ectopy following ablation

I am new to this forum..I am a 53 years old male, afib intermittently for 10 years or so (vagally induced) , failed rhythmol, flecanide..ablation with mansour august 2013. Heart rate increased since ablation, Did well till about 5-6 weeks post ablation, extra beats began. Have yet to characterize them as PVC's or PAC's, ..very disturbing, wake me from sleep..restarted flecanide which now works but at 50 mg 4 x daily, with metoprolol er 12.5mg 2 x daily, and magnesium chelate 400 mg sometimes 2 x daily if I can handle it.. Even tried a magnesium cream, and taking epsom salt baths. Serum mag middle range normal. RBC mag slightly low ( 3.8) despite above measures. Serum potassium 4.2 consistently.

Went to Steinberg for a second opinion who said that my ablation with Mansour was too aggressive, causing scar and is the likely cause of my ectopy. Advised me to taper the flec, get a holter, so we can determine if these are PAC's which is what he suspects. Then we can ablate , since he feels long term flec becomes risky with aging. Ruskin et al say this is very unusual and do not have a good explanation, saying they rarely see this in their patients

Now thinking about adding taurine, and potassium supplementation, but with normal serum potassium, not sure if that is smart.

Frustrated and concerned I will break thru this dose I am on, not wanting to go up further on flecanide. Also would love to get off the drugs...

Thoughts?

This is Moussa Mansour, head of EP Lab at Mass General?

yes..I consulted with Dr Ruskin..Dr Mansour did the ablation at Mass General

Just wondered. I was ablated by Dr Barrett. I just remember Dr. Mansour from the recovery area where he stopped by for a few minutes and asked how everything was.

are you having extra beats/? how did you do post ablation? steinberg feels they are too aggressive at mgh, and claims this is why i am struggling with all this ectopy...new foci of scar tissue due to overly aggressive ablation...i assume tho do not know if Dr Barrett is similarly aggressive...

Be very careful about accepting that claim by Steinberg, afapr14, or by any one making such a general speculation like that which is rather meaningless when he hasn't examined the details of your ablation It's not always possible to predict when either post ablation flutter or runs of ectopy will appear and that goes equally for Steinberg cases as for Mansour or anyone else. That is one reason why ablations are considerd a two step process over time and consider it a bonus if you get it done in one. It appears you are not having AFIB any longer so perhaps you got that major genie back in the bottle in round one and will just need round two as a relatively straight forward PAC ablation to vanquish the ectopy and thus become quiet for the long term?

I guarantee you Steinberg and most every experienced EP has cases just like yours as well from time to time. He also can't tell whether or not this particular case of ectopy is due to ablation 'scar' in excess, which is what he is implying, and is something he too is laying down with every ablation burn asnwell. Sounds like he is just guessing to scare you off from Moussa and get you to come to him so he can add the extra 'scar' himself to finish things up, assuming he can get the job done on round two. I appreciate EPs who tell the straight story and
don't speculate to that degree in an effort to slant the patient in their favor.

Why not go get a third opinion from Luigi Di Biase at Montefiore or David Callans at University of Penn and see what either of those experts say. You do need a touch up ablation by someone good, and don't rule out using Mass Gen again just based on that comment by Steinberg. It's possible had you gone to him to begin with you might still have AFIB from reconnected PVs which apparently is not the case now. Though for sure excess runs of ectopy is no gun and annoying as he'll even though with not the same stroke risk in most cases as with AFIB/Flutter.

The point being, that you should still be able to get to your goal of a quiet heart with a relatively straight forward touch up by a skilled EP and it sound like who ever you choose will only have to track down the one target causing this specific ectopy circuit to fire.

Best wishes in getting this put to bed soon. In the meantime, get your IC magnesium in order and take potassium gluconate when ever you are getting activity as your serum K can change rapidly intraday even if it looks relatively stable in
A decent range when doing serum
Testing. Has the majority if your serum tests been dinebatvriughky similar times each day you tested it??


Shannon



Edited 2 time(s). Last edit at 05/28/2014 01:31AM by Shannon.

Hi Shannon,
Thanks so much for your reply..I have never heard of the docs you mentioned.. I live about 1.5 hours north of NYC so the closer the better..especially because to have an ablation I need to be having the pac's so they can map them..going to Boston and having them disappear is very inconvenient..

Does anyone know about Dr Chinitz's rep? He is in NYC..more convenient..Then there is Dr Reddy at Sinai..

Getting the rbc mag up is easier said than done..not sure how to accomplish that with the dose maxed as far as GI tolerance goes, using the mag cream and epsom salt baths..Also is there an easy test for intracellular potassium? Again , my serum pottasium has always been above 4

When I asked Dr Steinberg about the significance of Magnesium, he dismissed it as not relevant.

I do find it hard to believe he would say what he said just to drum up business....I suspect he does believe what he said..whether it is accurate is a different issue...

Anyway thank you for your thoughtful response...it is very helpful!

Hi Shannon
Wondering who you would choose and why for my third opinion...Dr Callans or Dr Di Biase? I can get to either...just wondering how one can get info as to who is the best in these situations..you seem to have a wealth of info on the subject..
thanks!

You are in NYC AfAp14, I would go first to Dr Di Biase. He has great resources aligned with him and himself has 'the innate touch' with a catheter from all reports Ive heard from those who know him best and work with Dr DiBiase all the time. He is a rising star in the field and is the prime protege of Andrea Natale who sponsored him into America after Dr DiBiase caught the eye of his medical university in Italy some ten years ago as a bright young doctor going places. Dr Natale recognized his innate talent and took him under his wing to both sponsor and mentor him as he has done the last 7 years.

Luigi Di Biase is also director of the most prolific AFIB research center anywhere combining ST David's and CPMC as well as the rest of the Natale group including the Italian Groups and producing on average 3 full studies per month in published in major peer - reviewed cardio and EP related journals which is a prodigious output of knowledge and research.

Plus, should Dr N start doing periodic visits to NYC again before long as he has his eye on, who he would likely pair up there with his already right hand man who has been been at Montefiore two weeks per month the last few years as it is. Di Biase gets my vote at this point as the guy coming up in the AFIB world now most likely to truly follow in Dr Natale's shoes as a highly trained and talented ablationist who has now seen and assisted in many of the most challenging AFIB ablation cases while learning every tip and nuance that Dr Natale has to teach.

That's where I'd start if I was you, particularly you being in NYC and not inclined to travel much.

Also, keep in mind you do NOT have to be in PAC s the day of the procedure. Just arrange to be on call with Dr DiBiase or a Cardio he can arrange for you when he is out of town so that when you do get a strong run of PACs you can call right up and go right in to capture it all on a 12 lead EKG and then a skilled ablationist who knows what he or she is doing should easily be able to locate the origin of your PAC triggers. Plus they can induce PACs too during the procedure with isoproterenol and pacing in those already sensitive and prone to Ectopy triggering. No worries about that.

David Callans is plenty capable of handling this issue as well in Philadelphia, but you said you have logistic constraints and you won't be compromising at all going to DiBiase and all the more so, if and when, Dr N is working with him in the city once again before long.

Best of luck and you will do fine which ever of these two outstanding EPs you chose. I'd avoid the person trying to scare you with totally unfounded concepts though who came up with that comment that your ectopy was caused by Moussa Mansour doing a 'too aggressive' ablation on you. There is zero evidence that the two things would be related in any event. I prefer docs who can win you over by promoting their own honest attitributes rather than resorting to off the cuff convenient remarks that don't make any sense and are inherently misleading.

Certainly you might avoid have more PACs or flutter if you never did any ablating at all or only stayed in ine small area, but then again your odds of getting rid of your AFIB are vanishingly small as well. Much of the time any post ablation flutter or PACs that do arise after a first ablation resolve on their own in the first few months. Those that don't in around 50% of the time require a touch up ablation to out everything to sleep and it's simply not predictable who will and won't have post ablation activity requiring follow up work, regardless of who extensive or less extensive a given procedure was that were also successful in getting rid of your AFIB entirely as well. Its a clever ploy using that tactic to unnecessarily scare folks but it just doesn't hold water.

I'm sure Moussa can also clear up your ectopy too fairly easily. It's not uncommon for a person to need a touch up after a perfectly solid index AFIB ablation to chase down a remnant flutter circuit or some an lying ectopy triggering after an index ablation but this is true for all sorts of ablations unless the guy was so reticent he didn't do enough work to even address your prime AFIB!

From what I gather you do not have AFIB any longer which is the main endpoint of that first ablation anyway. Its true some are more skilled than others at chasing down and eliminating post index ablation flutters, tachy's or ectopy when they get too frequent, and that's why I gave you the names of those who would be my first choice in your region of the country.

Take care Shannon



Edited 1 time(s). Last edit at 06/02/2014 09:49AM by Shannon.

Thanks Shannon
I hear what you are saying.. Dr Steinberg read the op report,( which detailed the specifics of my ablation, which included a prophylactic aflutter ablation ) and then came up with his opinion that the ablation was too aggressive. Apparently he does a more focused ablation. He says his results are similar to Dr Mansour..ie 70 % cure on first ablation. Yes, I have not had AFIB since my ablation and that is great..I have been on flecanide , though, so I am not sure if I would be afib free off all meds..maybe...

Both Dr Steinberg and Dr Ruskin said I would need to be having the Pac's while in the lab for them to ablate the focus..the concept of triggering them is one I will bring up with Dr Di Biase...I will see him the end of June....I may also go to Penn to see Dr Callans ,,my son is starting Penn med ( maybe he can become an ablationist!!) , so I want to visit him anyway..never hurts to get another opinion, tho based on your comments, I am leaning toward Dr Di Biase..


Thanks for ALL your help...!!
I will keep you posted...

Has anyone had the experience of having PAC's post ablation , say for up to a year that spontaneously resolve? I am holding out hope that they may go away on their own so that I will not need another ablation...and I can stop this flecanide...any thoughts?

This is why the optimization and maintenance of the critical electrolytes are so important both before and after ablation since ablation doesn't do anything to replete the missing nutrients.

When I had my post ablation AF breakthroughs starting in year 4, I had become lax making sure I was optimal in magnesium and potassium.... and taurine. Once I got back to the strict routine I had established in those six months prior to ablation, the breakthroughs diminished to zero once again.

I also added d-ribose, more carnitine and doubled my dosing of CoQ10. This is covered in The Strategy. What's missing is that I neglected to include what had become an every-day habit... alkalizing every day with the WW (magnesium bicarbonate water) to maintain the alkaline tissue pH continually range to support heart energy (voltage) and several other measures I had incorporated into my daily routine including serrapeptase to work behind the scenes and reduce/eliminate any residual fibrosis.

Jackie

Jackie:

Maybe your problem is because you are too alkaline.

L

I do take 400 mg of magnesium chelate 2 x daily, put topical mag on and take epsom salt baths...still my rbc mag is slightly low...I just started pottasium...to be honest, I get a little overwhelmed and frustrated when I read about adding so many more supplements..I am a bit hesitant to put so many different substances in my system, especially because I have read here and there about taurine , for example actually worsening things for some...then there is coq10, hawthorne, carnitine, bicarb,,..etc..very confusing..this on top of the flecanide and metoprolol er I am on...I used to take NOTHING...I am becoming one of those crazed pill poppers and would like an easier out......I have avoided caffiene , most alcohol and am feeling a bit like a "bubbleboy"...frustrating...

afapr14 Wrote:
-------------------------------------------------------
> Has anyone had the experience of having PAC's post
> ablation , say for up to a year that spontaneously
> resolve? I am holding out hope that they may go
> away on their own so that I will not need another
> ablation...and I can stop this flecanide...any
> thoughts?


I would also like to hear from others who have had PACs a year or so after ablation and what their significance might be.

______________
Lone paroxysmal vagal atrial fibrillation. Age 62, female, no risk factors. Autonomic instability since severe Paxil withdrawal in 2004, including extreme sensitivity to neuro-active drugs, supplements, foods. Monthly tachycardia started 1/11, happened only at night, during sleep, or when waking, bouts of 5-15 hours. Changed to afib about a year ago, same pattern. Frequency increased over last 6 months, apparently with sensitivity to more triggers. Ablation 6/27/13 by Steven Hao.