increasing episodes. Need recommendation for EP in Houston, Tx please

I see that a lot of people see an EP in Austin. I'd like to find a good one n Houston to avoid the drive there. Any suggestions? I'm relatively new to the forum, but I've had lone afib for about 18 years. It used to occur about once a year, but recently increased to every three months and now it is every week. I've been on Flecainide for years and am wondering if that is why the episodes are increasing. I have a very nice cardiologist but he is not an EP. And he doesn't know much about vagal afib.

Hi CaroleF -

I took Flecainide for years and my episodes were also increasing in frequency although they never were very long in duration, just minutes to hour. Medications lose their efficacy over time. You may have to try another medication or consider an ablation.

I'm in Dallas and made the mistake of seeing a local EP recommended by a cardiologist who is a friend of my parents. He did my ablation for vagal afib. I had increasing late reoccurrence of afib and flutter after the procedure that required multiple cardioversions. I ended up making the drive to Austin (3.5 hours) to see Dr. Natale who did a second procedure last week. He found the original doctor had burned so close to two of my pulmonary veins that it caused stenosis. This should be a rare complication these days. Fortunately, what could have been a serious issues tuned out to be okay. The stenosis is mild/moderate and I don't need further treatment. Additionally, Dr. Natale found two of the right pulmonary veins still conducting. The original doctor did not isolate. I tell you this because, if at all possible, save yourself the nightmare and make the trip to Austin. You're not that far away from seeing one of the best in the world. I'm so glad I did!

Take care!



Edited 1 time(s). Last edit at 07/24/2015 11:32AM by alangford.

My best friend from childhood lives in Houston. When we talked last year I insisted he go see Dr. Natale in Austin (in my opinion, the best afib ablation EP in the world). He had an ablation March 5. He has thanked me profusely many times for insisting he go to Austin and can't say enough good things about Natale and his whole team. People fly in from all over the world to see Natale, you only have to drive from Houston.

A good friend's sister is now confined to a nursing home after a botched ablation by one of Houston's "best" and highly recommended EP's.

George

The biggest mistake you can make in this game Carole is to choose an EP out of convenience, when you have the most experienced and consistent maestro in the world barely 2 hrs and 45 minutes easy drive from you in Austin in Dr Natale.

I grew up in Houston too, and my older sister has Long standing persistent AFIB, and my father also who died from an AFIB related stroke at 69 years old in 1986. Even after I had my index ablation with Dr Natale in Austin and my sister and her husband had driven up to see me and met Dr Natale after he come into the family waiting room immediately after mybindex ablation with him ... and even after she promised me she would come to Austin and let no one but Dr Natale ablate her also difficult case (she has bad Rheumatoid Arthritis as well as a complicating factor) ... I then went back to Amsterdam where I was in the middle of living for four years at the time and since she, like you, did not yet really appreciate what a large gulf there is between most typical ablationists ... even those considered 'good' in local areas like Houston ... and those who are true elite level operators like Dr Natale, she let her local cardiologist talk her into going to this new head of AFIB ablations at a very large well-known Med Center within Houston's very large overall renowned Medical Center, who at the time many docs in Houston’s cardio community was saying was a new 'rock star' ablationist from the east coast who had recently been hired to run this large Houston hospitals AFIB program.

I did not know she had gone for ablation with this doctor until after she had to endure a 9 hour nightmare with this 'rock star ' who, it turns out, only had a measally 700 procedures under his belt, and yet had no problem agreeing to ablate my sister with a hugely challenging long standing persistent case complicated by multiple other serious co-morbidities in her case, and he literally butchered her!

She was so traumatized by the extremely long drawn out and bumbling ablation which started out with only conscious sedation until half-way into the marathon, the EP realized he was way over his head and they finally switched to general anesthesia with my sister crying out during the conscious sedation in terrible back pain from her RA and being strapped so long on this flat cold table and this guy who takes 9 hours to figure out what to do and still getting it wrong while leaving her, in the end, in even worse symptomatic persistent AFIB after the ablation than when she went in!!

Within several months later she had stroked out with a debilating stroke while on warfarin and has been totally bed ridden for the last 6 years as a result! I am not suggesting this horrible outcome awaits you with any EP in Houston, by any means, but there is a very large array of less than stellar results between what you are likely to find with anyone with far less experience ablationist compared with our very solid consistency of results posted over the last 16 or so years on this forum by those who have chosen to go to Austin/CPMC (and previously Cleveland Clinic when Dr Natale used to be director there from 1999 through late 2007) over the many years we have been following patients here.

For sure, some AFIB operators there are skilled enough for most typical cases and there are a few good ones too, but when you are talking long term more challenging cases your risk margin for anyone but the very best level of operator starts to go up substantially.

It's your heart, and baring a transplant you only get one. I'd say that is more than worth a 3 hour drive and a few nights stay in Austin!

Do your research here and you will soon come to see the very well-grounded logic in doing so. Many here would pay a handsome penny to be as lucky as you living only 3 hours away.

Check with Alangford here too, who just returned from having Dr Natale repair an index ablation down almost 5 months ago by a locally well-regarded young EP in Dallas where he lived and who had been recommended by a Cardiologist close friend of his parents in Dallas, and this Doc left two of his four pulmonary veins fully conductiing when Dr Natale went inside his heart to examine what needed to be done, and the other two left sided PVs that remained fully isolated BOTH had pulmonary vein stenosis of 25% and 50% respectively!!!

That should not happen to two veins this day and age, but we see ALL the time people who went to locally well-regarded EPs in various regions of the country and still are having lots of breakthroughs after a couple ablations before they make it to Dr Natale to try to fix them up finally, and so often they find that two or more PVs are now fully conducting still as the EP failed to make fully and consistently transmural burns needed for long term silence of AFIB.

You may well get a good result from an EP in Houston though there is no one there I would even dream of recommending over and above making the short drive with Natale such an easy access a few short hours away. And please understand, that there are also many diffident degrees of disappointment that fall far short of my sister's disaster experience, that have increasing levels of odds of happening to you in direct proportion to your willingness to let 'convenience' guide your single most important decision you will ever make in you entire AFIB history .. who will handle the catheters inside your heart doing those golden few hours of any ablation needed to fulfill a successful expert ablation process. Do NOT short change yourself here or out smart your self. Go with the safest bet you can arrange for yourself, especially with the great good fortune of being so close to truly the single most experienced ablationist in the world almost in your extended neighborhood!

You can go back in the search function here and read a very large number of such accounts as they unfolded over time in real time.

Best of luck to you, you made it here which is a great good step, now take advantage of the large pool of experience here for you own best interest as well.

Cheers!
Shannon



Edited 4 time(s). Last edit at 11/27/2017 09:02AM by Shannon.

Thank you for all this positive advice about Dr. Natale. When it becomes clear that ablation is my only choice, I will contact him. How long is the recovery period from ablation, typically?

I am not sure that I need ablation yet. I have hopes that a change in meds might work, and being more mindful of my diet. I have noticed that chocolate definitely increases pvcs and skipped beats, and it plus coffee and not enough water may have triggered the episode this week on 7/22. This one lasted 12 hours but was combined with a syncopal episode with profuse sweating that resulted in my lying on the kitchen floor for about fifteen minutes to recover. This is new. The new things are what is worrying me. I never had PVCs before this last year. I never had blurred vision and fainting before. And then yesterday evening, I had racing pulse and profuse sweating; never had that before either.

Anyway I am seeing my cardiologist on Monday. I'll see what he has to say. He is unusual in that he does applied kinesiology muscle testing and has established that while my body needs Flecainide, it doesn't like it. I was on Amiodarone before because Digoxin lowered my pulse too much and beta blockers made me light headed and nauseated. Amiodarone had horrible side effects including some kind of deposits on the lens of my eyes.



Thanks again
Carole

Stay away from Digoxin that would be a red flag for anyone prescribing that to an Afibber in this day and age. Amiodarone too is last ditch effort and only for short term.

There are many accounts you can search for here of ablations with Dr Natale, you can drive around and do light errands the following day in most cases, but take it easy too the first month with only progressively more exercise as the days and weeks pass during the first 4 to 6 weeks after which more often you are good to go full steam ahead.

Some have some degree of modest fatique or tiredness for a month or two, but its all quite handle-able and progressively improves while the vast majority of ablation patients feel pretty much back to normal after two weeks of steadily improving energy.

Shannon



Edited 1 time(s). Last edit at 11/27/2017 08:44AM by Shannon.

Dear CaroleF,

As someone who has benefitted from Shannon's impassioned advice above, I want to say that I believe the single biggest factor in the success of ablation at present is who is doing the procedure. This is why you will read over and over here that it is critical to ensure that the EP has the requisite level of skill and experience. Travel is inconvenient and expensive, but it is really transient compared to the long-term potential for relief from AF and the risk of adverse effects in the hands of the less experienced.

I live in a major urban area on the East Coast and NYC is an easy train ride. There are a huge number of outstanding medical centers in this area and some EPs with wonderful reputations. What I also knew about my case was that it had the potential to be complicated, since I had had AF for over 19 years when I had my first ablation. This was in NYC with Dr. Natale in 2013. Two weeks ago I had my second ablation with Dr. Natale in Austin, and the travel and expense were, in my opinion, the short-term stress for a long-term outcome that I could expect with his hands on the catheter. Everything went extremely well and I am feeling fine. The long-term prognosis is excellent. I viewed these two steps in the ablation process as necessary and likely expected given my long history with AF.

I was initially quite reticent in considering ablation and then in considering travel to have the procedure. But it didn't take me long in looking at the data to understand that this is one of the most operator dependent procedures being done today. It is also one of the most complex and demanding, although we sometimes talk about it with the highest tier of EP as if it is routine. It can feel that way when you choose wisely. It matters a lot. Duration of procedure matters, and especially if the job isn't getting done.

I think being on the other side of this process leads to strong feelings in some of us who've been through a very long struggle with AF. I know that my perspective is completely different now, and I was even somewhat hesitant at one point to consider a second procedure. This is because I hadn't fully accepted that even the best of the best are cautious and respectful of the limits of safety, and anesthesia can mask areas that may be triggers. No EP, no matter how skilled can find something that doesn't show up and none would responsibly be aggressive enough to burn healthy tissue if there was no justification. So, it's a process, especially if you have had AF a long time.

If you are going to have an ablation, the most important thing you must consider is who is doing it.

Best wishes,

Rob

Thank you Rob!

Do you have to be in Afib when you see Dr. Natale? How does he know what tissue to cut? Sorry if my question is nonsensical. I really am a beginner about this.

Best wishes,
Carole

Dear Carole,

Your questions are the ones we all have. You do not have to be in AF for an ablation. Dr. Natale can map the errant electrical patterns and he can induce AF with isuprel (an adrenaline-like drug) once you are under general anesthesia. The mapping system Dr. Natale uses is extremely sophisticated (Carto) and there are others on the list who can speak in much more detail about the technical aspects.

Radio frequency ablation uses high frequency energy to create lesions (burns) on the inside of your left atrium (and maybe the right atrium, too). There is no cutting as such, so it's not surgery. The goal is to create lesions (scars) that can electrically "isolate" (block) errant patterns of energy and restore the natural pattern of normal sinus rhythm (NSR). The catheter is carefully monitored in a number of ways for location and temperature and more recently in some instances for "contact force," which allows the EP to know how much force is being used at the tip of the catheter. The catheter is cooled by water, and you will gain some weight during the procedure from the water that your body absorbs. This weight is quickly lost after the procedure. You will also be monitored carefully for clotting and your blood's ability to clot is carefully controlled during the procedure as well as that no clots are created by the catheter. Dr. Natale is a pioneer in all these areas, and his safety record is at the top with the most difficult and challenging cases that present for ablation.

There is an ablation pattern that is widely accepted as the first and most important isolation to achieve and this is the PVI, pulmonary vein isolation. Especially in shorter term paroxysmal AF most of the reentrant signals (errant energy) are focused in the four pulmonary veins in the left atrium. In addition, Dr. Natale ablates another area that is associated with AF in this region (antrum), and so the procedure is called a PVAI (pulmonary vein antrum isolation). Again, others on the list know much more about the technical aspects, and Shannon has written extensively about this numerous times (search for PVAI). As you have AF longer, it's likely that there are other trigger sources beyond the PVAI, including the left atrial appendage (LAA). These source, too, will need to be isolated if they aren't completely so after the first ablation. And sometimes the LAA will need to be isolated, but Dr. Natale does not do this in the first procedure because this isolation may require you to be on anti-coagulation permanently, or have another procedure that closes up the LAA. This is why I noted that it's a process, and especially for those of us who have had AF for a long time.

If your episodes are becoming more frequent with flec, it could be that you have reached a point where it will no longer work for you. This happens not infrequently with AAR drugs, even if they an provide years of freedom from AF (and take it if you can get it!). But given the number of years you've had AF, I would consider ablation at this point. The top tier, like Dr. Natale, ablate longstanding AF most every day and this is why the choice is so important. It may take more than one procedure, but there is the prospect of being free of AF. If you are looking at a progression to longstanding persistent AF (24/7), which is where I was headed, this option is a Godsend, as long as you choose wisely about the EP.

Good luck with all the things that I know you are considering, Carole. And don't hesitate to ask questions. That's why this list exists, and it was the reason that I got the help I needed.

Best wishes,

Rob

NO you dont have to be in AFIB Carole, Dr Natale, or any EP, will trigger your AFIB as part of their mapping process during the Electro-physiology initial 30 to 40 mints of your procedure where they get a thorough real time understanding of just how your arrhythmia manifests and where in the left and right atria the triggers are.

As Rob noted, during a first index procedure Dr Natale will do his classic Extended PVAI procedure that he largely pioneered, with a complete Pulmonary antrum isolation far enough way from the inner ostium of the PVs to avoid any Pulmonary vein stenosis issues.

He will then isolate the posterior left atrial wall and when evidence indicates a need, will ablate or isolation the Superior Vena Cava. Any additional ablation will then be determined by active trigger searches via mapping pacing procedures to stimualte any further triggers from any non-PV trigger areas including certain types of complex fractionated Electrograms that meet certain consistent likelihood to be ongoing triggers for AFIB, and when needed addressign the coronary sinus, mitral isthmus and last but not least the Left atrial appendage in more long standing cases where that trigger source remains as the only remaining active trigger once everything else is made quite and unresponsive even under isoproterenol drug challenge which is a drug much like adrenaline used to ferret out any remaining triggers to address before ending the ablation.

But like Rob noted with the large number of active sources and wide spread high amplitude of noise floor often seen in a first ablation, it is not always possible to eliminate every sngle possible trigger on the first procedure though with Dr Natale very often he does achieve a one and done success.

In other cases either suppression of a few remnant triggers sources by the general anesthesia can prevent them from raising their head enough, especially for immature triggers, and they then might manifest at a later time. IF that is the case, then Dr Natale will go back in for what is invariably only a true touch up procedure including only a small one to five or so burns as opposed to the common practice among less skilled EPs who, when they have to do repeat ablations on their index patients typically have to redo reconnections of already ablations areas such as 30% to 90% of all repeat ablations entail EPs having to reburn areas they already tried to ablate the first time but were not successfully transmural in doing so.

Dr Natales reconnection rate on patients he did the index ablation on is in the mid to low single digits! And is a big reason that sets him apart from many other, otherwise relatively skilled and good quality ablationists. You have no need to fear Dr N wont know what to do when he is inside your heart, that you can take to the bank!

In short, with him looking at completing of an expert ablation process that, from your brief description of your case may well only take one procedure of two tops to address with the second one, if needed, just a much simply and shorter touch up process.

Shannon

Gosh, I've leaned such a lot from you guys today. Thank you so much. I feel more calm about ablation and Dr Natale.

I did look at the conference proceedings #8 on ablation and was struck by the number of ablutions Dr. Natalie must have done by now if he had done 600 in 2003. More reasons to trust him

I feel I'll have more questions when I understand enough to know what I don't know 😀. But in the meantime, here are a few:

.
When you contact dr Natale's office to ask about having the procedure done, is the first time you go there in person the day you have the procedure. Or is there a pre-op appointment? Do you send him your medical record? Does your cardiologist communicate with him? Is this a referral or can you just call him up and say you want an ablation?

Thanks again.

Best wishes, Carole

Best wishes,
Carole

Carole,

Shannon and other alums can give you the contact info.

My Houston buddy had an appointment around Dec 30 2014 and his ablation on March 5 2015. I think Natale has done over 8,000 ablations at this time (I think it is the most in the world). Some who come from far distances can have an appointment a day or so (or even same day in some cases) before the ablation.

I believe you can self-refer.

If you'd like to message me your contact info (email, phone), I can get my friend to contact you for a first hand chat. Another Houston Natale alum (from 2012 or so) did that for my friend and he thought it was very helpful.

George

Send me your cell number if you wish Carole and I'll give you the direct number to Dr N's main manager at St David's who runs the AFIB center there for him.

Cheers!
Shannon

Also, really diving into the strategy and reviewing your dietary program, though it sounds like you are doing a pretty good job there ... just perhaps need top confirm you are getting enough high quality fats and protein with a lacto-veg diet ... especially as we get older. But insuring good repletion of magnesium, potassium . taurine etc can really help in many cases.

Although, with very long standing cases like yours its much less likely to have a dramatic impact on stopping AFIB, but every bit helps that helps and its wise to go into an ablation with good electrolyte repletion as well as sufficient Vitamin D levels, Have you confirmed your 25(OH)D3 levels via a blood test after some months on your current dose of Daily Vitamin D and how much do you take each day? Be sure to take it with the largest fat connately meal of the day. At least you can take it with a large tablespoon full of extra virgin coconut oil which is very good for you in its own right and will greatly help absorb and assimilate the oral vitamin D.

Shannon