Update on my situation

I was ablated on 27 July, but had to go to the ER twice in the next six weeks due to out-of-control SVT and AF. I was placed on a six week regimen of Amiodarone, but it had to be extended when I went to the ER the second time. I went off Amiodarone 16 days before wearing a Holter Monitor for 18 hours.

We had to return from a visit to my daughter's early when my heart began to act up. In fact, it had acted up the night of the day I returned the monitor. However, I had been sleeping relatively well and felt well enough to travel. I didn't even need melatonin or Zopiclone during the next week. Then, the heartrate climbed to 130, often as low as 85, but that was while seated on a couch.

On the way home, I followed up on the AF clinic's outreach nurse's invitation to call her about the results of my monitor. She related to me that there was no AF, even when walking aggressively up a 8% grade for nearly three minutes. However, she said, there were a LOT of PACs.

To keep this both merciful and short, when I reported what I was going through the past week, she offered to consult with my EP directly and to report back what he wants of me. She did state that cases like mine respond to metoprolol, and if not, propafenone. I hope they won't put me back on Amiodarone. Not that I suffered unduly, but I know a lot about it...as you'd expect.

One odd effect since the ablation has been that when I start out on a walk, no matter how slowly, my heart rises to 125 BPM. This is without exception. If I sit for about two minutes, I can watch the rate drop slowly to 95 or so, and then in a blink the watch shows 72-75 BPM. It's like a reset of some kind, and from then on, usually, not always, I can walk more briskly and the heart won't go above 110 or so, at least watching to ensure it doesn't rise above 120. After the second MIBI test, the attending physician advised me to avoid going over 120 due to the onset of SVT.

So, that's where I am. I don't know if others can relate, or want to share, or offer advice. It has been a real roller-coaster for me, and I hope to see the end of it before March if that is possible with my exceedingly busy EP.

About high hr [www.afibbers.org]

I would imagine your EP will simply call in a prescription for metoprolol. That will most likely keep the rate down, which you do need to do. It needs to remain under 100 except when exerting yourself.

Not sure my input is relevant. I had my ablation 8/9/22. I was not having any symptoms to speak of and in NSR. Heart rate was 78-83. They took me off 50mgx2 per day Flecainide after 2.5 months. Heart rate at 85-93 now mostly 85-88. It does get in low 90s resting sometimes. They were going to ease me off 50mg of Metoprolol but are keeping me on it for now. Had one ekg “unclassified a week or so ago and had multiple unclassified ekgs on kardia today. Nurse said could be nothing but we will see. No symptoms

Thanks, everyone. I have not read the link above, but I will. Meanwhile, I did a lot of reading this morning, and have registered at the Mayo Connect forums which have modestly high volume. What I now know is that PACs, in and of themselves, are not particularly concerning to the medical establishment. If the burden is high, yes, they'll offer something, but most post-ablation cases have PACs (to help situate why I had to learn this, my first ER visit six days after ablation showed AF and SVT. So, I have assumed, until Tuesday, that I was still getting AF.)

I have avoided returning to metoprolol for now. I was on it post ablation when I went to the ER, and was told I was getting a lot of bradycardia...down to 30 BPM. That suggests my SA node was severely hampered. I'll keep a sharp eye on what my heart is doing, and I'll certainly do what the EP says to do thru the outreach nurse.

Be careful gloaming with your low hr for sinus pauses when the heart temporarily stops. I had from 6-15 second pauses where the ekg just flatlined every 5-10 minutes after my ablation. Perhaps get a holter monitor to see if it’s just a rare episode or if your SA was slightly damaged. You may need to get this watched.

Thanks, Susan. I do keep as good an eye as I can. Holter monitors are meted out by the medical establishment, and in Canada they're busy...overwhelmed with rising deaths due to COVID and Long COVID problems. Maybe my EP will want another one soon to see if there's any change.

Well, it turns out my Galaxy watch, and my sensations and suspicions, were correct all along. At her request, I sent in two ECGs to the outreach clinic nurse who has called a number of times to check up on me. These were downloaded from my watch and sent as pdf files. To me, they clearly show no P waves and the QSR complex intervals were quite noticeably varied in separation on the chart.

She agrees, and has referred me to the EP. Happily, I already have a phone consultation scheduled for 05 December, about six times as fast as when I was first referred to him this time last year.

As she pointed out, this is all good news. It means I don't have rocks in my head, that the watch was providing veridical information, and that I won't have to live with what I was told for the past six weeks were nothing but PACs, including from the Holter monitor. It means a second ablation, almost certainly, and that this time the gentleman physician will have to do what I asked him to do at that first consultation; map me out comprehensively so that I won't have to appear before him again...or he before me. When I asked if he would do that, he replied that there is no need and that he figured I was going to need nothing more than a PVI. He may still be right, and he'll just have to do a patch-up of the scarring stockade, but I don't think that's the problem any more. Those PACs, 'lots of' them according to the feedback from the nurse, were indicative of something else going on.

Thanks for reading. I enjoy reading, to the extent one would permit oneself enjoying reading of the suffering and anxiety of others, all of your accounts and descriptions of problems or experiences. I'm just adding my own....

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gloaming
When I asked if he would do that, he replied that there is no need and that he figured I was going to need nothing more than a PVI.

There is no way for him to know that in advance, and an EP who doesn't look for non-PV sources is an EP with a poor track record of successful ablations. If he's only going to do a PVI he may as well just use cryo. A good EP spends a fair amount of time doing nothing but mapping before using the ablation catheter. And then when they think they're done, they spend more time giving you an isoproterenol challenge to provoke any hidden sources into revealing themselves.

I agree, Carey. I'm disappointed, both in his cavalier attitude and in my results. I intend to ask him three questions when he calls:

a. What is your novel approach to my obviously complex case;

b. Does your record describe any atrial scarring in me; and

c. Has my ejection fraction changed over time since my diagnosis in 2017, and how would you describe any prolapse extant, if any? I was told I have a functional murmur many years ago that, as a competitive runner, was typical and of no particular concern. I want to know what the latest assessment of my ejection fraction is, both in NSR and when fibrillating...if both are noted in my record.

My hope is that the latter two will be both informative and non-consequential, and that he'll be much more comprehensive in his method, including explaining it to me. I have faith in his abilities, but not much in his care and concern. I feel he'll be a bit contrite this time, or at least acknowledge that he ought to have taken more time. I'll keep an open mind because he may reveal something about my first ablation, and why it hasn't worked, that I don't understand at the moment.

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Carey
A good EP spends a fair amount of time doing nothing but mapping before using the ablation catheter.

I was very surprised at how much Natale found on mapping during my ablation a week ago. He ablated the PVs, isolated the posterior wall of the left atrium using roof and infero-posterior lines, the anterior wall and floor of the left atrium and anterior roof of the left atrium, the LAA was ablated ad isolated, the coronary sinus was ablated and isolated.

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gloaming
Does your record describe any atrial scarring in me

Unless he has done a cardiac MRI, using contrast enhancement with gadolinium, I doubt if he could quantify atrial fibrosis. Natale noted atrial scarring during mapping.

Good to know, Daisy. Sorry to be so late acknowledging your contribution. A lot of water under my bridge recently, and I have neglected this thread.

I am going to get ablated again, but no date as of yet. In Canada, remember? Shouldn't me much more than four months from whenever his office calls to set me up.

I have had some intense excitement recently which resulted in loss of sleep. It was all good news, but the kind that can disrupt a life. The result is that I have had a rapid heartbeat since Friday. No palpitations, but I thought I was just getting used to AF when it was occurring. Long story short, it was flutter. This is a new development for me. I was injected with adenosine, and when the ECG stretched out enough, the internist said, "Yup, there it is." He had guessed that my rapid, apparent NSR was hiding flutter, and he was right. I was cardioverted within an hour, and the first low-joule zap did it.

Back home, about an hour and a half later, I glanced at my watch and it said 128 BPM. Fortunately, it reverted again quickly and has been stable since.

If it helps anyone reading, I was also somewhat dehydrated. I had gone to bed two nights with high heart rate, and it was still there in the morning. Stewing a bit all day, I probably neglected to drink as much clear liquids as I usually do. They gave me two bags of water in the ER, but they didn't help. So, maybe, perhaps, dehydration can put you in AF or flutter, but getting hydrated again won't necessarily cause you to revert.

I'm going to take half a Zopiclone tonight and see if I can't get some rest. I sure need it.

Thanks for reading, and for any comments. I'll try to be better about tending to the thread in the future.

Third cardioversion failed, and an IV drip of 150mg of Amiodarone didn't shift it. So the game plan is to try to reduce the rate and I'll have to live with flutter until I can get the second ablation. Fortunately, I am entirely asymptomatic. I don't know for how long, but right now I could live like this. For a while, anyway.

So do you have the rate under control? How high is it?

Carey, it was upwards of 125 for days. I have advanced, over 30 hours, to about 75 g of metoprolol/day, and I was relieved to glance at my watch near 2100 last night and found it down to 95. Overnight, it was in the 70-80 range, but has begun to climb again as of rising near 0350. I took another 12.5mg of metoprolol, and it's hanging on at 93 just now. There are times when it falls to 55 BPM, my normal sedentary rate, but it only lasts for minutes...sadly.

I suspect I'll top out near 80-100 mg most days.

You may as well just take 100 mg twice daily instead of trying to titrate.

Consider yourself lucky that metoprolol works for you because flutter is often resistant to rate control drugs. Mine was completely immune to metoprolol. Even 200 mg didn't slow it down by a single bpm (but it did crash my BP to 50/nothing and put me into cardiogenic shock).

I have a 4:1 block in the left atrium. We're trying to control my rate, not so much the arrhythmia. My HR is running between 140 and 125, usually much closer to the latter. As you would know, I can't go forever much over 100, so they want at least to beat it down to 95-ish if they can't lick the flutter.

I had some success over night. I awoke to it being near 70, but events through the day had me back up at 140 again. More metoprolol, and it's a tricky thing for me because I can crash hard right down to 30 BPM in an instant with that drug. I'm at 96 as I type, but it showed 55 just minutes ago. ???

My EP knows, and he'll make a decision to bump someone who is currently in line if he needs to. At least hearing that is reassuring. The way it's going, I'm not going to do well over the next 12 weeks.

I appreciate you popping in with your observations, Carey. It means a lot.

If metoprolol can dump your HR down into the 30s I can see why you're titrating it. Sorry you're having to deal with this. I know flutter too well and I know it sucks.