Ablation complication - sorry, long!!!

Hello, all.

I have just discovered today that I do not have to be signed in to post as was my previous understanding and why I have been absent. since I have lost my password (and my mind) since last posting and all attempts at recovery or re-signing in have been unsuccessful.

I had a rather revolting complication from my ablation. I believe I mentioned previously about my shortness of breath post-ablation and, in conjunction with my COPD, thought it was post-ablation inflammation, returning to high altititude and/or, heaven forbid, pulmonary vein stenosis.

We stayed at the Kabuki Hotel for three nights and I did not leave our room because of the steep hills around for walking. When it came time to leave I was so short of breath I had to stop three times on the way to the garage below. This SOB kept getting worse and worse and eventually Joan at Dr. N's office told me to go to my pulmonologist. He did not take an x-ray and diagnosed me off the cuff with asthmatic reaction to anesthesia (BTW: never had anything resembling asthma in my life, never any respiratory allergies, have had many general anesthesias which Dr. N uses, and told the doc so), and I told him I didn't think that was a correct diagnosis. At any rate, he tried to persuade me to take Methylprednisolone (nope) and Symbicort (I did try that twice a day without effect). My hub came home from hospital having had hip replacement and I was trying to keep going for him, but eventually, even with 5lt/hr O2 could barely walk across the room.

Here comes the funny part in this novel: went to the john in the middle of the night and fell asleep leaning with elbows on my knees (taking pressure off my lungs) When I awoke, because I have numbness in my feet, did not realize that my feet had gone to sleep too!! so when I stood up I crashed my knees onto tile floor and my head into the door. Now, still being on coumadin, was panicked about intracranial bleeding, I couldn't get off the floor and hubs was the other end of the house (and very hard of hearing). I finally managed to get erect and had him drive me to the ER (he had not driven post-surgery on right hip), where they promptly admitted me for....... aspiration pneumonia!!! Yes, they did x-ray my knees (as well as my chest and thank goodness for THAT!) and eventually did a brain MRI which was fine.

Now comes the unfunny part. Was in our local branch of the hospital for three days, then transferred to the main hospital where I was put on full life support in ICU for eight days, doped out on dilaudid, and restrained hands and feet because I kept trying to pull out the tubes, then transferred to an acute rehabilitation hospital for another three weeks, for five weeks in hospital in toto. Needless to say I don't remember a lot of it. Fortunately hubs was there to get me gluten free gruel in my feeding tube, and, oh fortuitous, the dietician at the rehab hospital was a celiac who did a special meal plan for me every day (once I got off the feeding tube). Then I was able to get off the breathing machine and they did a tracheostomy, and eventually I got off that and had a nasal cannula, and eventually I got off that except at night.

So have been home about six weeks (and Dr. N's office was wondering why I hadn't been sending in my LifeWatch recordings, but I assured them that my SpO2 had been closely monitored, along with my EKG and every other damned thing they could think of). At one point I actually managed to learn to use the iPad, and was able to look up MyChart and found they had been monitoring my magnesium, but not giving me any, and I complained bitterly that they were mining all my intracellular magnesium I had carefully built up, and for a while they gave me some magnesium, but then stopped so I had hubs bring in stuff from home (along with my Flec. since I wasn't going to wait 24 hrs while they approved that - had to take it once) So I had this little pouch of stuff I was taking sub rosa!!

Good news is that the afib appears to be gone!! Bad news is that Joan told me that they did, in fact, isolate the LAA. I had booked our airfares for us to be here for 6 months for any eventualities, but eventualities being what they are, not long enough. Joan said she did not want to book me for a TEE while I am still having esophageal problems (still have not regained my melodious voice - just a raspy, breathy kind of growl at the moment) and I do not fancy anything else going down there right now either. They are starting to talk snow here in Nevada, so I am left on coumadin (fortunately I can maintain on that at 2.3 taking 2.5mg/day pretty well.) We leave on Nov. 2 to return to NZ, and will return to US in June 2013 at which time they will do TEE and measure flow from LAA and through the AV node, and proceed from there.

Looked up Dr. Google and aspiration pneumonia occurs in 0.05% of various ablation procedures. I had not realized until then that with RF ablations they spray like a dentist does to cool off the tissues, and I guess some stray spray found its way (through my epiglottis??). So of course, with such a low occurrence rate, this was not something that was discussed before the procedure, and I had never heard of aspiration pneumnia......

Just another thing to be on the lookout for, and just my luck!!!

Hi and Wow Neroli!

What a roller coaster ride!!! So glad you are on the mend and that you went to the Pulmonologist as soon as Joan recommended you do that ASAP! Although it sounds like by that point it didnt take much convincing to get you there?

And aspiration pnuemonia of all things ! .... that is a first that I've heard of from anesthesia during an ablation, though I guess it happens rarely in all sorts of general anesthesia procedures from what I just googled on the matter. Did the pulmonary Doc say anything about your pre-existing COPD as maybe having predisposed you for this unwanted side effect from the anesthesia to some degree??

In any event, it's a good lesson to share for anyone to alert them to take action for any on-going shortness of breath after an ablation that doesn't resolve fairly quickly to get thee to a pulmonologist pronto to rule in or out this very rare outcome post anesthesia.

Good to hear the AFIB seems out the picture now, even if it took isolating the LAA to get it done. We're in the same boat on that one but it is very nice having a stable heart as the bonus.

Take care on your long trip to NZ and back.

Shannon



Edited 1 time(s). Last edit at 10/20/2012 02:46AM by Shannon.

Neroli - I'm so very sorry to read about your ordeal but very glad you are on the mend. Aspiration pneumonia can be a factor in some patients and in some surgeries. I've known a few patients having that complication but not with ablation. Nevertheless, when it happens to you, nothing is funny about that and it is serious. At least your heart is calm. Please take good care of yourself and let us know how you are as time goes on.
Best to you,
Jackie

Thanks, Shannon and Jackie.

Actually, Shannon, the pulmonologist did me no good at all - it was the hitting my head which got me to the ER that set me on the right path. At least they sent all his associates to see me in the hospital and not that idiot! I probably would have bopped him if I had had the energy (or was not in coma).

I have had one afib?? episode since out of the hospital, started out in tachycardia but not real fast, and took a recording of that. Since it continued I took 50mg metoprolol which cured the tachy and I went to sleep for a bit, but twoke up with a bunch of ectopics - I can't tell the difference between PAC's and PVC's - and then my pulse oximeter started showing irregular lines and I had to urinate frequently so I figured I was in afib (sure felt like it) and took a dose of flecainide (and took another reading). Joan said it didn't look like afib....?? Anyway, after about 4 hours total it went away.

Right now I am on 50mg metoprolol bid, and lasix, no other heart meds (for hypertension) and my resting pulse rate is around 71 (up from low 60's). and blood pressure 130/68 with 2.3 INR. Still have PIP flec. but have not needed it in a month. So I guess I'm doing okay by the numbers. Still struggling to get any strength back - and I know I will not be able to walk through all those airports!!!

So sorry to hear about your "adventure" and hoping that you are on the road to NSR and good health. I wasn't quite able to follow the flow of where you are from, who did the ablation and where, etc. Sure did get the punch line though and I can empathize to a great extent. Full life support is no cake walk and, having been there, I can really feel for you. I can also empathize with abject incompetence being flung at you - got that T shirt as well. Think I am on the right road now and looking forward to NSR on TIKOSYN as my left atrium shrinks to the point where I can do the ablation route when it becomes necessary.

Are we having fun yet?

Murray L

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

Sorry Murray, I live most of the year in New Zealand, spend summers here in Nevada. Had my ablation by Dr. Natale at CPMC in SF in mid-June. Over four months and I am just recovering (my strength) !!! What a summer vacation....

Hi Neroli,

You mentioned your COPD and need for oxygen, is that something you need every day now? And can you give us an idea of your age as well? Just curious since if I understand it correctly this was your first ablation right? Were you in persistent AFIB or if paroxysmal had you any long episodes exceeding 24 hr duration prior to the ablation?

Dr. Natale told me that he has discovered more women than men with primary active triggering from their Left Atrial Appendage, although with persistent AFIB a good percentage of both men and women it turns out have the LAA as a main trigger source. Yet for people still with paroxysmal AFIB with longer than 24 to 36 hr episodes it seem those women in that group have a significantly higher rate of LAA firing than men in the same sub-group.

Thus, I'm curious if you were in that paroxysmal group but with some longer episodes, or paroxysmal with all episodes shorter than 24 hour or in persistent AFIB when you got the ablation in mid June??

Hang in there with the energy it can take different people widely divergent time frames to bounce back with their energy, especially after a more comprehensive first ablation if I understand correct that this was for you? No doubt the adventure with the anesthesia aspiration didn't help any on the front as it is!

Take care and continued quite heart and a speedy recovery from here on.

Shannon

I am a paroxysmal vagal afibber, age 72. It had been going on for several (maybe five) years before I was diagnosed. I used to spontaneously convert after four hours or so - used to have pain in my shoulders, left arm, hand, and to some extent the right. Also in my head - could not rest head on pillow. Triggers were almost entirely lectin-containing foods, although (and this I am sure leads to the LAA), I could sometimes trigger an attack by certain movements involving lifting my left arm above my head. I have had COPD for years, getting progressively worse but no emphysema. Have used O2 at night for several years because I drop into very slow shallow breathing pattern.

Eventually I could no longer handle the altitude at Lake Tahoe. One summer when we arrived and finished unpacking personal belongings out of the garage I went into really bad afib where I was gasping for breath, could not speak or stand. At that time I had very low potassium, so they filled me with potassium and chemically converted me and sent me home to see my PCP next day (except that was her day off). Couldn't get any significant potassium in town without prescripton so spent the next three days eating bananas and dried apricots until I could see my doc, but by that time was in afib again. Even though I told them to give me potassium (different ER) they said my potassium was fine -- what was in the blood, not the cells. Next day they said, oh, you are low in potassium and after having tried various chemical converters, eventually converted me with -- potassium!!

The following year we moved to lower elevation but I had another, longer attack - it took them a couple of days to convert me and I was discharged with an Rx for amiodarone (which I did NOT take). Eventually got some flecainide and went for consult at Mayo where they said I shouldn't take that because of my edema/kidney problems and pescribed Rythmol which I did not tolerate, nor Multaq. so I ended up with Flec PIP. Mayo gave me a bad CHADs score and said I was not a candidate for ablation because of my COPD and were talking about a pacemaker. I did not want that. So made an appt. with Dr. Natale in June when we arrived this year, and the rest is history.

So. yes, I seem to fit the profile you describe.

My general weakness arises from my five weeks in hospital rather than from the ablation. But I have been having P.T. and using the equipment at the gym here and getting fitter (I was not in very good shape to start with having had a broken back!! from which I am now recovered) My P.T. says for every week in the hospital it will take a month to get back to where I was, but I think I am going to beat his estimate.

Neroli, I am so sorry you have had such a difficult time. And I'm embarrassed to have spent so much energy worrying about myself over issues that are so insignificant compared to yours. I am five years older than you and had my first and only ablation with Dr. Natale a little over two years ago, The LAA was isolated, resulting in my being on lifetime anticoagulation therapy. With the CHADS scoring, apparently being our age plus female gives us two points instantly. Interesting that Shannon mentions a higher percentage of women having LAA firing. I was a paroxysmal afibber, adrenergic, and usually self converted in less than 12 hours. Then I was put on the PIP. Until a few years ago, I lived in the East Bay area of San Francisco. You must have enjoyed spending time at Lake Tahoe--it's beautiful there. I wish you the best. Be well.

Laura

Thanks Laura. Have you ever been back to Dr. Natale and had a subsequent TEE and/or considered the Lariet or Lasso or Watchman procedures to get you off anti-coagulants? How often do you have your INR done? I find it a pain, besides worrying about not putting any gluten or high-lectin foods in my mouth, having to worrying about how much Vit. K I am putting in as well!! As well as getting the right amounts of potassium and magnesium and other nutrients, enough but not too much fluid, etc., etc. Lol!! Whoever thought that comestibles could be such a problem!

Hi Neroli,
I haven't been back to Dr. N, just my EP here. The consensus was that there was really no utility in doing the TEE because of my CHADS score. Plus, I had a TIA associated with the ablation, but no one knew why, most likely caused by char or something similar. I haven't talked to anyone about the Watchman or Lariet (which I have heard Dr. N is doing), mostly because I generally feel the farther away from doctors I stay, the better
The vitamin K issue is frustrating. I check my own INR once a week. Sometimes, for no reason I can fathom, it will go from 3.9 to 1.5 within a week and with no real change in diet that I can find. I'm looking forward to apixaban being approved here because it sounds like a good alternative to warfarin even though it doesn't have a reversal agent.
Take good care of yourself and travel safely back to NZ. (My son hiked through New Zealand the summer he graduated from college and he thought it was beautiful.) Please keep us posted on how you are doing.

Laura

Neroli and Laura,

You should absolutely have your EP prescribe a PHilips InRatio-2 home INR meter.. Its a god send! That is a reliable machine, and the only trick to getting excellent comparable results to the venous blood draw is to compare each new box of 'strips' you get from Philips ( 12 strips per box and or ask for two boxes at a time with the same Lot number particularly for travel stock). Then you compare the first strip from each new box with the last strip from the old box by doing back to back immediate INR finger prick tests.

You only need to follow the directions carefully and when you use the little finger poking lancer device to get a small blood draw you make sure just after you have poked your finger and gotten a good size drop to form to align your finger carefully directly over the little 'bulls-eye' hole on the plastic strip that you ahve inserted into the machine. and make sure you hacvew the full drop fall directly on that little bulls-eye hole without touching the strip with your finger. Nor do you want to milk you finger too much nor dap it twice over the hole .,.. you need to use only the one full drop and not mix a second drop a moment of two later in order to get an accurate reading.

Once you get the hang of it its a peice of cake and I recommend that every time you get two new boxes of strips with a new lot number compared to past boxes that you also directly compare the first of those new strip with your local lab's venous blood draw.

Just go to the lab and tell them you want to do your InRation-2 finger prick test jsut moments before the blood draw and they will let you do that in the same room you get the venous draw as well. As soon as you run the InRatio-2 test and get your INR number they will do the venous blood draw and when you get the report of that readign later in teh afternoon you will then know precisely how well that box of strips coorelate with the venous draw and can adapt your dosing accordingly for the rest of that box(s) os same lot number strips without going to hte lab at all.

Once you know the overall correlation of one set of strips with the venous draw then mostly you can just compare each new box of strips with the last box without always having to do the venous INR test at the local blood lab. Still I would do the venous INR comparison every now and then just to make sure your machine and strips are well calibrated.

Dont let the strips get really hot like in a car all day, and keep the small machine in good shape and dont drop it and you will be SOO glad you can test whenever you want and at least once a week.

Its great to far more quickly see the effect of different foods and supplements or other meds effect on your INR and just makes like a hell of a lot easier than having to hassle with a blood lab so often. Its important with LAA involvement too to test once a week and not let it drag out to every two weeks or a month as people so often do when they get complacent .. You DONT want to get complacent if the velocity of blood flow is below 0.4meters/sec and there is a persistent A-wave at the Mitral inflow ( this is the two make or break values they look for in the TEE six months post LAA-isolation) then you have to stay with Anti-coag anyway or go with the Lariet or Watchman.

Eliquis or Apixiban does seem like the best alternative for the drug route, but for me only once there is a practical reversal agent. Other wise careful control of INR with the home meter will help lessen some of the risks of Coumadin a far degree.

But we still will not know how truly effective Eliguis really is going to be in preventing Spontaneous Echo Contrasts(SECs) or even outright Thrombosis clots to form within our LAA if we are not getting enough blood flow in and out. Therefore, if you choose the drug only route, please also insist on periodic TEE tests to confirm how well it is working and that you are not forming clots in the LAA in spite of the Apixiban?? Until there is a much larger body in knowledge of just how well Aprixiban works in the wild, I think this is very prudent to stay on top of just how effective it is in helping to keep your LAA clear.

Maybe do two TEE's a year the first year or two and then once you are more confident in your protocol, maybe once a year or so do a TEE to make sure. We still dont know the longrange side effect of these drugs too, so that is something to watch.


Even as it is Coumadin maintained within the 2 to 3 INR range still is only about 92% effective in preventing actual strokes... to me that is compelling for considering the Lariet and then perhaps add Nattokinase with all the other healthy blood thinning nutrients to help get a close to a complete eliminate of any added stroke risk from having the LAA isolated as possible.

If you don't got for the Lariet, and while still on Coumadin then PLEASE get one of these machines that insurance will pay for for AFIB that requires anti-coag as we all certainly do!

Take care, Shannon

Shannon, you are so very kind to share your knowledge with us. It is greatly appreciated.
I have the Roche CoaguChek XS and Medicare pays for all the equipment, strips and reporting to my cardiologist. They're pretty particular about using just one strip a week although if requested by the cardiologist to do an extra test, there's no problem. I considered purchasing extra test strips myself but they are very expensive. I am going to take your advice about having an INR done at the lab to see how it compares to my monitor. Your advice about having a TEE done periodically if on apixaban makes perfect sense and it is not something I had considered. I will have to look closely at the Lariet procedure, despite my reluctance to go through any more procedures; it may serve to put my mind at ease.
Again, thank you so much for your help.

Laura

Thank you for the information, Shannon. I did not know there was a home test available. I will have to call Dr. N's office tomorrow -- time is running short. I did not know coumadin was only 92% effective in preventing strokes, although it seems my blood does tend to run on the thin side. I do have an EP in NZ who could do a TEE on me if and when my esophagus has recovered sufficiently. Getting the strips down there might be a problem since we have had to switch to Caremark/CVS this year and they are giving me problems!!! We used to have Medco and while they were a PITA they did at least come through with accommodations after you had listened to endless hours of their dreadful muzak!!

You are welcome Neroli and Laura,

And Neroli, be sure and ask for the newer Philips In-Ratio-2 INR home meter. I find it easier and more reliable than the CoaguChek Laura has and that I had from Dr. Natale when I lived in Amsterdam and was traveling a lot back and forth from Europe and Hawaii. Laura, Maybe newer versions of the Coag-u-Chek and their strips have improved by now??

Nevertheless, the new Philips unit has a good track record and the strips are easier to use with less finicky set up than the original version of Coag-u-Chek unit from 2008..
Laura your veru

Also Neroli, if Dr. Ns nurse says that some of the meters are less accurate tell her that is why you want the more accurate one and that you will learn how to use it properly ( as I explained above) so as to get consistently repeatable results.

You should tell Philips you will be in NZ for 6 months or however long and request a large number of strip boxes that have long expiration dates.

Shannon

Good luck, you

Thanks Shannon. I spoke to Dr. N's office and they told me that they don't "support" self-metering out of CPMC in SF. Since I am so close to leaving (one week) I figure this is something that I will explore further next year if after the TEE I find I still have to remain on coumadin. My INR remains very stable so I will continue with every two-week checks and find someone to monitor it down there, and continue to call in my LifeWatch over the phone every now and again. Just read Hans' update on blood thinners and I don't think I have a high stroke risk -- will take my chances for six months...

Cheers.!

Hi Neroli,'

I kind of figured you might not get that from Dr. N's SF office. They mostly want to transfer you back to your local Cardio/EP as soon as the blanking period is over and it would usually be that doc with whom you would arrange self-monitoring with Philips using their In-Ratio-2 meter.

Even if you are a pretty stable INR person on a given dose of Coumadin, it pays long term to check once a week and not just once a month however you do it, with a blood lab or home meter.

When do you return to NZ?

Best of luck Shannon

HI Neroli,
I hope you are continuing to improve and feel better. I saw my cardiologist this past week and he took me off my blood pessure medication mainly because the log I've kept shows my BP to range from the high 90s/70s to perhaps 125/74, off medication. Plus, the latest recommendation is to use 140/90 rather than 120/80 as optimal. So, as a result, my CHADS score has decreased by one point just overnight!! Amazing, isn't it?? Anyway, I agree with Shannon that it is in your best interest to check your own INR weekly and I hope you will be able to do that while you're in NZ.
Travel safely and be well.

Laura

LLois:

You said that the recommedation for BP is to be 140/90, where did you see that? Actually, I go to a holistic doctor and he did say to me that my BP was fine, it usually tests a little higher in the doctors office, it was 140/65, he said that is fine, most doctors want it lower.

Liz

Liz, I think I should correct the 140/90 as being "optimal"; however, my cardiologist and the article I read indicated that drug therapy for readings under that number, in an effort to get to 120/80 did not improve heart attack or stroke risk. The article was in Heartwire, I believe, and I will see if I can find it.

Laura