Concerning holter results at 6 months post ablation

I would appreciate advice from you wise souls on this forum, who have been a support to me for over 20 years, even though I am usually quiet (first with my husband, brother and now for myself). I had an ablation at Duke on 8/4/22 and was on Multaq afterwards. Tried to go off after two months but afib returned so restarted fairly quickly. Tristan Bahnson, MD and I decided to get through the holidays with the Multaq which seemed helpful and no side effects except a lower heart rate, which was great for my 4 times a week competitive tennis, even at age 71. I went off Multaq about three weeks ago and wore a halter monitor for two weeks. Had PACS and PVCs until finally afib returned on day 12 of my halter monitor(I was sending in Kardia readings to my doctor).. Restarted Multaq and within 24 hours was in sinus and seemingly okay since.

HOWEVER, the halter monitor results have really shaken me up. I fear the 6 hour ablation Dr. Bahnson so carefully performed has created additional arrhythmias that were not there before. Here is the narrative report:

"The observed rhythms are sinus bradycardia to sinus tachycardia with sustained episodes of atrial flutter. *The Maximum Heart Rate recorded was 172 bpm, Day 3 / 11:09:51 am, the Minimum Heart Rate recorded was 43 bpm, Day 6 / 06:11:09 am and the Average
Heart Rate was 72 bpm. *There were 463 PVCs with a burden of 0.04 %. *There were 32508 PSVCs with a burden of 3.15 %. There were 168 occurrences of Supraventricular Tachycardia with the longest episode 8 beats, Day 12 / 08:44:36 am and the fastest
episode 172 bpm, Day 3 / 11:09:55 am. *The study included an Atrial Fibrillation Burden of 4.63 %. The longest episode was 4h 44min, Day 9 / 01:44:21 pm and the fastest episode was 154 bpm, Day 9 / 01:44:21 pm."

First time for flutter, Supraventricular Tachycardia, and 32,508 PSVCs in impossible to imagine as I surely did not experience 3000/day symptoms.

I am meeting with Dr. Bahnson on 2/14 and am so stunned I am unsure of where to begin, other than wondering if that long ablation caused these additional electrical faults, if I now need more ablations, and if I am at risks for serious health issues should I continue to play competitive tennis, endure stress (which is aplenty with family issues, such as a sick daughter), etc. My afib burden for the last 15 years has been minimal--maybe 3 times a year for a few hours--at most 10 hours and I self converted every single time with liquid magnesium and a bit of cardizem. I wrote a previous post explaining my afib burst onto the scene after I broke my ankle in June and only the Multaq brought it into sinus. I can't believe Multaq can manage all these arrhythmias though.

If any of you could offer me questions to ask Dr. Bahnson next Tuesday that would be great. I am of course seriously considering arranging to see Dr. Natale at this point since my heart has suddenly gotten complicated.

Thanks,
Karin

I don't have time to break it down for you tonight, but I will tomorrow. The problem with reading raw reports like this is you see a bunch of scary sounding stuff that isn't actually all that scary, or even abnormal. Suffice it to say for now that you don't have a bunch of new arrhythmias.

I won't presume to anticipate what the more knowledgeable Carey will tell you when he can, but I can tell you two things that are very important to dealing with this disorder constructively:

a. It is a progressive disorder. It may be coincidental, or it may just be what are now unmasked arrhythmias because of what the EP achieved the first time. But your symptoms are NOT ATYPICAL, and they may very well be a sign of the typical progression we see as time passes for almost all of us; and

b. A second, a third, a fourth, and a fifth ablation may really be what it takes to bonk this on the head and to stop it. Just ask Carey. I'm going to be out and ablated about the same time you talk to your EP next Tuesday. It will be my second. First was a flop, and I knew it on Day 6.

I first learned I had pre-ventricular tachycardia when still puffing and the gentleman physician debriefed me on my MIBI test results. I was puffing because I was still sucking wind madly through a mask, and I had given it a good solid effort on the treadmill until the attendant ordered me to stop. He said I was starting to show PVCs. What a time to be reminded that my disorder was evolving as it ought. Unfortunately.

No, three things I should tell you, not two: AF will not kill you. Not soon, anyway. Uncontrolled, it creates a number of conditions which can hasten your death. But, we're pretty good at delaying that eventuality, often for two or three decades. By that time, who cares how we go?

The best 'fix' is ablation. It has a reasonable probability of success, even if it has to be repeated after six-twelve months. Next is drugs. The anti-coagulants don't fix anything, unless you count them as key to preventing strokes...which is why you'll have to take one if you don't already. For life, too. The various rate and rhythm fixer chemicals do a reasonable job, but the body seems bent on neutralizing them after a while...many months to years. One will work, and then you'll need another which will hopefully last.

As for a bit of optimism, there are so many sharp people doing intense research on this field, even though a lot about what afflicts us is still a puzzle to Medicine, that new methods and ideas abound. There's money to be had for that perfect mouse-trap if anyone can come up with one. It's the same with controlling heart arrhythmias. We're close, and getting closer. Meanwhile, one, two, or more ablations seems to be your best bet. Personally, I'm looking forward to mine. Won't come a pico-second too soon.

Thanks for your thoughts and optimism after the realism of having a progressive condition! My EP took 6 hours on what had seemed a conventional ablation because he found so many breakthroughs. Before the ablation he thought I had an 85 percent chance of success. Obviously, there was more going on than anticipated. He has completed 2500 ablations at Duke and I know he is smart and highly competent. I am also aware that a flutter ablation is an easier fix if I do have that as suggested. The supraventricular tachycardia is what has thrown me because it is very new. And I believe it is also a relatively easy ablation fix. I think I am weary because I watched and counseled my older brother on afib with the benefit of this forum (to little avail since his cardiologist--chief at the Oklahoma City hospital he work did not believe in new fangled ablation so my brother stayed on Coumadin (so many brain bleeds at the end) and was in persistent afib (though he stubbornly swam miles even towards the end), plus my husband has had afib with meds, 14 cardioversions, three ablations, coumadin, etc. etc. Perhaps Covid anxiety is creeping in too!

Best wishes for a successful ablation next week! Will look forward to your reports!

Quote
karin
"The observed rhythms are sinus bradycardia to sinus tachycardia with sustained episodes of atrial flutter. *The Maximum Heart Rate recorded was 172 bpm, Day 3 / 11:09:51 am, the Minimum Heart Rate recorded was 43 bpm, Day 6 / 06:11:09 am and the Average
Heart Rate was 72 bpm. *There were 463 PVCs with a burden of 0.04 %. *There were 32508 PSVCs with a burden of 3.15 %. There were 168 occurrences of Supraventricular Tachycardia with the longest episode 8 beats, Day 12 / 08:44:36 am and the fastest
episode 172 bpm, Day 3 / 11:09:55 am. *The study included an Atrial Fibrillation Burden of 4.63 %. The longest episode was 4h 44min, Day 9 / 01:44:21 pm and the fastest episode was 154 bpm, Day 9 / 01:44:21 pm."

These reports are meant for doctors to read, not patients, so they can be unnecessarily alarming. Let's go through this one by one....

The maximum and minimum heart rates are all completely unremarkable because they're based on very short periods of time (seconds). Put that monitor on literally anyone, including a healthy 25-year old, and you'll get the same results. The average of 72 is perfectly normal.

You had a small number of PVCs. Everyone does, including that healthy 25-year old.

You had more PSVCs (known as PACs to us mere mortals), which isn't surprising for someone with a history of afib. Although it sounds like a lot, the burden actually isn't remarkably high.

It mentions "sustained" flutter but for some strange reason doesn't say how long they were. EPs define "sustained" as 30 seconds or more, so those episodes could have been quite short.

The SVT is utterly meaningless with a maximum of 8 beats per episode. Again, that healthy 25-year old would probably have the same.

The only notable findings on this report are the 4.63% afib burden and the "sustained" flutter. That's more than you should have after an ablation. I'm afraid you can't call this ablation fully successful, but it's not at all the disaster it appears to you. You're in a pretty typical place right now for someone with a partially successful ablation.

If I were you, and the Multaq is working for you as it seems to be, I would ride that Multaq pony for a while and sort things out. Multaq is a pretty safe, "mild" drug with few side effects. The fact that it even works for you points to your afib having been at least improved. Wait and see what happens and don't get pressured into doing another procedure. I'd give it at least a full year to see how it plays out before making a decision.



Edited 1 time(s). Last edit at 02/11/2023 06:50PM by Carey.

How reassuring Carey! Thank you for your thoughts. This helps me formulate questions for my EP on Tuesday. I was also wanting to coast with the Multaq for a while. I like having a lowered heart rate which actually helps my tennis and endurance walking my English Setter! I did not realize PSVCs were PACS. I have known I have those for years and know they are not that unusual for regular people much less Afibbers. The bradycardia might be from metropolol I take at night. The higher rate was during tennis so no worries there. I am surprised by the SVT being fairly benign too. There were more details at the end of the report which will probably clarify these general comments to my EP but at least I know a bit what to expect and I feel relieved.

Thank you for your time in commenting so thoroughly. I will sleep better tonight and be more informed Tuesday!

You are the bomb!

K

Long story short, I met with Dr. Bahnson who carefully read all the Holter and Kardia results and said I do not have afib, flutter, or super ventricular tachycardia (actually sinus tachycardia the cardiologist misread on the print out but did not consider they occurred while I was playing tennis--not expecting a 71 year old was playing tennis at 2:00 pm 4 times a week?). My PAC burden is 3% which is within the normal range. He said I could even go off the Multaq and take 25 mg of metropolol in the am, along with the 25 I am already taking at night. I am staying on the Multaq another 3 months to cruise since I feel so good on it and he agreed. I feel very very lucky.

Quote
karin
(actually sinus tachycardia the cardiologist misread on the print out but did not consider they occurred while I was playing tennis--not expecting a 71 year old was playing tennis at 2:00 pm 4 times a week?).

I wonder if playing tennis is such a good idea after an ablation?
I am 1 month out from my first ablation and notice I can very easy exceed 120bpm with out doing much.
Perhaps Carey could coment and advise us how far we can push ourselves.

I once did a 50-mile bike ride in hilly terrain 3 days after an ablation. I asked the EP beforehand and he said go ahead. I pointed out that I wasn't talking about an easy 5 miles on some nice flat bike path, but 10 times that distance on hills with 10-20% grades. He still said go ahead.

I've asked other EPs about this and they all agree. Basically, it all comes down to how you feel and how your heart reacts. If you feel up to it and your heart rate stays reasonably close to what it would normally be for the level of effort, by all means exercise away. Maybe it seems counterintuitive but exercise won't do a post-ablation heart any harm.

Well....it could....still. Happened to me. I went for a s l ooo w walk with the missus on the second night. It was very warm, and to be honest, it might only have been the heat. But, shuffling along as I was, I couldn't get my heart below 120 bpm. Even 30 hours post ablation it should not have risen much past 105 with the very mild effort.

I think everyone should be counseled to watch their heart's performance very closely the entire week after an ablation to see if what the results show sound reasonable. I realize heart rates will be elevated, even by 20 BPM over what the patient had prior to their diagnosis and then the ablation. But for me, my effort didn't warrant 129 at one point. It suggested to me that I might be in trouble. Sure enough, a few days later I was in the ER for the first time during the blanking period. Five weeks later, I was back and had to have an extension on Amiodarone.

I was told not to play tennis for 10 days after my ablation, so I just walked. I did feel surprisingly good after a 6 hour ablation with Dr. Bahnson--no chest pain, heart rate fine, and even the wounds for the catheters healed well (which was the primary reason for the tennis delay). I was also on Multaq which I think was why it was possible to push without so much concern about break through afib. After two months I went off Multaq and did have breakthrough afib so went back on for three more months and let the heart heal. I also take potassium and a lot of magnesium daily which allows me to be more active. Everyone's situation is so very different I too think listening to your body is good advice. I am also glad I had protection from break through afib for months because it seems logical to think that allows the burns to heal more easily.