That was a bit of a Shock

After 12 plus years of lone atrial fibrillation (several years without any episodes) they finally found something.
My four previous echocardiograms were all fine as far as I understood.
However my recent echo has shown an immobile slightly aneurysmal intraatrial septum.
I ceased all exercise after my first a-fib attack 12 years ago when I was an athlete. My afib/flutter burden over the last 3 years is only about 12 hours in two separate episodes of approx. six hours each.
To tell the truth it's double sixed me a bit.
I am in NSR for the last three weeks.
I do not take any form of anticoagulation.
I have no follow up is from my cardiologist, he has discharged me, so it doesn't seem he is too concerned.
I am on 300mg daily flec and 120mg daily diltiazem.
I have to have a six monthly check on my QRS and QTC which are currently 104 and 428 milliseconds respectively with my GP.(own doctor)
My PR interval is 250 milliseconds which is classed as first degree heart block with a heart rate of 54bpm (bradycardia).
Again I didn't know I was classed as having first degree heart bloc which is a shock as well.
If anyone has any comments I would love to read them.

Regards
Mark R

Hi Mark,

After being diagnosed with afib 2 years ago my cardiologist prescribed 240 mg diltiazem and the next ecg I had about 3 months later showed first degree heart block for the first time in my life.

My doc said it was due to the diltiazem and not to worry. I was taken off the diltiazem in January of this year since it was not effective at rate control and caused a lot of fatigue. I had an ecg in March that showed no first degree block.

Allan

Many thanks Allan your input is very much appreciated.

Mark

Why stop exercising 12 years ago? I exercise right through my episodes (am rate-controlled), and am more likely to convert spontaneously after a hard exhausting work-out. I don't know how that finding on your Echo effects exercise though.

12 hours in 3 years is not much AFIB. How long have been on 300 Flecianide?
Flecainide does'nt even work preventively for some people, especially with Adrenergic AFIB.
Do you even know that the Flec is working?
That is a relatively high dose, and I wouldn't take it for only that small amount of AFIB,
you could still take the Flec just after an episode to help convert back to NSR.
For some Flec does not work preventively, but does work to reverse out of AFIB.

Why are you on Diltiazem?



Edited 3 time(s). Last edit at 09/02/2014 01:00AM by The Anti-Fib.

To The Anti-Fib.
I am generally in NSR because I avoid my triggers and I am on flec.
Exercise and alcohol are my biggest triggers.
Without the flec I am in permanent afib or flutter. My first ever afib/flutter attack was persistent for 9 weeks until DC cardioversion.
Previous to staring the flec I had a several hundred episodes of a fib in a period of a few months.
Below 200mg of daily flec I cannot maintain NSR and am in persistent afib/flutter.
250mg is my normal daily dose.
After my recent episodes after three years of NSR I am on 300mg until I feel confident to drop back to 250mg.
When not in NSR I have too much flutter with the afib to exercise which cannot be rate controlled. I cannot keep my rate below 200bpm if I exercise when not in NSR.
The diltiazem is for rate control if I break out of NSR to stop the dreaded and potentially lethal 1:1 conduction.
Since I am vagal, diltiazem is used instead of a beta-blocker.
Hope that helps, I know my protocol is very different to most who have ever posted on here.

Thanks
Mark

Is the 200bpm an AFIB rate, or a Flutter rate?

Have you tried other rate control methods? 200bpm is not very controlled.
I have no trouble trouble rate controlling in the 70's.

Flec is known to cause/increase Flutter, as I understand it, a Beta-Blocker is the normal protocol, to protect against the 1:1 ratio while on Flec.

I am not a proponent of Ablations, but a Flutter-Ablation is relatively simply and effective at stopping Flutter, it seems that if you cannot rate control any better than that, then that would make the Flutter-Ablation something to keep in mind.

I am not an expert on Flutter, just giving opinion, Shannon hopefully will come on here and give advice.

Anti-Fib,

Since Mark is vagal, taking a beta blocker all the time would be contra-indicated. It could very easily be a trigger.

George

I was just wondering about that, I don't remember reading about a differential between whether or a not an AFIBer is Vagal or not in the Flec protocols. In any regard 200bpm is not at all a controlled Heart rate, and the Diltizem appears to not be working.

Not surprising. Cardio #2 told me he didn't "believe" in vagal vs. adrenergic triggers. He also told me digioxin was his favorite afib med. He was soon replaced by EP #1 who told me, "you are obviously vagal and there are certain meds we won't prescribe for you." I had to bite my tongue to keep from suggesting he give his partner an in-service as his partner's knowledge was obviously dated.

The Anti-Fib Wrote:
-------------------------------------------------------
> Is the 200bpm an AFIB rate, or a Flutter rate?
>
> Have you tried other rate control methods? 200bpm
> is not very controlled.
> I have no trouble trouble rate controlling in the
> 70's.
>
> Flec is known to cause/increase Flutter, as I
> understand it, a Beta-Blocker is the normal
> protocol, to protect against the 1:1 ratio while
> on Flec.
>
> I am not a proponent of Ablations, but a
> Flutter-Ablation is relatively simply and
> effective at stopping Flutter, it seems that if
> you cannot rate control any better than that, then
> that would make the Flutter-Ablation something to
> keep in mind.
>
> I am not an expert on Flutter, just giving
> opinion, Shannon hopefully will come on here and
> give advice.

Why are you against Ablations? I had Cather Ablation done in Feb. 2014. I am no longer on a Arrhythmia Drug or a blood thinner. I was in Persistent Afib. Cather Ablation has been a God Send for me. Dr. Natale done my Cather Ablation in Austin Texas.

Just wondering why you are not a proponent of Ablations.

Many reasons why, for one, the long-term success rate goes down as time goes on. 6 months is not very far into it, but great if you if it has worked so far. I was trying to differentiate between Flutter-Ablations and AFIB Ablations. with Flutter-Ablations being a much safer bet for success with much less trauma to the Heart, and much less tissue is destroyed (ablated). I will post more later, I am trying to get ahold of a few trusted high-ranking contacts I have in the field. It's the kind of thing that Doctors are shy and cowardly about ratting out their collegues on, especially if it hurts the main cash-cow for the Heart Industry.

Hi Mark,

No one in his right mind would give a beta blocker dose to a person with 1st degree block and bradycardia. That is probably why you were given Diltiazem as a calcium channel blocker. While also potentially an issue for folks with the same kind of Heart block and Brady, a calcium channel blocker is usually (but not always) a bit less likely to cause problems with extreme bradycardia than a beta blocker is liable to do, especially for a person without an onboard pacemaker which can at least be used to keep a floor under your HR.

The Diltiazem along with the Flec, if it is given at the same time or shortly before the Flec and not given just for concomitant rate control, is there to help prevent the possibility of a pro-arrhythmic 1 to 1 flutter which I can tell you first hand is no joke and no fun at all. The is similar to how a Beta blocker could potentially be used with a PiP Flec dose to try to prevent the same dreaded 1 to 1 flutter. Although typically most savvy EPs will not use either a beta blocker or Flec with vagally-mediated lone AFIB, as George noted for all the well known reasons that long timers here, and those who have read Hans' excellent book 'Lone AFIB: Towards a Cure', are familiar with. Or those who may have read any of the research on the matter referenced in Hans' book or on Pubmed.

Regarding right atrial CTI (cavotricuspid) flutter ablation compared to a PVI of PVAI for AFIB its true the flutter ablation is a much simpler and shorter procedure with less overall lesions required and initial success rates for stopping the flutter itself are quite high. However, that success can be rather misleading as the culmination of a number of resent long term studies has unquestionably confirmed that such right sided flutter is almost invariably just an early manifestation of larger atrial tachycardia disease that will almost invariably spread to full blown AFIB sooner or later . As such, just doing a CTI flutter is a half measure almost surely doomed to long term inadequacy and the chances for long term success in preventing all arrhythmia take a big jump with a PVAI done right from the start of CTI flutter being discovered.

As such, for those presenting now to modern up-to date EPs with CTI flutter as their first arrhythmia manifestation prior to the condition progressing to full blown AFIB, they are given a full PVAI or PVI and then a quick CTI flutter ablation on the way out, if necessary.

In unskilled, or better to say 'underskilled' hands, an AFIB ablation is certainly more challenging than either a right sided SVT ablation or right sided CTI flutter ablation, that's why just because an EP who can pull off one of those much simpler right sided only ablations in no way does that qualify them for being able to do a left atrial AFIB or atypical left atrial flutter ablation (which is a completely different animal than a CTI flutter).

However a PVAI or PVI in 'expert hands' is not a very dangerous process as it is and has very strong real long term efficacy as either a one or two step process when performed by experienced and skilled ablationists in particular. The tissue that is ablated in a PVAI or PVI is almost all located in areas where tissue morphology and embryology are identical to the Pulmonary vein muscle sleave tissue, which indeed encompasses almost the entire lesion pattern of those ablation strategies.

This type of tissue has little to no impact on left atrial contractility whether it is found in the antrum around the four PVs, including the posterior LA wall and does NOT damage LA mechanical or pumping action when properly ablated.

In fact, a significant body of first class research has confirmed, repeatedly over the last 8 years or so, that in such procedures done by skilled ablationists, that LA mechanical functional nearly always improves considerably compared to pre-ablation function of the same persons LA, who has typically suffered some degree of electrical and/or structural remodeling, and often a lot of both is found in long time afibbers, from the years of ongoing bouts of pourly controlled AFIB.

After a successful PVAI or PVI that electrical, and even to strutural remodeling as the condition progresses (also known as fibrosis or scarring) typically undergoes steady 'reverse remodeling' once NSR is re-established for sufficiently long periods, as the direct basis for this improved mechanical function resulting from a successful expert ablation process which delivers a major reduction in overall AFIB burden to the patient's life.

Be careful in overstating the drop in effectiveness in NSR consistency as time passes after an ablation, Anti-AFIB. A large majority of ablation patients, even including all ablations done by all EPs show long term reduction in AFIB burden and increased quality of life.


While there are certainly some (too many still in my book) mediocre ablationists out there who have far less experience under their belt than needed for excellence, even patients of many of these decidedly average EPs when it comes to ablation skills, experienjce a decidedly positive net long turn reduction in total AFIB burden compared to pre-ablation 'process', even if on a fairly percentage of cases it might take two ablations, with the second invariably being a much shorter and more targeted touch up procedure, to deliver substantial long term reduction or full freedom from AFIB/Flutter.

This is why choosing the most elite level operators of the sort we here on this forum and in the AFIB Report newsletter so strongly urge every AFIB patient who has progressed far enough along to be considered for, and who are good candidates for ablation, to put atop of their priority list once all the conservative drug based and natural nutritional/life style methods have failed to quell the beast and there remain too frequent episodes, especially highly symptomatic life disrupting episodes. It is in such patients best interest, at that stage of progression and after really making a deducted effort to get this under control with all the means we share here, to do everything in their power to choose and arrange for a top tier highly ecmxoerienced EP with a stellar track record for success.

The levels of very solid long term success from one main index procedure are very good with such EPs, plus typically at most a second touch-up procedure in a minority of those cases in the first year and around 35 to 40 % maximum over 10 years needing a targeted touch up the achieve truly outstanding AFIB freedom, and much more rarely possibly a third procedure as yet one final targeted touch up in a smaller number of patients. the vast majority of such patients ablated by such top tier ablationist at leading centers report the whole process very well worth the effort even many years later, even for those who might still have an occasional breakthrough but for whom life is now lived without arrhythmia for the vast majority of time, and in most case off all AAR or rate control drugs,bcompared to before starting and finishing their ablation process.

This is a very common result from elite level ablation EPs, and is the very common experience of the vast majority of those patients smart enough and determined enough to do as much as they possibly can to stack the odds in their favor by not compromising on that most critical choice one has to make as an AFIB patient, at least any more than their circumstances demand of them. Most people now can find an experienced EP in there regional area at least with some effort put into the search. Don't just settle for the first EP that comes to mind or that your local cardio recommends without first thoroughly vetting him or her and finding ourmt what their true experience and skill level is.

Its midnight and time to close the light and my eyes here. Just be aware, Anti-AFIB, that there is a big difference in this field in the perspective and reality seen and experienced by Cardios, EPs and patients alike depending on which side of the competency fence they mostly reside on, when it comes to AFIB ablation knowledge and expertisee. Many patients get a very skewed and often superficial impression of what is possible with an expert ablation process in the right hands if their main source of information are other Cardios and even EPs who see mostly the result a of average to poor ablationists, some of whom should not even be doing ablations.

There is also a rather stunning difference in understanding of the nuances involved in this admittedly complex field even among otherwise decent Cardios or EPs within their own niches and subspecialties. At the AFIB conferences I attend you see the whole gamut from those who still harbor some out of date and frankly mistaken ideas about where this field stands and on the other side of the coin those on the cutting edge of this work who are trying to enlighten the others and get them up to speed. As such you can hear a wide range of insight and confusion ( the later often held with religious conviction) even among doctors in this field. Little wonder how and why it can be tough for well meaning and intelligent patients to get the big picture, if they happen to be mentored by docs still climbing the learning curve without a lot of direct daily experience with AF ablation in the EP lab.

Hence, our whole focus on encouraging prospects looking for an expert ablation process to bend over backward and hold out as much as possible for the very best doc they can arrange for themselves.

Cheers! Shannon



Edited 2 time(s). Last edit at 09/03/2014 11:01AM by Shannon.

Another well-written and informative post from Shannon, Thankyou.

You commonly reference highly skilled elite EP Ablationists, in reference to Ablation success.
Has there been any studies on the success rates of just a sub-set of elite Ablationists vs. all Ablationists?

I do believe it has been studied based on Elite, or high-volume Medical Centers.

Hi Anti-Fib,
My resting rate during my last episodes was very comfortable around 110, so that was fine.
It's just that because of the flutter element I cannot exercise and would never choose to exercise when not in NSR as I don't feel its very kind to the heart or a wise thing to do. I understand it helps you terminate your episodes, I get that.
Yes the 200+ bpm is due to flutter element.
My ECG's have shown a.fib, typical flutter and atypical flutter (and I think some specific tachycardia with a focus from the pulmonaries if memory serves me correctly).
I will only have an ablation when my afib/fluttter load is high enough. I have just had three years (my longest ever period on NSR in the last thirteen years) of NSR with a very quiet heart (bliss) with perhaps only three or four noticeable PAC's every three months or so.
If I can go a least 3 months between episodes I don't think I will have an ablation.
The problem is when I drop into an episode I am a mess. I cannot convert because of the flutter caused by the flec and need to be DC cardioverted. My recent episodes were only 10 days apart and I was in a right mess thinking the game was up and I needed an ablation. Hence my post hero to zero.
My heart is quite again now in NSR and if my episodes are infrequent on I am happy to Iive with it while ablation technology improves.
If I was persistently in a.fib/flutter I would have an ablation.
Before I ever had any afib I used to get tens of thousands of very symptomatic PACS every day. I was an athlete and wore my heart rate monitor a lot.
I am 100% sure I never had any afib/flutter at that time and since my first ever episode was persistent I feel that confirms my feelings.
Your input is appreciated Anti-Fib,

Hi Shannon,
Thanks for your post.

Mark



Edited 2 time(s). Last edit at 09/03/2014 07:57AM by Robo11.

The immobile slightly aneurysmal intraatrial septum was a surprise.
I believe this can be congenital and is rare.
It has never been spotted in the past but I have to admit it was the longest most thorough echo I have ever had I and presume imaging techniques have improved somewhat over the last thirteen years.
Still surprised I will not be called back for it to be monitored though.
Hopefully it won't get worse but it does make me question my anticoagulant status of zero.

Mark

What kind of athlete were you? Age now?

Well no reason to exercise during your short episodes anyway.

Flec is a "use dependent" drug which means the faster the Heart rate, the more pronounced the effects of the drug are.

I would get another opinion from another EP Doctor about your rate control. Do you have an EP Doctor, or just regular Cardio Dr?

I mentioned the Flutter-Ablation in part because you sounded worried about the potential for the 1:1 conduction ratio on your Flutter, that would stop the Flutter, but as Shannon points out probably not the AFIB. But the Flutter sounds like the worse risk of the two.

Electrocardioversions on a healthy heart and when you know when your episodes start present very little risk. So you have a few episodes, and get ECV within 48 hours of onset. Sounds like you could just go into the ER room right away, and just get it over with. You could do this until you exhaust other options, (like finding a magical cure on this site), and then consider a procedure.

Anti -AFIB,

It late here again as I have little time during the day to post much for the next couple weeks while I finish the Oct-Nov AFIB Report, so no time to pull out the link to the Desmukh study (spelling?) which is a 10 year study of complication rates from every single ablation done via Medicare in the US from 2000 to 2010... all 93,800 of them for the largest such complication yet done capturing not just the more experienced high volume EP and center results as so many if the past survey have mostly reflected.

The rather stunning finding of this study is that of all 93,800 some odd ablations over that seminal period in AFIB ablation gestation and evolution >81% of all ablation patients in the US were ablated by mostly greenhorn EPs doing less than 25 procedures a year (not enough to even come close to develope innate muscle memory and dexterity required fir consistently skillful ablation work, and these large percent of total US ablations were done at very low volume small country hospitals or clinics doing less than 50 AFIB ablations a year !!! That is a mind blowing stat to me. Not surprisingly the rather high 6.5% complication rate, including a high death rate of about 1 out of every 230 ablations or so overall was reflective largely of this huge majority of cases done by inexperienced EPs at very small volume centers.

This statistic also perfectly validates and underscores our strict recommendation for setting a very high and discriminating standard when choosing an ablationist for one self and there is not only improved efficacy but much safer too with much lower complications rates across the board the further up the food chain toward the top elite 5% to 10% of Ablationist from which better informed and wiser patients make their highly selective choice from.

On the flip side a new study published in Dec 2013 in the journal Curculation looking at the latest and longest term prospective study from an elite level and busiest AF ablation group in the US, and indeed the world, headed by Andrea Natale shows very impressive results looking also prospectively over 10 years from the late 2001 - early 2002 year period in which all 580 some odd paroxsymal patients all ablated in that one year timeframe and followed carefully and prospectively up until early 2012, with the vast majority ablated by Dr. Natale himself.

These ablations were all done within the first couple years of AF ablation history with old fashion non irrigated catheters and rudimentary imaging systems and still achieved amazing good 10 year results of 59% who made it the full 10 years with zero arrhythmia and none in any AAR drugs. Plus 87% experienced total freedom through 10 years with the help of approximately 1.35 touch up ablations over the entire ten years to remain in solid NSR and off all AAR drugs!

The major improvements over the last 10 years in ablation know how and in far more advanced catheters and tools only has improved those very good stats starting from so long ago. But it gives the best snapshot we gave so far in what is really possible with AFIB ablation over an average of around 1.25 to 1.3 total ablations needed now to insure a minimum of ten years of blessed NSR!

Anyway, time to hit the hay, but those two major studies well define the broad split in the real world experience if patients and doctors depending on if they hook up with a too tier maestro or a run of the mill ablationist still trying to navigate the labyrinth and climb the very learning curve that is this highly challenging technical procedure that not every doctor, by a long shot, who tries to become a skilled ablationist is capable of achieving that goal. Far from it I'm afraid.

Shannon

Anti-Fib
Age now 47.
I was a Motocross rider with running, swimming, cycling and gym work so was quite fit. (Not what I would call an athlete).
I then took up running. Nothing spectacular e.g. best place in the Blackpool 10K 33rd out of 3500.
But I did very high intensity intervals (at least for me) at a level way above what you would expect with my 10K times etc.
I just had a knack of slaughtering myself in training with the elite athletes. That was my bag, interval training to the max e.g. 16 x 400m to the max etc.
I really used to train too hard if I'm honest and coupled with an appalling diet and chronic insomnia I am surprised I didn't kill myself.

Mark

+1! Shannon and this forum of friends steered me in the proper direction for my permanent AFIB Ablation; Austin, Texas with Dr. Andrea Natale as the Architecture of my Ablation. I was scheduled to be ablated by a EP in another town but decided to take the 8 hour drive to Austin to Dr. Natale.

I am so grateful for my Ablation. It has worked extremely well for me. I am a thankful man because mentally and physically, the AFIB was kicking my ARS.

NOT NO MORE!



Edited 1 time(s). Last edit at 09/04/2014 10:49AM by Hans Larsen.

Cheers to you smackman

Robo11:

In your althlete days, what happened? Did you stretch out your Atria too much from the high load you put on it with high intensity training? A stretched out Atria predisposes one to AFIB. I have read numerous times, that it does happen to elite cardiovascularly trained athletes. After you quit training through the Atria should returned to normal, although maybe something to do with the electrical remodeling. How long were your episodes at first?

Does the dilitzem cause you to be sedated? I think that should play into your strategy, if you have to take drugs that negatively effect you.

On the Ablations, my EP (Ablationer) told me that an AFIB Ablation will not stop the Ectopics/PAC's, but if it works, will stop the condition from turning into AFIB/Flutter. That could still present an issue post-ablation, if your PAC's are so symptomatic.

I went to Bystolic 5mg (selective-beta blocker) that does not cause any sedation for me. It works well for me to stop Ectopics/PAC's. I know you said you can't take a beta-blocker, just saying it's been good for me, as I still like the work-out, and can't stand the sedated feeling. I guess I am lucky that my AFIB is so asymptomatic.



Edited 2 time(s). Last edit at 09/05/2014 03:54AM by The Anti-Fib.

The Anti-Fib,
I feel I tolerate my meds fine, I don't appear to have any side effects.
That said I have had chronic insomnia for nearly thirty years so you just learn to deal with that tired feeling.
My gut feeling about my athlete days are that I trained like a formula one car but I don't have a formula one engine. A good engine maybe, formula two or three, but not formula one. More importantly my race engine did not receive high octane race fuel it received low grade gasoline (aka food).
I did some pretty stupid things like getting a full 2 litre bottle of coke shaking it till it was completely flat then drinking it before the national cross country championships.
Pretty stupid I know, caffeine frenzy.
Coupled with extreme stress and insomnia something got broken, my heart.
I don't feel I had macro changes with my heart. I "think" my afib was caused by oxidative stress which altered my cell chemistry on a micro level (electronic ion channels etc) and along with the increased vagal tone on my autonomic nervous system (my heart rate on waking was often about 37bpm) that started the afib.
I had PACS for many years before the a.fib with the usual Doctors saying it's normal etc. It felt anything but normal but I was re-assured. The PACS increased in number but were always extremely symptomatic. Some days I would have thousands other days none.
Here is an example of how i could not figure it out. I would have a good day train hard, then at some stage would get runs of PACS other times I wouldn't. Another day I would be having runs of PACS and would train hard and they would disappear. I just couldn't work it out.
I first noticed my a.fib/flutter in a mile race in 2001. I looked at my monitor half way through the race and my rate was 212. I felt Ok and thought it was a malfunction of my monitor (my max heart rate was only about 175) but it scared me so I stopped and did a manual check to confirm there was a problem. More over due to my vagal tone my heart rate normally decreased very fast but was stuck at 212. I took myself to hospital. 9 weeks later I was finally cardioverted.
I think my next attack was about a year later. But from my first attack and ceasing exercise my PACS have never been in a large quantity.
Flec seems to suit me so well I would be happy to take it after an ablation if necessary so thats another reason I won't jump for one at this stage.

Mark

The Anti-Fib,
Race horses have large atria and are prone to a.fib.

Can anyone give me a detailed explanation (or any explanation) about ablation and PACs.
The whys and hows relationship please.

Thanks
Mark

At one time, like 27 years ago, my resting pulse rate was 33. Now it is in the 50's, and I have had an EP Doctor tell me that I have Bradycardia, and should get a pace-maker, to rasie my Heart-rate, not taking into account that cardiovascular activity normally does lower RHR.