Flutter, haven't experienced before, could use thoughts

I'm an old hand at afib. But Sunday afternoon my heart went into a weird pattern that I just thought was an odd afib development. Today I went for an EKG and discovered it was atrial flutter. My rate was pretty high over the past few days (100-130s) so nurse (my cardiologist wasn't there today) suggested I go to the Kaiser mini ER in the building.

Anyhow, got 3 different IV drips - Magnesium, the standard fluids one (tests showed I was moderately dehydrated), and diltiazem. After 3 hours of this, was still in flutter, but have come on home since there wasn't anything new & different they had to offer there.

Doc suggested I drink some Gatorade and/or Pedialyte (sp) to help with getting electrolytes into my body better.

Would love to hear from folks what has worked for them when they have flutter.

Nancy

Unreal Nancy, you have documented atrial flutter and they didn't mske more of an effort to cardiovert you and just tried a few drugs?

Depends on if it's typical CTI right atrial flutter which it may well be if you haven't had an ablation? If you have had a prior ablation then odds are higher it may be an atypical left atrial flutter and those are notoriously unlikely to self convert.. It can happen, but the vast majority of the time you will need an ECV (electro cardioversion) to reset to NSR from atypical left flutter and even often from CTI flutter too, though CTI has a bit higher chance of self conversion just not super good.

And drug Cardioversion almost never works with a real flutter, especially atypical left flutter. In fact, they typically use an Adenosine drug challenge protocol to see if you will convert to NSR if you come in a with a fast atrial tachycardia when they are not sure if it's SVT (supra-ventricular tachycardia) or atrial flutter of which ever variety. If you don't convert on three tries of ever larger doses of Adenosine then they diagnosis you with atrial flutter and shock you.

If you do convert to NSR on adenosine challenge during any of the three increasing doses of the progressive adenosine protocol, then you will officially be diagnosed with SVT and not flutter.

They did or did not do an Adenosine challenge on you in the ER? You would remember as it can be a bit scary of a procedure as the drug gradually stops your heart for a brief moment before kicking back in gear again. A nurse will usually hold your head and calmly reassure you that while this is going to feel a bit weird and unsettling you will be fine (they sincerely hope with crossed fingers :-).

I've had this done with a rockin 220bpm left atypical flutter from my LAA ( 220 is no fun at all) before finally having my LAA isolation ablation with Dr Natale which ended such very uncomfortable nonsense.

But if the ER just sent you home still in flutter of 110 to 130bpm that is not how it should go typically, if you were mostly at 100bpm or less, perhaps they figured you weren't in any real danger assuming you were on anticoagulantion already? Unless they were able to convert you with drugs which is a good deal less likely than with AFIB or SVT, but you noted they did not try to electro convert you and sent you home. Even SVT can be tough to convert without using adenosine.

Are you still in flutter now and if so what is your rate approximately?

Shannon



Edited 2 time(s). Last edit at 02/13/2015 08:28AM by Shannon.

Thanks Shannon,

Never had an ablation. My flutter went in at the 100-130 range, but I was in the 70-90 range when I left. Still in it I suppose, my finger monitor is showing a dance in the 80s range. Tests showed I was moderately dehydrated, which was what caused my afib to begin with back in 2000. So I'm drinking lots and lots of water this morning.

Nothing like the Adenosine challenge last night. The staff may have also been affected by my insistence that I was not spending the night. And yes, am on coumadin, have been since a pulmonary embolism episode in 2013.

Nancy

oops, sorry, rate in the 70s-80s now.

Thanks for the added details Nancy, it's easiervto understand why they didn't shock you or try Adenosine when you rate dropped down to 70-80... You were likely back in NSR or the Diltiazem and IV magnesium combo lowered your flutter rate to that very safe region, especially will on coumadin already.

You noted it was a 'mini Kaiser ER in your building' so Inassume that means where you work? It could well be that they were not equipped to do much more than they did if it wasnt a full service ER and I doubt adenosine would be on the menu at a place like that, perhaps not even what is deemed elective cardioversion, meaning one that wasn't required urgently to save your life.

Go see your asap and get it all checked out and discuss it with him or her.

Best wishes,
Shannon

Hi Nancy, Been there....done that. The flutter is a huge nuicance and yes feels uncomfortable. I have adenosine quite a few times. at first it worked then a couple of occassions it did not. Got to the point my doc would give me something as they did you to lower the heart rate and make it comfortable and send me home. It would usually convert after a while. He never acted as tho it was a real big deal (Was to me tho!!). This to shall pass

tsco,

'This too shall pass' it is the cardinal mantra for afibbers everywhere, that is one almost cliche that is full of handy wisdom! :-) Interesting you converted to NSR on Adenosine, that must have been a tachycardia episode... typical and atypical flutter will not usually convert on Adenosine,,,, the heart will slow WAY down as it does on that drug and even stop for a couple seconds but then when it kicks back in it will almost invariably resume the flutter, it it is indeed flutter, and thus why they use it to diagnose the difference between a true flutter and an SVT.

Not my favorite drug, but once you've been through it once its not too concerning .. just feels strange and weird when the world stops for those couple seconds.

Shannon



Edited 2 time(s). Last edit at 02/13/2015 11:32AM by Shannon.

Shannon, I wasn't back in NSR, but yeah, rate was low. Also the on call doc was in touch with my EP by phone during the evening. The mini ER is what I call the critical care unit in our Kaiser facility. It's set up just like an ER.

EP basically let me go home and I'm going back in on Thursday for another EKG. They aren't concerned about me unless things change for the worse. He has also switched out my Atenalol for Metoprolol, hoping that helps keep rate under control.

tsco, thanks for sharing, always helps.

Nancy

Nancy - when you are drinking lots and lots of water, be aware that if you are low in the critical electrolytes needed to maintain NSR, then you'll be flushing out those minerals as well...so important to keep replenishing electrolytes regularly... focus on both magnesium and potassium and they work together. If you have taurine, I'd take that as well as it helps balance them. As you know, it's very important to keep these optimized

Sorry you are struggling.

Jackie

Doc told me to drink Pedyalite (sp?) - something for babies. It tastes like something for babies too .
Nancy

Nancy, what is your regular resting heart rate? 70 or 80 sounds like NSR not aflutter. Aflutter is 2 (or in some cases 3) beats per usual beat - all rhythmic, so it is usually well over least twice your normal NSR.

Shannon, I'm not sure why you say that flutter rarely self-converts. I've had flutter both on its own (several times), and intermingled with my afib (many times). It has not only self converted everytime, for me it is usually a sign that I'm going to self -convert soon.

For the doubters, my first (of two) ER visits was aflutter only - and I was diagnosed by a visiting cardiologist with that. I knew it wasn't my normal afib rhythm so went back the next day to show my (new from the day before) cardio doc what my "normal" abnormal rhythm was (it was then I was diagnosed with afib). I've had only a few straight aflutter episodes since, but I will go back and forth from afib into flutter in about 10% of my afib episodes (the flutter lasts no longer than a few - 20 minutes at a time). It is SUPER easy to tell the difference (flutter is rhythmic and faster/more intense), and it shows up on Alivecor like a normal rhythm - just 150 beats per minute or so. Alivecor thinks I'm working out I guess, cause it doesn't suggest there is a problem as it does when I'm in afib.

The main reason I've never tried Flec is because it has been known to have adverse effects for those with Aflutter. I'm pretty sure I'd be one of those occasional horror stories you hear about with Flec if I took it.
In the meantime, I'd still like someone to figure out how to solve the cyclical (hormonal?) thing with afib. It is so bizarrely obvious that it is happening in cycles for me. But that is for another post...

Hi Ralph,

CTI (cavo-tricuspid Isthmus) flutter, which is the more typical form of flutter that can arise as a stand along arrhythmia, or also as a step in the natural conversion process from AFIB to NSR as sound like your case, can certainly be self-converting, though for a good many folks CTI manifest as more persistent and often does require cardioversion. Atypical Left atrial flutter which can also occur naturally but is far more often associated with prior catheter or surgical ablation, is much more often persistent and requires cardioverted or ablated away and most often will not respond to any drug or valsalva maneuvers that can sometimes work with CTI flutter or SVT .

Even atypical left flutter can be self converting in some instances, but that is much less often the case.

The standard of care in most ERs in the US when confronted with a high speed tachy-arrhythmia case that has a steady rhythmic but very high speed ... the high speed and uniform R to R interval spacing making it very difficult to distinguish between either a CTI flutter and an atypical left flutter OR an SVT (supra-ventricular tachycardia) ... is to break out the Adenosine challenge test as described in one of my posts above for the express purpose of diagnosing whether it is a flutter or a SVT. If the arrhythmia coverts to NSR it hold after Adenosine then it is almost 100% sure to be an SVT, if it does not convert to NSR or flips quickly back to the high speed flippies then is almost certainly either a CTI or an atypical left flutter .. the later especially if the person has had a left atrial ablation fairly recently.

The fact that your flutter has often happened at the tail end of an AFIB episode before it converts to NSR makes it almost certainly a CTI type flutter and those are definitely more prone to self conversion as you have experienced.

Have you ever had an adenosine test Ralph? Its very common for people coming to ERs with high speed tachy arrhythmia and who never had an adenosine test to leave with a flutter diagnosis when in fact they really have SVT ... and vice versa. It is very hard to tell without that test when the rate is clicking along at break neck speed.

Shannon

The 70-80s beats were flutter (I was still hooked up to the monitor & they did an EKG before I left), but were low thanks to the tons of drugs in the IVs I had during the stay. My rates are now mostly in the 90s, although in the late afternoon they get into the 110s-120.

My normal NSR rate is 65-68.
Nancy

Just wondering why the type of flutter associated with ablation isn't discussed as part of the risks of ablation. The possibility is such rhythms gives me pause when considering an ablation.

Lynn.

The atypical flutter is a possible outcome of an ablation but think of it as one step toward getting rid of your total arrhythmia burden. when an atypical flutter occurs as a result of all the work necessary to stop AFIB, on occasion a flutter will be created and roughly 50% of the time those are temporary as just part of the healing process with an unpredictable pattern of scar formation firming up at different rates in different hearts.

Its one reason why a course of AAR drugs like Flec is often prescribed during the three month healing process just to keep things quieter while such healing takes place. Mind you it is not by any means a majority that even have these temporary flutters or tachycardias post ablation, but we have talked endlessly hear about them for years as just an expected part of the process that can happen so everyone is fully aware and in the big picture they are not a big deal ...


The other 50% of so of post ablation flutters that continue on reappearing after the two month blanking period is a signal you need that touch up ablation we tirelessly inform everyone here to automatically expect as part of an overall successful expert ablation process.

It is really not a big deal provided you choose an experienced EP, which is out first criteria for any ablation to begin with, and make sure it is one who does a lot of follow up ablations and for whom zapping a follow up atypical flutter is an every day occurrence and not a big deal for them.

If you choose a dabbler ablationist who does a handful of paroxysmal ablations in between a load of pacemaker and ICD or CRT device installs and who themselves make a big issue out of a post ablation flutters in their conversation with you or an EP who tries to discourage you from even having an ablation that could benefit you simply because of the possibility of a late flutter that may have to be addressed , then thats a big red flag you may well be with the wrong ablationist as it is and that they may well feel out of their depth and frustrated by past experiences trying to track down and ablate such left sided flutters when they lack the know how and expertise.

Any highly experienced ablationist who also does a lot of persistent AFIB cases will handle all this in perfect stride as part of a days work and you can rest assured they will take care of whatever may arise.

Rates are getting lower for post ablation arrhythmia as it is, with progress in knowledge and improved catheters and imaging systems but they will still happen even with the best ablationist to some degree. Just keep in mind that when you choose well from the outside you buy yourself that peace of mind that an expert ablationist is fully capable of easily handling such issues, should they be a part of your journey toward real freedom from AFIB long term.

Dont fret at all Lynn, just follow our core guideline to compromise as little as you possible have to on who you partner with to head your ablation team and go forth with confidence.

It could be that 25% of ablation patients with top level EPs may have some degree of post ablation arrhythmia and less than half of those may require a touch up ablation as a result, but that leaves a good 85% to 90% of paroxysmal afibbers who wont have to get a second ablation in that 12 month typical screening period so your odds are very high as it is when choosing the best horse to ride to the dance with. And a second ablation with is a true small touch up is not by any means the end of the world or a big deal really, and the vast majority of those remaining smaller group who do wind up needing that touch up are done for good afterward. Keep you vision on the big picture Lynn and its easier to keep all the possible steps we may need to walk through on the road to freedom in perspective.

Best wishes,
Shannon

Shannon, I've had a treadmill and echocardiogram tests. The one time I was in the ER with aflutter I was tracked pretty close by a cardiologist - he was clear I had aflutter as opposed to an SVT. I converted in about 2 1/2 hours, and they didn't administer adenosine. That is about all I know.