Successful cardioversion - now what?

Hello Again,

Following your recommendations (and probably too much thinking), I finally had a (successful) cardioversion in August. After being in persistent AFIB for at least two years, I'm now in normal sinus rhythm. Still taking Amiodarone and Eliquis along with a few other drugs on the advice of cardiologists. I asked my EP about changing to Multaq (or some other anti-arrhythmic) and he quickly told me that wouldn't work.

Parenthetically, I do feel a little better in NSR (no fish-flopping in the chest); however, I still don't have the energy (speed? stamina?) I used to have; but that's likely due to the amiodarone capping my heart rate. At least I feel better than when I was on the beta-blocker

He said he'd write a prescription for Multaq if I wanted but it was against his advice. It wouldn't work. Then he said if I wanted to get off the meds, I had to get an ablation. OK. So, I've been doing some reading and lurking and understand that there is good evidence that ablation is superior to anti-arrhythmic meds for long-term positive outcomes (reduced risk of dementia, lower rate of subsequent return of arrhythmia, etc.); however, there is a downside (unintended complications, low, but non-zero, potential for very bad outcomes, potential a-flutter, need for 2nd round, etc.). Every time I convince myself to take the ablation plunge, I hear or read some horror-story, or, journal article that convinces me not to go down that road.

So, I'm perplexed again and am asking for your opinions, which I respect more than my own and trust more than my docs', since you guys don't profit from your recommendations.
1. If I'm on amiodarone and it's keeping me in NSR, why do I keep taking the Eliquis?
2. If I'm on Eliquis, what's the risk of changing anti-arrhythmic to something with a safer profile? If I happen to go back to AFIB, I'll probably know it and can deal with it then. Apparently I'm one of those who doesn't really mind being in AFIB (except, of course, for the damage it does.)

Is pill-in-pocket reasonable? I've read that it's not a good option for people with long-standing, or, persistent AFIB, but, do I have that? I've been NSR for four months. Likewise with dronedarone (multaq): it's not for folks with permanent AFIB, but, it's confusing, since I thought "permanent" just meant "persistent but not being treated/relieved". Since mine has been treated successfully, it's not persistent, is it?

3. Is it reasonable to assume that ablation would eventually allow me to get off the medications? (FWIW, I'm pretty much 0 on CHAD-VASC)

My original cardiologist recommended cardioversion and amiodarone. Fearing the meds, I ran for a second opinion, which led me on a two-year journey (sleep studies, dental appliances, stress tests, pulmonary tests, MRIs, cardiac imaging, etc, etc.) just to end up where I started with a cardioversion, amiodarone plus a handful of meds. Is this just life in 21st century?

Thank you, again, for your time and thoughts.

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mike111
3. Is it reasonable to assume that ablation would eventually allow me to get off the medications? (FWIW, I'm pretty much 0 on CHAD-VASC)

I do think that you are trying to think this through to a level that is not helping you. There is a good chance of getting off meds with an ablation but not so much unless you go to one of the top tier EPs who specialize in people with a history of persistent Afib. If you haven’t read Carey’s pinned post above, have a read. I agree with your docs about Multaq—it isn’t very effective. I took it for about a year. There can be complications with ablations (I held off on getting one way too long after reading about them), but again, the complications are minimized by going to one of the top docs. Antiarrythmic drugs just aren’t good for you long term and have some scary side-effects. I had a life threatening side-effect from Flecainide but none from my ablation, and yes I am off the meds except for a half dose of Eliquis (which is only a good idea in very limited circumstances.)

As to PIP, of course you could come off Amiodarone and experiment, however success is unlikely given your long term persistent status.

Catheter ablation is also far less effective for long-term persistent and at best you would probably be looking at a series of those procedures.

If I were in your position, I'd look into surgical ablation, like the Wolf Mini Maze (WMM) which have shown to be successful in hard to treat cases where catheter ablation often fails.

Jim

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mike111
Is this just life in the 21st century?

Sadly, it sure seems to be the case.

My history is similar to yours, After years of occasional AFIB without being able to catch it. I was diagnosed Jan 2020 and then had a chemical cardioversion immediately. Then about two weeks later had an electrical cardioversion done. The only medication I was put on was metoprolol at 100 mg BID. It did not agree with me, though at first it did help. Then went back into AFIB a couple of months later. About six months later, I stopped the medication and started my search for a way to at least correct what was happening and get my QOL back.

It took me two years to find a team I trusted enough to guide me through this. We started with a long list of medications to try and get things calmed down and in a reasonable state, and the best they could do was get my resting heart rate to 87 and still be in AFIB. I got a referral to an EP and had an ablation done 6 Sept this year. I was in NSR for about three days before going back into AFIB. The pharmacy had an issue and I did not get my multaq until the third day. I was better off than before the ablation, and it looked like I was trying to go back into NSR, so we scheduled a cardioversion and hoped it wouldn't be needed.

Oct 3rd I had the cardioversion and have been in NSR since then except for the two times I missed a dose of medication, and it took three days to get back into NSR.

From my experience, I would recommend and ablation. Look for the best EP you can work with, as the others have said. As for multaq working for you, the only way to truly find out is to try it. Odds are good, your doctor is right, but you never know. But I would start planning on the ablation and then worry about any medications you might need after that.

In January, we are going to start taking away medications, and I am hoping to stay in NSR. I could have done that already but wanted to get through the holidays in a known state that was stable. We have already discussed a second ablation, so I am just waiting to see if the extra time has helped.

The thing to remember is AFIB never really goes away, even after an ablation. It will have a potential to come back. I am fairly good right now, but my hope is to get off the medications for a few more years and push this farther down the road. Maybe something better will come along.

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mjamesone
As to PIP, of course you could come off Amiodarone and experiment, however success is unlikely given your long term persistent status.

Natale and a small number of other top EPs have very good success rates ablating longstanding persistent afib, better than most average EPs with paroxysmal. I know of a successful ablation on a gentleman who had been in persistent afib for 30 years.

The trouble with Maze procedures beyond the surgical risk and long recovery period is the atrial flutter that frequently comes with a Maze. I've lived with afib and flutter and I can tell you that flutter is no improvement over afib, and it's harder to stop with antiarrhythmic drugs. So in many cases a Maze procedure means an ablation anyway to deal with the flutter. The equation doesn't work for me.

The disorder is progressive by nature. It is always best to get robust intervention early. I have had several cardioversions. One of those lasted 16 hours, the last only took 20 whole minutes and I was back in AF, still in the hospital.

My first ablation failed inside of six otherwise blissful days. I, too, was placed on amiodarone. I asked why not Flecainide or Sotolol, or the commonly given propafenone, and the internist said amiodarone was the right hammer for now. Luckily, I was off it, with a short bout of AF at six weeks, after 10 weeks. My second ablation worked, and as anyone with the thumb-and-bump in the chest wall can tell you, the seemingly inconsequential things in life mean a great deal when you can find them again....NSR being one of them.

You might consider trying another EP., unless you have full confidence in the one who did your last ablation. There are several really top-tier EPS in the USA. We often tout Dr. Andrea Natale in Austin. His success rate is almost miraculous, according to many enthusiastic fans among the membership at afibbers. When he knows he'll probably have to do a touchup in a few months, he'll tell you. That should bring a lot of confidence because he has the skills and the intuition about his craft that he is candid about.

BTW, you stated that amiodarone keeps the rate down when you're in AF. It doesn't do that. It helps to regulate the dysrhythmia, but it would be a calcium channel blocker or a beta blocker that caps the rate....or rather, tries to.

From what I've read, the flutter occasionally following mini-maze is transient and in almost all cases resolves by itself, or after a single cardioversion and never read that it requires a follow-up ablation.

What you may be thinking of is that mini-maze does not treat flutter, which is true. But the OP did not mention flutter as an issue, only afib.

Have a lot of respect for Natale, but I would think the odds for a one-and-done in this case are much better with mini maze vs catheter ablation. It would be my choice if in the OP's position.

Jim

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mjamesone
What you may be thinking of is that mini-maze does not treat flutter, which is true. But the OP did not mention flutter as an issue, only afib.

Problem is, MM causes it in many cases (as can ablation).

Problem is, MM causes it in many cases (as can ablation).

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As mentioned, with MM flutter is transient and readily fixed by itself or a single cardioversion. With catheter ablation, if flutter presents because of scarring, it probably would have to be ablated. But let's just say for discussion sake, it's a wash, i.e. equal chance of flutter after either catheter ablation(s) or a MM and both would need similar treatment. The OP would still be better with MM, because it gives the best chance for one-and-done for the afib.

Jim

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mjamesone
As mentioned, with MM flutter is transient and readily fixed by itself or a single cardioversion.

I'd have to see a source for that claim. Ablations following Maze procedures are extremely common. So common in fact that a hybrid procedure exists where the surgeon brings an EP onto the team to do an ablation in combination with the Maze.

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Carey

As mentioned, with MM flutter is transient and readily fixed by itself or a single cardioversion.

I'd have to see a source for that claim. Ablations following Maze procedures are extremely common. So common in fact that a hybrid procedure exists where the surgeon brings an EP onto the team to do an ablation in combination with the Maze.

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Not trying to be cute, but as you know it's almost impossible to prove/"find a source" for a negative, so I should be asking you what source tells us that non-transient flutter is extremely common after MiniMaze? As to Hybrid, while it sounds like it's simply a mini maze plus a catheter ablation, the mini maze part is not the same as what Dr. Wolf does.

I will reach out to someone more familiar with WMM from their site to explain more in detail, but not sure if they want to contribute. Beyond that, I suggest anyone interested, to do their own research and not rely simply on what has been stated in this thread by either of us.

Jim



Edited 1 time(s). Last edit at 12/12/2023 07:16PM by mjamesone.

Thank you for the thoughtful and thought-provoking replies.

To clear up some misunderstanding, I have not had an ablation and am puzzling over the next decisions. The ECV was successful and I've been in NSR since then (4 months). I do feel better than I did having AFIB 24x7 for the prior 2 years but I wouldn't call it "a high" as someone on this forum described.
I do believe the amiodarone is affecting my heart rate in addition to helping with rhythm. (I understand that amiodarone is an anti-arrhythmic; however, it does seem prevent me from achieving a heart rate above about 120 - 124 bpm. According to a few sites I've seen, (and my NP) it can cause slowing heart rate and/or limiting of the maximum rate.)

My EP put the probability of successful ablation (for my case) at about 50% compared to 70-80% if I was paroxysmal. A few sentences later he said it's what he would do. Seems like an expensive, risky, coin toss, though perhaps less risky than the WMM. He presented no illusion of being "one and done" essentially telling me that I should expect two. That kind of sounds like one and a "touch up" per Natale.
Sure looking to avoid having six!

Thank you, again, for your responses.

Before going into an ablation with any EP, be sure to ask how many he/she has done and particularly how many they have done on patients with persistent Afib. You want to hear many thousands!