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Followup needed 11 years after successful Natale ablation
Posted by MRichard
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Followup needed 11 years after successful Natale ablation February 21, 2023 12:12AM |
Registered: 1 year ago Posts: 2 |
My first ablation was with Dr Natale in 2012 after dealing with intermittent afib for 6 years (chose Natale as a result of this forum). It went very well even though it turned out to be more extensive than just a PVI. I was pretty much trouble free until 2015 when "skipped" beats became a problem... literally thousands per day, and I felt every one of them. Solved that problem by switching my BP med from Lisinopril to Telmisartan. However, over the past 6-8 months I've started to have issues again. Brief afib (one 30 minute episode and another of maybe 5 minutes) and increasing numbers of brief episodes of rapid heart rate and skipped beats again. Most episodes are exercise induced. I'm 70 now, but still hit the gym 3-5 times a week. My cardio highly recommended Dr Brian Le here in Dallas. He recommended a cryo-balloon touch-up ablation. He is very familiar with Dr Natale and has a great appreciation for his skills, however, he is very, very confident that he can fix me if I choose not to use Natale. I swore if I ever had new issues I would go back to Natale, but Dr Le has been doing ablations since 2005 and seems to be highly regarded. I'm concerned about how long it might take to get scheduled with Natale (or if he would even take me or if he would have me see someone else in his office). So I guess I'm looking for advise on a couple of issues. 1) Is anyone familiar with Dr Brian Le and whether or not he would be a viable option for a follow-up ablation and 2) what is the current thinking on balloon cryo procedures? What is Natale using now? Thanks in advance for any guidance that can be provided!
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Re: Followup needed 11 years after successful Natale ablation February 21, 2023 06:57AM |
Registered: 11 years ago Posts: 4,219 |
As a non-ablatee, but someone who has been on this board for over 18 years, here are my thoughts.
My understanding is that balloon cryo only addresses PVI issues. Given that you had a Natale ablation, my hypothesis is that what you are experiencing is likely due to the progression of your illness, not a failure in Natale's earlier ablation. Hence I don't think that cryo will solve your problem.
My understanding is that Natale uses RF ablation. He is also involved in trials for pulsed field ablation (PFA). I don't know the status of those trials right now.
My own experience with exercise is that my (vagal) exercise trigger is the product of intensity times duration. Meaning that for long duration activity, high intensity is a trigger. In the 2nd paragraph of this post are references for Zone 2 levels of intensity as well as other ways to measure this. Before knowing about what researcher Iñigo San Millán calls Zone 2, I empirically came to this understanding with my afib and exercise. Having posted about this here numerous times, I've gotten feedback from others, that this seems to work for them as well. Is your exercise trigger adrenergic? In other words does exercise trigger the afib acutely or is it a delayed trigger (which is my case as I have vagal triggers). What kinds of exercise provide the trigger?
Yes, Natale will see you. It may take a while to get in. You might explore a rhythm med to help stay in NSR till you can get in. I've used flecainide on demand for over 18 years and recently have successfully used it prophylactically daily, but at minimal dose of 25 mg once a day, as I've posted about elsewhere here.
My understanding is that balloon cryo only addresses PVI issues. Given that you had a Natale ablation, my hypothesis is that what you are experiencing is likely due to the progression of your illness, not a failure in Natale's earlier ablation. Hence I don't think that cryo will solve your problem.
My understanding is that Natale uses RF ablation. He is also involved in trials for pulsed field ablation (PFA). I don't know the status of those trials right now.
My own experience with exercise is that my (vagal) exercise trigger is the product of intensity times duration. Meaning that for long duration activity, high intensity is a trigger. In the 2nd paragraph of this post are references for Zone 2 levels of intensity as well as other ways to measure this. Before knowing about what researcher Iñigo San Millán calls Zone 2, I empirically came to this understanding with my afib and exercise. Having posted about this here numerous times, I've gotten feedback from others, that this seems to work for them as well. Is your exercise trigger adrenergic? In other words does exercise trigger the afib acutely or is it a delayed trigger (which is my case as I have vagal triggers). What kinds of exercise provide the trigger?
Yes, Natale will see you. It may take a while to get in. You might explore a rhythm med to help stay in NSR till you can get in. I've used flecainide on demand for over 18 years and recently have successfully used it prophylactically daily, but at minimal dose of 25 mg once a day, as I've posted about elsewhere here.
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Re: Followup needed 11 years after successful Natale ablation February 21, 2023 09:35PM |
Registered: 1 year ago Posts: 150 |
Quote
GeorgeN
Is your exercise trigger adrenergic? In other words does exercise trigger the afib acutely or is it a delayed trigger (which is my case as I have vagal triggers). What kinds of exercise provide the trigger?
I've used flecainide on demand for over 18 years and recently have successfully used it prophylactically daily, but at minimal dose of 25 mg once a day, as I've posted about elsewhere here.
George, if exercise is a delayed trigger for you, how many hours later? I went to a new gym last Sunday first time in 3 years (my old gym closed when COVID started), and woke up in a nasty episode Monday morning, I don’t know if the one hour yoga and 15 min slow jogging on treadmill was the culprit or a coincidence, because it happened 12 hours later.
Also, may I ask why you started taking 25mg Flec every day as prevention instead of 200mg on demand? Yesterday I used 100mg (I’m 118 lbs) Flec as PIP, waited 6 hours, did not convert, added 50mg, my HR started racing to 130+, I then had to take 25mg metoprolol to lower my HR down. It finally convert to SNR 12 hours later. I wonder if I should start taking small dose Flec on a daily basis before bed as I get an episode once a week now and most of time during sleep (I don’t have sleep apnea). I have an appointment with a new EP on March 22, I want to discuss ablation with him, in the meantime trying to figure out how to cope with my episode before now and then.
Edited 1 time(s). Last edit at 02/21/2023 09:39PM by Yuxi.
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Re: Followup needed 11 years after successful Natale ablation February 21, 2023 10:27PM |
Registered: 11 years ago Posts: 4,219 |
It really depends. My first ever episode (over 18 1/2 years ago) was several days after a training run on a 14,000' elevation mountain. Generally delay an hour up to 12 or 14. For me, it is a vagal trigger, so after I settle down.Quote
Yuxi
George, if exercise is a delayed trigger for you, how many hours later?
Quote
Also, may I ask why you started taking 25mg Flec every day as prevention instead of 200mg on demand?
In 2021, there was an association with an increase in episodes with me taking CV vaccines. I had 15 episodes in 9.5 months, which was very high for me. I posted about it here. 25 mg seems to work. I've had a few episodes subsequently when I've titrated the dose to 0, but 12.5 mg also seems to work. Though I take 200 mg flec on demand to convert, I weigh more than 154 #''s (70kg), so a 300 mg dose is OK, for me, but I think I get better results with 200. If I have a breakthrough episode taking 25 mg, I have no issue taking 200 mg to convert. Most episodes historically occur 3-6 am for me. As the half life of flec in the body is about 12 hours, I'd have less than 12.5 mg in my system, so adding in 200 mg would not kick me over my 300 mg limit. As mentioned, I've had some episodes some days after titrating the dose to 0, but only one when I'd taken the 25 mg the afternoon before. I'd stressed my body pretty good as I'd soaked 3 minutes at 33 deg F in my outside cold plunge tank (I break ice so I can get in), then thrown on KAATSU BFR bands on all four limbs (which KAATSU does not recommend - they suggest arms or legs only) & started strength training without letting my body return to normal temperature first. I've done this a lot, but normally give my body 20 minutes or so inside to sort of warm back to a normal core before HIT isometric training with the BFR. I don't recommend others do what I do. I hypothesize that the restricted venous return with 4 BFR bands on, on top of having chilled my core in the cold plunge, which also restricts blood flow and adding in the stress of high intensity strength training was enough stress to be the trigger.
Edited 2 time(s). Last edit at 02/22/2023 12:01PM by GeorgeN.
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Re: Followup needed 11 years after successful Natale ablation February 22, 2023 04:08AM |
Registered: 6 years ago Posts: 920 |
Yuxi, I'm a vagal afibber too. Always AFib at rest or while digesting. I agree with George about intensity and duration.
In my case, it seems I'm very reactive to blood sugar level, despite having no diabetes.
Here are my observations :
- Quiet exercise after meal is far better than sitting and resting.
- Sustained high level exercise (mouth breathing) is more likely to give me AFib at rest than moderate level (nasal breathing) exercise.
- The proportion of carbohydrates in a meal seems more crucial than its quantity.
- If a big evening (6-8 PM) meal high in fats and carbs does not give me AFib in the following hour, I'm more likely to get it 5 to 7 hours later (= between midnight and dawn).
- Eating while exercising (bicycling) for more than 1 hour is a good idea. I usually take a couple home-made muesli bars with me when leaving home for a ride.
- Forgetting to eat in the above case is a bad idea, and rushing to the fridge when coming back home is a bad one too. So, I'm better not forgetting my muesli bars, which prevents me from feeling hungry when I finish my ride.
Sustained high level exercise asks for carbs. Moderate level can burn fats. It seems the good idea for me is keeping my blood sugar level as stable as possible. And it's easier saying than doing.
In my case, it seems I'm very reactive to blood sugar level, despite having no diabetes.
Here are my observations :
- Quiet exercise after meal is far better than sitting and resting.
- Sustained high level exercise (mouth breathing) is more likely to give me AFib at rest than moderate level (nasal breathing) exercise.
- The proportion of carbohydrates in a meal seems more crucial than its quantity.
- If a big evening (6-8 PM) meal high in fats and carbs does not give me AFib in the following hour, I'm more likely to get it 5 to 7 hours later (= between midnight and dawn).
- Eating while exercising (bicycling) for more than 1 hour is a good idea. I usually take a couple home-made muesli bars with me when leaving home for a ride.
- Forgetting to eat in the above case is a bad idea, and rushing to the fridge when coming back home is a bad one too. So, I'm better not forgetting my muesli bars, which prevents me from feeling hungry when I finish my ride.
Sustained high level exercise asks for carbs. Moderate level can burn fats. It seems the good idea for me is keeping my blood sugar level as stable as possible. And it's easier saying than doing.
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Re: Followup needed 11 years after successful Natale ablation February 22, 2023 12:39PM |
Registered: 1 year ago Posts: 150 |
George, I read several posts of yours and very impressed that you figured out the coping mechanism with your Afib without an ablation. I will start taking 25mg Flec in the evening and see how it works for me.
I also got the JNJ vaccine in April 2021 and realized later on there might be an association of my increased episodes after that. I report it to JNJ safety department recently.
I also got the JNJ vaccine in April 2021 and realized later on there might be an association of my increased episodes after that. I report it to JNJ safety department recently.
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Re: Followup needed 11 years after successful Natale ablation February 22, 2023 12:50PM |
Registered: 1 year ago Posts: 150 |
Pompon, thanks for all the good hints, many can be used for myself. Besides exercise, I also tend to wake up with an episode after having a bigger meal of carbs at dinner time. I can tell by my Apple watch that my HR increased from my normal 50-60's to 70-90's during 3-5 am, but I won't know it until I wake up, usually between 6-7am, so I missed the best time to take my 100mg PIP Flec. I wish I know it right away and take the Flec immediately after an episode starts.
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Re: Followup needed 11 years after successful Natale ablation February 22, 2023 03:31PM |
Registered: 1 year ago Posts: 2 |
Quote
GeorgeN
Is your exercise trigger adrenergic? In other words does exercise trigger the afib acutely or is it a delayed trigger (which is my case as I have vagal triggers). What kinds of exercise provide the trigger?
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Thanks for the info. I think over the years my afib was acutely triggered. First episode way back in 2006, I was playing basketball. Second was six or so months later while playing a little touch football. Other episodes started at the gym during workouts. That was all prior to my first ablation. More recently, it's more of a mixed bag. I had a 30-minute episode one morning just doing my pre-gym warm-ups... a few squats, pushups, ab work, stretching, etc.. I guess that would also be considered acutely triggered. However, I think the real cause was from the day before. I had recently laid off my workouts for a couple of weeks due to an overseas trip. Upon returning to my pre-trip routine I was getting very frustrated by not being able to get back to my previous cardio levels (I measure everything, so I knew exactly how far I had regressed). Part of being 70 is that regaining lost ground takes much longer than when I was younger. As a result I did something really stupid the day before. I increased both my time and intensity on the stair-stepper and held a heart rate of 135-145 for the last 20 minutes or so of that session. Normally I make a point these days of keeping my heart rate below 120 except for brief periods (usually during the weight part of my workout). I knew it was unwise, but I was so frustrated by my lack of progress that I reverted to the "no pain, no gain" philosophy of my younger pre-afib days. I survived that session with no major issues, but I felt pretty sure it was what caused my afib early in the next morning's warmup. So, I guess that was maybe a vagal trigger?
Since that day I have not been the same. I have to carefully monitor my workouts and back off when I start getting increases in the number of skipped beats and runs of rapid beats (generally a warning sign of potential afib for me). Typically, the cardio part of my workout is when I am at highest risk, though I'm starting to have more brief runs of rapid beats during my resistance training now, particularly doing the leg press. There is something about being that "scrunched" up with relatively heavy weight that seems to put pressure on my heart and can cause problems. All this makes me think you may be on to something with your Duration/Intensity analysis. I have seen it posted before, but never spent a proper amount of time trying to understand it. I will do that now. It may well have a correlation to some of my issues.
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Re: Followup needed 11 years after successful Natale ablation February 22, 2023 03:57PM |
Registered: 6 years ago Posts: 920 |
Our bodies react sometimes strangely, but I believe they have a language we've better trying to learn. There are signs...Quote
Yuxi
Pompon, thanks for all the good hints, many can be used for myself. Besides exercise, I also tend to wake up with an episode after having a bigger meal of carbs at dinner time. I can tell by my Apple watch that my HR increased from my normal 50-60's to 70-90's during 3-5 am, but I won't know it until I wake up, usually between 6-7am, so I missed the best time to take my 100mg PIP Flec. I wish I know it right away and take the Flec immediately after an episode starts.
About HR troubles in the very early hours, for example...
I never wake UP with AFib. I just wake up, my heart beating normally around 60, but there's something wrong to come. I can feel it. I'm warmer than usual, maybe a little sweaty. Hypoglycemia has this kind of symptoms, among others. Who knows ?
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