Turns out I'm in Flutter....cardioversion tomorrow..

So my heart has felt "off" since 5pm last night, while getting acupuncture. I had trouble getting a good reading on the beat, as it felt faint and quick. I decided to go into my cardiologist office, which is about 8 minutes away, to get an EKG. Turns out I'm in flutter (a-flutter?), with a heart rate of 131. I've never had to be cardioverted in my 10+ years of frequent Afib, but it is what it is. I'm hoping this is a one time occurence, but am already thinking of when and how I might travel down to see Dr. Natale for a "touch up" ablation, if needed. Not sure if Dr. Barrett is up to par on that, as he's the guy Dr. Natale brought into NYC to work with him, and who I've seen since Dr. Natale went back to Austin, Tx. Is it as important to have a top EP for a second ablation/touch up?

It's pretty awkward dealing with the local EP, as I really don't care for this guy, and I think he feels he's as good as Dr. Natale. Had I gone with Dr. Altman (local EP), I'm sure I would be needing 2-3 ablations and wouldn't have had the relief I've had between last Sept and now. (ablation was on Sept. 5). Nonetheless, I have to trust him to at least do a good cardioversion!

Anyway..I'm kind of scared in spite of reassurances from Shannon and Dr. Barrett...and disappointed that I'm having any arrythmia at all now. But like Shannon likes to say, this is a process.....so we do what we have to do.

Barb



Edited 1 time(s). Last edit at 04/29/2014 04:47PM by tobherd.

Best of luck tomorrow Barb! My second ablation with Dr Natale was pretty much a non event. Felt well after the proceedure and it has been hoding me in NSR even though there is a 40% chance I will need a third to complete the process. But positive thoughts your way that the cardioversion, tomorrow, does the trick Dennis

Hi Barb,

Like we discussed on the phone this morning, while I was hoping you would be one and done too Barb and I know its a bit disappointing but as you know and we have discussed there was a pretty strong likelihood with your degree of fibrosis and long term AFIB that you would need one more touch up, though 'one and done's' are happening more frequently these days when it used to be a given that two procedures for sure would always been needed in cases like yours.

Your case was particularly challenging with the degree of fibrosis from the long duration of AFIB for many years such that three of your four PVs were already fully dormant electrically and thus were 'self-isolated' from the degree of scar tissue around those three PV ostiums. This left only one PV for Dr Natale to actually isolate himself and then he had to move on to the posterior wall isolation, SVC and CS Isolation, a number of CAFEs and finally Isolation of the LAA. The LAA is where this flutter.tachcardia is likely coming from as Dennis noted above, there is a roundly 35 up to 40% chance for LAA isolations to require one last touch up to be fully sealed due to the more delicate thin tissue of which the LAA is made and the many variegated ridges of pectinate muscle strands inside the LAA that make knocking it off fully and finally with one procedure a good deal more challenging than is ablating other areas of the LA.

That is one reason why many EPs shy away from even going there and they will tend to try to preselect patients as much as possible and prescreen those more likely to have such challenging cases out of their ablation list so they dont have to deal with issues about their skill level and pay grade.

In any event, as Ive noted to you from day one and again reiterated on the phone this morning, this is all still absolutely par for the course in what is shaping up to be a textbook advanced AFIB ablation case that required LAA isolation. While it would have been a nice bonus to have it all done in one, that is not always realistic and you are so lucky you went with Dr N who knows well how to address all these areas systematically and successfully in a one two or at most three step process. The majority of the time the more challenging cases like yours require one big index and a much easier and smaller targeted touch up procedure to be done for the long haul.

Dennis mentioned he might need one extra one for three total, if his LAA isolation needs to be tune up a bit at some point, but he may well not too and I think his odds are a good deal less than 40% for needing that last tune up due to the Atriclip that was installed during his Aortic valve replacement surgery which also complicated Dennis' arrhythmia process and helped trigger the need for the second ablation for isolation of his LAA ,which he got in early February in Austin.

And as Dennis also noted, his second procedure was a piece of cake and a 'non event' as I too discovered with my LAA isolation which was my second procedure as well four years to the month after my index ablation with Dr Natale.

Keep in mind too Barb that this was always a big possibility, and even a likelihood in your case, as you have known from the outset, and again Im sure you will find this 'tune-up' to be little more than that and then it will be finished and you will be on the mend.

Do you recall how frightened and ready to bail you were before your index ablation last summer, and how much easier it all was than you had projected and imagined before hand?! This one will be much easier still, and as Dennis said, really a non-issue after the fact.

This is all a par for the course step as part of this ablation process, and is nothing at all unexpected for more challenging cases Barb, so there is no reason for any real disappointment. Of course, its only natural and okay to feel a little bummed for the afternoon, but after a good sleep tonight just go forth from tomorrow with a positive attitude for the ECV cardio-version and then you will be back in the saddle and can dial-in what is almost certainly the last visit with Dr Natale and h EP lab during a brief trip to Austin before long to button everything down good and tight once and for all.

Best wishes,
Shannon



Edited 3 time(s). Last edit at 04/29/2014 06:05PM by Shannon.

Barb,
So sorry to hear you went into flutter, been there myself for 2 weeks in flutter 133bpm after my ablation. Never been cardioverted before either but it's just part of the "experience", just enjoy the propofol ride.

Best,

McHale

Barb,
Nothing to fear from cardioversion. You will feel good as new again, although I know how disappointing it is for you to have any type of arrhythmia these many months after ablation. Good luck tomorrow!

Jean

McHale - are you slated to have a touch up ablation now too? How soon after your ablation did flutter occur for you?

Feeling a little rushed on the second ablation idea..isnt there any chance that I just need to be cardioverted and then I might be fine? I know you have said, Shannon, that we tend to talk ourselves out of these things and then end up like we did - with a more advanced situation. But isn't it possible to have Flutter as part of the healing process and it not be necessarily a sign that a touch up is needed? Right now my heart rate feels slower and pretty normal - from what I can tell - ...I may even convert on my own, who knows?

Dr. Barrett seemed to feel we should see how I do after the cardioversion, and was not indicating the need to rush for a second ablation. While I certainly don't want to wait too long like I did the first time, rushing to make a Natale appt. feels a little premature to me. No?

I will be eager to hear from Dr. Natale as to whether he feels it's inevitable or what my odds are of not needing to go back for Round 2.

I do greatly appreciate you taking the time to talk to me over the phone today, Shannon. You are like a life line, always willing to help and provide information whenever we need it. Thank you.

Thanks ALL for your good wishes I appreciate it. ~ Barb

The thing to do Barb is take the time now to set up the touch up which is very likely needed. McHales Flutter happened within the first 6 weeks of his ablation and no longer than 2 months which is the blanking period. Yours is at more than 7 months which is clearly beyond any conceivable blanking period.

Could you have a number or months, or even longer, of quiet from here still before things started to act up more again?? Yes that is possible after a cardioversion of these late appearing atypical left atrial flutter/tachycardia's, but the chances of it not returning ever again are very slim and its best with these things to see the situation clearly for what it is and take steps to wrap things up quickly and for the long haul. It's rare for an atypical left flutter that first appears 3 to 4 months or more past the ablation date and well after the blanking period is over to just suddenly disappear again for good on its own. And the actual blanking period is 2 months tops in any event.

If you were having only some runs of actual AFIB and not this flutter/tachy, I might be a little less quick to say go for the touch up ASAP at 7 months, though even then the odds are very likely you would need a touch up too to stop the AFIB as well. But for atypical flutter/tachy that is not original blanking period stuff, which it clearly is not in your case at this late stage of the game, the odds are very high you do need to get this taken care of Barb, so why beat around the bush?

What typically happens if you start playing the waiting and watching game at this stage of the ablation process, is that most often you will fall into the natural tendency to procrastinate as one ECV cardio-version after another rolls by. You won't stay in flutter for long each episode as you will get used to getting zapped quickly so most of your time will be spent in NSR anyway which automatically makes you downplay the arrhythmia parts and help you to ignore the fact that you're still arrhythmo-genic. Or at least you think your are mostly in NSR even though some silent activity might be going on as it likely was for you recently as well. This is especially true for those with an innate tendency to over think things and get worried easily and thus find convenient and seemingly plausible reasons for one more delay after another until suddenly you can find you've had another 14 cardio-version like I did before finally making it back for my LAA isolation.

This is very easy to let happen in spite of all ones protestations now that we never would let it draw out like that, believe me life has a way of intervening and suddenly a year passes of frequent visits to the ER for a zap before you finally make it back to Dr N's EP lab. Of course, if you want to get shocked again or repeatedly that is okay too and certainly a choice you can make. But as we discussed repeatedly, it pays little in delaying with advanced AFIB ablation which is, after all, a process.

If there was any reasonable chance you would never have another breakthrough at this stage of the game I would say why not wait it out and see. But that chance is incredibly small at this point.

Besides, as I noted today on the phone with you, it will likely take a couple months or so anyway before you have a date in Austin to get zapped and you may well by then be more than ready to get it taken care of in any event. You will certainly have had time to prepare and figure out the score yourself and this is not at all rushing you as if you were suddenly going in on this Friday for the touch up ablation. You don't even have a date scheduled yet. And if for some reason you feel confident in postponing that date before the time comes you can certainly do that as well, so there is no pressure here and its is only begin wise to set up all your best options now instead of waiting for life to prove that you would have been better to have done so earlier.

The point is, you know now what Dr N feels would be best for you after seeing your EKG today. That's good enough for me. We all know the least amount of time spent in arrhythmia the better and this is particularly true for those of us who already spent most of our procrastination chips bank account over many years of mastering the art, and as a result, wound up with more advanced disease in the bargain and which thus now requires a couple of procedures to begin with to get the job fully done.

I can tell you from experience as well, that remnant LAA triggers are not at all very amenable to being put on ice with supplemental efforts as I did all that to the max with truly heroic effort, but the nature of these kind of arrhythmias that are mostly flutter/tachycardia of atypical left atrial origin that first appear after post ablation blanking period and especially if they involve the LAA, is that you need the services of a guy like Dr N to do this up right.

You can bargain all your want and try this or that angle from ten different ways and at some point you are going to realize the better part of valor here is to go forth with confidence and a positive attitude and try to take this opportunity to say no to those fearful and negative 'what if' stories that can really take the mind for a ride during the waiting period before a procedure as you well know.

You have had a great experience over all with your process Barb, and this added step which was a very well known and even fairly predictable occurrence in your case, is no exception to your over all good fortune here. Just view this as a chance to finally put a quicker end to the whole process sooner rather than later, since it seems clear you will not likely be one and done after all.

'One and done' would have been the exception in a case like yours and yet I was still very much hoping you would draw that lucky straw, but its not a big deal that yours will be a more typical outstanding advanced AFIB case by Dr N with one big index ablation followed by a relatively minor targeted touch-up to seal the deal, just as you knew was a strong possibility from day one. Again, nothing here that has happened in your case has in any way been out of the ordinary or come as some unexpected surprise.

So keep that in mind through all of this Barb and be strong here. You are the lucky one. Can you imagine if you had chosen an EP that didn't even recognize LAA triggers and hardly ever did any work in that area?! You would have been in hot water still right from the start after that first ablation with little prospect for it to get much better with repeat ablations which continued to avoid the real elephant in the room.

The final point here to take to heart too Barb, is in a case like yours with fairly extensive fibrosis, we don't want to procrastinate too much longer as well which will only tend to halt, and even start to undo the longer it goes on, the reverse remodeling process that has likely just gotten started to work in your favor some in recent months of continuous NSR after the ablation. To try to wait it out now and see how many breakthroughs it might take in order to finally convince you that it would have been better overall to have followed Dr Natale's inclination here and gotten this thing put to bed once and for all sooner rather than later.

Time for bed here and hope you are sleeping well Barb,

Shannon



Edited 4 time(s). Last edit at 04/30/2014 09:55AM by Shannon.

Shannon - I will be honest and say that I am half mad at you for suggesting that I need to plan for Ablation #2, and half grateful for your encouragment. I think you might understand those conflicting feelings. We have had a very similar Afib history of denial, procrastination and hope that we can somehow manage all of this on our own. My many, many walks that stopped my Afib episodes had me convinced that I was somehow different - MY afib was able to be "controlled". Trouble is, it kept returning, until I finally "gave in" and took Flecainide - which also had me thinking I was doing alright for over 5 years.

I am finding this hard also because now I am on my own. Since Doug died, I have been feeling very concerned about having any big health issues and having to deal with it without my life partner. My sister has said she would go with me to Austin, which is great, but she has not taken this Afib ride with me like Doug did...and doesn't really understand how this has affected my life over the past 10+ years. So I guess I'm feeling sorry for myself...which is something I need to get over.

I need to get the phone number for Dr. Natale's office in Austin from you, and I will make that call. Maybe Phyllis and I will go a day or two earlier and explore the town.

Thanks for sticking with me in spite of my vascillations, pushbacks, and repeated concerns.

Off for a good cry - and then to put "my big girl pants on", as they say ~ Barb

Hi Barb,

You are welcome :-) . It's all going to be just fine, and now your sister Phyliss is going with you that's great and will make what will be a much easier ride than even the first one turned out to be seem even more like a piece of cake. Austin is a cool college city with wonderful restaurants and a beautiful river front and large campus of University of Texas very close to St David's Med Center.

Of course you are a little disappointed to need one final step, but like we discussed you were always aware this was going to be a big possibility in your case. And I say, the sooner the better in that case! You've got the best guy going in this business in your corner doing what he does best and who knows your heart inside and out now doing this final housekeeping tune-up and you're done.

Without question this IS a lousy condition that demands a large measure of fortitude, patience, resolve and a clear vision of where we are in the process from us all throughout the course of our lives, and often it demands these things from us when few of those attributes seem close at hand. That's also what all of us in this wonderful little community are here for, to help offer another leg to stand on and to remind each of us that we are not alone in this experience at all and that so many others have been there and done that and are so much the better for it as a result of just putting one foot in front of the other and moving forward with as postive and confident a demeanor as you can muster, come what may.

I understand too the temporary pity party too, but just put a short shelf life on that with a quick expiration date as there really is not a lot to feel too awfully sorrow for oneself over here when this has always been a par for the course strong possibility as part of a highly successful advanced AFIB ablation process, and is nothing at all out of the ordinary or unexpected with the type of arrhythmia history you have had.

Regarding the loss of Doug's presence and support, nothing can really replace that and we all feel very much for you on that account Barb, for sure. But look too at one silver lining that now you have a chance to forge a new level of connection and support with your sister Phyliss and share all sorts of new experiences with her in your corner and bonding all the deeper. That's a small blessing in itself, and you can now be the teacher for her and showing/telling her what is going on. And I can reaffirm the old adage is completely true that 'the teacher always learns and gets more than the taught'.

Best wishes Barb and I will send you the Austin contact info later today.

Enjoy your day and zero worries on the cardio-version later this afternoon, just bring the short check list I gave you yesterday and its smooth sailing for sure.

Shannon



Edited 1 time(s). Last edit at 04/30/2014 09:51AM by Shannon.

Good luck on your decision, Barb. I'm watching, with great curiosity and empathy, your events unfold, since I too recently had a Natale ablation pretty much with the same outcome as you. LAA ablation, on Xeralto till 6 months, will need the TEE, and so on. I'm sorry to hear that after 7 months the beast, or its cousin, the flutter beast, reemerged. But just as I was told, part of the deal with having our LAA worked on is the possible touch up for flutter.
Like you I dread going down for the count again via anesthesia, not to mention having those darn sheaths prodded inside me for the catheters. But it's not done till it's done.
Sorry, Barb.

Chris

Barb got her ECV yesterday and like a few of us predicted and reassured her it was pretty much a non-event and she left the hospital ticking away in NSR and prepared to call Dr N's office to start setting up the LAA touch up when available in Austin. She is doing fine and in good spirits when I last heard from her, just an update.

Shannon

Good news. Thanks.

Thanks for the update. When Barb said flutter, my thought was "don't the EP usually ablate the CTI as part of the procedure?" LAA once again, that explains it.

Researcher,

A lot of post ablation flutter is of the atypical left atrial flutter variety rather than the more typical right atrial CTI flutter you mention. Though that too can make it's first appearance after a left atrial AFIB ablation as well and thus is often zapped on the way out from an AFIB ablation first procedure. The atypical left atrial flutters post ablation tend to be less amenable to converting on their own back to NSR without a cardioversion. About 50% of the time those that first appear during the blanking period will self resolve and go away for good. Alas, this is much less common to happen for those appearing anytime after the blanking period which almost invariably signals the need for a touch up procedure to nail that errant circuit down for good.

Shannon

Thank you all for being her for me and for "listening" to me and offering your help and support. I am back in NSR, but as you would expect, not feeling as assured that it will remain that way. So at Shannon's encouragement, I made the call to Austin to try to get on their schedule, rather than wait and see. I spent way too many years in denial while wrestling with Afib, as it came and went (a LOT)..but when it stopped, I conned myself into believing I could manage living that way....Not smart, I know now.

As my son is graduating from law school in two weeks and a dear friend is visiting for a few days right after that, I would like to look at June as a good time to have the ablation. Hopefully they have some availability at that time.

Good luck to you too, Chris. Pretty soon we won't need to be worrying about this anymore..it will be done and we will start a new and happier chapter.

Thanks for letting others know my status, Shannon. I may have to start calling you St. Shannon You are a welcome beacon of light in the fog.

~ Barb