Persistent a-flutter after 2 ablations

First post on this forum after quite a bit of reading here.. I feel motivated to write about my own experience (a) to share and (b) to receive some more relevant advice.
56 yo physically active male. Love to run and x-country ski. I’ve been living with paroxysmal afib for about 10 years. It has been increasing in intensity from short (~30 min) episodes a couple of times per year to weekly bouts lasting quite a bit longer. I’ve been occasionally taking propafenone as PIP, but I doubt that I ever felt anything more than the side effects from it. Finally, the local EP that I’ve been seeing for all this time convinced me to seriously consider an ablation, which I did. I had it done by the same EP on September 9 at Ascension Heart Institute in Southfield, Michigan. He did PVI + isolated some spots on the atrium roof. The procedure and the initial recovery went well. After the first 3 days in NSR, I had a few episodes of afib, eventually developing into non-stop atrial flutter (HR 115-140). Had 2 cardioversions done: one on Oct 6 was a complete failure, the second one on Oct 21 put me back in NSR for only 2 days. My second ablation was done on Nov 19 by the same EP. After I woke up in NSR he briefed me that he was able to pinpoint a few circuits that were ablated successfully. Well, 3 days later – I slipped back into the same persistent flutter. Of course, this could still be the blanking period thing.. but something is telling me that the beast is still alive.
Now, what to do next? I am on Xarelto + 20mg Metoprolol +325mg Propafenone twice per day, which are not doing much except making me feel more miserable. I need to get this thing fixed as it is now affecting my life way worse than I had it before the first ablation. Not sure how soon I can go back into cath lab as I don’t think there are any other options. It’s also clear that I need to move on from my current EP to Dr Natale or another subject matter expert. Looks like Natale’s lead time is about 3 months, correct? Also considering Dr Santangeli (Cleveland Clinic). Any other possible recommendations in the Midwest?
Reflecting on my experience so far, I would not say that I regret my decision to consider ablation (my wife disagrees..) . But what I was not expecting going ahead with the ablation was that at least for some period of time you may end up way worse than before the ablation, and then you’re committed to more of them. This flutter complication does not appear to be that uncommon.. Thank you to this community, it has been very helpful!



Edited 1 time(s). Last edit at 11/27/2022 12:12PM by Dmi.

I just had an ablation with Dr. Natale—I think that the lead time varies according to the patient’s circumstances and his travel schedule. Maybe consider getting into their system and seeing what is possible.

It’s a risk to get flutter from the scar tissue formed from the ablation. I’m curious if the pulse technology, not using heat, decreases the chances of flutter.

Your conclusion that it's time to step up your game to somebody like Natale or Santangeli is correct. Perhaps you already read my story and my advice on multiple ablations because you came to the conclusion I recommended. You're on the same track I was on but you have the advantage of being earlier in the course. You're a complex case now beyond the abilities of most EPs, and definitely beyond the abilities of the EP who turned you into a complex case.

No matter how long it takes you to get in for a procedure; you need to see one of those two, and I would go with Natale if possible.

In the meantime, you can't spend the next 3 months in flutter at 115-140. I would ask your current EP to switch you to something other than propafenone and after that try another cardioversion. Flutter can be very stubborn and resistant to being stopped by antiarrhythmic drugs (AADs). But AADs can often maintain NSR and keep you out of flutter much better than they can stop it.

If you can't get yourself out of flutter and stay out, you've got to control the heart rate, and 20 mg metoprolol sure isn't going to do it. That's a really low dose. Unfortunately, flutter is often unresponsive to rate control. My flutter didn't care how much beta blocker they put in me. Even 200 mg didn't slow it down by a single beat (but it did lower my BP to 50/nothing - never doing that again). If you can't get out of the flutter, then I would just stop the propafenone because it's doing nothing for you.

Call Natale's office tomorrow morning. The longer you wait to start the process, the longer you'll be miserable. Make sure they understand your persistent heart rate. Like Daisy said, your circumstances will affect scheduling decisions. You should be a high priority unless you can get that rate down under 100.

Thank you for the responses. I will definitely call Natale’s office tomorrow. I’m also seeing my local EP on Wednesday and will talk about another cardioversion and changes in meds.
Carey, yes - your post indeed influenced my line of thought. Thank you for that! I think it’s a very impactful story and it needs to be pinned at the top of the forum! Until I read it and connected the dots with my own case, I was skeptical about having to pick one of the few elite EPs. I thought “how hard can it be? A well trained and hard working doctor has to be able to master the skill in 10+ years of practicing it (which is the case with my EP)”. But after going through ablation a couple of times and educating myself more on it, it’s getting clear to me that while the “mechanics” of the procedure may not be that big of a barrier and most EPs get there eventually, the number of variables to consider, interpret and control during the procedure in real time is huge and that increases the complexity of even slightly complicated ablations exponentially. That’s the barrier that most EPs never overcome.
Carey, I hope you’re doing well after your procedure done by Natale in 2017.

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Dmi
Carey, I hope you’re doing well after your procedure done by Natale in 2017.

Thank you, I am. I've been consistently in NSR ever since. He accomplished in 2 hours 20 minutes what 3 other EPs with excellent credentials and experience had failed to accomplish in 7 years with 5 tries. I was skeptical at first just like you. I felt that any EP with decent training and experience should be able to solve my problem, and I shied away from what I perceived to be a sort of Natale fan club. It took Shannon Dickson to help me understand that it's not a fan club. Natale really just is that good.

I ll second all this. I had an afib and right flutter ablated 2012. The left flutter march 2021. Didnt work. Was worse. The to Austin. Natale flutter ablation Aug 2021. Nothing since other than an alcohol induced 20 min episode. Atypical Flutter is not the easiest. Dr Natale isolated my LAA then put a Watchman in me Feb 2022

“How hard can it be?” Is the obvious mindset after talking with a respected EP—an experienced EP should be able to handle most anything, right? From the experiences reported here—wrong! Ablation seems to be an art as well as a skill with so many variables presenting themselves. For my recent Natale ablation, I arrived in atypical flutter which, during the ablation, turned into Afib, then as he worked, back into flutter until he finally got it all after isolating a number of areas including the left atrial appendage. Note: there are not many EPs who have the skill to isolate the LAA. This is likely to mean a Watchman in a few months, but that is an extra layer of stroke prevention in any case. It is really worth traveling to have an ablation with one of the best.



Edited 1 time(s). Last edit at 11/28/2022 10:53AM by Daisy.

My ep here who i love told me of atypical flutter: it’s problematic. He didnt touch LAA. I got waaaay worse
Natale fixec me. 16 months of zero

A quick update and a question:
Just came back from the office visit with my regular EP. He was somewhat stumbled pointing out a different flutter pattern on my ECG compared to the pattern before the second ablation . His best idea was to put me on amiodarone and see what happens over the next couple of months. I said that I'd like to see other specialists and his suggestion was to go see Dr David Hines at Beaumont Heat Rhythm Center in Royal Oak, Michigan. So, my question is - does this name mean anything to the veterans on this forum? He appears to be among the "who is who" list in the global EP world. e.g. a member of 2023 AF Symposium faculty. I will likely see this EP just to see what he says..
In the meantime the wheels are in motion to set up a consult/procedure visit with Natale (likely Feb), also have an appointment scheduled with Dr Santangeli for Feb 13 in Cleveland. I'll have to pick one of these paths.



Edited 1 time(s). Last edit at 11/30/2022 03:12PM by Dmi.

Have you contacted Dr Natale’s office yet? When I called originally, Norma asked if I wanted a consultation or if I knew I needed the ablation. I had already decided I wanted ablation based on conversations with my EP but I wanted it done by someone who I could prove was one of the best. This forum helped me settle on Dr Natale.

Someone here can correct me but based on what I was told, you can choose a consultation 1st to see what Natale suggests

@Geocappy, Yes, I've been in touch with Norma and working on setting up the same week consult and ablation visit. My working assumption is that I will need another procedure.

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Dmi
Carey, yes - your post indeed influenced my line of thought. Thank you for that! I think it’s a very impactful story and it needs to be pinned at the top of the forum!

Is it possible to pin this post at the top of your list of posts, Carey?

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Poppino
Atypical Flutter is not the easiest. Dr Natale isolated my LAA then put a Watchman in me Feb 2022

He isolated my LAA on my recent index ablation--I also had atypical flutter. So I am wondering if anyone knows whether atypical flutter usually comes from the LAA? I think that was the case for Carey as well.