Ablation complications

I am a fit 49 year old male, workout 6-7 days per week with kettle bells , p90x, etc. I have had paroxysmal a-fib for the past 12 years which was becoming more frequent and medication resistant . I had an ablation by Dr. Natale on 6/29/15. After the procedure he stated that it was an easy ablation with PVI and some superior vena cava isolation. He expects excellent results. Unfortunately, I am not having an easy recovery.

Two days after the ablation I had a day of chills and have had night sweats every night since (today is post-op day 12). I have not had any fever. I developed some upper respiratory congestion and had a chest X-ray (post-op day 11) that showed atelectasis and an elevated right diaphragm suggesting phrenic nerve palsy. My neck has been painful and tight since the procedure and doesn't seem to be getting any better. My rhythm has been good as far as I can tell. My blood pressure has been elevated for the past 2 days at 130/98 (I don't have high blood pressure).

I'm starting to get worried, and scared of other complications. Any insight or advice would be appreciated.

Ron M

Ron,

Sorry to hear of your situation. What did your doctor advise you yesterday in terms of treatment and follow-up?

Chuck

Chuck,

My gp put me on a prophylaxis Abx ( augmentin 875 mg bid x10 days) , & instructed me to use a spirometer to help inflate my lung........nothing as far as a follow up . I did notify Shirley at Natales office who had nothing more to offer. I also talked my gp into obtaining blood cultures...which where negative @ 24 hrs. I,m wondering what's others have experienced in relation to phrenic nerve issues as well as cath related issues.

R

Shannon, any insight would be appreciated.

R

Sorry to hear of your drawn out and uncomfortable recovery RonM,, some people do have variable recovery experiences that so far everyone I know who went to Austin, CPMC or La Jolla has indeed pretty much recovered thoroughly with a little time.

Concerning you specific issues, have you had neck problems before? Such neck issues can indeed happen from laying flat on the table under anesthesia for a good while but they should not last this long with no improvement at all unless perhaps you have some underlying long term neck problem and for those that do, be sure to notify the anesthesiologist so they can take special care to move around and support your neck during the procedure. Have you tried any massage or body work that might help?

Also, for your lung issue, you should ask for an incentive spirometer and practice with it at least 2 hours or so a day tohelp clear and strengthen your lungs as this can be a part of anesthesia recovery for some people. Also regarding the atelectatsis and 'possible' phrenic nerve paresis the atelectasis could also be from general anesthesia as well or potential some diaphragm paresis of focal temporary paralysis with an an emphasis on temporary which is almost always is from the type of ablation you had. Its quite rare when it does happen but almost certainly will recover on its own before too long at all. And if its anesthesia related you might need a short course of anti-biottcs too but most important for either case of general anesthesia effect or a diaphragm stunning, you do need to force deep breathing with the incentive spirometer and that should help speed things along to a full recovery before too long.

And RonM have you checked you White blood cell count too? If it's out of whack talk to your EP nurse about possibly stopping the Multaq as well, but do NOT stop anything without talking to your nurse and discussing it fully with her.

Make sure you contact your nurse practitioner from Austin if you haven't already and make sure she is in the loop too, so you can get all this sorted out with Dr Natale to speed too on everything, and rest assured all of these issues will surely settle down before long and you will be able to speed it along by following their suggestions.

The good news too is once this less common but not unheard of recovery rollercoaster comes to a rest, the odds are very high you will have very smooth sailing from then on based on what an easy ablation it apparently was with Dr Natale being very confident of a great outcome.

Best wishes and keep me posted by PM if you wish,

Shannon



Edited 1 time(s). Last edit at 07/11/2015 09:47PM by Shannon.

My neck seems to be improving with the help of some deep tissue massage ( thanks Shannon for the recommendation). My blood pressure has still been fluctuating from 110/78 to 148/108 & have since been started on low dose medication until it stabilizes. I continue to use my incentive spirometer for lung expansion. No night sweats for 2 days.....I hope these are done for good. I'm still very fatigued, but feel marginally better. I've also been reassured that the phrenic nerve stunning is most likely temporary & should resolve over time. Will repeat a chest x-ray in 2-3 months. Heart has been pretty good with some PVCs, but overall solid.

R



Edited 1 time(s). Last edit at 07/14/2015 02:57PM by RonM.

Hi Ron,

I'm very sorry to hear about your lung and phrenic nerve issues, and hope you get better soon.

Did Dr. Natale's office offer any theories as to why you incurred these issues? (eg, unusual anatomy, unexpected lengthy use of Cryo, ...?)

Sounds like you've found a good deep tissue massage practicioner, which is great. When I had neck issues, I had to go through quite a few PT's and massage therapists until I found one who was really good. It turns out a massage therapist can be really good for relaxing massages, but not nearly as good for relieving pain issues. And visa versa. The key (in my scenario) was going to someone who was a "Certified Advanced Rolfer". Rolfing has a reputation for being painful, but in my case it wasn't. And the rolfer I saw (in Seattle) knew her anatomy inside and out, and her explanation of what she thought the root cause of the neck pain was (particular layers of muscle/fascia, whose names I've forgotten, adhering together) made a lot of sense. Best way to find a good rolfer is by word of mouth, but the second best way is using the search function here: Finding a certified rolfer

The other thing which helped resolve my neck issues was ice. Of course, icing one's own neck is incredibly awkward (and unergonomic), so I highly recommend using a pair of these freezer ice packs that drape over one's shoulders Neck Contour Cold Pack 23" . The cold doesn't last incredibly long, hence the recommendation to get two of them.

By the way, I've been told by several orthopedic surgeons and neurosurgeons that it's "normal" for people our age (I'm 50) to have osteophytes (bone spurs) in the neck vertebrae. They said if someone 50 didn't have bone spurs, that would be highly unusual. The bone spurs often go unnoticed until one turns one's head in an awkward position for an extended period of time, which stretches ("tractions" ) the nerve root across the bone spur, causing inflammation. Perhaps that occurred during your procedure...

Often the problem doesn't show up until after a few hours, because it takes a few hours for the nerve to swell to the point where it's used up all the "slack space" in the foramen (the hole in the vertebra that the nerve traverses). This can make it a bit difficult to tie the cause to the effect. At any rate, once a nerve root (c6, c7, etc) becomes inflamed, it can take quite a while (multiple weeks) for the nerve to calm down. One thing which helped a lot in my scenario was taking a lot of ibuprofen (800 mg, 3x/day). That seemed like a crazy-high amount when the Dr. suggested it, but they said for someone my weight (225), that's how much it takes. Any lesser amount wouldn't reach therapeutic levels. (It still sounds crazy high, but I've confirmed that quantity with 3 different MD's at different practices, so apparently it is safe). Another tip is to try to avoid "testing" the neck to see if the pain is gone, because the act of testing reaggravates the nerve... and essentially takes you back to step zero in the inflammation reduction process.

Best wishes for a quick recovery, and if/when you feel up to it, please let us know how your side effects resolve (or if they don't).

-Ted

20 day post ablation update;

I haven't had any night sweats for over a week now. My upper respiratory congestion is much improved as I continue to take Augmentin and use the incentive spirometer (with which I consistently hit 2500ml. I am a 49 y/o, 5'7" 178 lbs). I have also started acupuncture therapy for the phrenic nerve palsy & am breathing so much better that I hope it is resolving already (I will have a follow-up chest X-ray in 3 months). Regarding the blood pressure fluctuations- they have seemed to have stabilized with the highest reading in the last 2 days of 128/84 with no medications (I took blood pressure medication for 2 days and bottomed out at 98/64). This neck issue is better overall but continues to plague me. I will allow gentle massage but no chiropractic adjustment. I have started taking magnesium glycolate #3 120mg capsules and #1 low sodium v8 daily. My heart rhythm, as far as I can tell by taking my pulse, has been rock solid with a somewhat elevated heart rate around 90 (I was 65-70 prior to ablation). I haven't done any exercise yet except a couple of 30 minute leisurely walks which were quite easy.

Ron

Very glad to hear that things are going so much better, Ron. Don't worry about the elevated heart rate. Much has been written about that here, and most all of us have had an elevated HR for months, if not longer, after an ablation (and especially the index ablation). My HR was 85 or higher for over a year after the first ablation, but it did return back to the low 70's. This was higher than my pre-ablation resting HR of around 60, but certainly acceptable. After my second ablation less than two weeks ago, my HR is around 75, but this procedure was not nearly as extensive as the first.

I can't really comment on the neck issues, but it sounds like you are being sensible with this concern. Hope all continues to improve steadily, as I expect it will.

Best wishes,

Rob

Good morning everyone,

27 day post ablation update:

My local EP was concerned with my recovery & previous chest x-ray, so he ordered a repeat chest X-ray, lab work, and Echo. Chest X-ray showed no change. Radiologist report recommends CT of chest w/contrast to determine if it is atelectasis vs scarring. I am still using my incentive spirometer and have now exceeded my estimated max volume by close to 500ml. My breathing is much improved. Should I be worried? Lab work was all normal with a small increase (since last study) in eosinophils (but still within normal limits). Also, in the last few days my heart has been very mad. I believe I have had some AF episodes and am currently in a bigeminy rhythm. I haven't heard from Shirley in Texas yet, but wondering if an ECV is in my future? How long can I stay in an arrhythmia before I seek medical treatment especially in the blanking period?

Ron



Edited 1 time(s). Last edit at 07/26/2015 01:40PM by RonM.

The Bigeminy isn't a static Arrythmia like AFIB. ECV will not stop it. I get those all the time, and Trigeminy, Quadrigeminy and so on. Sometimes it's every 7, or 8 beats. I may be in Bigeminy, and then as it improves it goes to every 3 beats, then every 4 or 5 and so on until it gets to about every 10th beat, after that it usually just smooths completely out. Beta-Blockers help with these Rythmic PAC's. Have you ever tried Bystolic? Body position effects them, and walking usually makes them better.



Edited 1 time(s). Last edit at 07/27/2015 06:04AM by The Anti-Fib.

Ron - After my touch up ablation #3, which was nearly 4 months ago, and for a while, I noticed Quadgeminy.... and it was also reproduced on my heart monitor recording device. Felt very weird, but not like AF as it wasn't constant.

I increased magnesium, potassium and taurine supplements and that irregular pattern disappeared.

I wish you continued success with your recovery process.

Jackie

Quote

Chest X-ray showed no change. Radiologist report recommends CT of chest w/contrast to determine if it is atelectasis vs scarring.

Very interesting, thanks for the update.

If it's scarring, does that mean... that it was not caused by the Natale ablation? Or could the scarring be caused by heat from the catheter, crossing through the heart and into the lung?

On the other hand, if the scarring wasn't caused by the ablation, does that mean it was a pre-existing condition (from prior smoking or childhood infection) and (perhaps) would never have been noticed had you not experienced the phrenic nerve damage (which prompted the chest X-ray)?

-Ted

Has it been determined what caused the phrenic nerve stunning? From what I've read, this is not very common in the hands of an experienced doctor like Dr. Natale.

Travis

Quote

Has it been determined what caused the phrenic nerve stunning? From what I've read, this is not very common in the hands of an experienced doctor like Dr. Natale.

Excellent question!

On a related note, Shannon earlier wrote:

Quote

Also regarding the atelectatsis and 'possible' phrenic nerve paresis the atelectasis could also be from general anesthesia as well

Shannon: do you have any more info on this? I've got a detailed write-up of the Rx's I received when I had general anesthesia for neck surgery, so I'd like to cross-reference it against the list of Rx's which Natale uses.

For reference/comparison, here's what "general anesthesia" means at Swedish Medical Center, in Seattle:

[1] midazolam - used before surgery or medical tests to make you feel sleepy and relaxed. This medicine is a benzodiazepine.
[2] fentanyl - treats moderate to severe chronic pain. This medicine is a narcotic pain reliever.
[3] propofol - causes a person to relax or sleep (be unconscious) before and during a surgery.
[4] lidocaine - causes numbness or loss of feeling in an area of your body. Given before and during surgery, childbirth, or dental work. Also treats emergency heart rhythm problems.
[5] succinylcholine - relaxes muscles during surgery or other medical procedures.
[6] dexamethasone - treats inflammation and many other medical problems. This medicine is a corticosteroid.
[7] cefazolin - treats serious infections caused by bacteria. Also prevents infection after surgery. This medicine is a cephalosporin antibiotic.
[8] phenylephrine - a synthetic compound related to epinephrine, used as a vasoconstrictor and nasal decongestant.
[9] ondansetron -prevents nausea and vomiting.
[10] hydromorphone - treats moderate to severe chronic pain. This medicine is a narcotic analgesic
[11] lactated ringer's IV solution - a sterile, nonpyrogenic solution for fluid and electrolyte replenishment

I was amazed at how long the list was. I've added 1-line descriptions for each item. In addition to this summary list, Swedish also gave me a very cool timeline chart, which indicated how much of each Rx was administered (from 9:15->11:15, the duration of the surgery), as well as my pulse and blood pressure for every 10 minute interval. Very nice summary information.

But getting back to the point... when Shannon writes that phrenic nerve injury can be a result of "general anesthesia", I'm guessing it may not necessarily be the propofol (which is what of us think when we read "general anesthesia" ), but perhaps another one of the Rx's...

So... which of the 11 items above can be responsible for a collapsed lung (aka, atelectatsis), and/or phrenic nerve injury. Or is it a different "general anesthesia" Rx that is the culprit?

Thanks,
-Ted

Yea, how does one get a collapsed lung 3 weeks out from an Ablation? Has that situation resolved itself? If there was scarring, how did the scarring occur?

Quote
Anti-Fib
how does one get a collapsed lung 3 weeks out from an Ablation?

Actually... I thougt the original poster said it started 2 days out, and was confirmed on day 11. Not day 21.
Here's the relevant excerpt:

Quote

Two days after the ablation I had a day of chills and have had night sweats every night since (today is post-op day 12). I have not had any fever. I developed some upper respiratory congestion and had a chest X-ray (post-op day 11) that showed atelectasis and an elevated right diaphragm suggesting phrenic nerve palsy.

My read (which may be incorrect) is that the above is describing a scenario where the phrenic nerve was injured during the ablation, which caused breathing issues which in turn caused respiratory congestion. Upon X-ray examination on day 11 (and I presume ongoing breathing issues), a collapsed lung was found. The going theory is that the injured phrenic nerve caused the impaired breathing which in turn caused the collapsed lung.

Google also provides this alternate theory:

Quote

Sometimes, very tall, thin people are prone to a spontaneous pneumothorax. In this condition, the lung collapses after minimal or no trauma. Other risk factors are cigarette smoking and recreational drug use or abuse.

Ref: [www.emedicinehealth.com]

But Occam's razor would seem to dictate that it is related to the ablation.

5 weeks postop;

I am feeling a little better, but remain often fatigued. So far, I have had blood cultures, blood work, 2 chest X-rays, and an echocardiogram. The blood cultures were negative, all blood counts were normal, chest X-rays as above, echo normal w/ EF of 70% and minimal atrial dilation. Is atrial dilation normal in the blanking period as most don't get a follow up echo so soon? I haven't spoken to my local EP regarding the results yet as I see him later this week. My blood pressure has began fluctuating again, and my heart rate remains 90-100. I am wondering if the fatigue, HR, and BP could be indirectly related to decreased oxygenation? I am up to 3000ml on the incentive spirometer (I was at 1500ml initially). My exercise tolerance remains greatly reduced as I haven't felt well enough to really push hard. I feel like my heart has calmed down and believe that I'm in NSR .

Regarding the atelectasis and elevated right diaphragm: The radiologists report recommended a chest CT w/ contrast because the atelectasis didn't resolve in 2 weeks, and wanted to rule out scarring. Is it possible that there was some preexisting issue with the diaphragm? Sure, but given the timing of my procedure, trouble breathing, and chest X-ray, I'm thinking it was from the ablation or anesthesia. My previous chest X-ray was over 4 years prior and was unremarkable. I really don't want to be exposed to CT dye for a CT and hope this all just resolves with time. Really, I can't wait to sing Dr. Natales praise.

Ron

Wouldn't an elevated non-functioning right diaphragm have been apparent while phrenic neve mapping was performed during the superior vena cava isolation?

R

That makes sense that if you had decreased Oxygenation, that your HR would go up, but how do you know what you are oxygenating at? Are you using an Pulse Oxymeter, or something else? You can get one of those pulse Oxymeters, like the Dr's use for $30 and up on the Internet.



Edited 1 time(s). Last edit at 08/03/2015 09:05AM by The Anti-Fib.

Quote

You can get one of those pulse Oxymeters, like the Dr's use for $30 and up on the Internet

To Anti-Fib's point,
here's a Pulse/Oxygen Saturation Meter that I got 2 years ago from Amazon ($42)

It's really small, but very robust. And very accurate. Apparently it's one of the preferred models for mountain climbers.

Hey Ron,

Here is a thought from left field. "I am up to 3000ml on the incentive spirometer" Your deep breathing on the spirometer could be causing you to "overbreathe" and deplete CO2. I'm not saying not to do the exercise, but you may want to follow up with Buteyko type breathing exercises after you practice on the spirometer, to increase CO2. As noted here <[www.afibbers.org] , CO2 is needed. Hemoglobin needs it to release O2 to the cells. In addition, it is a vaso dialator. A simple exercise you could do after the spirometer would be to have gentle inhales and exhales through the nose. On a gentle exhale hold your breath out. When you feel a slight need to breathe (caused by the brain sensing increased serum CO2), start breathing again. Try to keep your breathing light. There is a lot more info following the links in my link and I can supply more if you care.

George

George, that's a very good idea. Certainly makes sense and in light of what 'overbreathing' does in terms of free radical production, no one needs to stimulate that and the resulting inflammatory response.

[www.normalbreathing.com]

[buteykoselfteach.com]

[www.sciencedirect.com]

Jackie

Quote
Jackie
Ted – Sorry this took a bit longer to find and organize than I thought... hope it's useful to you.

Thanks for putting that together Jackie, much appreciated!

Cheers,
-Ted