Perplexed with it all - recommendations?

First Post. I've been lurking on this forum since I was diagnosed a year and a half ago. (M 61, persistent, lone AFIB.)

I still find it hard to believe that I'm *always* in AFIB. 24x7 according to the Holter. Since I've been on metoprolol, I rarely feel anything. First cardiologist/EP recommended amiodarone + cardioversion. I ran for a second opinion. Ended up with a slew of tests that ruled out valves, blockages, etc., treated sleep apnea but still have AFIB and a few more cardiologists. Except for being unable to maintain high heart rate (due to metoprolol, apparently) I feel fine; walking, stairs, yard work, etc. My newest doc is recommending amiodarone and a cardioversion - just to see if I feel better. IF so, she'd recommend pursuing ablation since she thinks there's a good chance the cardioversion won't last (esp if I don't add the amiodarone)

I was originally going to ask for a recommended EP in the Chicago area; however, after reading so many posts, it seems the only answer here is Natale. (I read the thread about provider rankings and dennistondata and really got confused - those rankings don't seem to match the recs. of friends and of other sites. Couldn't find an attendee list from recent ISLAA symposium in KS).

Anyway, what do you think of getting a cardioversion as a "test" to see if I can feel better in NSR? and/or
do you have any recommendations on Chicago area EPs?
Thank you.

I agree with getting a Cardioversion. The odds are against it holding, but since it's a relatively easy procedure with low risks, the Dr's are recommending you try it before going to the next step. You could try an alternative Anti-Arrythmic medication instead of Amioderone. There is value to testing how you feel in NSR, even if it doesn't hold. If you have been in AFIB you may not realize how much better you feel in NSR, or you might not notice a difference, and that would still have value. Finally, even if you do proceed to try for Ablation, you would probably have to wait months to have Natale do it.

There's no harm in doing the test. If you don't really notice your afib when the rate is kept down by metoprolol, my guess is you're not going to feel much different, but I could be wrong and you'll never know until you try. That will also tell you how much the metoprolol is impacting you since you won't need to take it with the amio.

Natale isn't the only EP who can ablate persistent afib, but the number I would personally recommend is only about 3-4 names. Trying to find the ISLAA attendee list was clever because those are the EPs at the leading edge, but you can definitely find a list of speakers and that might be an even better list.

Yes, it will likely take weeks or months to get in for an ablation with Natale, but that's probably true of any EP with the skills you need.

Hi, Mike!

You said, "...reated sleep apnea but still have AFIB..."

Unfortunately, AF is a progressive disorder once it is established, and it doesn't appear to matter much what the progenitor was. If yuz got it, yuz got it. So, even though you were diagnosed with OSA, as I and many thousands of others have been, it doesn't mean that managing the OSA will make the AF go away any more than managing the AF, itself, will attenuate it to the point of extinction. Yuz got it.

But there's more: once you have the disorder it will progress, even if very slowly, and regardless of the technique...pretty much. While this may seem daunting and disappointing, it needn't be. As our hosts here say many times each month, AF won't kill you. It may make living with it kinda awful and onerous as times, but it won't kill you. Further, and as important, the longer you delay dealing with it using any available means, whether chemical or mechanical, the more inclined it is to progress. You should really nip it in the bud, to the extent possible, sooner rather than later. For many of us, cardioversion offers a temporary respite. There are members here, as you must know from lurking, who have have umpteen of them. Obviously they aren't especially permanent. Much more so is the mechanical intervention of ablation. It has a modest success rate, but second attempts do somewhat better statistically, and many of us have had more than two.

As the waiting times are understandably longish for the best EPs, you should probably make up your mind about ablation soon and get in line. The longer you are in AF, the more intractable it will be. So get on the list asap.

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The Anti-Fib
If you have been in AFIB you may not realize how much better you feel in NSR, or you might not notice a difference, and that would still have value.

I've had afib for 18.75 years. In the first 4 months, I had a 2.5 month episode for the last part of the 4 months. My resting afib rate was ~80 BPM. I felt fine. My EP wanted me to just stay out of rhythm. I proposed a plan that included moderating intense, long duration exercise, supplementing with electrolytes, converting me back to NSR and a script for on-demand flecainide to be used for converting future episodes. EP agreed and I used flec to convert the 2.5 month episode. Per Anti-Fib's comment, after my conversion, I literally felt like I was "high" for about a month. I had no idea what a difference NSR meant to how I felt. In a broad sense, I've followed my plan since.

Thank you, all, for the perspectives and information. I appreciate your time and welcome any other thoughts.

Mike - you're in persistent AF and didn't mention if you were taking a NOAC/DOAC.

Avoiding a stroke should be priority 1 regardless of how you feel.

Get an ECV even if just to test how good NSR feels to remind you and hopefully see if it sticks.

go for wolf mini maze and its over and no more thinners...check it out

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Dovewing
go for wolf mini maze and its over and no more thinners...check it out

Beware of the atrial flutter that can be caused by the MM, but needs to be solved by an ablation. Wolf doesn't mention that. See: [www.afibbers.org]



Edited 1 time(s). Last edit at 03/19/2023 01:18PM by GeorgeN.

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Dovewing
go for wolf mini maze and its over and no more thinners...check it out

You need to start qualifying these statements. A Maze procedure isn't necessarily a one-and-done and it doesn't necessarily free you from anticoagulants.

I had the WMM (Wolf Mini Maze) in Tokyo 4 months ago. It is done by Dr Ohtsuka who trained with Dr Wolf.
Dr Wolf mentions possible atrial flutter in patients who have had several unsuccessful catheter ablations, due to the scarring inside the heart.
I was five years paroxysmal AFib and since the Op I am in NSR every day all day.
After the WMM you are off anti-coagulants and after three months on just 50mg Flecainide, during the blanking period, I am not taking any medication. I am back to rowing on the ergo and up to 8 chin-ups.
I am 76 and you can ask me anything about the experience.



Edited 1 time(s). Last edit at 03/23/2023 04:19PM by saulger.

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saulger
Dr Wolf mentions possible atrial flutter in patients who have had several unsuccessful catheter ablations, due to the scarring inside the heart.

It's not just patients who've had prior ablations. Flutter is a common complication of Maze procedures regardless of prior ablations, and the only way to deal with that is drugs or an ablation. That's why hybrid procedures that combine a Mini-Maze with an ablation are becoming more common.

I'm glad it went well for you but coming off anticoagulants is determined more by your CHADS-Vasc score than the presence or absence of afib, so it's not true for everyone that getting a MM will get them off anticoagulants.