When is it too late to get an ablation?

Hi everyone - I have not posted here much in awhile as Flecainide has kept my afib fairly well controlled for the past 3.5 years. However, I seem to be having a bad month and have had afib "kick ups" 7-8 times this month so far (I used to get afib 1-2 times a day!) I have not wanted to get an ablation as it seems scary and not always successful - or has even made matters worse for some. However, since things have kicked up a bit this month, it is back on my radar.
I remember my cardiologist saying that I may want to wait until things become almost unbearable before going for an ablation. If I were to do that, and then it took 6-9 months before I could actually get it done, would that be too late? (heart remodeling, afib might become persistent or permanet?, etc.).

I am hoping things will settle back down again soon, but would like to hear your thoughts and suggestions.

Also...where do things stand with regard to only needing one ablation - i think I read something in Hans reports saying they were getting closer to making the ablations more effective and safer.

~

The only thing that I can really add to any advice you receive is this:
1. I was a candidate for ablation 18 months ago and was not referred to an EP by my quack cardiologist who figured he would have me on Warfarin until he had 6 - 8 weeks in 'the range' and then do an electrocardioversion, which, of course, failed miserably.
2. When he finally gave me that electrocardioversion (I was in 24/7 aFib) it was many months down the road and my left atrium was already enlarged. By the time I got to see a good EP at a different hospital it was 60mm and too large to be a candidate for ablation. Period.
3. The EP has put me on TIKOSYN and I have been in NSR since December 2011, my creatinine being monitored by family doctor every two weeks and being followed by the EP with my next examination at 6 months (June 2011) at which time we are going to see if the left atrium is shrinking.
4. The moment I am within range for an ablation I am going to have one done at a top notch facility by a top notch cardiologist/EP. I am prepared for a second "touch up" ablation if necessary, but their track record is pretty darned good I gather.

When is it too late to get an ablation? I would think that asides from whatever advice you may get on the forum here (and it will be top notch advice you may rest assured).... it is too late to get an ablation should your left atrium be enlarged to the point that it becomes difficult or dangerous and that is generally in excess of 55mm I gather. It is too late if you have calcified arteries that will not take the catherization. So, for me, as I say, the moment I am below 55mm and hopefully below 50mm and a candidate, I am up for the adventure. Although, having said that, if I continue in NSR on Tikosyn I may wait a little while longer as technology improves and my left atrium shrinks. Dunno at this point as far as I am concerned.... but there is certainly good cause for you to seek out a top notch electrophysiologist and a top notch institution that does many, many ablations annually (lots of experience makes for experienced hands) right now and get an examination and an opinion. Just my humble opinion.

Had I not waited to drop my quack cardiologist (who spent more time on vacation and pushing meds for big Pharma than practicing on aFibbers) and get to a top notch EP (I am so very lucky) I might have already had my ablation and be sitting back on an aspirin a day.

Oh, one other thing that comes to mind and that is simply that systemic inflammation(s) seem to have a driving effect on aFib. I have been supplementing for about 18 months now and note that my last CT scan 18 months ago had pleural effusion and cardiopulmonary effusion as well as a host of other indications of systemic "inflammations". My CT scan 3 weeks ago or so had a one paragraph evaluation and it simply said "nothing of note found". Progress? I don't know. But I do know that you want the best working with you and you need to be a vocal patient stating what you want..... let there be no leaf left unturned as they say.

Wishing you good progress and NSR.

Murray

Murray L

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Tikosyn uptake Dec 2011 500ug b.i.d. NSR since!
Herein lies opinion, not professional advice, which all are well advised to seek.

The updated expert consensus guidelines issued this month by the USA and European heart rhythm societies puts ablation as first line therapy for paroxysmal AF, if you can get it done at an experienced center. I think the only reason to delay, if you are have paroxysmal AF, would be that you do not have access to experienced ablation centers. Otherwise, the docs keeping you on AADs are really not doing you a favor because you will eventually get to persistent or permanent conditions which would probably require surgery to get same level of success rate that you have obtained if you were to ablate while it was still paroxysmal. The expert consensus guidelines are available at hrs.org. It's written by the top experts including experts who advocate drugs, catheter ablation and surgical ablation.

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions,
Endpoints, and Research Trial Design

[www.hrsonline.org]

Hi Barb

I second what Murray says.

I recently had a 3rd ablation, Feb. 29th. The first two ablations were 8 hour procedures and this last one was just 3 1/2 hours with an overnight stay in the hospital for observation and Sotalol until my heart calms down. I may post more on the results once I am further along in my recovery.

When I saw my new EP he looked at my Echocardiogram and told me that I had "waited too long" because my left Atrium was enlarged. He also told me that "my heart was chasing it's tail" which I thought was a good way to explain how crazy my heart has been since the first week in Dec. !! He told me that there was a chance I would not have a permanant cure but he would try his very best. I'm still in the 3 month healing process and am hopeful for the best outcome. I have tried most of the anti-arrythima drugs, including Tikosyn. I have tried diet, supplements and alternative medicine. But, the afib and flutter and pac's just kept getting more frequent and longer. There was no more time to wait so here I am, 3rd ablation behind me and done by an EP that was referred to me by another EP who felt he was the best one in Atlanta. Actually, I told the referring EP that if he thought he could

cure me than fine. If not, to refer me to someone who he thought could! He was not at all offended and I really admire him for that. So, find the best EP in your area and go talk to him!

Christy

I waited 8 years tinkering with various 'solutions' to the afib problem and using debilitating medications. Eventually, it became nearly permanent so I made an ablation date and had six months to try harder to solve it on my own and I nearly did. However, at age 67, I proceeded with the ablation that I never wanted. It's been mostly successful as long as I am very mindful about electrolyte intake and the other nutritional support that is in The Strategy report. That said... one of the doctors in the EP lab at the Cleveland Clinic where I had my ablation said there is no age limit for ablation in a healthy person. Obviously, if the atrium becomes enlarged or fibrotic, that's another issue entirely.

In my opinion, to rush into ablation without trying all the other options first is a mistake. The procedure is invasive and is not guaranteed totally 100% risk-free. You can have the best EP on the planet but something may be amiss in your body that renders the result less than satisfactory... so my thought is to give every option a good trial first.

Nevertheless, it is a highly personal decision that only the patient can make.

Jackie

tobherd being on Flec does prevent electrical and structural remodeling according to some recent Europace studies. If my next echo LA comes in at under 4.4cm was 4.6 before I started Flec then that will be great.
I'm in the same boat I go out of wack every 7-8 days even now that I started supplementing again with Mag/K. The only thing I will say the duration may have shortened instead of lasting 2 days now it lasts less than 12 hours. I also take Flec and hoping it prevents the calcium ion deposits that lead to remodeling



Edited 1 time(s). Last edit at 03/22/2012 12:01AM by McHale.

Thanks for your comments everyone. Of course, I am having a good day today and that makes me think, let's just ride this out some more. At my last checkup, there wasn't any remodeling or atrium enlargement..but how long does that take to occur? If Flec were to stop working, and I had months before a I could get an ablation, how quickly can that begin?

Jackie - it almost sounded like you wished you hadn't had the ablation...is that true? I know you've been very diligent with doing things right even after having the ablation.... And how far have they really come with regards to being able to treat this with just one ablation? I've read that this should be the case...but not sure when.... Another year? Then I would try to wait if that were the case. I would not be rushing into an ablation, as I've wrestled with this now for 9 years(!), but have I tried everything? Not everything..but alot.

Sure wish there were an easy way OUT!

~ Barb

The question is wether you want to be on meds and all of their side effects for the rest of your life, if not and you are a able to get an ablation, just do it and don't look back. Keep in mind that the factors that made you go into afib are still present, that is a sensativity to the levels of Sodium, Magnesium and Potassium, so to make the ablation last you must continue to supplement and watch the normal triggers or you will be right back where you started.

Barb - No I'm not sorry I went for the ablation... but because I was so close to solving it on my own, I often reflect back that I should have waited longer...and I would have except for the threat of losing my very good insurance at the time... which didn't happen, but who knew? When I began my afib journey over 16 years ago, I said at the onset I didn't want a procedure unless I absolutely had to since I had already had several unnecessary surgeries and didn't want to risk another only to find out the problem could be managed another way.

Mine was a single ablation BUT... at year four, I began to have breakthrough arrhythmia every 6 or 9 months... and it was because I wasn't as careful as I needed to be with the critical electrolyte stores and balances and also what I needed for heart energy. I was reminded that this is an ongoing priority; and that,with aging we often become less efficient at hanging on to the essentials like magnesium and potassium... and of course, I wasn't as careful then about the Na/K ratio as I am now. Although, the addition of high dose Ubiquinol and ribose definitely helped as well. Out of those revelations that stabilized my heart, I wrote the observational report, The Strategy.

Time will tell if those who have the second or third ablations and are afib free remain so in their senior years... especially if they are not watching the electrolyte and energy mechanisms that facilitate NSR.

Jackie

in response to mchale 4.4 La really isnt enlarged 4.6 La is maybe borderline pretty close to normal

Darrell,
Thanks for that I needed to hear it. My cardiologist did note I was mildly dilated on the echo at 4.4cm. My prior readings were 4.1cm.
The prior echo showed 4.6cm but I think the technologist doing it was clueless. Also echos are open to interpretation with the X Y axis as to accuracy that has something to do with the Tech's skill. I have to dig up the article.
In any case I was in full blown afib during my last echo/ stress test that showed 4.4cm and there's a phenomenon called atrial stretching that is temporary. I was also getting PAC's/AFIB during the 4.6cm echo. Also even when in afib my symptoms are minimal no pounding heart and my heart rate is usually no moe than 100 so why the enlargement however slight?
I've been on Flec now almost a year since my last echo will be interesting to see my diameter now.



Edited 3 time(s). Last edit at 03/24/2012 12:47AM by McHale.

Barb,
Are you out on long Island NY from I recall?
Where are you going to have it done if you need to? I sure you thought about it.

Researcher,
Both my cardiologist and my mom's EP both told me this is a rapidly evolving field.
The EP is from Mt Sinai New York under Dr Reddy top Heart/CA center and he told me to hold off on an ablation big breakthrough's coming.
I need to set up an appointment with him for myself. Me thinks they are experimenting with lots of toys there.................
I don't want to wait too long supplements are just not cutting it.

Jackie - how much Ubiquinol and Ribose do you take? I am having another bad day with afib and am feeling that the Flec may not be working so well anymore...and I'm scared and very depressed. I was so hoping to avoid an ablation as I have read some of the horror stories on that - but I really am starting to lose my patience with this. It's been 9 long years, 5 of them with me struggling on my own as it only became more frequent, and the last 3.5 pretty good - after taking Flecainide. But this has been a bad month and I am feeling like I need to go back to the doctor and figure out what next. I'm already on 300 mgs./day of Flec, so don't think they will want to increase it.

McHale - I have thougtht about it, but as I mentioned in the paragraph above, I've been doing pretty well on the Flec - until recently. It's 3pm in the afternoon and I am in afib again...I have considered whether to go to Dr. Natale in Texas or Dr. Chinitz at NYU. but haven't done anything due to things being overall OK.....I'm feeling like that may not be true anymore however. Dod your doctor give you an idea how soon something new was supposed to happen regarding some kind of breakthrough?

Is Dr. Natale or Bordeaux the only two places most of you would go for an ablation?

Not sure if I should go back to my cardiologist for an appt., go to the EP I like but would probably not use for an ablation, or go right in to see Dr. Chinitz in NYC....any thoughts on that?

Barb,
The three doctors I would consider would be Dr Reddy Mt Sinai Dr Chiniitz at NYU and Dr Steinberg St Lukes.
I was thinking Dr Chinitz or Dr Vivek Reddy but after ending up at Mt Sinai for my mothers aortic stenosis where she almost died a few months ago
but the incredible talent, professionalism and empathy of all the doctors, EP's and staff that saved her life I'm leaning toward Mt Sinai.
She's developed afib after the balloon valvuplasty to open her aortic valve but I saw her monitor display irregular HB on and off all day before her procedure most likely due to mitral valve stenosis too, diabetes, and high blood pressure. Even with all that rate control and coagulation is all that's needed and she feels great...go figure.
Her EP work works for Dr Reddy is fantastic went to Brown University did his fellowship at NYU under Dr Chinitz I'm assuming and now is at Mt Sinai and is device certified and member of heart rhythm society and I really like him. I'm thinking of going to see him Wednesday or do I see his boss Dr Reddy and risk pissing him off. Usually it's a team effort at these centers so it wouldn't matter. Evelyn another poster from Yahoo went to Reddy almost 2 years ago and is afib free.

Or do I go to France or Texas or Cleveland? I think we have the best right here too.
My heart has been really erratic lately and I'm getting nervous.