Another apparent Natale Ablation Cure

I underwent an ablation by Dr. Andrea Natale April 9 of this year -- my second ablation in 12 years -- to correct lone atrial fibrillation, which had redeveloped in November, 2014, after more than 11 years in normal sinus rhythm following the earlier ablation. The earlier ablation was performed by Dr. John Marcus Wharton of the Medical University of South Carolina back in 2004.

I am now 74 years old and pretty physically active.

My recent ablation appears to have been a complete success, though the recovery had some bumps. Post-ablation I experienced increasingly longer periods of atrial flutter until Dr. Natale's staff convinced me to seek an electrical cardioversion in June, about 7 weeks after my ablation.. I live in Idaho and the cardioversion was performed at a medical center about 70 miles from our home.

That was the definitive turning point, and I have been in normal sinus rhythm ever since, though Dr. Natale's staff has asked that I continue to submit "heart card" monitor recordings for a while. In September I was weaned off the rate control drugs I had been taking, but I was told to continue an anti-coagulant until I am able to return to San Francisco for a final post-ablation check-up that will include a trans-esophageal echocardiogram and a final consultation with Dr. Natale.

Normally I would be going to San Francisco about now but my wife and I are about to leave on a two-month trip outside the USA, so the final appointment in San Francisco has been pushed to December or more likely January. As preparation for that appointment, I will be sent an "event monitor" which I will wear for a week to determine if I am having any arrhythmias that I just don't notice.

For those of you who follow this bulletin board and are schooled in the technical aspects of ablations, mine was described as "elimination of high-frequency fractionated signal in the left atrium including the roof, septum, posterior wall, left atrial appendage base, MVA and other regions," and "Isolation of CS."

I am anticipating that I will be declared "cured", and I want to take this opportunity to thank Shannon Dickson for his wonderful advice and help. Thanks go also to Dr. Natale's executive assistant Salwa Beheiry and to all of Dr. Natale's staff, especially nurse practitioners Julie Jehnsen, Heather McFarlin and staffer Sandra Jones.

I welcome any questions but will be somewhat disconnected after this coming Sunday, October 4.

Jim Pearre

Really good news things are going well Jim!

I recall our conversations fondly as a real old timer in terms of prior ablation success too getting ready for one more ride to hopefully seal the deal for the duration.

Your ablation case report summary that you recounted above reveals a textbook example of what is often seen now many years later during the initial EP study portion of a new touch up ablation some 10 to 12 or more years later, from what was a clearly successful early first to second generation ablation that has held up well, with your first one no doubt being a rather typical PVI, I imagine, by Dr Wharton .. a fine man too from all reports .. who did a good job for you then.

But while the PVI has held and should indefinitely continue to do so from now on, the tendency is for the progressive substrate condition to continue to gradually continue to spread out into these other fringe areas away from the PV antrum areas that were originally targeted in the first PVI-only or PVI plus some posterior wall procedure. And since these new fringe areas were never even looked at way back then anyway, the existing subclinical trigger sources in those areas could very slowly continue to remodel .. though at a dramatically slower pace than had you been still dealing with ongoing AFIB all of the intervening years.

Nowadays, these 4th to 5th generation cutting edge ablations by the likes of Dr Natale, can track down and zap those trigger new sources that have now raised their heads and become active triggers in all the major parts where they might be have also been stimulated to some degree and tracked down and taken care of in the first ablation had they known to do so back then, and assuming which ones would be mature enough back then to show themselves during the first procedure.

For those now getting a more comprehensive ablation process, the odds of a very long freedom going forward once they pass through a substatianial initial period free from arrhythmia, are much higher indeed than back when it was just the PVI-only and thats about it that was addressed.

Enjoy your trip with your wife and best wishes with the TEE in Dec or Jan... be sure to call me just before and after to let me know how it goes Jim.

Cheers!
Shannon



Edited 1 time(s). Last edit at 09/27/2015 06:43AM by Shannon.

Congratulations Jim. I am still sitting on the fence re:ablation and one of my fears is flutter. Why doesn't Dr. Natalie perform a flutter ablation on everyone. I believe that there are some docs who do this. It seems like a common and uncomfortable problem post ablation.

Thanks, Lynn. Regarding flutter, I do not know how it may fit into the overall picture of post-ablation recovery, but, like you, I have gotten the impression from reading this bulletin board that it is not unusual.

I think I may have been experiencing mild and short periods of flutter prior to the redevelopment of my A-fib. Not sure. Flutter in my case was pretty subtle. I was in denial about having it after my ablation until an ECG was administered showing it. It certainly was intermittent. I would assume cardioversion is the treatment of choice for persons who are experiencing flutter without any A-fib, since cardioversion is non-invasive. Whether something could be done during an ablation prophylactically to prevent flutter as a potential post-ablation complication, I do not know.

I expect others more experienced in such questions will respond to your question about this..

Jim Pearre

Jim, so glad to hear your ablation was successful. I wondered if the hills behind your home in Idaho was a good thing. It seems it was

I was one day before you in San Francisco. My ablation was great for 9 weeks, then went south. I ended up with that dreaded flutter that I had heard about, as addressed in the post by Lynn. In my case, that is worse than the afib. Shannon has helped me thru the mental part of it, now I am eager to get on with the game. No regrets in trying at this point. My biggest fear was living with afib the rest of my life without at least trying to rid myself of it. I had a good chance of being one and done, but it was not to be...I will have my touch-up at the end of next month and I am in hopes this will do the trick.

Keep us posted on your final test and hopefully you will be good to go and off all drugs.


...ronH



Edited 3 time(s). Last edit at 09/30/2015 03:40AM by ron.

Hi Lynn,

the flutter ablation preformed by some EPs during the first ablation is for evidence of existing RIGHT sided typical flutter such as CTI (cavotricuspid flutter which is a very different animal than the kind of atypical fuller that can appear after a left sides AFIB ablation, and which is an unpredictable, but not that uncommon of an occurrence,

About 50% of this atypical flutters which define probably 90% of post ablation flutters that were never a problem prior to the ablation, will disappear never to return during the blanking period as the lesions heal nd firm up over that 3 month period allowing the ablation to fully 'take' if you will.

The other 50% of these flutters that either persist well past the blanking period or only first show up after that 3 month healing process, typically require a revisit to the EPs table and this is when, in particular, you want the most experienced ablationist you can arrange to handle that part.

For a EP like Dr Natale and many of those he has trained, as well as other top EPs from other high volume centers, its not a big deal at all to track down and render quiet these atypical flutters. For less experienced EPs who do not commonly address non-PV triggers, many get nervious when having to use real time electrophysiology to track these left atypical flutters and reliably ablate them.

that can be from being part of a fellowship training program headed by often as very smart and good clinical EP, but not necessarily one that is a front line busy ablationist ( many such programs or NOT headed by elite level ablationists) as such its not so surprising when their offspring in the form of EPs they have trained have learned a more text book anatomical PVI type process and also a more 'basic guideline" approach to tracking down and addressing these atypical flutters .. but it can leave a lot to be desired compared to being fully trained by a true top tier maestro of an ablationist as head of their fellowship program who is busy everyday doing the most difficult kind of ablations.

Alas, while nearly all of the EP fellowship directors are very smart and dedicated clinical EPs and are very good at training their students over the wide array of EP treatments and procedures, only a relatively few of these leaders and teachers are themselves true high volume persistent and long standing persistent ablationists and as such, all the little nuances the elite EPs can pass along don't all make it to the majority of EPs who wind up learning how to be an EP from a less than top volume ablationist.

There are a handful of top programs guided by very skilled ablationists, but not the majority by a long shot.

YOU really want to partner with the best EP you can from the beginning and stick with them until your own ablation process is complete. The best of these folks have no problem at all addressing any remnant left atrial flutters as so many of us here are living proof.

All of these worried Lynn, can be mitigated in reality to a huge degree by making that one single choice for the best and most experience EP you can from the outset and then just trust in that process .. before you know it you are on the other side.

I know how easy it is to get caught up in all the 'yes but' and 'what if' self talk and internal debate over every possible 'gotcha' but the bottomline truth is that those who hook up with top line EPs and follow through have an enormously successful track record of stories at the end of the day with vanishingly few negative outcomes.

The procrastination in the face of ongoing AFIB, even after trying all the natural approaches it what will wind up putting you really behind the eight ball before long and making your life and AFIB history a whole lot more difficult and drawn out than it has to be.

Shannon


Lynn Wrote:
-------------------------------------------------------
> Congratulations Jim. I am still sitting on the
> fence re:ablation and one of my fears is flutter.
> Why doesn't Dr. Natalie perform a flutter ablation
> on everyone. I believe that there are some docs
> who do this. It seems like a common and
> uncomfortable problem post ablation.