Round Three and Another Failed Attempt

Well, Made a trip four hours away to another EP to attempt another ablation for Atrial Tachycardia. Yet again, now a second time, this ridiculously elusive rhythm evaded them and they could not do the ablation . Not sure what options that I have left to me now. Probably will have to take Metoprolol, which allows lots of breakthrough SVT. Basically, I have to just hope the rhythm resolves itself eventually, gets worse so they can fix it, or simmers down enough for the meds to work. Cannot even express how discouraging this is.....

Aw crap, sorry. I totally understand how discouraging that must be. AT is notoriously difficult to pin down.

I feel for you, Megan. When my first ablation failed spectacularly inside of six days, I couldn't believe it. But it just didn't work. I have AF, and know little or nothing about VT and what it makes you feel like, but my guess is that the worst is the anxiety and disappointment after all you have worked up to through these three procedures. I sincerely hope you find relief somehow. Would you have recourse to a highly specialized EP, maybe in France? Is that doable? There is a lot of solid work and research going on in Europe these days around heart arrhythmias.

Thank you for the responses. It was really pretty awful to have to go through a long EP Study and attempts ablation with no sedation. They felt it was necessary to maximize chances to induce the Atrial Tachycardia. It sounds like my future options are to wait it out, see if it improves on its own, or gets worse. The EP really wanted to see if someone would do an EP Study at night since my symptoms literally happen EVERY night, stating around 7-8pm and ending around 7-8 in the morning. Not likely to happen though! Anyone else have chest pain/burning after an extensive EP study? They paced me for a long time, I am guessing it is somewhat expected.....

Megan,
I also developed AT after two ablations. I have been on dofetilide (after sotalol and multaq were ineffective) which has kept me in sinus for the last seven months.
During a discussion with the EP regarding a 3d ablation, I asked if they would stop the dofetilide some time before the ablation so hopefully I would be in AT at the time of the procedure. They stated they would continue the dofetilide. Hearing your issue of not being able to induce AT makes me want to revisit the response I received.

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MeganMN
It sounds like my future options are to wait it out, see if it improves on its own, or gets worse.

You have more options than that. Go see Natale in Austin or Pasquale Santangeli at Cleveland Clinic.

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Carey

It sounds like my future options are to wait it out, see if it improves on its own, or gets worse.

You have more options than that. Go see Natale in Austin or Pasquale Santangeli at Cleveland Clinic.

I could certainly look into it. But have to figure out how any other doctor would have better luck inducing? I suppose if someone else was willing to try the procedure at night, that would certainly do the trick. Something to ponder for certain!

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MeganMN
You have more options than that. Go see Natale in Austin or Pasquale Santangeli at Cleveland Clinic.

I could certainly look into it. But have to figure out how any other doctor would have better luck inducing? I suppose if someone else was willing to try the procedure at night, that would certainly do the trick. Something to ponder for certain!

A virtual consult to chat about it with one of those two EP's would be warranted, IMO.

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MeganMN
I could certainly look into it. But have to figure out how any other doctor would have better luck inducing?

As George suggested, arrange a virtual consult and just ask them.

Did the docs who did your EP study administer any drugs during the procedure to try to provoke the AT? I know that Natale uses isoproterenol routinely at the end of an afib ablation when he thinks he's got it. It makes the heart very excitable and will provoke lurking arrhythmias he might have missed.

Thanks for the suggestions. I will certainly try to set up a zoom consult and see if they have any additional input! The last EP study was very thorough. They tried pacing, burst pacing,.no sedation, sedation, and isoproterinol. None of it worked. I suspect that no ablation attempt will work unless it is performed at night, or they can figure out a way to simulate the body's changes at night that are causing my arrhythmia. It is literally like clockwork every single night, a switch flips on and I zoom into Atrial Tachycardia and every morning it flips off. No matter what I do, don't do, if I sleep or don't, etc...

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MeganMN
It is literally like clockwork every single night, a switch flips on and I zoom into Atrial Tachycardia and every morning it flips off. No matter what I do, don't do, if I sleep or don't, etc...

That's very strange, but it suggests cortisol could be involved. Your cortisol levels drop from morning to evening and then begin rising again at night until they reach a peak in the early morning. So your AT could be tied to higher levels of cortisol. Do you also experience AT episodes following stressful events?

I've had an Integrative Medicine doc check my cortisol levels at four times throughout the day/night and they were not measurably off. It is obviously something hormonal or related to vagal tone. I do also experience it with stressful events but not all the time, more so in the evening than the daytime. This was an interesting read:

[www.ncbi.nlm.nih.gov]

The doctor is thinking it is related to the nocturnal increase in vagal tone and nocturnal variations in potassium/calcium/sodium responses that is the culprit, although there is little consensus in what to do about it or how to fix it, and also, how to induce it. I need to find someone intrigued enough about it to go after it and try to help me figure it out! Looking at my 14 day Holter results was quite interesting as there was an obvious nocturnal pattern that the doctor could clearly observe. Oh how I wish they could just do the EP study in the late evening!

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MeganMN
The doctor is thinking it is related to the nocturnal increase in vagal tone and nocturnal variations
in potassium/calcium/sodium responses that is the culprit, although there is little consensus in what to do about it

Here is a thought—I have Dysautonomia and saw an automatic specialist for years. Testing showed very high vagal tone. He prescribed Strattera which increases norepinephrine in the synapses and it worked like a charm…but it might keep you awake though I did not “feel” stimulated when taking it. It took several weeks to get used to even the lowest dose though and he titrated it from a tiny dose to finally the standard low-dose.



Edited 1 time(s). Last edit at 12/15/2023 09:30PM by Daisy.

I had a similar experience. Afib ablation in 2012 worked well til 2021. Flutter and ATs Ablated again here in Charlotte. Failed after 6 wks. I flew to Austin. Natale told me the next morning afterwards “youre fixed”. He was right. 2.4 yrs nothing. Go!!

That is really interesting. I have thought something like that could be the culprit and have explored options to treat it but have been unsuccessful. In will look into Natale but at the moment am in excruciating pain from the pericarditis so am fed up with procedures. How did the insurance piece go for those of you from out of town? Did it pay for any of it? Most of it? That would be a huge factor for us.

Insurance will depend on what you have. If you're on a plan with a network such as an HMO or Medicare Advantage plan, then it will depend on whether Natale is in network or not. But if you're on traditional Medicare or a private plan that Natale accepts, there won't be any issues. When I did my ablation with him and later my Watchman I had employer-provided insurance so I had to pay a deductible, but I'm on Medicare now and if I did it today it wouldn't cost me a dime other than travel expenses. I traveled alone and my total travel expenses were about $1000. When you get to the point of planning I can offer some more tips for making the trip. It's easy.

Thanks Carey. We have family in Dallas, so that would probably be a viable option.

Do you know if either of those ep's would withhold sedation as in Megan's case to more easily provoke the atach? This is fairly common in Europe, but most US ep's tend to do the ep studies under GA. I've been empirically ablated both for afib and typical flutter, but both persist, so I'm looking for someone to induce my remaining arrhythmia's without more empirical burning. And since I am slow to recover from GA -- probably due to age -- I'd prefer to endure the discomfort of being conscious on a long procedure, versus the after affects of a long time under GA.

Jim

Although I'm sure they've skipped GA due to necessity or patient preference, both the EPs I named use GA as a general rule. There are reasons beyond patient preference for using GA. It gives them total control over your breathing, for example, which they sometimes need to stop or slow briefly, and it eliminates the risks of things like coughing, sneezing or unexpected movements at inopportune moments. I expect they would both put Megan under fully and then most likely they'd be able to provoke the AT. If anyone can provoke it, it will be those guys. Jim, they absolutely can provoke afib and flutter pretty much at will.

Natale is incredibly good at finding the source of arrhythmias. And while he uses GA for the important reasons Carey mentioned, he is selective in the meds used—for instance if you usually take something like a benzo, you are asked not to take it or other sedating drugs the day before the ablation. The GA is induced with meds that he feels won’t interfere. He is so careful about every step of the procedure—even the type of intubation tube.

Jim, my last attempt was without any sedation. It was not a pleasant experience or one that I would want to repeat. In my case, I don't know if that was even the right choice because my Atrial Tachycardia happens at night, when I am relaxed! I feel like I am pretty tough, but it was actually quite a terrible experience. I felt everything quite acutely and the constant pacing was pretty intense. My EP study was about 3 hours long. Your mileage may vary, however, but I would definitely NOT repeat that, especially in lieau of the fact that they couldn't induce it anyway.

Well, I am on the waiting list for a consult with Dr Natale (maybe sometime in April) and have also reached out to Dr santangeli for consideration. Now I wait and try whatever I can come up with to try and chill my heart out.... Thanks for the recommendations.

Thank you for the replies! I saw the doctor today for follow up. I had been taking Metoprolol and stopped it prior to the procedure. I didn't take any prophylactic Colchicine but am now on it for a month with ibuprofen. The doctor doesn't even want to switch up my meds for the atrial tachycardia until the Pericarditis has resolved. My echo was okay, which is good. He has me on another three day monitor to check because he thinks the Pericarditis has made my rhythm worse. Ugh. The pain is finally asking but nighttime is still tough. I'm not sure what my options are at this point. Another ablation is off the table for now. the meds all mess me up. I may just be living with uncontrolled Atrial Tachycardia until I can get a consult with Natale (April or May). I did also see my Naturopath today and she gave me the green light to try the TENS unit to stimulate the vagus nerve.