Ablation Dilemma

I'm facing a dilemma regarding a possible ablation for my atrial fibrillation/flutter and am hoping for some advice/insight.

62 year old male. I was diagnosed about 22 years ago with afib. The episode was triggered by binge drinking/dehydration/stress and ended in the ER with medication. I had a few more episodes with no obvious trigger in the months that followed. I was put on flecainide (100mg-twice daily) and extended release metoprolol (25mg-once daily) and have suffered no ill effects from either for all these years. I do have occasional breakthrough episodes. Maybe 2-4 a year. Always in the middle of the night, usually after lying on my left side. My heart rate goes as high as 135. In the past I frequently had pretty troubling symptoms (palpitations, dizziness on standing, anxiety) and would often go to the ER for either IV treatments or a cardioversion. Have had numerous tests over the years including echocardiograms, nuclear stress tests, etc... all found normal range of heart function.

After an episode while on vacation a few years ago which led to an ER visit (big city, no fun!) I asked my EP if I would be a candidate for PIP Eliquis to avoid need for ER. (ChadsVasc score of 1 for moderataly high blood pressure, taking amlodipine). I Would take 5mg of Eliquis twice a day, also take a Xanax along with an extra Flec tab and one or two additional Metoprolol tabs and go about my business. Monitor symptoms, track with Kardia device, wait it out, hope to convert on my own, schedule a CV if it hasn't resolved in a week or so. Would remain on Eliquis for 30 days after conversion. He agreed and this system has worked and my episodes usually convert within 48 hours with no ER visit. I also have sleep apnea and ALWAYS use my cpap. I have also made lifestyle/diet modifications that help reduce the number of episodes.

My EP says I should consider ablation since my condition is more akin to flutter than afib and might be an easy fix. But my dilemma is that I am fine 90-95%% of the time. It has very little impact on my daily life. Yes, it would be nice to travel overseas if I chose or to have a few drinks by the pool occasionally without going to bed afraid of another episode that might require an ER visit. But am I putting 90-95% of good health and happiness at risk by trying to squeeze out that other 5-10% of quality of life? Should I just be happy with what I CAN do rather than feel sorry for myself about what I CAN'T or shouldn't do?

While ablations are almost always safe, they do have risks (perforations, stroke, worsened arrythmia, liklihood of repeat procedure, and of course the cost). I am currently retired and on a Health Exchange insurance plan (Obamacare) as I am not eligible for Medicare for another 3 years.

Advice from others who faced the choice?? Does waiting three more years make it more likely an ablation would fail? Evan a successful ablation doesn't guarantee it won't come back in a few years so you never have total peace of mind right? I also realize its very likely my afib will get worse as I get older.
Also, for those who have had an ablation with Dr. Natale or others, what was your out of pocket cost? Was it Medicare or other insurance?

Thanks

I agree with your hesitance to seek an ablation. I've had six, just to give you some perspective on where I'm coming from. If I were in your shoes, I would probably hold off.

I actually went 8 years having 1-2 episodes per year that always lasted six hours and I did absolutely nothing about it until the episodes started becoming more frequent and lasting longer. Then I sought an ablation, but unfortunately from the wrong guy. He did 3 ablations that succeeded only in adding multiple flutter circuits to my afib. And he had extremely impressive credentials, which is why academic credentials don't mean diddly to me when it comes to choosing an ablationist. The refrain you'll hear over and over here is to pick the EP with the most experience doing afib ablations that you can find. Trust me, that's the best advice you'll ever get.

I'm a little concerned with your current doc's statement that it seems to be mainly flutter so it might be an easy ablation. First off, if you have afib documented by ECG then that statement is strange. You can have afib and flutter, but it's doesn't make sense to say it's mostly flutter. If there's afib present in any amount then it's not going to be resolved by a flutter ablation.


Holding off on an ablation won't change your odds of a successful ablation if you put it off unless you put it off so long that you end up in persistent afib, and then it will reduce your chances of success significantly. So when the afib starts becoming more frequent and/or lasting longer, it's time to take the plunge. It probably will become worse eventually, but you don't know if that's going to be one month or 5 years from now.

If you can hold off for 3 years when you're covered by Medicare, your out of pocket cost will be your deductible, if any. It will be virtually free. Currently, it will cost you whatever your deductible and copays are. When I did mine I had employer-provided private insurance with high deductibles, so each procedure was costing me about $5-6K.



Edited 1 time(s). Last edit at 06/06/2022 02:59PM by Carey.

I have only had three flutter episodes in three years since my ablation for A-fib. I’m wondering if you are saying that if it’s not a big problem just leave it be. I kind of thought I was perhaps wrong in that I didn’t go sooner for my “touchup “ablation after the A-Fib ablation. But after having this third episode & not liking to be on meds, it seems like a very good idea to have it taken care of now. My Medicare and supplemental will take care of it, so it seems risky to wait because you never know how they might end up changing Medicare benefits as times get worse. Also, since Dr. Natale did my first ablation & I have such trust in him & the team which includes everyone here too, I want to make sure to get him to finish the job before he retires. Who knows when that will be though I don’t want to take any chances.

Good luck, hacksman.

As Carey sys if you wait a few years you’ll be in Medicare so it’ll be free. Also by that time Pulse Field Ablation might be fully approved and common. Supposedly much safer so that might help with your worries.

I got an ablation last December. My burden was pretty minimal, but the mental burden was larger. I just worried that it might happen when I travel, if I have some wine, if I get dehydrated etc. So even though that possibility is still there, it’s minimized, and certainly the mental burden is zero, whether it should be or not.

It’s never going away, and in many cases will get worse. So I’d plan to have one at some stage.

Your frankly not that bad as Afib goes so my advice as Carey says is to wait 3 years as most likely by then i am sorry to say there will be no doubt about the status of your flutter/afib malady you are currently suffering from. In the meantime try a PIP of dif. sorts as you have tried Flec. already look into Propafenone + as you are doing that try natural supl. that sometimes help a lot like dif. types of Mag. just to name 1 as there are endless posts about that particular supl.

GL

Thanks so much for the replies! I've lurked on this forum for some time and thought I would tap into the vast knowledge and experience of the members. You did not disappoint!

To Carey's point; it was definitely afib the first few times I had episodes. Confirmed in ER (I recently moved to another state and had to change health care providers so my records aren't at his fingertips). But lately, my Kardia readings when I showed them to my doctor suggested mainly flutter (fast but mostly regular). I have no doubt my episodes still include at least SOME afib. My EP says they don't do ablations at his facility but do refer to other clinics that do so he's certainly not pushing an ablation.

I guess while waiting might increase the possibility of new treatments, it may also mean more frequent episodes. But, maybe they won't get worse and I can avoid the procedure altogether? Argghh! I have in fact slowly come to terms with the high likelihood that I will need an ablation eventually.

I have gotten lazy about magnesium supplementation. I was good about it for a few years but I ran out of my supply and I didn't restock. I will do that today.

I would very much prefer to wait for Medicare as I will face an approximate cost of $8000 (max out of pocket) if I use in-network doctors for the procedure or unlimited cost if I go outside the network (which I almost certainly would). I will do plenty of research regarding coverage for ablation procedures before I choose an insurance policy next year.

At my age, I have come to realize there are sooo many people dealing with health issues that have many more restrictions on activities, lifestyle, diet, travel, etc... than I face (at least for now). Perhaps these health issues force us to appreciate the small joys of life that we often take for granted.

Thanks again

When you sign up for Medicare make sure you get regular Medicare and a Medigap Plan such as G. That way you can use any EP in USA. Don’t get an advantage plan.

See if your employer offers retirement secondary medical insurance once you retire and get Medicare. Ours did as a benefit and my ablation only cost me under $500.

My Medicare adv plan has a low copay and has Nationwide coverage.



Edited 2 time(s). Last edit at 06/26/2022 09:29PM by SailorGuy1.