What does remodeling mean in semi technical terms?

Curious as to what happens? Some cells go sleepy and the wrong ones are active and the circuit is messed up?



Edited 1 time(s). Last edit at 04/23/2014 09:04PM by PH.

Hi PH,

I think you might have the term confused with structural and/or electrical remodeling. Remapping isn't something that happens to the heart or cells within the heart. Mapping is a technical process for identifying certain areas of the heart tissue such as inside the left atrium and using Electroanatomical mapping systems like Carto 3 or the FIRM rotor and focal mapping or the non-invasive Cardio-insight mapping vest etc for location structures and identifying likely trigger sources for ablation.

Electrical remodeling tends to happen first as a consequence of more and more exposure to AFIB ... the old adage 'AFIB begets more AFIB' making it easier and easier to get triggered into AFIB the more time you are in episodes and the harder it becomes for the heart to convert back to NSR .. eventually often times results in the person sliding into persistent AFIB.

This progressive process is greatly helped along by the corresponding structural remodeling that also happens with accumulated time in AFIB over time and this is manifest as more area of the inside lining of the left and right atrium developing fibrosis and collagen build up as scarring, which in turn makes the pacing cells and tissue able to sustain only lower and lower voltage until it is more or less dormant. These fibrotic areas can spread over time and as they do the perimeter of these fibrotic or scarred fields or patches tend to be key trigger area but not in the body of the fibrosis where the voltage is pretty much nil. That is why in more advanced longer term AFIB you often see the more active trigger areas migrating from the PVs and posterior LA wall toward to peripheral areas of the LA such as around and within the Coronary Sinus at the lower edge of the right and left atrial septal juncture as well as to the LAA up in the left superior anterior side of the left atrium.

Typically in early stages of paroxysmal AFIB you dont see much CS and LAA activity, there are exceptions but not often. Hence, those who think juts because they are in easy paroxysmal AFIB that they have plenty of time to horse around and not try too hard with either conservative and/or ablation methods to control the beast can easily set themselves up for a big disappointment.

You can never accurately gauge when your paroxysmal time is up and it can switch from modestly active paroxysmal to full blown persistent overnight literally. Though there is usually some indication of progression for a good period of time before it does. The thing is, when you are in the middle of it the tendency is not to accurately see the forest for the trees and the bargaining procrastinating mind will almost always urge you to take it easy and let it slide once again as soon as yet another rough episode converts back to NSR again and you get that temporary respite and feeling that 'that wasn't so bad, I can handle this'..... then before you know it one day you simple dont convert again and you have passed the point of what could have been an easier ablation process in most cases.

That is when your list for choices for a good persistent ablationist suddenly gets a lot smaller and more exclusive.

Its a fine psychological game AFIB plays on everyone. Many people who have a deep-seated resistance or fear of having an ablation can really push this thing out a long while with very convincing rationales and procrastinations until one day they find they went a little too long and too far with the denial for their own best interest. Thankfully there is still hope for those of us, like me as 'Exhibit A' who played out that every same scenario and thus know well how easy a game it is to play with oneself. But you then need to chose only between a small handful of elites if you want to stack the deck in your favor for a good ablation process outcome and it most often will require two procedures then to get the whole thing sewn up good especially with persistent cases.

The good news is more recent experience over the last few years from Dr Natale indicates further improvement in persistent AFIB ablation at his centers now well under 2 ablations per person needed with the new tools and new refinements in his procedure over the last few years. Still though it's always best to assume one main index ablation plus a shorter touch up will be required to more or less slay the beast for the long haul and when you are done in one procedure, consider it a bonus ... A bonus more likely to be earned by choosing the most experienced and successful persistent AFIB ablationist that you can.

Shannon



Edited 1 time(s). Last edit at 04/27/2014 09:32AM by Shannon.

As I mentioned in another post, I'm a big fan of PIP (on-demand) use of meds like Flecainide to terminate episodes while one is "horsing around" trying to control afib with lifestyle, trigger avoidance and supplements. My philosophy is to try to minimize, however possible, the amount of time in afib so as to minimize the remodeling. This is beneficial both for the probability of success of the lifestyle/supplement approach and also with the ablation approach. After terminating a 2 1/2 month event 9 1/2 years ago with 300 mg Flec, I made a choice at that point to never "wait and see" if an afib episode would terminate on its own again.

Of course nothing is risk free and Shannon is Exhibit "A" on Flec creating atrial flutter with 1:1 conduction.

Pretreating with betablockers before the Flec can help mitigate this risk. Additionally, the EP blogger, Dr. John (Mandrola) mentioned a different risk mitigation approach, which is to lie down and relax after taking the Flec till you convert. He followed this himself on afib brought on by exercise. It is the approach I use. It is easy for me as my episodes tend to be in the wee hours of the morning, so I just go back to bed. I tried to find Dr. J's comment again, but he's reorganized his blog and I think it was in a comment, not the blog text.

George

What do you recommend for the vast majority of us who cannot afford, or do not have access to these elite ablationists?
My cardiologist remarked that he would "soon be getting the equipment" when i asked him about the option of a PVA a few years ago. When i asked him how many proceedures he had done he replied none yet, and looked at me with a glint in his eye.
Mind you he was fairly handy with the angiogram alright.
Would ablation with him still be a good idea?

Shannon, footnote question: no atrial scarring was observed during my ablation, yet ablation on the floor of the LA along the coronary sinus and base of the LAA was required. In the absence of atrial scarring, does this mean that migration was not fibrotic based and that in my case the active triggers along the coronary sinus and base of the LAA arose independently of migration per se, or does it mean that there is fibrotic spread that is characterizable as something less than scarring? Thanks, Randy

Thanks. I wonder in hindsight if this is what happened to me. Post first ablation in 2006, my afib frequency was twice per annul then more and more frequent, up to every two weeksfir 12 hours.

Well I would have to say I'm pretty much of a "poster child" here too, based on this post. I had Afib on and off for 5 years, progressing & getting more and more frequent until it became twice/day. I then "gave in" and took Flecainide for another 5 years, which greatly improved the quality of my life. I still did have a few Afib episodes each month, but they were usually fairly short. Because I could always get my Afib to stop, and it never went more than 14 hours tops - and only a few times it went that long - I thought I had it managed well enough....and I could deal with it. When I got the nerve to finally get an ablation, I went with Dr. Natale during the brief window of time he was here in NY. As it turned out, I had quite a bit of fibrosis and ended up need a LAA isolation and work done in my right coronary sinus. He told me 2 of my Pulmonary Veins (I believe) were scarred to the point that they didnt' even need ablating - it was as if they already had been! While I fared well and am Afib free now too - I now have to be on Xarelto as my left atrium is not moving like it should (all my other indicators were good). Had I gotten the ablation done a few years earlier, I may have avoided the need to have such an extensive ablation and avoided a LOT of uncomfortable episodes and missed time... Thankfully, I found this Board years ago and learned of Dr. Natale, and am very grateful HE was the one to do my ablation. Had anyone else done it, there's a very good chance I would still be struggling with the Afib beast. Most EP's don't like to go into the Left Atrium Appendage area....

Thanks again to Jackie for letting me know about Dr. Natale coming into NY and her support, and to Shannon for his encouragement and tremendous support too.
This Board and the contributing members such as Jackie, Shannon, George, and others has been a God send!

My take on this?...do your best to manage your Afib as George and some others have done, but if it's not keeping your episodes to a real minimum, you might really want to think about looking into an ablation sooner, rather than later.

~ Barb

JohnBM, don't do it. Do not allow an inexperienced cardiologist to ablate your heart. I did, and I spent four long years with persitent afib until I finally had Dr. Natale do it for me right. Find a way, John, to your nearest Natale EP center.

Thanks chrisdodt, i haven't felt too comfortable with the idea!

JohnBM Wrote:
-------------------------------------------------------
> What do you recommend for the vast majority of us
> who cannot afford, or do not have access to these
> elite ablationists?
> My cardiologist remarked that he would "soon be
> getting the equipment" when i asked him about the
> option of a PVA a few years ago. When i asked him
> how many proceedures he had done he replied none
> yet, and looked at me with a glint in his eye.
> Mind you he was fairly handy with the angiogram
> alright.
> Would ablation with him still be a good idea?

Hi JohnBM
Reading this post gave me the instant WILLY's! Even considering the offer of a Cardio who is just getting in his first ablation gear, but hasn't done one yet to be your ablationist would, in all likelihood, be about as close as one could come for throwing all caution to the wind and just winging it!

As George said, please elevate your innate uneasiness with this idea to a three alarm DEFCON 1 warning to never consider it again!

Yes everyone has to learn somehow, but I can assure you there are huge number of sheep more than willing to run right off the cliff with every greenhorn new to the procedure. If you've made it to this site at least, please consider yourself lucky and fortunate both as you have many better options now than this proposal. Though I can imagine your Cardio my well be a fine man and a very good overall cardiologist and physician.

Just remember that this procedure is among the most highly skill dependent of procedures in all of medicine, and the serious complications plus odds for a bad outcome skyrocket considerably with folks who are just learning their way around an EP lab and ablation gear.

Be discriminating and don't at all assume you can't afford an ablation by Natale while you could with someones who is trained enough to do a good job. If you have insurance the chances are good you could afford one with Dr N more or less as much as you could most anyone else. Travel cost for a few days being the possible only difference.

Cheers
Shannon

I'm 1 year, 2 mos. into my diagnosed Paroxysmal A Fib. I may have had it much longer. I have mitral valve prolapse/regurgitation and an enlarged right atrium. I had a stroke 1 year ago. Luckily I had no physical consequences and minor vocabulary lapses initially with a complete recovery less that 24 hours later. I had been taking a number of herbs that I was told to stop when I was first diagnosed. My sense is that many of them thinned my blood and had kept me from having a stroke sooner. I'm not sure sure I qualify for Lone A Fib because of the valve involvement. I'm taking diltiazam 180 mg time released once a day, Warfarin and Lipitor 20 mg a day. From what I've read so far I think I will talk to my Cardiologist about adding Flecainide. I have episodes approximately twice a week from 11 pm till 3 pm the next day. I have been taking Ativan, 1/2 mg, and 30 extra mg of diltiazam when I have an episode. The flecainide is an antiarrythmic medication. After reading other posts, I realize stopping the episode as guickly as possible may be more apt to happen if I use Flecainide on-demand (I'm not sure what PIP means). I definitely find eating late or large meals are usually my triggers. I was told about this site by Shannon because a friend had told me to contact him and am grateful to begin interacting with all of you who have been on this journey. Currently I'm getting Chi Nei Tsang, a digestion massage. I'm also aware that in Chinese medicine foods that produce heat can affect the heart. Anyway, I'm taking herbs again and checking with the Warfarin people to help me decide which herbs are acceptable in terms of blood thinning. I don't see much in the way of alternative information on this site, but I haven't read very much yet. I didn't really think this was the topic where I'd start my posting, but I was reading this one and felt moved to begin. Thanks.

Hi LeeLocy,

Welcome and its as good a place as any to start. Once you explore the site and archives in more depth you will find a huge ocean of alternative perspectives on addressing AFIB and an attempt at underlying mechanisms that work hand in hand with electrophysiological methods. Explore the AFIB Resources link about include The Strategy- Metabolic Cardiology for starters ...

Have to fly home to Arizona shortly from San Fran and will be glad to get settled in again and out of a suitcase and catch up here more over the coming days,

Cheers!
Shannon

I just finished browsing The Strategy- Metabolic Cardiology and appreciate your reference to a source for alternative possibilities. This by itself is ripe with potential. I sent it to my naturopath, with whom I have been working for over a decade, and between us we can begin to extrapolate the information on supplements to create a program for me. Thank you Shannon. Today in San Francisco was beautiful, though being home after a long journey is even better. Wishing you a safe journey home.

Lee,

PIP means "Pill in Pocket," the same as on-demand.

George

Thanks George for the PIP interpretation. I have a lot to learn.
Linda

Randy,

The distribution of fibrosis varies and the description I gave is a general rule of thumb and not exclusive. Also, when reading ablation reports the report on the presence or lack of scar or fibrosis is also rather general and not so specific as you might think. You can have patches and small clumps of scar or fibrosis or a narrow ridge-shaped line of scar along a part or area of the overall LAA that might otherwise look relatively clean with no large swaths of fibrosis. And which my then get reported in an ablation report as a general absence of scar or fibrosis when they really may me a modest amount in certain areas. It happens al! The time in such reports since until recently mutation if fibrosis was a secondary priority on most such reports so it wasn't as reliably defined in the past, though very recently that has started to change with a bit more consistency and rigorous reporting of general scar areas are being recorded more carefully to a degree.

But you could very much have had a modest degree of selected scarring near the LAA and CS while still, overall, Dr Natale may well have noted a general absence of widespread pervasive scarring.



Edited 1 time(s). Last edit at 05/07/2014 01:03AM by Shannon.

Shannon, thanks. Yes, I took the ablation report of no scarring observed maybe a bit too literally. As you say, it may have been intended as a general statement and didn't preclude selective scarring near the LAA and CS.

Obviously, after ten+ years of AFIB including a couple years with a large burden I was likely not in the early stages of paroxysmal AFIB and no surprise then that work was needed around the CS and LAA.

Main concern right now is how much my moderately enlarged left atrium might shrink post-ablation and also whether any LA shrinking in turn might improve the grade II diastolic dysfunction of the left ventricle that was noted on my January 2014 echo. The latter concerns me the most and maybe I'm stuck with it (with fears it could progress to CHF even if I remain AFIB free) regardless of the success of a solid ablation.

Randy - remember that magnesium deficiency relates to cardiac fibrosis formation and of course, the Afib manifestation. Now that you are ablated you can focus on a continual, therapeutic supply of magnesium to help in that regard. Also, for the left ventricle function, keep in mind that Coenzyme 10 and d-ribose help provide the raw materials for optimal mitochondrial energy production (ATP) which gives a huge assist so that you can have a better chance to normalize that as well. It does take time.

Jackie

Thanks, Jackie. Yes, been back to continual therapeutic mag supply for some time now post-ablation. Nearing the point in my add-one-thing-back-at-a-time-then-study-the-effect plan where I'm ready to add something next, probably CoQ10.