Ablation with Natale March 4

I have been following this message board for the last several years -- as my AFIB has steadily progressed from paroxysmal to borderline persistent -- and last Tuesday I finally took the plunge and had an ablation -- with Dr. Natale at CPMC.

As background, I am a 57 year old very active male. I probably had AFIB for at least five years -- but it only happened on occasion and I always passed it off as dehydration or whatever -- I was not formally diagnosed until three years ago with a 24 hour Holter monitor.

My EP in Florida diagnosed atrial flutter and attempted an ablation at my local hospital -- a supposedly simple procedure. When I awakened from the procedure I was told that my atrial flutter was in fact AFIB -- but at least my EP had the good sense to stop while he was ahead and I was discharged a day later with a prescription for Amiodarone. My GP sent me off for a sleep study and to my surprise (I don't snore) I was diagnosed with severe sleep apnea. I've been on a CPAP machine ever since -- but the damage was done.

It was reading about the nasty side effects of Amiodarone that led me to this site -- and this board has been the best thing around for the last three years. Unless you have AFIB -- you just can't explain it -- and many EP's don't seem to understand the very real triggers associated with simple posture changes, reading with your neck elevated (in my case), etc. AFIB takes control of your life.

Anyhow, for the last three years I have attempted to "manage" my AFIB with a combination of propafenone and beta blockers -- but as the episodes became more consistent -- as I found myself abandoning five day hikes on Day 3 because I was out of rhythm -- I finally decided to go for the ablation. I interviewed Dr. Pinski at the Cleveland Clinic in Florida and also Dr. Natale in San Francisco. They both seemed like great choices. In May 2013, I was scheduled with Dr. Natale in SF -- but I backed out. I had a period of NSR that seduced me into thinking it was all no big deal -- and I was very worried about any work being done on the left atrial appendage -- I do not want to be on anti-coagulants the rest of my life.

Five weeks ago -- the medication stopped working. I was always able to convert to NSR with a combination of 40 mg of propranolol and 300mg to 600mg of propafenone -- but this time -- nothing. I watched the clock -- I (stupidly) took more propafenone -- but at about the 24 hour mark I took 20 mg of Xarelto -- and the next day I called Dr. Natale's office.

First, the staff at CPMC is just great. Morna Estandian is the gate keeper for Dr. Natale it seems -- and she could not have been more helpful -- despite the fact that I was a no show in May 2013. Miranda and Michelle took great care of me -- getting me off of the beta blockers and propafenone and putting me on Xarelto and diltiazem instead. I took the first available appointment -- about ten weeks out -- but there was a cancellation and I was able to go on March 4 -- last Tuesday. I was pretty much in persistent AFIB for the five weeks prior to my surgery -- but I actually felt 100% better than I did when I was taking drugs to keep me in rhythm I had more energy and my mood lifted.

All of which brings me to last Tuesday's ablation -- and I can only say that I wish I had taken care of this three years ago and saved myself three years of misery. Dr. Natale comes exactly as advertised. If you have a chance to sit in his "office" it is quite entertaining -- as it clearly is a place he uses to hang a coat and drop a bag and that's about it. He is 100% focused on complex ablation procedures all day and seemingly every day -- and I don't think I could have been in any better hands.

The procedure itself went perfectly. I was scheduled to go at 11:30 a.m. and the last thing I remember was the clock showing 11:29 a.m. when the general anesthesia took effect. I awoke two and half hours later with the instructions "don't move your legs"! There was very little pain -- I had been warned about all sorts of things but everything went well.

Dr. Natale came by my room about 6 p.m. and told me it was a very straightforward procedure. I was in and out of AFIB throughout and he was confident that he has addressed the problem areas. There was no need to address the left atrial appendage.

I was discharged bright and early Wednesday morning -- with only mild chest discomfort and some weight gain due to fluid retention. Today, 48 hours post ablation -- I took a three mile walk and felt absolutely fine. They tell me I can resume exercise (running) in about a week. I plan to take it slowly.

For the moment, I am taking 20 mg of Xarelto and 180 mg of diltiazem and that is it. So far -- at least -- I am in NSR. And I now realize that I was calling "NSR" before -- was probably not quite.

I apologize for the length of this post -- but as I have been reading this board for the last several years -- I always appreciated the details.

I hope this is useful -- Tom

Tom,

Thanks for the great report and good luck for continued NSR!

George

This was a great post! Thanks for sharing!

My Ablation with Dr. Natale was Feb. 27 in Austin Texas. So far for me all is going well. I enjoyed reading your post. Did you get the Medtronic monitoring device implanted in your chest? I did and it is something; everything is wireless and automatic.

Thanks for sharing! This website brought me to Dr. Natale and I am so thankful for this.

No -- I did not get the implanted device. I have a handheld device that I need to transmit data once a day for a week and then three times a week thereafter.

I forgot to mention that in my three years of AFIB my left atrium increased in size from 45mm to 48mm. All of my reading indicated that the probability of a successful ablation was diminishing as the left atrium increased in size. It made it much easier to go ahead and do it.

Great review Deluge (I get the play on words with your name ... Just be glad you got it done, but your is a good learning lesson too as you were clearly knocking on persistent AFIB's door and with growing to a size 48 LA that is not the direction you want to go.

Many while they are still paroxysmal think they have plenty of time to wait it out but that can be a delimma as it's very difficult to time it just right and procrastinate right up until the moment before you flip to persistent. Plus you don't have to reach full persistence to make for greater structural remodeling and the odds of needing a more extensive ablation process being required.

Anyway, sounds like you were lucky and definitely made the right choice in whom to entrust your heart too.

And your prior worries about having to get an LAA isolation are instructive too. That fear cost you an extra year, and yet the only way Dr N would have isolated your LAA is if you had significant involvement from the LAA to begin with. And if that is true, no amount of beating around the bush and avoiding it will buy you anything good. It's dramatically better to have a quiet heart rather than avoid an ablation just on that account, the risk of slipping into potential long term persistent AFIB is there and even with ongoing breakthroughs at a certain point for sure you would need AC drugs for life in any event, or at least until you got the LAA taken care of one way or another, and yet will still have a difficult to treat progressive arrhythmia beating away causing more remodeling as you go. Its much better on the other side of the fence I can tell you, whether or not AC drugs wind up as part of the equation.

Anyway, all is well and you threaded the needle with very good choice and best wishes on a speedy recovery Deluge.

Shannon



Edited 3 time(s). Last edit at 03/08/2014 02:17PM by Shannon.

PS Deluge, glad to hear you are taking the exercise return slowly, I know they say you can restarts in 5days, but the better part of valor is more like three to four weeks for more strenuous exercise, by all means long brisk walks are okay earlier, yoga, Pilates and even mild to modest body weight resistance such as with TRX straps for example (one of my favorite). Let the inflammation really heal and settle in before really hitting it harder.

Shannon

Thanks Shannon. The weather is beautiful back in Florida but I am going to follow that advice -- not easy. I flew across the country yesterday and noticed a definite shortness of breath. Not sure if I flew too soon after the procedure -- but it went away once I was off the plane. Since Smackman and I pretty much had the same procedure at the same time I will be interested in how it goes over the next several months. Dr. Natale said if my heart stays quiet through the ninety day period he will consider stopping Xarelto at that time. I have zero side effects from the drug -- but I'm highly aware of the absence of a reversal agent. I'd love to be off of it.

Enjoy Florida Deluge, I'll be in Orlando next Thursday.

Three days is okay to fly, but after an index ablation you can certainly still feel some tightness in the chest and SOB at what amounts to 8,000 feet altitude which is what most plane's cabin pressure is set at .... other than the new 787 which is set for more like 6,000 feet cabin pressure, or a bit less, and is a big reason why people experience less jet lag on that plane in addition to the 787's very large windows which lets in more light and horizon view which helps jet lag too on very long flights.

In any event, I'd be curious to see your ablation report if you are up to it, by PM. But you should definitely request a copy of it be sent to you if you don't already have it. Smackman had a persistent AFIB ablation and yours might have been a little less extensive but probably not too much with your longish time in dealing with AFIB and the 48cm LA volume.

Have a nice homecoming weekend!
Shannon



Edited 1 time(s). Last edit at 03/08/2014 04:56PM by Shannon.

Shannon -- if you can send your PM I will send it along the moment I get it -- I'm curious what you think --- Tom

Deluge,

You just click the little 'PM" icon right next to my name at the top of each post I, or anyone else you want to PM.

Shannon

I'm curious. Are you still using your CPAP for sleep apnea treatment? Did the doctor say it would prevent fibrosis from reoccurring, or didn't he get into that? (After 4 months on CPAP, my own frequent, sometimes 24-hour bouts of afib have stopped.) Do you think the sleep apnea was the direct cause of your fibrosis/afib? -- Ellen

Yes. I use it every night. I have no idea how many years I had sleep apnea -- but I suspect quite a few -- and I am convinced that sleep apnea caused my AFIB. I was waking up multiple times every hour (I did not realize it) with a suffocation response and a blast of adrenaline to the heart. I am fortunate that it has not been a problem for me to use the CPAP. I have a Resmed -- a very quiet machine -- and the mask is really just a nasal device -- it does not cover my face --and at this point I cannot sleep without it. It was a bit of hassle at first on international flights but I think I have that sorted now as well.

Stick with the CPAP. I have been told that in some cases if you eliminate the apnea trigger the AFIB will diminish or even stop. Good luck!