What a Mess Afib/aflutter/tachy

Hi fellow sufferers, wondering through our experiences if anyone can help me. Im prepping for my fourth ablation / first in left atrium. 1) Does anyone taking flecainide have the effect of bundle block? I get rate dependent LBBB with pain at around 100 to 120 bpm. 2) Does this mean if I discontinued the Flec my LBBB would move up the scale to a higher rate or possibly go away?
3) Does everyone else (for the most part) have other weird rythyms? I have PAF but earlier I had Right atrial Flutter and before that SVT reentrant tachy. Is it the nature of the beast that there are all these other ones just hanging out.
My problem now is something triggers (aflut or Afib) and then my rate goes to 120 and then my EKG shows LBBB. 4) So does this mean I am really in Afib but the EKG is not identifiable because of the irregular LBBB waves? In other words if the LBBB wasnt there would I be having Afib show on the EKG?
I will have the ablation done this month with Topera equipment and FIRM software. 5) Anyone have opinions on the new equipment? I just wonder because I am still only given a 70% possibility of success. I was hoping for better and still am. Health to all of you.

Hi tsco,

Welcome to Afibbers.org and sorry to hear you have had a rough go of it. I presume this will be your first left side ablation, in other words the first one in the left atrium for atrial fibrillation/Flutter as compared to your earlier three ablations which, if I glean what you are saying above, sounds like they were for SVT and typical right atrial flutter for the most part? Is that correct? Did you have two ablations for right flutter or SVT and then one for the other one?

Your rate dependent LBBB is not par for the course with most lone AFIB patients but it can and does co-exist with AFIB/ Flutter at times. Has anyone told you you have a 'Infrahisian Left Bundle Branch Block' ? This is often a rate-dependent LBBB and I have that too and have a pacemaker set to prevent it from triggering and crashing my blood pressure should I ever hit that fast rate at which my LBBB would trigger. A scenario that is exceedingly unlikely to ever happen again after having gotten both my persistent AFIB and then subsequent left atrial appendage derived left atrial tachycardia/atypical flutter successfully addressed and put to bed in a two ablation process by Dr Andrea Natale.

In any event, regarding FIRM, it is a highly investigational and still very much too early in development to offer any real confidence about long term outcome for you with that procedure. The jury is very much still out about whether this approach buys you anything at all compared to an excellent ablation by the most skilled ablationist you can arrange for yourself.

The best advice is not to focus on the technology, especially some very experimental and still debatable technology as your main priority and instead to choose first the ablationist for his or her vast experience with as many challenging ablations under their belt as possible, especially for a case like yours that is already with added complexity from the outset and having had three procedures for various atrial tachycardias already, and then let that top gun EP choose the best tools and equipment for your ablation.

A lesser experienced EP with a still very much 'under-development' FIRM system is not nearly so confidence inspiring as a top tier elite EP who has been getting elite level results for years with the latest 'proven' tools and techniques and can choose from the full range of technological options they see as worthwhile with which to best treat you.

In other words, the better part of valor in a case like yours is to be careful of getting overly enamored by a nice sounding story, especially when even at the most recent major international AFIB conference weekend before last in Orlando, there was as much caution and skepticism expressed by some of the top people in this field suggesting it is still much too early for EPs to be considering this type of phase mapping technology you are considering as ready for prime time and thus start adding in EP labs around the world at this point in its development, as there was more muted optimism expressed almost solely by those with a significant stake in the success of this new concept.

With all that you have been through already, I'd be a little leery of going so experimental with a first AFIB ablation, at the very least unless you know for sure that the EP who is going to use FIRM in his own investigations of the technology with your case is also a truly elite-level ablationist with at least several thousand AFIB/Flutter ablations under their belt.

Im not at all suggesting that the FIRM concept has no merit or that it is not worthwhile for EPs to be exploring the possibilities of this type of phase-mapping technology, as it is worthwhile to see where it might lead with more development. But rather, Im suggesting that you need to be fully aware that this is still very much in the Guinea pig stage of development and I would be loath to recommend it now for someone with your history of three prior ablations already an still in a 'mess' as you describe it.

Certainly, I can understand your reluctance to go with a more standard approach again, perhaps with the same EPs who have done the first three so far, but instead of swinging too far to the other side of they coin and winging it with FIRM at this point, you will likely be better served by really making an effort to align with the very best and most experienced ablationist you can find, even if that requires traveling across the US to make it happen.

If you are in Europe, its hard to go wrong with the Bordeaux France group. Likewise, if you are in the US, it's equally hard to go wrong with Natale and his group of highly trained EPs in Austin and San Francisco. There certainly are other highly skilled ablationist as well to choose from that can do a fine job too, but these are the top two elite centers nearly universally recognized around the world for their excellence and pioneering work and the rest are some steps down the food chain from there, so at least you know where to start ... and perhaps end ... your search for what true excellence in this arena looks like.

In any event, it you are still really committed to trying a FIRM ablation at this stage, just make certain they are not trying to shoe horn you into a non-PVI version of FIRM ablation where they will not even be doing a PVI at all and will ONLY ablate focal 'rotor' areas that are implied as such with their Topera phase mapping system. The promoters and key investors behind Topera and FIRM were touting this PVI-less ablation strategy the last two years at this same Boston AFIB Symposium with high hopes it was going to be here to stay with FIRM, and yet there was zero mention of that idea at the latest Boston AFIB 2014 held in Orlando. On the contrary, the necessity of PVI or PVAI as a foundation for more consistent long term results in AFIB/Flutter ablation was essentially and universally reinforced by nearly every speaker at the symposium!

My sense is that its easy for people to get all excited about some new way of looking at a problem (especially when its 'their baby' and they have strong vested interest in it being proved useful) and along those lines it seems some EPs have become enamored with the idea of being able to convert what is inherently a more complex AFIB ablation scenario into a more simple and targeted 'SVT-like' or 'Right flutter CTI-type' of ablation. This concept has a superficial appeal since they were able to refine SVT and right flutter ablation down from not knowing where to ablate in the early days of ablation technology, to discovering a reliable and much simpler process through better understanding of the pathways involved in those more localize sources of arrhythmia. As such, some EPs have thus projected that they should automatically be able to do the same thing with ablating AFIB.

That may not at all be the case however, and evidence now seems to point that while we can use some of these new tools for fine tuning the strategy, AFIB is not just a single straightforward arrhythmo-genic process with a defined and repeatable focal area of origin for most everyone like these much easier to address arrhythmias.

As such, even some very smart docs can get themselves too far out on a conceptual limb by trying too hard to make a square peg fit into too small of a round hole.

Again, your safest and best course after three ablations and still dealing with the beast, is to seek out the most elite operator you can and then trust that they will use the most cutting-edge proven tools and strategies to address your problems successfully.

Best wishes,
Shannon



Edited 1 time(s). Last edit at 01/21/2014 06:25PM by Shannon.

Shannon, thanks for reply it is a godsend. Just having help and comment from someone who has experienced this stuff helps so much.
I initially (2002) had svt ablation in lexington, ky. Then after a while it came back with vengeance. Tomassoni sent me to see Natale in Cleveland and he killed it for a while and then it came back and just seemed to start multiplying. So then I'm hearing a flutter. Had another ablate in 2007 in lex by Gery Tomassoni. I've done well until the past two yrs.
dr. Tomassoni has Topera but to clarify his plan of attack is to ablate the PVs then check the top of the left atrium and back wall and then move into the right atrium for anything left over there. I don't think we are shooting just for focal points, it's a combination of the two. .......I hope
I had the option to see Natale but i know dr. Tomassoni studied under him and is in close relation with him so I hope I am making the right decision.
I don't see his name come up maybe because the center is smaller. I have talked to two EPs in louisville who spoke highly of him.
How do you feel about combining the typical pvi ablation and firm tech?
On my lbbb I have never heard that term. Mine is def rate dependent tho