Back in AF after blanking period

Hello All. I've been following the forum for almost a year and appreciate everyone's insight on AF subject.
First diagnosis for AF was June '19 and after several episodes had ablation Nov '20 at Penn Medicine Philadelphia with highly experienced EP. I'm 58 and have always been committed to a vigorous exercise program - CrossFit for the past 8 years.
I finished the blanking period on Feb 10 '21 and had no issues during this period. Was prescribed Profafenone and Xarelto for the period and stopped on Feb 10 as instructed.
Last week I flew to AZ for an outing and pacs started as soon as I left PA. First night RHR jumped to 85-100 from normal of 65-70. Next morning had AF for 2-3 hours.
Came home early and was in NSR over the weekend and RHR came back to 65-70.
Early this morning AF began and took Metoprolol as PIP but after 7 hours still in AF.
I have a follow-up appt with EP this week and wanted to ask the forum what questions I should have prepared for discussion. I know it may be too soon to start scheduling a second ablation and even then I will strongly consider someone like Dr. Natale.
Ah, I also wanted to mention that I developed a gastro issue two weeks ago where every food and drink I swallow creates discomfort in the sternum. Have appt with gastro tomorrow but wanted to mention as some medical experts draw a correlation between gastro and heart issues.
Thank you Carey, Shannon and everyone for your past contributions - it has helped a lot - and I look forward to participating in the future.

I agree it's too early to be talking a repeat procedure, but not TOO too soon. You're out of the blanking period and as soon as you stopped the antiarrhythmic, afib reappeared. I would give it more time to find out often the episodes are going to occur and how long they're going to last, but I would recommend bringing the subject up with the EP.

I would also ask him to prescribe a PIP. It could be the propafenone since you know that works for you.



Edited 1 time(s). Last edit at 02/24/2021 02:46PM by Carey.

My experience - had ablation in August mistook blanking period as NSR until I got wise and had an ECV in Nov. Been in NSR ever since but thinking time to ween off and see how solid the ablation is. I've been taking Flec for 6 months now.
Would like to be 'normal'.

Good luck NLAMA!

I can’t wean off. Even the sotalol isn’t as effective to prevent af and flutter. Now my hr highest was 244. I’m just waiting for my next ablation whenever it will be. At least I’m vaccinated.

I’m hoped NLAMA yours is one and done.

Thanks Carey and all - your responses are much appreciated.
Started back on Propafenone last night and this morning and now NSR restored. Does this possibly mean the antiarrythmic was just covering up AF during blanking period? Thought I was a good candidate for successful ablation and will have to decide if just bad luck or the EP is not as good as advertised.

Dean, it’s possible you could still be in your blanking period. It’s only been 4 months and imho the 3 month rule is not carved in stone but varies from person to person.

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deanpaul
Started back on Propafenone last night and this morning and now NSR restored. Does this possibly mean the antiarrythmic was just covering up AF during blanking period? Thought I was a good candidate for successful ablation and will have to decide if just bad luck or the EP is not as good as advertised.

Yes, it's quite possible the smooth sailing was due to the propafenone, but it's also possible that a month from now you won't need it. That's why I think it's too early to seek a second procedure. I'd say take the propafenone another 3-4 weeks and then try stopping it again. Keep some handy in case you go back into AF.

If you end up deciding you need to go that way, don't just discount your EP as being less than advertised. Virtually any index ablation can require a second touch-up procedure no matter how skilled the EP. I know of several people who've undergone ablations with Natale who required a second procedure, and he usually advises patients in advance that it might be necessary.

Penn Medicine has a very good electrophysiology program and at least one Natale protege, which might be who did yours. Go have that chat with him next week and just tell him what you've told us.

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Carey

I know of several people who've undergone ablations with Natale who required a second procedure, and he usually advises patients in advance that it might be necessary.

or a rare third...since he is super cautious and isolating the LAA may need an additional LAA touch-up. I was told upfront I may need a third. EVERYONE is different and many are lucky to have a one and done.

Thank you both so much for your replies. Carey, if there are specific questions I should ask the EP during tomorrow appointment any guidance would be much appreciated. But I have a pretty good idea of what should be discussed.
Thanks!

Comments from the peanut gallery.

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deanpaul
I'm 58 and have always been committed to a vigorous exercise program - CrossFit for the past 8 years.
I finished the blanking period on Feb 10 '21 and had no issues during this period.

Likely what brought you to afib, however should not be an issue after a successful ablation. Though by no means the majority of lifetime exercisers, it is common for those who are chronically fit to get afib. I'm 65, I came to afib via this path at age 49 (I've never been ablated, even though I had a 2 1/2 month episode in the first 4 months of afib, now AF burden is < 0.02%). I have a couple of hypotheses. One is that there is a genetic reason that all the chronically fit don't get afib, said differently, those who are chronically fit and get afib have a genetic predisposition. Second, is many studies show inverted "U" or "J" shaped benefit curves with exercise. As you push the far end of the distribution in terms of intensity and volume, you are more likely to have issues. In my case, the delayed parasympathetic trigger from exercise is from the product of duration and intensity. Very short high intensity is OK (i.e. 4 minutes of Tabatas) relatively infrequently. Long duration, but low intensity is OK. Long duration, high intensity, not OK . For example, I can lift ski off piste all day without issue, if I'm not pushing every turn as hard as possible. Adding additional vertical by hiking up at the beginning of each lap is bad, as is skinning up and skiing down without benefit of the lift.

I came up with subjective parameters that have been the detraining part of my afib remission plan for over 16 years. When my military son-in-law presented with afib, I wanted to quantify what I did to use for coaching him. The Zone 2/MAF/Nasal Breathing part of this post are what I'm referring to. More recently, I've decided I should not only use this as a governor on exercise frequency & intensity, but I should strive to exercise at this level (but not more) with material volume because of the mitochondrial and blood sugar effect at this intensity. More detail and links here.

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Early this morning AF began and took Metoprolol as PIP but after 7 hours still in AF.

Metoprolol will act as rate control, unlikely to keep you in rhythm. Need a rhythm med like propafenone.

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Ah, I also wanted to mention that I developed a gastro issue two weeks ago where every food and drink I swallow creates discomfort in the sternum. Have appt with gastro tomorrow but wanted to mention as some medical experts draw a correlation between gastro and heart issues.

Certainly there can be an afib/ectopic connection, however, this should not be an issue once you've had a successful ablation.

interesting information George and very much appreciated.
Prior to crossfit exercise was primarily med-intensity cardio with weight-training. CF is mostly 10-15 min high intensity training with the occasional 25-30 min w less intensity. I've been considering detraining and adopting MAF program along with weight-training.
I've never put a finger on triggers: was it wine (avid hobby and was drinking 2 glasses/day forever-not now), intense exercise, or dehydration. I drink a lot of water/day and my blood sodium level has been below min target for years. Blood mag & potassium are normally on low end. How did you confirm parasympathetic trigger?
Genetic predisposition is very interesting. Are you aware of any testing/studies pertaining to exercise and genetics?
Very interesting subjects and I'll be back with additional questions.

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deanpaul
I've been considering detraining and adopting MAF program along with weight-training..

After relistening to the Peter Attia - Iñigo San Milan interview, I'm a big fan of Zone 2/MAF training for almost everyone because of the mitochondrial remodeling that happens. It is not like I'm not fit. I weigh what I did in grade 10 and am leaner than I was then. I got 12" of snow last night and am shoveling it wearing only shorts - no shoes, gloves or shirt (hypothermic conditioning). My heart rate doesn't go above 90 shoveling. I do titrate my exercise with care.

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I've never put a finger on triggers: was it wine (avid hobby and was drinking 2 glasses/day forever-not now), intense exercise, or dehydration. I drink a lot of water/day and my blood sodium level has been below min target for years. Blood mag & potassium are normally on low end. How did you confirm parasympathetic trigger?

Basically, I look at an adrenergic trigger (sympathetic) as afib that happens during exertion. A friend was hauling a deer he'd shot up a hill and got afib. Parasympathetic triggers happen after exercise in a quiet/relaxed state, maybe during sleep or while eating. Of course, some are mixed, who can get both types.

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Genetic predisposition is very interesting. Are you aware of any testing/studies pertaining to exercise and genetics?

Back in 2004 ish, there was a small study out of the Cleveland Clinic and in autopsy, the afibbers all had p cells in their pulmonary veins. The non afibbers did not. No proof, but just a hypothesis. Only 15-20% of the chronically fit get afib - genetic predisposition is an obvious explanation.

Afib can run in families. For example, Shannon's dad died of an afib stroke and his sister also had afib. In my family, 3 of my male cousins (same family) all have afib. Two of them are the fit folk and the other has been a quadraplegic for 40 years.

What GeorgeN said about exercise (length and intensity) applies to me. I don't know about my triggers, I think there are no obvious ones for me. Alcohol, dehydration, infections, stress and tiredness may increase the risk of having afib, as well as heavy meals or high level of carbohydrates, but no certainty about that.
Both my parents got afib in their 80ies. Both my sisters are still afib free to date. I've had my first episode at 57. I'm now 63. I'm the only endurance "athlete" (bicycling) in our family.

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deanpaul
I drink a lot of water/day and my blood sodium level has been below min target for years. Blood mag & potassium are normally on low end.

First, I'm not a doc. Wondering about your water consumption. High thirst? Blood sugar issues? If your blood sugar is high (even intermittently - a fasting level may not tell the whole story), sugar can spill into your urine, taking water and electrolytes with it.

Serum magnesium test is not considered a great one as it can be normal and you can be low in magnesium. However if it is low, you are low. Supplementing can be useful. Start low and increase till you approach or exceed bowel tolerance, then back down a bit.

Low serum potassium (which can be transient) is common when presenting with afib. As I recall, my serum level was around 3.1 when I went to the ER with my first afib episode nearly 17 years ago. A similar level for my son-in-law. The issue with potassium supplementation is if you take it as a bolus, those with healthy kidneys will excrete it in the urine almost immediately. My solution is to put 2 tsp of potassium as citrate in a liter of water and sip over the day - DIY timed release. I'd also put in 1/2 tsp table salt (sea?) . The citrate is easier on the kidney and a 2 tsp: 1/2 tsp ratio of potassium to sodium is considered to be the ratio during paleo times.

There was a time early on in my developing my protocol that I was really successful keeping afib at bay. Then I had a couple episodes. I wondered what had changed. Turns out I'd run out of taurine. When I added my 1/2 tsp of taurine powder to my stack, I went two years without an episode. I later figured out that excess calcium would enable many triggers, so I quit dairy. That was in 2013.

With any supplements, start small & work up. Do one at a time. Suggest starting with magnesium, if you do decide to use supplements.

Getting digestion figured out can also be useful. If you look at this PDF of success stories we put together in 2007, you'll see quite a few related to solving gut issues. I'm not partial to a pharma approach, but to figuring out a food approach to doing so.

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susan.d
I know of several people who've undergone ablations with Natale who required a second procedure, and he usually advises patients in advance that it might be necessary.

or a rare third...since he is super cautious and isolating the LAA may need an additional LAA touch-up. I was told upfront I may need a third. EVERYONE is different and many are lucky to have a one and done.

I have had 3 with Dr. Natale and 5 total. It's definitely a journey.

So far as blanking period goes IMHO it could be longer. Following my first ablation with Natale I was having some other health issues. I had several ECV's that summer following the ablation.

I was beyond the 3 month period and had another ECV scheduled. Then a couple days before I self converted and stayed in rhythm for many months before returning to intermittent afib. So don't be too discouraged yet.

My issues come from my LAA and that particular area can require extra attention.

Who knows how long the blanking period is.......

Jan 2020 - second ablation - On Eliquis and Flec. for one month.
Feb, Mar. - Nothing
April - four short afib breakthroughs at night, all stopped with Flec. (pill in a pocket).
May - one long bout of afib, lasted 34 hrs, stopped with two doses of Flec.
Aug - one short bout of afib stopped with Flec.
Sept, Oct, Nov, Dec, Jan, Feb - NOTHING.

Doesn't make sense - Certainly, the blanking period doesn't last 7 months, but it seems that my experience is strange.

My first ablation 14 years ago - there was no blanking period. After the ablation and one month on a blood thinner and an antiarrhythmic, I had no breakthroughs - period.



Edited 1 time(s). Last edit at 02/28/2021 10:18AM by Ken.