Back out of rhythm

Well, after almost exactly one BLISSFUL year of being in perfect sinus rhythm (thanks to index afib ablation with Dr. Natale), a good month or two of success easing back into running, etc., I noticed one day that my heart seemed to be kind of "exaggerating things" after the climb up the stairs to my 3rd floor condo. Turned out it didn't want to calm back down again, and in the next couple of days I woke up around 6 am well rested, but with a RHR of 105-115 before even getting out of bed. (Then a few days later I had an episode or two of having it shoot up to around 240 for a few minutes due to a stressful event.)

I've been in touch with one of the nurses down at TCAI, and she sent me to get an EKG locally - and upon seeing the results she says I am in atypical flutter.

Things had been going so well that this feels very out of the blue, and I'm still trying to wrap my head around this. Options I discussed with the nurse are: seek cardioversion, go on AARs, or just go straight to a second ablation. (Dr. Natale's scheduling ablations in April now she thought, so it would be a month or two of a wait in any case.) In the meantime, I'm back on Eliquis and metoprolol tartrate (25 mg bid). The metoprolol might be helping a bit, but I've been sittting in an office chair for the last hour, and my Kardia says my heart rate is 112, so things are definitely not normal.

I'm unclear as to whether this is the half-expected "touchup ablation" many folks need after the index ablation, or whether the timeline or atypical flutter make this something sort of different / less expected?

If I were you I'd go for a cardioversion. After all, why not? It's a couple hours out of your life and the worst case is it gives you a break for a few days or weeks. Best case, maybe months. Don't expect a permanent cure but in my view at least one cardioversion is always worth trying. I would go ahead and schedule the touch up at the same time. With any luck the cardioversion will hold until you get to Austin. Adding an AAD before the cardioversion would make that a lot more likely.

As for the metoprolol, don't be surprised if it doesn't actually lower your rate. Flutter is often immune to rate control. Mine was completely immune to it so I didn't bother taking it. All it did for me was add fatigue to the discomfort.

Hi kbog,

An atypical left atrial flutter can, indeed, appear at this stage after your index ablation. It happens less often at the1.5 year mark and later, assuming there were no to very few breakthrough episodes during that first year or so after an index ablation.

What we have learned over the last two decades is that after an advanced expert index ablation by a top operator, such as Dr. Natale, it's not uncommon for such an atypical left flutter to appear usually within then first year to 1.5yrs after index ablation.

And if the person has had sporadic recurrent episodes after the blanking period, and yet has not gotten such a repeat recurrence durably silenced with a follow-up ablation, then it usually will continue to make unwanted appearances going forward until you do get it addressed via elimination of the atypical flutter circuit where-ever it is found in the left/right atria.

It appears that certain people with more advanced paroxysmal or persistent AFIB will require addressing such an atypical flutter circuit, often as the last step in achieving true freedom from all atrial arrhythmia.

And in such cases of very late recurrence after a decade or more of silence, when the triggered activity typically arises from the LAA/CS, it almost always then recurs as an atypical left flutter when the LAA/CS is the source of the late recurring flutter.

Much more rarely, when a decade or longer freedom from AFIB is achieved via a successful PVI, and a very late recurrence of AFIB (and not an atypical flutter) is found to be the new late recurring trigger, the new AFIB is more likely to arise from an area that was not ablated a decade earlier and only became active many years later.

However, I have heard of some other rare cases in which a previously isolated PVI can also show a very late reconnection of AFIB many years later, if that trigger was not durably isolated during the PVI and/or was in area with very infrequent sporadic activity.

Bottomline Kbog, with your having documented atypical left flutter with increasing actively roughly 2 yrs post ABL, I would for sure sign up for a touch-up of that atypical flutter circuit by Dr Natale, ASAP, and put the genie back in the bottle for the long haul. As Carey noted above too a Cardioversion could buy you some more time in NSR, especially as Carey noted, if you have to wait several months for the touch-up with Dr Natale.

Shannon



Edited 2 time(s). Last edit at 02/24/2020 05:29PM by Shannon.

Layman dumb question:
what is an index ablation? Is it a regular typical ablation or something else..somewhere else in the heart that is ablated?

Hi Susan,

An 'Index ablation' is the commonly used term by Cardios and EPs for a 'first ablation' (as in 'index' = 'first') ... or it can be used as a first ablation for a given patient by a given EP as well.

Plus, an 'index ablation' usually represents the main or most comprehensive ablation, but not in all cases.

Shannon



Edited 1 time(s). Last edit at 02/24/2020 07:43PM by Shannon.

Great
Thanks

Hi kbog.

I would certainly go for the cardioversion as a first step, I am currently 6 months out from one and in solid NSR touch wood. I have had 5 ablations, 2 for atypical flutter (Left Sided Flutter) with the last one in 2010 for atypical flutter. I fully believe that the Flutter kicked in because the major 'damages' of the AFIB ablations will not let AF start up.

I had all my ablations so that I could 'be me' again i.e.able to go running thru the hills and training in the gym however now at 70 I have just accepted that the running days are over and only do easy exercise levels in the gym. My life's aim now is to be arrhythmia free as long as possible with a return to Bordeaux if things turn out otherwise.

In my experience atypical flutter is more difficult to to ablate than AFIB given that Professor Jais virtually gave up on my last ablation saying he couldn't get the last bit but the ablation should be considered successful which indeed it was for almost 10 years. Note: All running and intense gym work was stopped after that last ablation but feeling in top form and solid NSR I started jogging again about a year ago and pushed the cardio up a bit in the gym with the Flutter kicking in out of the blue whilst on the Concept 2 rowing machine last June.

PS. At that cardioversion 6 months ago the docs said they could not tell if my EKG indicated left or right flutter and the only way to know was to 'go in' and find out. They said the 5 ablations could have complicated the EKG readings.

Cheers,
Barry G.



Edited 1 time(s). Last edit at 02/27/2020 04:00AM by Barry G..

Cardioversion accomplished and successful - hoping for NSR to continue so I can stretch a return to Austin to the summer months, since I have two school-aged kids.

This was my first cardioversion and i’m not exactly sure what I was so afraid of before. I remember nothing of either the TEE or the CV. Easy peasy - though it looks from the insurance summary that it’s not a cheap procedure!

Thank you for the explanations and advice, Carey and Shannon!

Oops, I almost didn't see your post, Barry. Thank you to you as well for sharing your experience!

So far the cardioversion is holding and I am hoping for good long-lasting results like you have had!

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kbog
hoping for NSR to continue so I can stretch a return to Austin to the summer months

I sure hope you like HOT weather.

Glad the cardioversion gave you some relief! That seems so scary to me.

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Carey

hoping for NSR to continue so I can stretch a return to Austin to the summer months

I sure hope you like HOT weather.

Well, I flipped back out of rhythm today, so maybe it will wind up that I try to schedule sooner after all. Damn this condition. So so tired of it.

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cirenepurzalot
Glad the cardioversion gave you some relief! That seems so scary to me.

Cardioversions are perfectly safe. It's a nothing procedure.

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Carey

hoping for NSR to continue so I can stretch a return to Austin to the summer months

I sure hope you like HOT weather.

Made it back last week to have the touch-up ablation done. You were right Carey - it was over a hundred! But, I got it done.

There was more ablating to do than I had expected - 2 of the 4 PVs had reconnected, and the posterior wall of the LA had regained conductivity. Dr. Natale redid those and a few spots on the roof and floor of the LA, and additionally, he isolated the coronary sinus (this was new). He also re-isolated the SVC.

Is this a typical 2nd Natale ablation? I'm a little bit freaked out that so much needed to be done only 16 months after the first afib ablation, and a little worried that it's indicative of rapid progression. I'm only 49... really hoping this doesn't mean I have a future of yearly ablations in store!