meds vs.ablation quandary

Greetings and Thank You to the admin for providing this venue. I am scheduled for 3- day Tikosyn
loading and am uneasy about it. My EP has pesented this as my best option; personally I view L/T drug
therapy as a last resort after I try 2 ablations. My condition has progressed to persistent this year; I knew I had to do
something about it, but have found getting access to EP's difficult ; 2 month waits for appointments typical.
My stats : 60 y.o. M , HR 79 , BP 116 /78, BMI 21.82 , chads vasc 0 ; pretty fit . still in gym 5x/wk ,have been all my adult life.
Past year now, increasingly out of breath upon exertion. Only taking Xarelto right now. I have had bad reactions to BB's , was only on them for a few days.
Consultation w/ PA, dismissed ablation option as low chance of success < 50% , but sucess rate maybe higher after I am on rhythm meds
for some time. I have never heard that before. If i were to schedule an ablation with one of the top providers, would they take you off
the rhythm meds before the procedure to induce the AF? Well, I would appreciate any input from those who have been down this road.

Read and follow Susan's case. Having an ablation is a serious decision. Not every one is a success and not every "success" is a success when it comes to overall quality of life. Maybe some advances are being made but I believe that one day current 'state of the art' will be looked back upon as primitively barbaric.

MDs in 50 years will be telling patients the horror stories of how hearts used to be burned, scarred and sliced (Maze) and how far they've come since the dark days of AF.

It could just as well be 5 years out when a better solution is found.



Edited 1 time(s). Last edit at 12/07/2022 03:16PM by PavanPharter.

I have a different perspective on this, mostly because of my own experience and evolution in AF.

I started off on metoprolol. Over time, both the frequency of episodes, as well as their severity, and the resultant dose increases became worrisome and intrusive...for me. I was actually going into a highly symptomatic bradycardia when I reverted, often with long pauses in heartbeat before the first NSR beat commenced.

I now had two problems. Three if you count having to go on Amiodarone to get my heart to behave in the weeks after my first ablation.

I am slated for a second ablation. I refuse to take metoprolol at anything close to the last dose I was prescribed (25 mg BID). Too dangerous for me. I take half a tablet if it feels like it will be hard to get to sleep later that evening. It takes the edge off, but isn't so much that I have to endure the bradycardia.

So, I have a question: you say you have been advised that your chances of success after a (second, third..?) ablation are less than 50%? Why? What is the reasoning? Several people here have had four, five, even six ablations. They aren't common, and every case is unique. Maybe you need the 'unique' EP who will finally treat you constructively.

PavanPharter said:
MDs in 50 years will be telling patients the horror stories of how hearts used to be burned, scarred and sliced (Maze) and how far they've come since the dark days of AF.

While waiting 50 years for a better solution, there is no reason to avoid an ablation from a HIGHLY qualified EP if you want to manage your afib. I have had two successful ablations (day surgery) the first good for 13 years and the second going on 3 years.

If I am understanding you, you have not yet had an ablation, are in persistent Afib and are evaluating whether to do Tikosyn loading? The comment from the PA saying that ablation success rates might be 50% may be about right for “non top-tier” EPs, but the few in the top tier have much better success rates in ablating persistent patients. And while in 50 years it is likely that they will have found better approaches to Afib than ablation, that would be true for most approaches to all diseases as well. Our problem is our Afib right now and how to deal with it—not in 50 years.. I also resisted ablation and followed drug therapy for many years until the toxic reactions to the increasing doses of drugs became too much and I approached Dr. Natale for an ablation—which I had one month ago. So far no arrhythmias after the first few days. Going into the work up for ablation, I thought my case would be simple, but it turned out not to be and only a top tier EP like Dr. Natale could have handled it. And yes, you are instructed to stop antiarrythmics about 5 days before the ablation and rate control a day or 2 before.

It does take time to get in to see a top tier EP—or probably most any EP—but you are facing very important decisions with long term consequences and it is worth the uncomfortable wait. Members here can share strategies that have helped them in the interim. If you do decide to explore an ablation it is very important to go to the best, as you are persistent and that is more of a challenge.

Thanks for the replies. To be clear, I have no reservation about the ablation procedure itself . I intend to pursue that route with one of the top providers . I assume it would take several months to schedule. Current EP wants to start Tikosyn , then reevaluate when/if in NSR. I am leery about the 3-day hospital stay and medication itself. I asked about cardioversion- that would be at the end of the stay if I don't medically convert.
My main question is : is it worth the risk / hospital stay/expense to go on a medication that I don't want to take L/T? I was advised that my chances of ablation success would be better if I am in NSR on the meds for some time. Is that commonly understood? I have not heard that before. I suppose my other option is to try to schedule w/ Natale or one of his proteges , and try to ride out the interim period . I can function at a low level right now , but as everyone knows it's a day to day adventure.

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skinman
I was advised that my chances of ablation success would be better if I am in NSR on the meds for some time. Is that commonly understood? I

That is not my understanding. I believe it is easier for them to ablate if you are in arrhythmias when you present to them. If you aren’t, they will try to provoke arrhythmia with drugs. Perhaps others can comment on whether having a history of being in NSR due to an antiarrhythmic before an ablation is helpful.

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skinman
I was advised that my chances of ablation success would be better if I am in NSR on the meds for some time. Is that commonly understood? I have not heard that before.

You haven't heard it before because it's not true. And that 50% success number is true only for average EPs. The EPs of Natale's caliber have much better success rates with persistent afib, upwards of 80-90%. However, with longstanding persistent afib needing a second touch-up procedure is often necessary.

Frankly, I wouldn't do the Tikosyn. I think it has low chances of success, and it's definitely not a drug to be trifled with. I was on it for a few months and it was effective, but I didn't have persistent afib like you do.

They typically want to ablate the heart w/o the drugs and as part of the procedure will use drugs to excite the heart and ablate those areas too. I believe that's what happened in my case.

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Daisy



I believe it is easier for them to ablate if you are in arrhythmias when you present to them. If you aren’t, they will try to provoke arrhythmia with drugs.

That's what I thought beforehand.

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Carey

The EPs of Natale's caliber have much better success rates with persistent afib, upwards of 80-90%. However, with longstanding persistent afib needing a second touch-up procedure is often necessary.

Frankly, I wouldn't do the Tikosyn. I think it has low chances of success, and it's definitely not a drug to be trifled with. I was on it for a few months and it was effective, but I didn't have persistent afib like you do.

That was my understanding before this consultation...I appreciate your candor on the drug.

skinman - "... I was advised that my chances of ablation success would be better if I am in NSR on the meds for some time. Is that commonly understood? ..."

You were fed a line, no matter how well-intentioned the speaker may have been. I was almost getting worse by the hour in the three days prior to my first ablation in July. Both times I had procedures involving cardiac catheterization, first an angiogram, and four months later it was the ablation, my heart was doing headstands. The gentleman doing the angiography withdrew the catheter after perhaps two whole minutes and muttered, "Too many ectopics." I know that my heart was in arrhythmia when I sat on the surgical table and lay back for the ablation. Neither time was I refused or waved off as a risk somehow, or as presenting less-than-ideally.

Think about it. If the heart is getting spurious signaling via additional pathways, it will develop arrhythmia. How likely is it that an EP is going to encounter someone with AF going on when they get them into that cold operatory with all the lights and stainless steal and then begin to administer the propofol, and the intent of the surgery is to correct the arrhythmic heart? I'd guess around 50%, especially if the trigger is adrenergic for that particular patient. An EP won't send away half his patients because they're suddenly presenting AF.

Thinking further, if the heart is already in AF, and the EP corrects the fault by isolating the focus/foci, won't the heart return to normal rhythm very shortly after the last lesion? It is no longer getting the extra signal, so it should revert to NSR almost immediately, but certainly in the next few hours. The EP will then challenge the heart by presenting it with a drug called isoproterenol. This will accelerate the heart as if it were under stress or duress. If the heart remains in NSR for up to ten minutes, it is considered successful, and the EP will send you on to recovery.