My Ablation Experience

Hi Folks!
Had my index ablation at TCAI 5 days ago and wanted to share some info and get some input. This is a follow-up to my post a few months ago entitled “ablation dilemma”. It is long but I always enjoyed reading other people’s detailed stories so I’ll offer mine.

After 20 years of paroxysmal afib/flutter including 3 ECV’s and several ER visits, my episodes began increasing from 0-4 per year to 8 over just a 6 week period in 2022 lasting from 5 to 50 hours. The big trigger was when my car was stolen in early August. The stress/anxiety set off a cycle of episodes. Others were triggered by alcohol, turning onto my left side in bed, or just taking a shower or eating a large meal. I was having to cancel events, or stress about upcoming plans and whether an afib episode would interfere. It was beginning to run my life. Plus, the flecainide (100mg bid) was becoming ineffective and perhaps even pro-arrhythmic, and my local EP said my QRS was showing a small delay. He wanted me to switch to amiodarone as a bridge to an ablation, but after doing research and reading this forum, I declined and chose to reduce my flec dose to 50mg bid. Thanks to years of advice on this forum, I realized it was time to seek an ablation.

I made contact with the TCAI through the website. I asked my local EP to send my medical records there and about a week later I received a phone call. I asked about Dr. Natale’s availability but was told there was a separate process for contacting his staff and the wait might be extensive. But I was offered to be put in contact with Dr. Rodney Horton who had some upcoming availabilities within the next 6 weeks or so. Since I am still paroxysmal and on the younger side (61), without significant co-morbidities and this would be my first ablation, I’ve been told my ablation SHOULD be fairly uncomplicated. In doing research I felt very comfortable with Dr. Horton (or really any EP affiliated with TCAI) and I chose to go forward with the process and was given a date in late November. Dr. Horton has also been mentioned on this forum including by Shannon who identified him as an excellent EP. TCAI is out-of-network with my new insurance company but my maximum out-of-pocket even out-of-network is very reasonable.

Austin is a 7 hour drive from my home so I had my consultation by phone with Dr. Horton who approved me for the ablation based on my medical records even though they did not include a 12 lead ECG while in Afib. I sent a Kardia 6 lead tracing during a recent episode and Dr. Horton said that was sufficient. We drove to Austin the day before, checked into the midtown Holiday Inn (using the St. David’s discount-$79.00 per night!”) and showed up at St. David's the morning of the procedure. I was told by his nurses to discontinue flecainide 4 days before the procedure (I actually stopped it midday on the 5th day before) and to stop the metoprolol on the day before the ablation. I did go into afib 3 days before the procedure. It was a 10 hour episode that converted at home overnight.

My procedure went very well!! Dr. Horton told my wife while I was in recovery that he was very pleased and that there were no complications. He did a standard PVAI along with the posterior wall of the left atrium. Isuprel test at up to 10mcg for 10 minutes showed evidence of reconnection with the pulmonary veins so those areas were re-isolated by RF. The report ends that phase with the line; “no arrhythmias were induced”. Does that mean I was never in afib/flutter during the entire procedure? I did feel a few weird heartbeats in the hours afterward but unlike in the past few months, they never progressed into afib. Yay! As of today, I have not had any afib or flutter episodes. I do have some ectopics that put me on edge, but they go away after a minute or so. I’m sure that’s just blanking period stuff?

I wish I could say the recovery was a breeze but it has been a challenge. Make no mistake; this is a surgical procedure. You are fully prepped, shaved, IV inserted, and put under general anesthesia. You also spend a few hours in the recovery area and must spend the night in the hospital being monitored (unfortunately, the new 6th floor rooms were all occupied so I was sent to a room on the 2nd floor. I’m not complaining. It was private but my wife had to sleep in a recliner rather than a pull-out couch). I had some minor chest pain and coughing, but my main issues were pain from the catheter insertion sites and a sore throat. The site pain can be at times searing, like a knife being plunged into the skin. But it only hurts when I tried to walk. No pain when lying down or sitting. I had no bleeding or hematomas, or even bruising, it was healing perfectly, they just hurt like crazy! The TCAI nurse (Becky) graciously spent a lot of time with me the day after and said there is a bundle of nerves there that may have gotten irritated. It is getting better as the days go by. I was told I could take ibuprofen for a few days to help. But not to take it long term due to the Eliquis. I was discharged the day after the procedure and spent the next two nights in Austin in case of complications. There were none. We drove home on the third day following the ablation.

I am no longer on flecainide but was told to continue the 12.5mg bid metoprolol and the 5mg bid eliquis. I have a follow up scheduled by phone with Dr. Horton in five weeks. I will also send Kardia ecg’s once a week to his office and will receive a patch to wear in a month or so in order to determine whether I can come off the met and the eliquis (Chadsvasc score of 1 due to HBP). On a related note; to this day I have not met Dr. Horton in person. My first consultation was by phone (my choice) and I did not see him before, during or after my procedure. I did mention he met with my wife in the waiting area which I appreciated, and his staff has been superb! HIs nurse said Dr. Horton is a man of few words and she does the talking for him. My next appointment will be by phone as well due to my distance from Austin. I guess I’d rather have a top tier EP that I never meet than a mediocre one that I get to know personally.

I’d welcome any comments or questions from the forum.

My research shows about an 80% success rate from my index ablation with success being defined as 1 year without afib without AAR drugs. In doing other research, an article in the JAHA authored by Dr’s Natale, DiBiasi and Horton, et al, finds that those who make it to the 2 year point have about a 68% chance of remaining arrythmia free for at least 10 years in a person with no comorbidities (untreated HBP, obesity, heart disease, diabetes, untreated sleep apnea). But only about 31% long term success WITH comorbidities. Even so, a follow up procedure at that point offers a 90%-95% chance of no future episodes.

Are any future breakthrough episodes likely to be worse, the same or less severe than before the ablation?

Thanks for reading.

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hacksman
Isuprel test at up to 10mcg for 10 minutes showed evidence of reconnection with the pulmonary veins so those areas were re-isolated by RF. The report ends that phase with the line; “no arrhythmias were induced”. Does that mean I was never in afib/flutter during the entire procedure?

Well, that one sentence is only referring to the testing after they re-isolated your PVs, so it doesn't mean that. But something led them to re-isolate the PVs, and that something may have been afib originating from that area when stimulated by the Isuprel. I would expect the report to have mentioned if you were in afib during the procedure at some other time, so you probably weren't.

Glad it turned out well for you (minus the groin pain). After my first ablation I developed a hematoma at the insertion site that hurt like hell because it was pressing against my femoral nerve. That was before the opioid hysteria so I got a 10-day prescription for oxycodone. Today they'd probably just tell me to use Tylenol.

They only gave me Tylenol and mine still hurts a lot. But it’s only been 3 days.

Wishing you success!

Thanks for the detailed report, and congratulations on your index ablation at TCAI. I was there a couple of weeks before you for mine and also stayed at the Holiday Inn Midtown which was fine for my purposes. Sorry about the groin pain!

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Carey
Glad it turned out well for you (minus the groin pain). After my first ablation I developed a hematoma at the insertion site that hurt like hell because it was pressing against my femoral nerve. That was before the opioid hysteria so I got a 10-day prescription for oxycodone. Today they'd probably just tell me to use Tylenol.

I was told that they would be willing to give opioids if necessary, though one dose of Tylenol in Recovery knocked out the moderate chest ache/pain I had when I woke up. The nurses gave me throat lozenges as needed for the irritation from intubation. The only groin pain I had was from the removal of the pump-up pressure bandage over the right femoral vein insertion site. The adhesive was really strong and covered an area that they hadn’t shaved!

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Daisy
The adhesive was really strong and covered an area that they hadn’t shaved!

Nurses are never as thorough as you need to be. So one of my standard pieces of advice for ablation prep is to give yourself a thorough shaving in the area involved in a bikini waxing. It's either that or you're going to get a bikini waxing.

And for guys with chest and/or back hair, shave ALL of it. I'm sure you noticed the size of some of those pads they put on you.

Especially those bears with hairy backs and shoulders. Be warned.

Carey,
The only other notation regarding heart rhythm in my post procedure description came at the very beginning where it reads: "Patient arrived to the EP lab in sinus rhythm". I wish I HAD gone into afib/flutter during the ablation so it was clear where those signals were coming from.
I'm having lots of ectopics today. My Kardia calls them "sinus rhythm with supraventricular ectopy". About 7 SVE's every 30 seconds. Trying to keep in mind that it's not unusual just five days after ablation. Had some caffeine today for the first time in about two months. Perhaps a connection?

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hacksman
Carey,
The only other notation regarding heart rhythm in my post procedure description came at the very beginning where it reads: "Patient arrived to the EP lab in sinus rhythm". I wish I HAD gone into afib/flutter during the ablation so it was clear where those signals were coming from.
I'm having lots of ectopics today. My Kardia calls them "sinus rhythm with supraventricular ectopy". About 7 SVE's every 30 seconds. Trying to keep in mind that it's not unusual just five days after ablation. Had some caffeine today for the first time in about two months. Perhaps a connection?

They do remarkably well without you being in afib at the time. It's really not necessary with a solid EP like Horton, so I doubt it would have made a difference. That's also the whole point of the Isuprel challenge -- to provoke afib out of its hiding holes. It's pretty good at doing that.

I also doubt the caffeine had anything to do with those ectopics. I could be wrong, of course, so go ahead and test it by holding off on caffeine a while then having some again, but caffeine gets a bad rap with afib that it doesn't deserve. When it's actually been studied it turns out to be harmless or even moderately helpful. You should expect ectopics for the next few weeks whether you drink any caffeine or not.

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Carey
You should expect ectopics for the next few weeks…

I am three and a half weeks out from an ablation and I also got that reading on Kardia today— though
I didn’t feel it.

On a related note; to this day I have not met Dr. Horton in person. My first consultation was by phone (my choice) and I did not see him before, during or after my procedure.

Reminds me of Arthur when discussing if he should see a doctor and his butler corrects him with "More importantly the doctor should see you."

Something like that, going from a 40 yr old memory

Dang it! Ten days after index ablation at TCAI I woke up this morning in afib/flutter. Kardia called one reading afib and the other tachycardia. Rate of 130-138. I was doing well until now with only some annoying ectopics. TCAI nurse for Dr. Horton suggested an extra 25mg metoprolol for now. Will revisit on Monday. I won't go to ER unless short of breath, fainting, etc...
I know it's still blanking period but I'm worried my now atypical flutter won't resolve without cardioversion. Even then not for long. Also, that having this so soon after ablation suggests more recurrence in the future and the need for a another, more complicated second ablation.
How long can I stay in 140 heart rate waiting to convert at home? Metoprolol used to get my rate down to 115 or so but not this time.

Thanks

You can spend the entire weekend and all day Monday at 140 without harm. Might not be comfortable, but it won't do you any harm. If the metoprolol isn't slowing it down, that points to it being flutter since flutter is often unresponsive to rate control drugs. Just feel your pulse. Is it a regular rhythm? If so, it's probably flutter. The Kardia will spot afib.

An afib/flutter episode 10 days out from an ablation isn't surprising or meaningful. It doesn't say anything about the ablation nor does it predict anything about the future, so don't be planning a second ablation.

I had my ablation November 8 and was blissfully in rhythm for two weeks. I was on 25 mg metoprolol and amiodarone - for just a month. After three week I experienced breathing, vision and arrhythmia effects and was taken off the amio and metoprolol increased to 75 mg twice a day as my BPM went up to 130-140 for over a week. My electrophysiologist wanted to cardiovert me and I agreed and now I am back in rhythm and BPM 55 give or take - but he wants me to take Multaq for a month just to keep things quiet and slow and in rhythm. I am very concerned about being on Multaq and would like to know anyone's experience, good or bad, with that drug - and is it effective for maintaining low BPM and rhythm. I

Multaq is probably the safest antiarrhythmic out there. There's no reason to be worried about it.

It's generally the "mildest" antiarrhythmic there is. For example, it was completely ineffective at preventing my afib when it was in full swing, but Natale gave it to me for a month after my ablation with him just as your EP wants to do. In that role it worked beautifully without any side effects and kept me in NSR. I know it was doing its job because I tried stopping it early and the afib came creeping back. I went back on it, and the afib went away again. So I took it for 3-4 weeks, and then I was able to stop it a bit early.

What your doc is doing makes perfect sense. I would go along with it.

Thank you Carey for sharing your experience with Multaq. I will proceed with the Multaq for a month and hope for an outcome similar to yours.

I got my flutter to self convert by going outside in the cold barefoot for 5 minutes wearing a jacket but face and feet cold and exposed. I did it a few times until it warmed up in CA and I didn’t get the shock value. It worked but I got a sore throat. I recommend trying barefooted wearing a jacket and stay indoors with an open window and stick your head out for a few minutes. I know it sounds crazy and very non scientific but if it converts you by chance you might go into nsr. That’s why try indoors with a window first so you don’t get pneumonia especially if you live somewhere cold. Ca nights are 37-49 at most, your winters maybe colder and not worth the risk of trying it outdoors. Well..GeorgeN can safely do this outdoors in the snow because his core temperature is used to it.

Drugs may probably not work as Carey mentioned for flutter. I know because drugs stopped being effective for me and I’ve been paddled (ecv) 54 times as the only way to stop the flutter. My heart is neutered now with an av ablation because after 54 ecvs they stopped working.

Good luck.

A quick update...

I converted at home after 90 hours in afib/flutter that began 10 days after my index ablation on 11/29 at TCAI. In consultation with Dr. Horton's nurse, I resumed taking 50 mg twice daily of flecainide after I had been in afib/flutter for about 24 hours along with the 25 mg metoprolol and of course the eliquis. I went to my local EP for an ECG after about 72 hours and they scheduled me for an ecv the next morning. Fortunately, I converted at home (confirmed on Kardia) about 8 hours before my ecv appointment!! I went in anyway and they hooked me up to an ecg to be sure and sent me on my way after it showed NSR. That 90 hour episode was the longest in my 20 year afib history. The previous record was 50 hours.

I have been in NSR since (12 days) and have continued taking the flec along with the other drugs and will continue to do so at least until I speak with the TCAI nurse next week. I do continue to have occasional weird beats and runs of ectopics but so far no afib/flutter since my latest conversion. Tuesday will mark one month since the ablation and I realize I am still in the blanking period. I will occasionally feel like afib is starting but never getting any traction and going away. Scary but manageable. I am hopeful that is a sign the scar tissue is forming properly and will protect me from afib/flutter in the days, weeks, months and hopefully??? years to come.

I asked the nurse about switching to diltiazem since the metoprolol didn't affect my HR at all during my latest post-ablation episode. It was stuck at around 140bpm until it began to come down in the hours before I converted. She said to wait until my February follow up with Dr. Horton to consider that change.
In the months before my ablation when I was taking 100 bid of flecainide plus an extra 100 mg during an episode, I developed a bit of a delayed QRS interval (110ms) according to my local EP so they reduced my flec to 50 bid (it was that or switch to amiodarone...yuck). But that also suggests I shouldn't take a large pip dose to convert any subsequent episodes.

To Susan's comment about running outside in the cold during an episode, I'd like to try something like that if it happens again but I'm afraid I would pass out! I don't handle activity well during an episode and get light-headed easily. It would be entertaining for the neighbors though!

Happy Holidays

I wanted to offer an update on my situation following my ablation in late November with Dr. Rodney Horton at TCAI in Austin. My previous story is documented above on this thread.

Other than my 90 hour afib/flutter episode that began ten days after my ablation and resolved just hours before a scheduled ECV, things are going well with no further episodes. I stopped taking flecainide in late January per Doctor’s advice and have just completed and received results from my 7 day VitalConnect monitor.

I was very happy to hear that I had no episodes during the monitoring period and Dr. Horton’s nurse said I could stop the Eliquis. I am a 1 on the ChadsVasc scale due to controlled HBP for which I am on medication. I have 3 more years until I hit 65 and will have to add another point. But for now, I am enjoying the respite from Eliquis. I handled it well but I don’t like being on it due to fear of head injury, increased bleeding from minor cuts, inability to take occasional ibuprofen, and of course, the cost. I was advised to continue taking 12.5 mg of metoprolol twice daily.

My VitalConnect monitor showed no AFib but numerous PAC’s and a few PVC’s concentrated into an 18 hour period on just one day. I knew I was having them and pressed the button on the phone 3 times that day. The TCAI nurse who went over my results said I had 4,366 PSVC’s that day. She wasn’t concerned. My main concern, of course, is that they would kick off an afib/flutter episode, which thankfully, they did not. Those ectopic beats represented 0.65% of all beats over the recording period.
I asked for a copy of my report and found the monitor also showed one count of “VT” or Non- Sustained Ventricular Tachycardia lasting 3 beats at 119bpm. The nurse didn’t even mention it during our phone call so I wasn’t aware of it to ask her at the time. I know they can be dangerous but I have no structural heart disease and it was a one-time incident so I’m not really concerned. The report also showed “Other SVT” of 10 beats with a max heart rate of 158 but no "Pauses" or "AV Block".

I have a couple of questions regarding the ablation recovery period. Are my previous triggers (alcohol, stress, anxiety, adrenaline surges, lying on my left side) now unlikely to cause afib/flutter episodes? Does the fact that I haven’t had any episodes suggest that the source was in fact the PV’s or the posterior wall of the left atrium which Dr. Horton ablated? I was never in afib during my ablation so the source did not reveal itself despite the Isuprel infusion. I’ll of course ask these questions of my EP team at future appointments but I always enjoy hearing from the afibbers community.

I am very pleased I chose to move forward with an ablation and that I sought out TCAI for the procedure. My thanks to fellow afibbers on this board who strongly urge everyone to choose the most experienced EP they can find. I am beginning to stop obsessing over possible afib episodes and enjoying the routines of daily life. I am aware that I am only four months into the recovery and that a future ablation may prove necessary. But I hope that is years away.

Thanks

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hacksman
I have a couple of questions regarding the ablation recovery period. Are my previous triggers (alcohol, stress, anxiety, adrenaline surges, lying on my left side) now unlikely to cause afib/flutter episodes? Does the fact that I haven’t had any episodes suggest that the source was in fact the PV’s or the posterior wall of the left atrium which Dr. Horton ablated? I was never in afib during my ablation so the source did not reveal itself despite the Isuprel infusion. I’ll of course ask these questions of my EP team at future appointments but I always enjoy hearing from the afibbers community.

Yes, your previous triggers are now much less likely to trigger afib now (although alcohol in excess can put people in afib who don't even have afib -- lookup Holiday Heart Syndrome). So I guess it's time for my monkey in the cage analogy again. Read this post for the story.

And yes, the fact that your afib went away after Horton's ablation indicates he did indeed ablate the correct places. A PVI with posterior wall ablation is pretty much the standard PVI procedure. The PVs are the sole source of afib in a majority of afibbers. That's why doing nothing more than a PVI is sufficient for about 70-75% of first time ablations.

Thanks Carey, loved the Monkey Cage analogy!

I am intentionally trying to spend a few hours a night sleeping on my left side despite the occasional ectopics it triggers. All part of the "getting back to normal" journey after the ablation. Dr. Horton did not discourage me from putting the ablation to the test in this way. If it kicks off afib/flutter, I guess it means the ablation wasn't fully successful and I will need another procedure eventually anyway. So far, so good!

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hacksman
Dr. Horton did not discourage me from putting the ablation to the test in this way. If it kicks off afib/flutter, I guess it means the ablation wasn't fully successful and I will need another procedure eventually anyway. So far, so good!

That's exactly what it would mean. After the blanking period afib caused by any normal activities is proof the ablation isn't complete.