Hi, I am 79.For a few reasons, my Dr thinks it is time to get an ablation and/or switch to a different arrhythmia drug ( I went on Flecainide 2 x 100mg 17 years ago when I got a pacemaker. Over those years a typical year was 5-10 shortish self converting episodes. A few years back (2023) I did have my only episode that did not self convert after 8 days, and I had a successful cardio conversion with no episodes thereafter for 18 months or so. My question: if I get the ablation here in Boston —- vs switch to a drug like Sotolol which requires a hospital stay — is pulse field proving to be effective? Thanks for any insights.

Yes, PFA has been proven effective and it's safer than RF ablations, which were the norm for many years. But it's not clear to me how many episodes you're having lately and how long they last. How many episodes have you had in the last six months and on average how long did they last? Choosing between an ablation and sotalol isn't a simple choice.

Sounds like Flecainide has been very effective all these years, except for a single 2023 episode. BTW, you try a self-convert with an additional PIP dose or just rate control it out and then cardiovert?

In any event, the first question is why switch to an arguably less effective antiarrhythmic? Have there been concerning EKG changes recently? Is your EP concerned about any new structural heart issues? Or is he changing just to change?

Once you've sorted that out, the question is either stay on the medication course, or an ablation, and given your relatively light Afib burden, not clear cut.

On the anti-arrhythmic side, it's worked for many years, so why fix what isn't broken and expose yourself to the risks of ablation, and there are risks, and newer data shows the risks with PFA are about the same as RF and Cryo.

On the other hand, you're approaching 80 and probably in the best health of your life now, which argues for getting the ablation sooner rather than later. That was one of the reasons that persuaded me to get an ablation in my 70s, rather than wait much longer. That, and I did not want to be dependent on Flecainide for life.

If you do undergo an ablation, PFA seems to be the popular choice; however, results and complications are still relatively similar to those of RF and Cryo. That said, operative time can be significantly shorter, which is particularly important at your age, with General Anesthesia (GA), the benefits of PFA are still unclear.

Personally, I do not do well with GA, or even MAC (monitored sedation), both of which use the drug Propofol, so Cryo would actually be my first choice, if you can find an EP who will do it under conscious sedation. Second choice would be PFA, again, because of the shorter operative times.

t is unfortunate that in this country, GA is so widely used, whereas in the UK and elsewhere, conscious sedation is the default. Especially as we get older, it can be difficult to clear some of these drugs. It took me over six months to feel like myself again, because of the sedation, so something to consider at your age as well.

Jim

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Edited 3 time(s). Last edit at 11/07/2025 11:10AM by mjamesone.

I am in the 'AF is a progressive disorder and it's best to get strict control of it while you can...................meaning as early as you can,' camp.

You have done all the right things, but you suspect that the wheel nuts have come loose and the wheels are starting to wobble on those botts. It's time for a look-see and at least to tighten those lug nuts again. Analogy aside now, things seem to be changing. Probably an evolution going on, and you feel it's time to take a strategic look at options and possible outcomes. To me, an ablated patient in NSR for three solid years now, ablations done properly should have you in NSR..........................without...............any further resort to AAC drugs. All you'll probably need are possibly a statin and a DOAC (direct-acting oral anti-coagulant). A heart not fibrillating will have the pace of the disorder severely curtailed in most cases since it is during the act of fibrillating the the fibrosis, collagen deposition, and mitral valve problems are likely to develop.

Ablations are rocket science, but everyone is sending up rockets these days. Same with ablations, and like the rocketry, ablations are improving all the time. They've worked for most of us replying here, even if it took two, three, six stabs at it. I would rather submit to an ablation than to continue to take drugs, especially if the one that has worked so well has begun to lose its efficacy. There's always another drug (that might work for a while, maybe a good long while), or there's the day surgery that is an ablation.

Thanks Carey,
Since the cardio conversion 2 years ago, the pacemaker shows a short 6 minute episode late this summer.
My EP, whom I like, feels my recent calcium score, (which has my cardio dr ordering echo, and maybe stress, etc. and my EP switching me from Lovastatin to Crestor. My EP is concerned that I may now possibly have a heart situation in play that might make Flecainide (used by me for many years)a poor choice ( SALT study). He thinks either switching to a different drug - Sotolol, Multaq, etc. or getting an ablation should be considered.
A typical year had me having 10-12 episodes. Usually short, but I did have several of 3-6 hours and one of 24 one year when conversion almost can in to play. I am hugely symptomatic, and when I needed the cardio conversion after a week plus of afib, my EF function had dropped from 55-60 down to 20. It came back after the conversion. I am leaning towards getting an ablation keeping in my Jim’s point below about age or trying the Multaq. Thanks

Gloaming,
Thank you for your inputs!

Jim,
Great info. Thank you. The age thing is a factor. I am in good shape now, but getting up there.
Also, a factor in my minds and the doctors, is I travel a lot to Maine, to Fla etc. and am away. He thinks PIP not worth it to chance a try.See my response to Carey for more detail…and EP is concerned the Flec at this point may not be best if I have something heart related going.on.



Edited 2 time(s). Last edit at 11/08/2025 01:30AM by tibbar.

Quote
mjamesone
Sounds like Flecainide has been very effective all these years, except for a single 2023 episode. BTW, you try a self-convert with an additional PIP dose or just rate control it out and then cardiovert?

Not that Tibbar is doing this, but for others reading, I would suggest you not stack PIP flec on top of 2x/day chronic dosing without a serious conversation with your EP/doc and looking at how much you are taking. Generally for those weighing 154 lbs or less (70 kg) the max flec per day is 200 mg and 300 mg for those weighing more.

I have done this stacking, but it has been when I've been taking 25-50 mg of flec/day. For my size, a max dose is 300 mg. The PIP dose I take is 200 mg. Hence the sum of the total amount of flec I take is less than my max, by quite a bit. In addition. when I've done this, it has generally been 12 hours or more since my 25 mg flec dose.

I would suggest you not stack PIP flec on top of 2x/day chronic dosing without a serious conversation with your EP/doc and looking at how much you are taking. Generally, for those weighing 154 lbs or less (70 kg), the max flec per day is 200 mg, and 300 mg for those weighing more.

I agree with the part that you need to get your 24-hour max dose from your EP. However, while weight can play a part with PIP dosing, maximum 24-hour dosing is primarily related to your overall clinical profile, such as heart structure, conduction status, and kidney, liver function, age, tolerability, etc. I weighed over 70mg, and my maximum allowed 24-hour dose was only 200mg. So best to go over all possible scenarios with EP on how much to take and when, and under what time window, and when to call in if needed.

Jim



Edited 1 time(s). Last edit at 11/09/2025 12:11AM by mjamesone.

Jim, again, thanks for info and insights…