Long overdue report on Feb ablation with Dr. Natale

Hello, illustrious afibbers. I'm finally circling back after my February 2019 index afib ablation with Dr. Natale to let you all know how everything has turned out so far.

First, a quick rundown of my arrhythmia history. I was diagnosed in Sept 2017 one week prior to running my first marathon. It took a month to get through a full round of tests (cardiac MRI, 14-day Zio patch, echo, stress echo), during which time I was having episodes every other day at the drop of a hat and was unmedicated (except for baby aspirin). My heart was in great shape but my AF burden was around 10%. I spent some time pursuing PiP flecainide + metoprolol, as I didn't really want to be on meds at all (but wasn't ready to go the ablation route). High PiP doses of flecainide resulted in near 200s flutter, and shortly after that I went on daily meds. The EP I was seeing suggested that I have a flutter ablation and continue on low-dose meds to keep things in check. I was still hopeful that maybe I'd be able to get off the meds eventually, once my heart settled down.

I had the flutter ablation (nightmare experience with the hospital afterward, and a fellowship candidate performed the ablation rather than the EP I had chosen for her experience) and my heart was beautifully quiet for about 3 weeks - then it started acting up again - lots of runs of SVT, afib, ectopics. The EP kind of shrugged and just kept prescribing more and more flecainide, until I was on 300 mg per day, maintaining that I could have a full afib ablation to address it (which would likely be performed by a fellow again). Meanwhile, I had stumbled on this forum. I was not about to go back into that hospital's EP lab, and when I found out my insurance would cover a Natale ablation, I decided that was the way to go.

About 18 months after my original AF diagnosis, I flew down to Austin from Chicago to do the one-trip ablation option. Everything (cardiac CT scan, bloodwork, consult) went extremely smoothly the day before the ablation. I was shocked to find out in my consult that, in my unmedicated state, the arrhythmia I was experiencing was flutter (which I'd understood to be the one thing it COULDN'T be, after my supposedly successful flutter ablation). Dr. Natale's nurse practitioner was really really knowledgeable and spent a ton of time with me answering questions before Dr. Natale arrived to the consult. (There was some waiting here, as he was performing procedures that morning - I knew to expect this and it was not a problem.) On the day of the procedure, everything went super smoothly as well. (I am still blown away by the warmth and caring of the staff at the hospital.) Again, though, there was waiting - so it was several hours after my expected procedure time before I was taken down (or was it up? I don't recall) for the ablation. At this point, though I am usually an anxious person, I was feeling incredibly comfortable and confident that I was in great hands, and this extra wait didn't cause any problem (other than being more hungry than I might have wanted to be). When I did move to the EP lab, again, everyone was fantastic and warm (including Dr. Natale), and the next thing I knew, I was waking up in the lab. Being moved to a private room is kinda fuzzy, but I was back with my family fairly quickly. Dr. Natale came up to see us a while later and said things went very well and just warned me that I might have some issues with slower digestion for a few days. (He was right.)

I saw Dr. Natale again in the morning, when he made rounds along with a hospital representative, and I also saw the internal medicine doctor from the hospital briefly as a matter of routine (he had seen me briefly before the ablation as well). I got three sets of discharge instructions, if I remember correctly - one from him, one from Dr. Natale's nurse Curry, and one from the duty nurse. (This stood in sharp contrast to the Chicago hospital experience (at Northwestern!!!!), where no doctor was going to see me at all on the day of discharge and the duty nurse just told me informally that I could go "whenever" - no lie, there was no discharge paperwork or anything!)

Now, on to recovery. I had a dressing on my neck (where they made an incision for a reason I can no longer remember) and the two groin incisions (which had the collagen plugs). The neck incision was kinda itchy for a week or so, but not a huge deal. The groin incisions healed quickly and were much less tender by comparison to the one I'd had for my flutter ablation. I did have issues with slowed digestion which led to a feeling of being bloated/full for several days after the procedure. (This was sad, since it meant I couldn't really take advantage of the Austin restaurant scene in my last couple of days in Austin.) Once I returned home, Curry (Dr. Natale's nurse) advised ginger chews, which did get digestion moving - (proceed with caution) - and that was the end of that issue. I think this was all due to the close proximity of the vagal nerve to the ablation site. I also had a higher resting heart rate - 20-30 beats per minute more than my usual RHR of 60ish.

I was instructed to stay on 100 mg of flecainide for 3 months or so, and Eliquis for 6 months or so. My heart was quiet. Every once in a while I'd feel some faint ectopics. They felt really distant, somehow. I'm not sure if that's because they are "less" or if the ablation's effects changed my perception of them (perhaps due, again, to the proximity of the vagal nerve to the ablation site?). In any case, going off of the flecainide was uneventful and remained so. (YAY!) In August, after another Zio patch (during which there were no patient-triggered events and <1.0% SVEs), I got the go-ahead to stop the Eliquis. (DOUBLE yay - that one deep finger cut over the summer that didn't want to stop bleeding was no joke!)

So, I realize there is no such thing as a cure for afib, but I have to tell you, I feel pretty close to cured at this point. I have my life back. I'm not training for any marathons - in fact, I'm still working on getting into a good regular exercise habit - but when I do run, my heart behaves. No spikes, no light-headedness. I don't notice ectopics (they were really bothersome and frequent before), and due to the Zio patch results, I tend to think this is because they're really just nonexistent. What a huge relief!

I am truly thrilled to feel like I'm closing this chapter on afib. I still drink green tea instead of strong black coffee, and avoid alcohol (mostly - I have allowed myself one beer a few times since stopping Eliquis), and I'm continuing magnesium/CoQ10/omegas indefinitely for now. All of those are completely and totally acceptable changes! (But for me they were not enough, though I'm glad I took the time to make sure of that, as it also gave me the time to find Dr. Natale.)

Appreciation to all of you that have shared your stories and wisdom here. Thank you especially to Shannon for the time spent on the phone and over email providing guidance and help. I'm forever grateful to Dr. Natale, and though I hope to not have to repeat the ablation experience, I would not hesitate for a moment to put myself in his hands again!!

I do have two questions surrounding my still elevated RHR (in the 80s):

1) Is there a length of time after which I should be concerned if my RHR remains this high?
2) Is this elevated RHR also elevating my HR by 20 beats or so when I am active, so that it's "inflated" by about 20 beats or so all the time?


Karen



Edited 1 time(s). Last edit at 10/09/2019 05:14PM by kbog.

Great report, thanks!

Quote
kbog
1) Is there a length of time after which I should be concerned if my RHR remains this high?
2) Is this elevated RHR also elevating my HR by 20 beats or so when I am active, so that it's "inflated" by about 20 beats or so all the time?

The elevated heart rate is perfectly normal and to be expected. It can last a surprisingly long time, upwards of a year or more. In my experience it doesn't add on to a heart rate elevated by exertion, or at least not by much. It only seems to affect the resting rate.

Welcome to the club. It’s a wonderful feeling, something I don’t take for granted. I had a higher resting rate after my Natale ablation, for a good 9 months. Getting back into my exercise regiment helped, once I convinced myself I really was fine.

Great to hear Kbog,

I’m so pleased, but not in the slightest surprised, by your very typical and yet exceptionally thorough report!
And I say ‘Ditto’ to Carey’s answer on the ubiquitous moderate increase in resting heart rate which is actually a good sign that you’ve had a thorough and effective ablation!

I was an outlier after my very long index ablation with Dr Natale for aggressive persistent AFIB with a total RF burn time of
117 minutes ... still the record in my recollection among the legions of peoples ablation reports with Dr Natale and many other EPs, though one other of our members came with in 3 minute mark of my very long burn time.

As a result of the very extensive index ablation I had, my elevated Heart rate also lasted just over two years! In fact, after the first five months post ablation during which Dr. Natale had me stay on Sotalol the entire time, when I stopped the Sotalol rather quickly my resting HR cycled between 109 and 105bpm at 5 months post ablation!

It did start to drop fairly quickly over the next few weeks and months once stopping Sotalol, but then settled in to a very slow and very gradual reduction to my final previous normal resting HR or 60 beats a minutes a coupe months past the two year mark. However, during the bulk of the last two years it was all very tolerable even if slightly elevated from the upper 60s to upper 70s mostly to which I easily adapted.

Keep in mind that this is a very rare length of time for most afibbers to recover their prior RHR. the vast majority of folks experience elevated post ablation HR from 5 months to a year max of moderately elevated levels above prior resting rate.

A very small and benign price to pay for freedom from all atrial arrhythmia!

Cheers Kbog!
Shannon



Edited 1 time(s). Last edit at 10/10/2019 01:01PM by Shannon.

At 105-109, why didn’t you take a beta blocker once stopping solalol? I’m waiting to go back on it. Wear and tear. I’m asking because I walked to my backyard and my HR jumped to 130. Last week 120-130s when walking one block. It isn’t the numbers but the syncope. Did you have that during your blanking period?