalkonium Chloride is a Very Bad Thing:

[med.stanford.edu]

[Or choose your own from among an innumerable selection of reputable sources. It's ridiculously well documented].

I actually think that using saline spray -- maybe before and 15 minutes after -- the Flonase is probably a good idea. An even better idea, though -- IMHO -- is to ask your doctor if there are any preservative-free alternatives -- maybe Astepro (?)

Sincerely,
NBeener
[Whose EYES were permanently damaged as a direct result of Benzalkonium Chloride-preserved eye drops]

Based on what you have revealed about your circumstances, I don't think this was anything more than the proverbial last straw problem. You have a lot going on, and they ALL contributed to rising cortisol and edginess, self-recrimination when you made small errors, maybe costly ones, because you were sleepy or exhausted from lack of good quality sleep...etc. It all adds up.

But, Carey nailed it, and my extensive reading about blips here and there any time post-ablation suggests that you want early blips, like within the first five or six weeks post ablation. This is normal. If they persist, it's not normal. If they don't come on until later in the blanking period, that is a poor sign. So, you want the blips early in the blanking period, and no later, including out to the 12 month mark post ablation. Your recent history suggests that your ablation lesions did not fully seal off the pathway of the electrical signals out into the wide atrial endothelium.

So, yup, you need a redo. Happened to me.

I was recently prescribed Azelastinen Hydrochloride nasal spray for allergies. This doesn't smell like another time I had Flonase. Now I'm curious as to what the complications are using it. I am a year and a month out from an ablation and had one episode involving AFIB lasting a couple of hours and converting on its own.. That was after playing in a band for 2 hours on stage in the hot sun and humidity and failing to drink enough water and eat properly before the gig.I'm considering that a one off and not a ruined ablation. But now I don't want to complicate it anymore with this spray. I specifically asked the ENT if this was OK with AFIB. She said it was fine. So I would appreciate the input. Thanks



Edited 1 time(s). Last edit at 08/03/2025 03:48AM by JDfiB.

Thanks for the feedback everyone. Sounds like a redo ablation is warranted…..I failed to mention another possible contribution to my 2 bouts of AFib post ablation. Maybe it’s not the Flonase at all??? In February I was put on 50mg of doxepin for sleep & pain. My cardiologist OKed it. I think that was a mistake as I have read that doxepin, a tricyclic antidepressant can aggravate AFib in some people. My psych PA knew I had an ablation for AFib as well. I guess I should have researched it more, but you’d think/hope these people with their advanced medical degrees/training would know this stuff 🤨. However I am in the process of getting off it as it has been of no help with my pain & sleep, but it requires a very slow taper. Thankfully I’m on a low dose. Perhaps my only saving grace??? My redo is scheduled for September 12. Soon!!!

I would wait a bit.

First, no episodes during blanking whicn statistically suggests better long term outcomes. Second, we all heal differently and you're still within the first year. And third, a successful ablation is not binary — it's not simply pass or fail. The best definition of a successful ablation was given to me by two very well respected, EPs, and that is that is a significant reduction in Afib burden. That could be subjective and for you to decide.

On a personal note, I also had no blanking episodes. Six months later I had an episode which I terminated with Flecainide in a few hours. No episodes in the last 12 months. My EP considers it a success, but more important, I consider it a success.

Sure, I could have another ablation and try for 0% burden, but at what cost. Another invasive procedure and more burning without a guarantee it will make a difference. It's risks versus benefits and I see more risks than benefits. Should I get another episode, I will simply reach for the Flecainide. Should the frequency get to the point where daily Flecainide would be required, I will then sit down with the ep and discuss another ablation.

Meanwhile, consider getting a PIP strategy, such as Flecainide. No reason to sit in Afib for nine hours, when you can terminate it in a few.

Good luck whatever you decide.

Jim



Edited 1 time(s). Last edit at 08/04/2025 05:23PM by mjamesone.

Good point, Jim.

Thanks. And if I remember correctly, didn't you also post here that you had an Afib episode several months after your ablation? And that both you and your EP decided another ablation wasn't warranted?

Jim

Yes, I had one 2 hours episode 7 month after the ablation, which was terminated with Flecainide and Diltiazem. I was advised not to be too concerned unless I experience more episodes.

I used to have year-round allergy symptoms—stuffy nose, headaches, skin rashes—and used Flonase off and on without heart issues, though it didn’t really help. Last year, I finally discovered the root cause after an allergy test: histamine intolerance. Since then, I’ve been following a low-histamine diet, and it has brought significant relief.

What does a low histamine diet look like?

How many redo ablations are enough? Each kills good heart tissue and for a few of us an ablation can contribute to flutter which may require yet another ablation. I would watch and avoid your triggers and sit tight for a bit. There is no free lunch thinking an ablation is a cure for afib. It just fixes the existing firing cells and makes a monkey cage barricade. But if you have a genetically disposition to afib, new areas will form outside the areas previously ablated…and then what?

Which brings me back to how many redos are enough?

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Carey
What does a low histamine diet look like?

There’s a long list of dos and don’ts, but the core principle of a low-histamine diet is to eat fresh foods and avoid processed foods, fermented foods and leftovers. For me, I’ve found that the worst triggers are cured meats (I used to eat smoked salmon and sausages) and aged cheese. I cook every day now and only eat out occasionally.

I cannot currently take Flecainide again. I mistakenly allowed one of my docs to put me on 50mg of doxepin for fibromyalgia like pain, anxiety & sleep issues. Flecainide & doxepin are a no no as it can result in QT elongation I’m told. I’ve not had any bouts of AFib since I terminated the Flonase. Don’t know if that was the cause for sure or not. I just know no bouts since stopping. I guess I’m wondering if I should get a redo or not after 2 bouts since ablation 9 months ago. But per advice here since I had a bout recently that lasted 9 hours I should. BUT………I’m wonder if my ablation has weakened my heart. I’ve been feeling so much more tired with less stamina since my ablation Which admittedly may be due to other things I have going on- such as me and cpap are not doing well together. I hear about all the folks who claim to feel so much better after starting cpap. That’s not been my experience.

I’m scheduled for a redo ablation 10/20 because I’ve had a couple bouts of AFib after the blanking period. I had none during the blanking period. That 2nd bout was over a month ago. None since. But that one bout lasted 8 hours. My EP thought maybe it was because I was taking Flonase to reduce nasal congestion while on cpap. Flonase is a corticosteroid. I stopped the Flonase and have had no bouts of AFib since. So I’m really questioning if I need 2 catheters run up my vena cava, through my atrial septum into my left atrium to burn tissue in my heart again. How do I decide if this redo is really warranted or not ??

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Pokey
How do I decide if this redo is really warranted or not ??

By waiting. It's the only way to know. If you want to be sure it's needed (and I would), then cancel the procedure and wait to see what happens without steroids being involved.

Well here I am again fidgeting about if I should get a redo ablation. Last night I had a 3rd bout of AFib since my ablation almost a year ago now. I’m not sure what triggered it. I’m not sure it matters what triggered it, it happened. It started about 7pm, was calming down ( HR <100 & less irregularity) by 10 at bedtime. Went to sleep with it at 1030. Awoke at midnight and was back in sinus rhythm……. I just don’t know what I should do. I’ve got other health issues going on that could be a contributor. For one my sleep is crap. I’m struggling with back pain at night that wakes me up hurting 2-3x a night. I’m often very tired as a result. I’m tapering off an antidepressant (AD)that my one doc gave me to help ??? with pain and sleep. Didn’t help, so now I’m stuck with a long slow taper. The AD may be the culprit but I think I’d known that before now as I started taking it back in February and I’ve reduced the dose by 40% thus far. It should have never been prescribed in the first place given its known side affects and I should have researched it more before taking it. But here I am. Unfortunately I can’t take Flecainide while on the AD due to possible negative interactions such as QT elongation. I’m supposed to travel in December for a month to see my kids. I don’t want be dealing with AFib at their house at Christmas time & away from the security of home.

So I’ve had 3 bouts since my blanking period ended 2/25. One lasted a few minutes, the 2nd one lasted 8 hrs and last nights lasted about 3.5hrs. All self corrected. I don’t know what I should do. It’s my understanding that AFIB won’t kill you per my cardiology NP. But it’s very uncomfortable and to be honest scares the bejesus out of me.

Id appreciate any kind advice. Thanks
Pokey

It sounds like you may be dealing with an adrenergic response. I had the same thing, sort of. I didn't know I was severely apneic, but found out after my cardiologist sent me for an over night polysomnography that showed I had been severely apneic for some unknown length of time, and that my heart was tired of trying to keep me alive 30 times each hour...all night long...for months. Once I had my PAP therapy dialed in, my heart would still fibrillate during the day the odd time, but with 100% reliability it would revert to NSR at about the time I had my first 'time to turn on my side and go to sleep' jerk. It was uncanny how reliably this phenomenon happened, night after night after night. I relaxed, began to fade, jerked awake, turned on my side, and I noticed without fail that my heart was calmed.

Your heart seems to do better after you have slept for a bit and don't have the repeated conscious stressed responses that involved some adrenaline. This is just a guess, and perhaps my guess suggests something far too simple to be the actual case.

I see that you're informed and being cautious, in addition to being concerned, about long Q-T. I don't see how it could be much fun, if salutary, to wean oneself off of an anti-depressant, especially if it didn't help much on balance and if its withdrawal encourages an arrhythmia.

You still have some time to get fully off the drug and to see how your heart calms, if it will. Another five weeks should have you off the drug with any luck, and you'll still have a couple of weeks to decide if you'd rather not just stay home due to how things have gone...or to travel.

Your recurrent AF tells me that you have not had a successful ablation (12 months free of the treated arrhythmia). I was bummed at the six day mark after my first ablation to realize it was a complete bust, and to add insult to injury, I had to go on amiodarone for eight weeks. Sx(it) happens, even to the best of us. I can't advise you since I don't know you and everything else to do with you, health-wise, relationships-wise, your financial circumstances, etc. But, I would submit to at least one more ablation. Several posting here regularly have had at least two, and some as many as six....before the right guy got the right things done. And that would be Carey's message, if I dare to speak for him...choose a really good EP, travel if you must, and get the job done correctly. You may need the services of someone comfortable with, and skilled enough to carry out, complex cases. Clearly your case is more complex than the limited ablation done to you last time.

Thanks Gloaming for the detailed response. After my bout of Afib in August my EP recommended a 2nd ablation. Several months went by without any more bouts thinking the bout in August was due to the flonase I had been taking nightly for nasal congestion which I had stopped. My PCP and regular cardio doc recommended I hold off and see how things went. which I did. But then I "cheated' two nights ago and took a dose up each nostril because I was so congested making breathing with my PAP therapy difficult. I figured one dose in 4 months would not be an issue. Theres no way to know for sure, but maybe it was the trigger? I need to throw that stuff away!!

You mentioned getting off the AD in 5 weeks. There's no way I can get off in 5 weeks. Its going to be months yet. I have a past history of being on and getting off psych medications. They are the most difficult medications to get off of that there is. Withdrawal sxs can be brutal if tapered to fast. So I am stuck with some time before I am off that med. I guess I think if the doxepin was the cause of my AFIB bouts I'd have had more at the higher dose I was one or bouts would be more frequent even at my current reduced dose.

One question my worry spot keeps asking is could having a redo actually make things worse or be more complicated this time. I read the report of my ablation. The report sounded complicated & they had to zap me 3x to get me out of AFIB, the 3rd time at 350 joules. Does that say anything about, well, anything?

Finally, what if I just continued watchful waiting? Whats the worst that can happen? Another bout(s) of AFIb? If that happens then I'd I know for sure I need the 2nd ablation?? Or would that just be delaying the inevitable from what we already know?? That this is not going to timidly go away and leave me AFIB free the rest of my life??

I'd say an ablation is probably warranted but it's unlikely you'd be able to get it done before Christmas. That's barely two months away and any EP worth seeing probably won't be able to get you in before then (I'd be cautious if they can).

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Finally, what if I just continued watchful waiting? Whats the worst that can happen?

That's what I would do for now. And yeah, throw the Flonase away. (Try a neti pot instead?) As for the worst that can happen, not much really as long as you're still on an anticoagulant. The worst is you have another episode or two. It will probably behave as it has so far, so no need to rushing off to the ER. Just wait it out. And yeah, I'd say another episode without the Flonase being involved cinches the decision.

Carey. Thanks for helping me make sense out of all my misunderstanding, confusion and fear surrounding this AFIB stuff. The medical professionals don’t necessarily do that very well. I’m going to hang tight and see what happens. If I get another bout without the Flonase being involved then as you say that pretty well will be a good indicator I need a redo.