Laying on Left side question to Dr. Natale

I ask Dr. Natale about AFIB and laying on your left side. He does not believe laying on your left side,right side whatever side causes AFIB episodes.

This conversation came up when talking to him about my sleep apnea. I struggle with wearing the mask.

Dr. Natale said laying on your side causes less sleep apnea episodes. He told me why this is so and then I ask about AFIB and laying on your left side. He believes that is in the mind(He pointed to the Brain).

As an ablationist and regarding most things around the ablation question and field of interest, Dr Natale is at the top of the heep in terms of quality insights and advice.

When it comes to various systemic triggers, we are all in the realm of more or less educated hunches and rules of thumb. And this includes EPs and patients alike.

Keep in mind too that the majority of EPs have never once actually felt an AFIB trigger or how it feels when one is coming on. This is one area where I have a hard time seeing a psychological origin of laying on your left side stimulating increased ectopic action for many people. It's also probably not technically correct to say that laying on one's left side 'causes' AFIB, but it can stimulate an ectopic prone persons tendency toward PACs/PVCs which, when there is an AFIB sensitive substrate as well, can easily move from a few runs of annoying PACs to a full blown AFIB episode as well.

The truth is, though, that none of us knows for sure exactly what mechanism actually triggers all AFIB episodes, so you are going to hear mostly from people's direct experience and their sense of what is a contribution. As such, neither Dr Natale nor anyone else that I know of has done an in depth study or research in the direct mechanism of these trigger associations of laying on the left side, other than the obvious common sense Vagal influence so many of us ascribe it too.

I can certainly appreciate why Dr N might not see much of that, even though he may hear a lot about it from patients, as his focus is so much in the realm of direct substrate modification of active trigger foci and such and with a well placed ablation lesion he can watch such a focal trigger disappear. Yet with the laying on your left side contribution to ectopic sensitivity, this can continue on - even after a perfectly solid ablation -and even though in that case the effect is almost always more muted and will not lead secondarily to a full blown AFIB/Flutter episode ever again.

That is why it seems to be related more to a second order mechanical/Vagal process in my view rather than the kind of more direct and immediate AF triggers in the atrial substrate that Dr N has as his prime focus of attention.

No one knows everything there is to know about this complex subject, but Dr N is as good as it gets anywhere in the world when it comes to practical real world ablation results and thus in directly helping to put an effective lid on the beast. Regardless of the most proximal or fundamental origins of arrhythmia that we are all still very much trying to decipher.

Shannon



Edited 2 time(s). Last edit at 01/23/2014 01:48AM by Shannon.

Fifteen years ago they laughed at me when my episodes started and I told them it was directly related to my digestion.
Now ep's will tell you it can have a lot to do with digestion, upset stomach etc.
laying on your left side can trigger rhythm junk, it's not in my head I can prove it!

I never intended on asking that question but it popped in my head when he started talking about sleep apnea and laying on your side.

For me, I believe my biggest trigger is Anxiety.

Not believing in a left-side trigger is almost enough to get me to look for another EP. I get that it must be hard hearing antecdotal stories all day long - some people are not very good at tracking things (or worse) and doctors don't have a good way of knowing whether I (or you) am one of those people. So I'm giving him a pass on it, although I will register one mark in the Arrogance column for Dr. Natale.

Not arrogance, Ralph, just focusing on what the good doctor knows and sticking to it. Bottom line: Dr, Natale is going to treat your symptoms, not heal them. EPs or cardiologists don't have the time or resourses to research the hundreds of varables regarding afib triggers; leave that for those of us who suffer with them---and you're right, it comes down to anecdotal stories, which can drive any man or woman of science bonkers. That's why they disregard the subject.

Agree with ya, Shannon.

/L

Hi Larry,

I certainly don't have any issue with Dr Natale or any other EP not recognizing laying on ones side as a physiological/mechanical trigger for ectopics. I suspect if we sat down and discussed it he would acknowledge the possibility of a mechanical/anatomical mechanism for this phenomena which such a huge percentage of Afibbers became spontaneously aware of very early in their AFIB experience. But he might even rightly take issue with it being labeled a direct trigger for AFIB as it may well be secondary effect from mechanical pressure on the the left side of the heart/vagus nerve area that might stimulate an ectopic sensitivity which might then lead into actual AFIB secondarily in a person easily triggered into AF. In that way we might all be correct from our perspective.

I'm not sure too if any one has done any studies on whether this primarily occurs in only or mostly vagally mediated folks and not so often in Adrenergic or non-lone AF cases where underlying heart disease or hypertension is the main driver? Those are likely the lions share of patients Natale sees each day too as even if one started out purely Vagal, it's not at all uncommon to become a mixed Vagal/Adrenergic bag on the way toward persistent AFIB when the distinctions between the two loses much of its meaning.

In any event, my sense is that this left sided sleeping issue is true for both Vagal and Adrenergic folks but I'm not sure about that. It's possible if you started out mostly Vagal and thus had that left sided sensitivity you might sustain that trigger or at least be annoyed by ectopics when laying on the left side, even when morphing into a mixed bag or progressing to persistent AFIB. This is all speculation though.

I DO know that the effect is very real and happened long before anyone ever told me to expect such a triggering response. It's thus highly unlikely to be directly due to a psychological conditioning.

If I can remember in March when I next see Dr N at the International Symposium on Left Atrial Appendage, again in Orlando, I'll discuss this with him in more depth when we have the time.

Nevertheless, it's no big deal whether or not he knows the origins of every systemic trigger, the stuff he really needs to know in order to do his challenging job to help all of us the best he knows extremely well indeed.

Shannon



Edited 2 time(s). Last edit at 01/23/2014 01:00PM by Shannon.

There was a good discussion on this topic some years ago in the Conference Room in which PC (a medical doctor who was a regular poster then) sheds some light on this. See [www.afibbers.org].

Hans

I've previously written about a period a year or so ago when my afib was much less controlled. During that time, I was much more sensitive to triggers. These included frozen food (frozen blueberries in almond milk, large quantities of ice water), being prone on my left side and the very vagal time after orgasm. Prior to this time of poor control and after I made the discovery that excess dietary calcium was contributing to this sensitivity, none of these items were triggers. I am very vagal and certainly the other two triggers (beside being on left side) are vagal ones. With the frozen fruit, I'd notice my heart rate would drop significantly, say from high 50's to low 40's and then the ectopics would start. I could normally stop these using Hans' technique of drinking a bunch of hot water. When I'd turn onto my left side, I could feel the ectopics start and I could stop them by getting in a different position. On the after orgasm trigger, I could feel my heart beating and also slowing dramatically. It was during this slowing that I could feel the ectopics. If I stood up and moved around, this would usually reset my system and prevent an afib episode. Early on, I'd just stay there and hope it it didn't lead to afib, as jumping up and running around just isn't that romantic. However I learned this strategy often would result in afib. Fortunately, I have an understanding partner and I would just get up and move around or at least sit up to prevent the afib.

Eight months back into excellent control, none of these scenarios are triggers, nor have they been during these eight months. So there is an underlying issue that creates the opportunity for the trigger to be a trigger. In my case, excess dietary calcium was the culprit. I should note that intake of magnesium, potassium and taurine have been a constant for keeping afib in remission. It has generally worked well for over nine years save for the time when I was eating large quantities of cheese.

George

Interesting reading the posts on this topic -- Triggers (and stoppers) in general always get my attention. I have been lucky in the last couple of years
with flec keeping my episodes to a few. But there was a time getting episodes every week or so where I was pretty sure trying to sleep on my left side increased the odds I might get an episode. I believe I had this opinion BEFORE I read about it (sleeping left) being a potential trigger.

Shannon thank you for picking up the mantle...and Hans let me thank you again one more time. Your work has helped so many. You must feel good. While I have not been on the site as much lately, it and the people on it are my go to source. You have been so helpful to me and to others. THANKS! ......................Tibbar