New to AFIB- Confusion!

I'm a 59 year old male and I've been recently diagnosed with persistent afib. For about 12 years I had PACs with no issues. Then at the end of March I felt funny in the chest and in the ER I was in atrial flutter. I did echo, stress test, and TEE / Cardiovert. After conversion I was in rhythm less than 3 days and I've been in continuous afib (not flutter) since.
Since then I've seen an EP at Vanderbilt (Dr. Ellis) and had heart cath - no issues.
I don't have any other issues such as diabetes, weight, hypertension, etc. - so I assume I would be considered LAF. Currently I'm on Eliquis 5 mg 2 x day, metoprolol 25 mg 2 x day, and 81 mg aspirin 1 x day. I do not feel the afib and have no symptoms except for some tiredness (may be meds). I excercise regularly and eat pretty healthy.
Vanderbilt wants my next step to be antiarrhythmic drugs with another cardioversion if necessary. I've rejected trying amiodarone because of the possible side effects and long half life of the drug. Alternatives offered have been Tikosyn and Sotalol - which I'd need to be hospitalized for 3-4 days and still don't like the side effect possibilties (other arrhythmia complications more severe than afib).
Vanderbilt has the hybrid ablation that is suppose to have a good success rate for persistent afib- but I'm told that insurance won't pay unless I try a antiarrhythmic drug first. Of course I know that the hybrid ablation is a serious surgery - but the prospect of being drug free in the future is certainly a goal.
There seems to be a lot of opinions on the best treatment options for someone with persistent afib without major symptoms- from do nothing to the hybrid ablation or mini maze.

Questions...
Thoughts about skipping antiarrhythmic drugs like I want to do- am I being over cautious about the possible side effects and not looking at the possibility of regular rhythm? I don't feel "bad" now... and don't want to these mean drugs to do more harm than good.

Thoughts about someone without major symptoms doing a major surgery like the hybrid or mini-maze... wait until if/when I become more symptomatic- or address quickly since the longer persistent the less likely success?

Has anyone with Humana insurance bypassed antiarrhythmic drugs and gone to ablation and have insurance agree/pay?

If I do need to do antiarrthythmic drugs- any comments on Sotalol vs. Tikosyn?

Has anyone had experience (good or bad) with Dr. EIllis at Vanderbilt's heart program?

Any suggestions or comments appreciated!
Thanks!

Ken,

Don't know about insurance (you should ask them), but antiarrthythmic drugs don't generally work long term for most, so an ablation initially is a good option.

If you are persistent, you are most likely to be a "complex" case. This requires the best team for increased odds of success. Don't know Vanderbuilt's success rate. A mini maze is much more invasive, in my opinion, than an ablation. I would do a combo as a last resort.

My choice would be Dr. Natale at St. David's in Austin: <[www.tcainstitute.com]

Shannon, our moderator, can give you more info.

Good luck!

George

Ken - I just did a quick review of their web site info on AF treatment and their approach is the surgical approach. Although it is done with minimally invasive laparoscopic tools now, it is still quite a bit more morbid than catheter ablation and success rate range is about the same as high volume catheter ablation centers. The latter is probably the better way to go.

Hi, Ken! Know some folks with Humana. Based on their comments, I doubt this insurer willl foot the bill for an ablation without first going through conservative treatments.

Some of your questions are very much a personal matter. Like you, I'm in persistent AF, but asymptomatic, and with a Chads score of zero. I've chosen not to go the ablation route because of potential complications, and the liklihood that it'll only need to be repeated... at least once.

I'm 66, still work, exercise, and I'm fairly active -- physically and mentally. Diet is good, take supplements, and a beta blocker. The only time AF has any noticeable impact is when I over-exert during my sessions at the gym... then I back-off and go slower. Flecainide didn't keep me in NSR.

Have had decent cardios and EPs, through the years, who have checked me out quite well. This will continue.

Should things change in the future... including significant improvement in ablation success rates, then I'd re-consider an ablation.

Good luck!

/L

I was a persistent Afibber.

After 2 years of fighting this beast with anti arrhythmic drugs and beta blockers, I decided to have a Cather Ablation. I had taken amiodarone and multaq at different times for Afib. I was shocked (electrical cardio verted) 4 times in 2 years. I also was on Cardizam at one point then I was put on Metroprolol ER.
My Ablation was with Dr. Andrea Natale in Austin Texas on Feb. 27,2014.

So far am doing really well. I have been in NSR since the Ablation. I drove 8 hours to get to Austin and I would do it again because I wanted the "TOP MAN" Ablating my heart especially since I was in persistent AFIB.

Ken,

There were a number of posters here several years ago who'd chosen to do the mini maze approach ('07-'09?). Later there was talk about the combo. My impression from reading about their experiences is that it is a much longer and more difficult recovery than an ablation. I'm not sure, but I think Natale may have experimented with the combo, but decided pure ablation was the way to go.

As with any approach, going to the top guy/center is important. Also, if you go to a teaching hospital, make sure you communicate you want THE guy doing the work, not a fellow with the top guy supervising! Actually, it is good to clarify this wherever you go.

George

Be very careful with a hybrid approach for persistent AFIB KenKY,

It has its place when compared to run of the mill catheter ablationists who struggle to get consistent results with a standard PVI for paroxysmal AFIB, and it can be useful for folks with extremely enlarged LA diameters and with very long standing persistent AFIB most of whom have a host of other co-morbities. But the hybrid procedure needs to be done by the very top people and in such a case with your lack of anything more than clearly persistent AFIB I would NEVER consider a hybrid approach before at least letting a true catheter ablation maestro like Dr Natale have his way with a two procedure process.

He may well get a case like yours done in one shot but its always best to expect two, a main index ablation and a true smaller touch up during the first year or so after the first more comprehensive ablation, and be tickled pink if you turn out to be done in one.

A good hybrid ablation should start with the epicardial surgical phase and then, if needed ... as is so often the case ... then have the endocardial catheter ablation phase done two to three months later. Never do both phases on at the same time as its much too risky. In essence, to do this right it is typically a two procedure process in any event and the surgical phase can be a brutal recovery compared to the relative walk in the park from a skilled elite level endocardial persistent AFIB ablationist.

It makes no sense to go for a hybrid ablation without first truly failing an endocardiol process by one of the best EPs in persistent AFIB. Sure, if you choose an average 'decent' EP who hasn't done a few thousand persistent AFIB ablations yet, you will likely need several procedures to start to get it well under control long term, but such is not the case with the true elites like Natale and the top two at Bordeaux Prof Jais and Haissaguerre as well as a good number of Natale's proteges who are capable as well, as are a number of other top ablationists from different centers. David Callans for example at Penn.

But the same is true for selecting a hybrid team and no matter what team you choose the hybrid team will be far less experienced at this than Dr Natale or the Bordeaux group for sure. Natale is now approaching 8,000 total ablations under his belt by himself, and a large percentage of those cases have been of the more challenging persistent and long standing paroxysmal AFIB.

The only patients for whom a hybrid approach using top surgeons and very skilled EPs would be worth considering up front, prior to at least trying an expert catheter ablation process, is with those patients having extremely large Left atrium diameters, and who typically are grossly obese as well and typically have other cardiovascular and/or diabetic/metabolic syndrome co-morbities as well.

I was just with Dr Natale all last week in San Francisco as he ablated one of my closest long time friends of the last 26 years from Hawaii. My friend I'll call 'Tony' only discovered just a month ago as of tomorrow, on May 10th, that he even had AFIB during a routine colonoscopy, He is very athletic and fit 64 year old, and when they told him he had AFIB and would not do the colonoscopy his first reply was: "No I can't have AFIB that's my friend Shannon". ..Anyway he failed a cardioversion in less than a day and has a really big 53mm left atrium, as well as bradycardic AFIB which prevents use of any AAR drugs as well as rate control which he doesn't need anyway.

Tony also has applied the full strategy supplement routine for quite a few years, plus other supplements as well, as I sent him The Strategy at least four yeas ago if not a good deal earlier and he followed it all closely, so it was clear too that natural nutritional repletion protocol wasn't going to cut it alone in his case.

All those factors were taken into consideration and thus Dr Natale agreed to ablate him so early after diagnosis as he clearly had no other real options rather than resign himself to throwing in the towel and just rely only on anti-coagulation for life and be sent out to pasture, with any doc managing him just hoping he didnt stroke out on their watch as the extent of his treatment.

In any event, a very lucky cancellation got him in last week and the procedure went exceedingly well! Fortunately for me as well, I got to watch the whole thing dressed up in the smock 'Bunny suit' there at CPMC which was fascinating. And inspite of Tony having long standing persistent AFIB of unknown duration, but likely at least several years when he started noting shortness of breath on exercise, the Maestro converted him to NSR in only 47 minutes of ablation time, and exactly within a total of one hour from the start of insertion of the catheters into his body. That is pretty remarkable and the NSR held up all through the isoproterenol challenge and continues to do so now almost a week later.

The control room where all the instruments and CARTO 3 mapping system was operated by a very knowledgable Biosence Webster technician under Dr Natale's commands, as well as several other techs, erupted in applause and a few cheers when Tony converted to NSR. This happened just as Dr N was ablating around the base of his Left Atrial Appendage (LAA) which, not too surprisingly in a case like his, was found to have been a huge driver of his AFIB.

Dr Natale did not have to isolate Tony's LAA in this Index ablation since, during isoproterenol drug infusion challenge, the LAA signals which Dr N had reduced in amplitude in an effort to delay the conduction within the LAA without full isolation, those LAA signals never got bigger or more chaotic again after his ablation work in spite of 20 full minutes of high dose isoproterenol infusion! Isoproterenol (drug name 'Isuprel' ) is an adrenaline-like drug used to stimulate the heart and trigger any remaining, and to this point suppressed, triggers and reveal those triggers that had just been ablated but may have reconnected already while the patient is still in the ablation itself.

And yet, there was not one single reconnection from all the extensive ablation work Dr Natale had just performed that was triggered during the Isuprel challenge. The only area at all that required addressing after the isuprel infusion was isolation of the Coronary Sinus as the isuprel ( isoproterenol) revealed some small and relatively benign, but what could become annoying PACS in the CS, so Dr N went back and isolated the CS to take care or that. These PACs had not been seen prior to Isuprel infusion proving, once again, how vitally important performing high dose and long duration Isuprel infusion can be in an index ablation as well as during any follow up procedure. Don't even bother with an EP if they say they do not use isoproterenol drug challenge in their ablations.

It's crazy not to use it with all that has been learned about its value in the last few years and the fact that a fair number of ablationist still do not use drug challenge is one reason for the continued epidemic of reconnected or missed triggers as a main reason for repeat ablations. This, rather than simply finding new sources that either had been suppressed in the original ablation by general anesthesia and/or that had been newly formed since the first procedure which is more typically the reason for repeat ablations done by experienced and highly competent EPs.

Alas, for all the very real improvements in ablation knowledge and skill, there is still no substitute for demanding the very best ablationist you can arrange for yourself. Dr Natale lamented to me the large numbers of people who come to him to fix failed attempts after often multiple ablations in which he still finds all four PVs fully reconnected!! That should NEVER happen after multiple ablations with even minimal competence by the EP. He recounted one patient from the Los Angeles area who who had had SIX ablations done in his home town area in LA by two or three different EPs with each EP doing at least two procedures on the poor guy and still ALL four PVs were still fully connected and conducting AFIB!!

Stunning the big gulf there is between those with enough experience to trust and, unfortunately, still a significant number of EPs doing ablations out there who probably should not be doing them. Please head our strong advise here for years to not settle for a local EP who is not clearly one of your most experienced possible options for the kind of AFIB you have.

In any event, It's been six days now and my friend has only had two quick PACS of less than a second duration in total and that is it. Total NSR the whole time so far, and his bradycardia is now back to a normal 64bpm resting HR and his mildly elevated BP dropped from around 140 /95 to 130/78...

Tony may still well require that touch up ablation in a few month to finish isolating his LAA in order to be finally done with this business for the long term with solid NSR, but he may not need it as well, and time will tell. Regardless, this index ablation was a textbook huge success for a man with such a large LA and persistent AFIB to begin with.

He feels fine and is already resting with his grown daughter downin San Diego for the next week before returning to Hawaii.

Please do yourself a big favor and do not subject yourself to the heavy recovery period and greater uncertainty of a hybrid ablation as your first step in the process to eliminate your persistent AFIN KenKy! I promise you the folks there doing the hybrid work, even though Im sure they are fine doctors and excellent clinicians, they nevertheless do not have any where near the experience of Andrea Natale at handling persistent AFIB. They many be very good, but seeing Dr Natale as your first step is your very best shot at having to endure a minimal recovery and gain outstanding results with the least invasive and mosts successful outcome at the completion of your ablation process for a straight forward persistent case like yours.

All the best, Shannon



Edited 5 time(s). Last edit at 06/10/2014 11:16AM by Shannon.

Thanks so much for all the feedback- it has been a big help!
I have definately decided not to seek the hybrid as a first line of action on my afib.
LarryG- it sounds like my profile is alot like yours.... and have seriously considered just continuing a healthy lifestyle for the near future. Then I hear others say that the longer I stay in persistent afib the hard to correct in the future, so the debate on what to do.

Sharon- thanks so much for the info on Dr. Natale. I will look into that more.
I selected Vanderbilt because they did have an afib center and is a very respected hospital in this part of the country... it is about 2 hours to go there from my home town.

With Humana as my insurance- I may have to at least try the meds before I can do anything.
If I do the meds I was planning on doing it this month when I have some vacation days. I've already passed on amiodarone and even if I wanted to do it now, the 30 day load time doesn't fit with the schedule I wanted.
Has anyone has first hand experience with Tikosyn (dofetilide) or Sotalol? Both require hospitalization to make sure Q wave arrhythmia doesn't happen. I guess the thing that bothers me, is that if things are fine for the time hopitalized does that mean there is little chance for the very serious arrhythmia like Torsades de Pointes to occur later when excercising, etc.

Thanks again for all the comments and feedback- it is much appreciated!

Ken,

Regarding your medication question, I'd go to the advanced search in the upper right hand corner. Put each in, in turn, and set the search time for at least a year.

You can read what people have posted and perhaps PM them with your questions.

I recall Murry L from Canada has been on Tikosyn for a couple of years.

Good luck!

George

KenKY,

Prior to my Natale ablation a year ago, I talked with my EP at Vandy about an ablation on a couple different visits requesting specific information about his stats. In particular I wanted to know how many he had done and what his success rate and complication rates were. Both times I felt like I got a canned speech about how many the facility in general had done and how they worked as a team with two EPs doing the ablation. It seemed to me that the stats I was given were general and not specific like I was wanting. Another employee in the department told me that my EP had done seven that year. I knew I was not going to be number eight.

In regards to your insurance company, they may require you to fill a prescription for a heart rhythm drug before consenting to paying for an ablation. However the insurance company is not going to be in your home monitoring your compliance.

Best wishes as you sort this out and consider your options.

Betty

KEN KY,

Your instinct not to start with Amioderone now is a excellent one. This drug has such a long half life that most EPs will not consider you for an ablation until you have been off of it a minimum of 3 to 4 months and preferably 6 months to avoid its suppressive effects on finding your AFIB triggers during your ablation.

Regarding insurance and AAR drug failure, its possible Humana doesn't require at least one AAR drug failure with persistent AFIB. Blue Cross requires at least one AAR failure unless there are extenuating circumstances such as bradycardic AFIB, as with my friend last week, that prevents use of those drugs. Betty and George are right on the approach to take, in that regardless just getting a single script and not finding it effective will do the trick. Nevertheless, fortunately more and more now ablation is being recognized outright as a superior front line therapy for many cases.

Cheers!

Shannon (and FYI, I'm a guy :-)



Edited 3 time(s). Last edit at 06/10/2014 11:19AM by Shannon.

Hi Ken,

We have some things in common. I am a Kentuckian by birth and have been treated at Vanderbilt, although through the VA window. Perhaps my experience will enlighten you. I had a flutter ablation there in 2008. The facilities I believe are shared with Vanderbilt. My doctor was Jeffrey Rottman. (The VA only provides flutter ablations, perhaps the afib ablations do not provide sufficient success rates.) My ablation was a failure.

Over the past 7 years I have tried dofetilide (tikosyn) and sotalol. Finally afib surfaced. Sotalol always had significant side effects. My breathing was oppressed and painful. Eventually lifestyle changes improved this aspect. Chiropractic brought some relief of symproms. Sotalol was effective but consistently failed as I became more energetic through other approaches such as acupuncture. Tikosyn didn't hold me in nsr nor did it give side effects. I am far from an ideal patient in terms of general health so you may have better results. Most recently I have used multaq/dronedarone. My resident doctor at the VA was concerned that this was not a good long term solution as it is a cousin of amiodarone so when a Natale ablation became an option I opted for that.

My ablation was 3 weeks ago. I'm in NSR but not up to speed in terms of capabilities. Don't be too hurried in making a decision. You sound like a good candidiate for a Natale ablation but understandably you would hesitate given the minor symptoms. This site has many resources regarding alternative approaches. I often wonder if there isn't an afibber profile that would reveal lifestyle correspondences to afib susseptibility. Judging from the contributors here, not many artists get afib!

Keep us posted,
JohnC

persistent flutter treating with enzymes, acupuncture, supps,

John C The observation made some years ago is that the majority of afibbers tend to be Type A personalities... driven, stressed, achievers, perfectionists... overworked, over-committed...often, intentionally. I certainly know that described me at the onset and some years beyond until I was forced to retire early because of Afib and also forced to re-think priorities and make time for relaxing and 'down-time'.... And actually, I did take water-color instructional classes as it was something I always wanted to do but never made the time. The experience was/is delightfully relaxing.

Here's a recent Huffington Post report on Type A observations. [www.huffingtonpost.com]

John - if you missed my post on EFT or Tapping technique, you may find it very useful. I certainly do and many afibbers and former afibbers to whom I sent the info responded they find it most useful.

EFT for stress and anxiety that comes with Afib
[www.afibbers.org] November 14, 2013

The video references are excellent - especially Nick Orter as he updates continually.

Happy tapping.

Jackie

" the majority of afibbers tend to be Type A personalities... driven, stressed, achievers, perfectionists... overworked, over-committed.."

Definitely not me. The first EP I saw said being tall was a factor. I expect there a lots of stats on Google Scholar.

Good discussion! I am both tall and type A- haha!
I made a call to the Texas Cardiac Arrhythmia Institute today to talk with someone on their nurse support team to discuss my specifics and options with Dr. Natale. I haven't heard back yet, but look forward to talking with them.
I did get some more specs on the EP at Vanderbilt- he does about 200 ablations a year with about 75 of them being the persistent type. State success rate for persistent is 65% for the first ablation and 80-85% when a second one is necessary.
Millenianman- thanks for the info on the drugs from your perspective!
I appreciate all the feedback and information

KenKY,
Did you ask if those stats were for him in particular or are they for all the EPs combined? Are these numbers for the hybrid procedure? Did you ask about his stats for complications? Has he had anyone die during the procedure or in the first month as a result of the ablation? These are all reasonable questions i'ld be asking before they branded my heart.
Betty

Hi Betty,
They are his stats for the regular ablation (not hybrid). (At this point I'm not interested in the hybrid.)
Complications were groups at less than 1% for tamponade, mini strokes, other risks.

I'm still very much on the fence on whether to continue as is (like LarryG) with healthy lifestyle as long as I don't have any significant symptoms and I don't have other risk factors - or act early and do an ablation sooner rather than later. Even with the best EPs I'd have quite a setback in function for several months ... wondering if in the end I'll feel any better than I do today (which isn't bad).
Ken

Hi Ken,

I have quite a lot of experience with Sotalol, I've been on it continuously for four years! Actually right now I'm starting to wean off it in anticipation of my six month check up with Dr. Natale in San Francisco (my ablation with him was in late December). Coming off Sotalol after being on it for so long is no picnic, I feel a bit jumpy, going on it though is a piece of cake!

Sotalol didn't really have any disturbing side effects for me in all that time, it does make you much more easily tired though. Eventually though all these sort of drugs stop working unfortunately. When I got a-fib in 2007 Sotalol alone converted me within a week. When I got it again in 2010 Sotalol alone would not do that trick anymore, it took a cardioversion. But after that Sotalol held me in sinus for almost three years. Then the a-fib broke through, and within months Sotalol didn't even hold my heart rate down very well. I was up around 80 beats even though I was taking 120mg of Sotalol twice a day, before the Sotalol could keep it under 70 easily. The last few months while I was waiting for my ablation date my heart was pretty wildly misfiring from quite a few locations. It ended up that I had to have a very extensive and long ablation, Natale's "kitchen sink" version including full isolation of my left atrial appendage.

From what I gather this is pretty typical of a-fib's progressive nature. But I can absolutely vouch for Dr. Natale and his staff, more than staff they are a true team with not only their communication to you but to each other. When they say they are going to call you, they do, when they forward one of your emails to another team member, it happens quickly and you get a call or email. I've seen lots of doctors in the last ten years, including three EP's in the Los Angeles area as part of my DD. None come even remotely close to Natale.

Best of luck to you, and I look forward to your experiences!

I don't think stats as in tall, short, fat, thin, driven, passive etc have anything to do with deciding whether to ablate or not.

OK... another Type A checking in to say "hi." ;>)

Not a radical Type A... more of a balanced "A." ;>)

And for the more complete profile... also not tall. ;>)

/L

Thanks for the profiles.
I am tall and thin and a reformed type A.

JohnC

persistent flutter treating with enzymes, acupuncture, supps,

Hi afhound,

The one physical metric besides an overly enlarged LA that can influence whether many EPs will attempt an ablation or not is how big a person is. With severely obese people it's very hard to get good imaging as well as Fluoroscopy views and those that have both a very wide girth and torso as well as a large LA with long standing persistent AFIB are often referred for a hybrid procedure rather than an endocardial.
Shannon



Edited 1 time(s). Last edit at 06/18/2014 01:48AM by Shannon.

KenKY,

you might want to look into Central Baptist in Lexington, KY. we have a really goo dprogram there with Dr. Gery Tomassoni.

After talking with St. David's in Austin today, I have tentative dates of July 7 for a consult with Dr. Natale and a reservation for July 8 for the ablation (assuming everything is a go).
Special thanks to Shannon for giving me the name of the right person to contact there- that helped a lot!
I'll keep you posted!

Excellent choice!

Ken I am late posting to this thread and hope you get this. Do you have sinus bradycardia? In other words is your resting heart rate lower than 60, and more important is it around 50. If so, be very careful of the antiarythmic drugs as some of them have the side effect of lowering your heart rate, and as you probably know, a low heart rate puts you at greater risk of triggering afib. I had to stand firm against a cardiologist on this issue.

If you are against drugs, as I am and yet you want to have your ablation covered by insurance, why not just fill the prescription and toss it in the garbage?
Ron

Thanks, Ron. Indeed I filled the Rx and did not take it. I'm schedule for consult and ablation with Dr. Natale soon. I'll post results soon