Persistant flutter after ablation and late Eliquis dose

Hi Folks,

I had an ablation with Dr. Natale in November and so far it's not working great. I have persistent flutter. Dr. Natalte's office is recommending I get a CV but my local provider says they don't worry about it unless my resting bpm is 120 or above, it's about 72. I see them again on the 27th to try and figure out what they're going to do. Here is a complicating issue. I've been very consistent about taking my Eliquis until yesterday when I took my first dose of the day 3 hours late and then I tried to monkey with my timing to get back on track and I forgot again so I ended up taking the next dose 16 hours after that one.

Is that a serious enough lapse to keep me from getting a CV even if they agree to do one?

Also, Dr. Natale is suggesting if they won't do a CV to come on back for a touch up. What do you think?

Thank you in advance for your input!

Steve

Being 3 hours late is no crisis, and you don't need to try to fix it on the next dose. Just take the next dose when due. The fact that you've been on it consistently for months with only two late doses won't lead them to withhold the cardioversion.

With a rate of 72 I wouldn't worry much about the flutter, but I also wouldn't just let it go for weeks. I think your local EP ought to be willing to cardiovert you, but a lot of them don't like to if the rate isn't abnormal. An ER almost certainly wouldn't be willing.

There are a few things you can try to break the episode yourself. I sometimes had luck with exercise, and even more luck if I augmented that with a hefty dose of potassium first. The easiest way to do that is go to the store and buy two of the large size cans of low sodium V8 juice. Guzzle both of them on an empty stomach, and then about 30 minutes later do something that will raise your heart rate to 120m or above. Running, cycling, swimming, jogging flights of stairs... whatever you like, just anything to get your heart rate cranked up. Keep at it at least 10-15 minutes.

I wouldn't agree to a touch up until you've managed to break this episode and more episodes follow.



Edited 1 time(s). Last edit at 01/23/2022 05:07PM by Carey.

“ An ER almost certainly wouldn't be willing.”

Maybe true at your ER but I had 51 ECVs at five Californian ERs and I never had a problem getting one even if my hr was <85…sometimes they ecv me at 67-70. I think it depends if one pushes hard enough in requesting an ecv.

So question.. on the CV post ablation. I understand the blanking period... I am having a hard time understand when folks do a CV post ablation. Some I have read they won't touch it for months. Others they do. I get the rate thing- if too high they want to do "something". But I though the whole blanking period was for the heart to work out the kinks.. heal the burns etc.. I suppose in this case you are nearing that 3 month mark so they want to CV and see what happens. just trying to understand as I continue to gather info on if I will do an ablation or not. thanks.

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bettylou4488
So question.. on the CV post ablation. I understand the blanking period... I am having a hard time understand when folks do a CV post ablation. Some I have read they won't touch it for months. Others they do. I get the rate thing- if too high they want to do "something". But I though the whole blanking period was for the heart to work out the kinks.. heal the burns etc.. I suppose in this case you are nearing that 3 month mark so they want to CV and see what happens. just trying to understand as I continue to gather info on if I will do an ablation or not. thanks.

If the rate is over 100, they can't just ignore it. Prolonged tachycardia can lead to heart enlargement and heart failure, so it can't be allowed to continue for weeks or months. If the rate is under 100, it poses no threat but it's not helpful either. Your atria are working harder than they need to, and for many people it's uncomfortable. There's no benefit to allowing the heart to remain in an abnormal rhythm. That's not how your heart works out the kinks. I think you may have misinterpreted what people are saying if you think they're intentionally avoiding managing arrhythmias. The optimal situation is for your heart to remain in NSR during the entire blanking period -- to give it a rest and let it heal. That's why antiarrhythmics are very commonly prescribed during that period.

The only problem here is Steve's rate is perfectly normal, so many/most doctors won't want to intervene.

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susan.d
Maybe true at your ER but I had 51 ECVs at five Californian ERs and I never had a problem getting one even if my hr was <85…sometimes they ecv me at 67-70. I think it depends if one pushes hard enough in requesting an ecv.

It's not California vs. Connecticut ERs; it's you. You're an unusual patient with an unusual medical history, so they're more likely to accommodate you. If I walked into almost any ER in the US in atrial flutter and a rate of 72, I'd be surprised if any of them would be willing to cardiovert me, even in California. That wouldn't be an emergent problem for me, and ERs don't have the time and resources to treat things that aren't emergent, especially these days.

I’m not an unusual patient. Everyone is unique in their own heart performance. For example in one extreme, to be physically able to bike with their EP’s blessing 50 miles three days after an ablation — or the opposite have debilitating symptoms from escalating toll from afib and elect to suffer at home for days or weeks until they see their cardiologist —to those converted by ECV quickly to nsr to get on with their life.

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susan.d
I’m not an unusual patient.

You're extraordinarily unusual. You know that, Susan. You've said it yourself.

But whatever the case, I promise you that most ERs are going to be very reluctant to cardiovert a stable patient with a normal heart rate. It's not a life threatening condition and it's a time consuming procedure requiring a lot of staff. It's just not in the realm of what ERs do so most simply won't. I've heard from many people who've been turned away from cardioversions at ERs for reasons like this, and I spent 15 years visiting ERs on a daily basis. I'm pretty familiar with how they operate.

I'm going to give the V-8 protocol a go Carey. Thanks!

Tried it out today Carey. No luck. Kardia was reviewed by Audrey in Dr. Natale's office. Still in flutter. She said mine looks atypical and likely arising in the the left atrium. Don't really know what that means in terms of treatment.

Not sure if my experience will be helpful or not, but in the event it is..... I had a LAA isolation back in Sept. 2013. It was a extensive ablation, and all was quiet, until an acupuncture session. No sooner than the second the acupuncturist put a needle in my left shoulder area, I felt my heart go fast...not uneven, just fast. I called Dr. Natale's office and for the first and only time in my 10 year history of Afib, I was told to get a ECV. My NSR lasted for approx. 2 weeks, at which point it came back. Dr. Natale told me I needed a touch up ablation for what was now Flutter (never had it before), so I flew down to Austin to get a Flutter ablation done. I have been in NSR ever since 7.5 years so far - and just had the Watchman implanted on January 11th, by Dr. Natale himself.

It's my hope that once I reach the 6 months post Watchman implant, I will be able to get off of Eliquis and the baby aspirin they have me on for now. I hope you have good results and can look forward to a quiet heart too, Steve.

This sounds a bit like what I'm going through. I had by 3rd ablation plus Watchman in mid December and it was suppose to be a touch up to hopefully get off Multaq. (first two by Natale, the last at Vanderbilt). The arrhythmia has gotten worse since the touch up ablation - not afib, but in flutter most of the time with some PACs. Meds was changed to amio because Multaq was not helping any (don't like that drug!)... and added Metroprolol ER once a day. My resting heart rate is not bad- around 70. But the flutter is a concern. I'm still within the 3 month blanking period- but I'm not optomistic at this point since the problem has increased over time.
My TEE for the Watchman follow up is not until April. So, I doubt that anything will be done until then as far as a plan of action. At this point I'm just dealing with the flutter on a daily basis.
Ken