Left or Right Atrial Flutter

Hi to all.

Most of the regulars will be familiar with my AFIB career so I will just say that I was cleared of AF in 2010 by Bordeaux after 5 ablations, 4 in Bordeaux and first 1 in New Delhi.

A couple of months ago I was training in the gym and noticed after about 30mins that there was suddenly no 'zip' so I called the session off and returned home where I checked my heart rate and found it was never lower than 80BPM whereas normal heart rate was 56ish. Went to the hospital next day and they said 80BPM was normal but I finally convinced them I was in Atrial Flutter that then lasted up to 2 months when I was finally cardioverted? back to NSR. I then selected to have an ablation to rid me of the Flutter 100% (cardioversions are not a cure) and 3 weeks later, today, I turned up for a pre-ablation check up and discussion with the local Hong Kong Hospital EP who apparently works in one of the top private hospitals but carries out work at the local hospitals when available as part of his duties. To cut a long story short he said he could not tell off the ECG what kind of Flutter I had had as the five previous ablations had caused quite a bit of damage which they really try to avoid these days. Bottom line he said the only real way to find out what Flutter I had - left or right atrium - he would have to go in and encourage the Flutter to start up again. This set me back a bit as Left Atrial Flutter is a totally different animal than normal run of the mill Right Atrial Flutter. I have had Left Atrial Flutter twice and ablated twice and never want to go there again.

To finish up we agreed that for the moment I just carry on in NSR until anything goes wrong and then attend the hospital again with the Flutter in full flow when he could then tell whether it was the Left or Right flavour. If its Right Flutter I would go with the EP I was talking to but if Left Flutter I would go to Bordeaux. To be fair to the EP he fully understood that I would want to go to Bordeaux if Left Flutter showed up. He seemed in awe that I had met up with Proffessors, Hassiguerre, Jais and Hocini in Bordeaux, Haissigurre obviously his hero.

I asked if this local hospital had the latest up to date equipment and he said we have exactly the same as anywhere else, Mapping, Cryo?. RF etc much better gear than when Bordeaux were doing things back in 2010 but stopped well short of putting himself in the league of the Professors in France.

So no more cardio workouts any more, just stick with a bit of hiking and light weight training, can't afford all these ablations.

Barry G.

Hi Barry,

No fun, hope the NSR continues!!

Exercise has been a trigger for me, as you likely know. I have two suggestions on potential limits that may be useful.

The first is to always breathe through your nose, if you have to open your mouth, your exertion is too high.

The second is to follow Phill Maffetone's approach. A friend of mine, Dr. Mark Cucuzzella is an avid endurance athlete. Around the year 2000, he was advised to give up running because of his injuries and feet surgery. Mark started using Maffetone's approach, basically limiting heart rate to 180-age. Mark started out not being able to run very fast, but he persisted and he could accomplish a lot while maintaining this heart rate limit (Mark has run 30 marathons under 3 hours). At one time I had a discussion with him about the negative effects of exercise, especially long endurance running. Mark said his objective was to always feel better when he finished than when he started - never tired or worn out. I also asked about troponin, which is a marker for heart damage after a heart attack, but also gets elevated on marathoners after a race. He said his did not elevate.

In any case I tend to use these approaches, actually the 2nd is more conservative than the first as I can work pretty hard breathing only through my nose. Hence I favor the second approach, if I have a monitor on.

Cheers,

George

Aloha Barry,
I too had afib followed six years later by aflutter and had the same dilemma - is it right or left sided. If you’ve had an afib ablation in Bordeaux, they generally do a cavotricuspid isthmus (CTI) ablation prophylactically for aflutter. Your ablation report should have documented this.
According to Bordeaux’s data, this is 99% successful. However my aflutter EKG showed down going F waves in the inferior leads which is supposedly associated with right sided flutter 90% of the time.
I asked Dr. H and J about this and they assured me it was left sided. So like you I felt that Bordeaux was best for left-sided flutter ablation.
Interestingly enough after the successful flutter ablation I asked Dr. Jais whether it was right or left. He sheepishly admitted it was right, as there was a thin rim of residual myocardium where the CTI ablation had been performed.
Good luck

Hi George, thanks for your reply.

That's great information and so simple to do. When I do get back in the gym on the light weights I will certainly try both. The hard part will be keeping the brakes on after a lifetime of 'going for it'. Breathing through my nose only will certainly keep me in check. At the moment I am working on a large construction site so I am getting plenty of light cardio exercise going up and down the buildings external fire escapes/staircases etc and even though I don't need to I purposely stop for a 'rest' every 2 floors and can easily do this just breathing through my nose.

Regards,
Barry G.

Hi PC, thanks for your reply.

I certainly remember your very interesting reports from over 10 years ago on this BB.

Yes I bet you were kicking yourself when Prof Jais said it was Right Sided Atrial Flutter, going to Bordeaux isn't cheap when it turns out you could have had the Right Sided Flutter eliminated out there in Hawaii.

My case will be a similar gamble as if the Hong Kong EP ever does go in to find whether Right or Left I will be paying much the same price as a regular ablation anyway. Hong Kong public hospitals are very cheap when compared to say a Bordeaux visit i.e. you only pay for the 'use once only' equipment and the Private Hospital EP comes for free. If the EP finds its Right Atrial Flutter after agitating the heart he will ablate there and then however if its Left Sided he closes up shop and I go to Bordeaux when needed. So basically I will have to have to go through, and pay, for two 'ablations' if Left Atrial Flutter is agitated. The EP did say that my previous AFL and accompanying AF ablations should almost certainly rule out Right Sided Flutter ever appearing again but the only sure way to find out was to 'go in'.

Being probably the worst gambler in the world with my glass always half empty no doubt I will choose the wrong route out of this as it seems unfortunately did you. :-(

Just remembered, my last ablation was for Left Atrial Flutter and was carried out by Prof Jais. After just over 2 hours Prof Jais did say he couldn't get the 'final bit' but as it took an agitated heart rate of 300BPM to induce the LAFL and I would never be able to raise my heart rate anywhere near the 300BPM the ablation should be OK. It did last over 9 years.

Regards,
Barry G.