Anyone have a failed Typical Aflutter Ablation?

Haven't posted here for some time, so brief background -- Mid 70's male. Had afib for over 35 years. For most of this time only a few episodes so no medications or ablation. Four years ago afib episodes became more frequent and also developed aflutter. Had a right-sided typical aflutter ablation in January and a Cryo Afib ablation in April.

Two weeks after January's flutter ablation, the aflutter returned.Short self terminating episodes as usual. Since no real blanking for flutter, ep said it either failed, or I had left-sided atypical flutter, which he thought was unlikely as I had never been ablated on left side before.

In April had a Cryo PVI and during the procedure the CTI flutter line was checked and found intact Now it's nine weeks post ablation and had a 15 minute aflutter episode this morning. It felt all too familiar in so many ways to my previous flutter episodes that I do not attribute it to the afib ablation blanking period. Feel more that it was always there and just now as I was on day 6 of a one week wean off Flecainide.

So if the flutter persists, I will have to make a decision. Live with it, re-do the flutter line, or do an atypical flutter ablation on the left side. I am reluctant to do the latter because I am adverse to general anesthesia, which seems to be the norm on the left side, at least in this country.

1. Anyone have a typical aflutter ablation that didn't work and what steps were taken next?

2. How reliable is visually checking and electrically testing the CTI line as opposed to completely re-doing the CTI line all over again with RF?

3. Does anyone know an ep that will do an atypical flutter ablation under true conscious sedation such as with Fentanyl, as opposed to GA or MAC (monitored) using propofol?

4. Any other thoughts?

The good news is that flutter didn't convert into afib, which it has a tendency to do. So still hopeful that at least the PVI part of my Cryo worked.

Mjames

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mjamesone

1. Anyone have a typical aflutter ablation that didn't work and what steps were taken next?

More than one. https://www.afibbers.org/forum/read.php?9,158643

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2. How reliable is visually checking and electrically testing the CTI line as opposed to completely re-doing the CTI line all over again with RF?

It's not visually checked; it's electrically checked. They apply electrical stimulation on one side and see if it's conducted to the other side. If not, the line is intact. Assuming a competent EP it's completely reliable and was the right thing to do. Making unnecessary burns inside your heart is to be avoided, for obvious reasons.

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3. Does anyone know an ep that will do an atypical flutter ablation under true conscious sedation such as with Fentanyl, as opposed to GA or MAC (monitored) using propofol?

There are some, but I would avoid them. There are good reasons for full sedation during an ablation.

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4. Any other thoughts?

The good news is that flutter didn't convert into afib, which it has a tendency to do. So still hopeful that at least the PVI part of my Cryo worked.

Yes, a cryo ablation probably wasn't the best choice since you were already a complicated case. Cryo is for index (first) ablations by less experienced EPs. It's not appropriate for more complicated cases like yours already is.

Although it's late in your blanking period you shouldn't give up hope yet. Flutter appearing late in the blanking period isn't entirely unusual and can sometimes be a positive sign.

Thanks! Will check the archives. Problem is I'm getting conflicting information. On one hand, they are telling me the flutter line is intact after checking CTI line electrically (complete bilateral block) but on the other hand they're telling me it's unlikely on the left side since no prior PVI and no fibrosis observed in left atrium. So where is it LOL From what I've read they may miss 5% after testing the line, so that could be me, or it's on the left side, where I really don't want to go at the moment.

I agree that Cryo is a limited tool, however my ep uses RF where needed. High output major teaching hospital. I do differ on your take regarding anesthesia. In Europe conscious sedation is used more than GA and their results are just as good. I see GA more for the ep's convenience and less for the patient if you factor in the side effects of GA, which can be considerable and lasting for some, especially the elderly, which is me Unfortunately, this is the way they are trained here.

Trying to stay positive, however my gut tells me this is not post operative flutter, but my old flutter that never went away. The lead up to this morning's episode, the ekg, everything, is just so unwelcomingly familiar Certainly hope I'm wrong. Hopefully, my PVI will hod better than the flutter ablation.

I think that flutter line is probably intact. But no matter the case you need to give it more time to settle down to see what's what.

Thanks again, but it's been six months since my flutter ablation I certainly will not take any action, until I at least see how my Cryo turned out, which is only 8 weeks old. From your link, I see you have been ablated by Natale. Does he only use GA, or does he have some flexibility where someone cannot tolerate GA?

But it's only been 9 weeks since your cryo ablation. I'm sure he can be flexible in the type of anesthesia used.

Thanks. We can hope

I like propofol, not as much as Michael Jackson but enough to understand why he loved it so much.

James, so what side effects does propofol cause for you?

My first procedure under MAC with Propofol was a recent colonoscopy. Unlike other colonoscopies, that used various combinations of narcotics and/or versed, instead of returning to my pre operative alert state in a matter of a day or so, it took me a month. My typical flutter ablation and following cryo were also under Propofol (MAC not GA). With longer operative times than the colonoscopy, it took even longer. Very hesitant to chance a fourth time under Propofol unless absolutely necessary.

Truth is they don't know a lot about how anesthesia agents like Propofol work. It may feel like a peaceful, happy sleep, but it is not anything like that inside your brain. There's a building body of evidence that some people are a lot more susceptible to the lingering and possible permanent side effects than others. The elderly -- and that would be me -- are a group that are susceptible as a whole.

In the UK and Europe, GA and Propofol are hardly even used during an aflutter ablation and it's not uncommon for a patient to be conscious even during a PVI, where they would simply sedate with narcotics. The American ep will tell you that it's too dangerous to ablate under sedation because the patient might move during a critical part of the procedure. Sounds good, but the UK and European ablation results are just as good as ours. Is it because their ep's have steadier hands? Quicker reflexes? I don't think so. They just got used to doing it that way and have shown that it will not effect patient outcomes. Is it easier for the ep to use GA? Of course, patient is out, fully compliant and all anesthesia responsibilities are left to another person, the anesthesiologist. But at what expense to the patient?

Some may cringe at being awake during a PVI, but given my experience, I'll take the trade off of some discomfort over lingering and possibly unknown side effects inside my brain, any day.

I couldn't find the paper that defined this best, but here are a couple of reads. A lot more out there with a quick google search.

[www.uchicagomedicine.org]

[www.sciencedaily.com]



Edited 1 time(s). Last edit at 06/28/2023 06:19PM by mjamesone.

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mjamesone
Truth is they don't know a lot about how anesthesia agents like Propofol work.

You might be interested in a YouTube channel done by a Stanford and Harvard trained anesthesiologist—Dr. Anthony Kaveh. It is called Medical Secrets and he talks a lot about this and other under-discussed topics in anesthesiology—I have found it very educational.

P.S. He just did one this evening on how long it takes anesthesia agents to leave the body. He did it live giving people the chance to ask questions: [youtube.com]



Edited 1 time(s). Last edit at 06/28/2023 09:39PM by Daisy.

Thanks! I take a look.

Saw it. Yup. That man knows and loves his drugs Might shoot him a note at some point. In China they have done studies using acupuncture as either the sole method of anesthesia, or in conjunction with a reduced agent. Something tells me there will not be a lot of interest or funding for those types of studies here

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mjamesone
Saw it. Yup. That man knows and loves his drugs Might shoot him a note at some point. In China they have done studies using acupuncture as either the sole method of anesthesia, or in conjunction with a reduced agent. Something tells me there will not be a lot of interest or funding for those types of studies here

You’d be surprised as he often talks about how no one fully understands how anesthesia drugs work and gives patients tips on how to lower their needs for these drugs through natural means such as breathing techniques and other means of reducing stress. He doesn’t hesitate to talk about the side effects of these drugs and possible consequences of multiple general anesthesia, especially in the elderly. But yes, he does practice in hospitals in the US and uses anesthesia medications daily for surgeries though he phones each patient the night before to answer their questions and to try to lower their anxiety and thus their needs for higher dosing.

I don't doubt that he and I could find a solution. In fact, I had a nice talk with the anesthesiologist, just prior to my ablation and pretty sure we could have agreed on some Fentanyl combination without Propofol. However, her last words were, "Now I'll talk to the doctor and see what he wants", Guess what I got