Significance of a Single Late Afib Occurrence after Ablation.

It's 11 months since my first PVI. First two months on daily Flecainide and then stopped. I've only had a single afib episode at month six, which terminated 3 hours after PIP Flecainide.

I would be more than happy with just one afib episode a year, however the concern is will the frequency increase? Welcome any similar experiences or thoughts. The literature is sparse on this.

Jim



Edited 2 time(s). Last edit at 03/07/2024 12:27PM by mjamesone.

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The literature is sparse on this.

Here is a recent article: [pubmed.ncbi.nlm.nih.gov]

Identifying the prognostic significance of early arrhythmia recurrence during the blanking period and the optimal blanking period duration: insights from the DECAAF II study

Thanks. But article was about "early recurrence". Mine was a late occurrence at month 6. Literature sparse on where things go from there, so hoping for anecdotals here.

Jim

I believe the intent of the article is to spur further study. Also, I feel that the authors figured that, as a general rule, the later the recurrence, the worse the prognosis for staying AF-free over the long term. I saw this study last year, or one very much in line with it, and reported here that the gist is that if one gets the odd run of AF within the first four or five weeks, it's not so bad, and poorly predictive of recurrence later. However, if one gets runs LATER in the blanking period, or after, then one should assume that the ablation or other remedial measures have not succeeded in isolating the focus/foci re-entrants and that AF will continue, even if at a greatly reduced frequency. And we should remember that there is only a predictive coefficient, not an absolute here. Individuals vary greatly. But from there, I assume that 'triggers' become more important to the sufferer.

[Edited to fix mangled syntax]



Edited 1 time(s). Last edit at 03/07/2024 06:01PM by gloaming.

If you have no more episodes in the next month your ablation will "officially" be a success. However, the episode at 6 months isn't a positive indicator. Your ablation lines should have been fully formed at that point, so a sustained episode of afib suggests you still have afib sources that haven't been fully isolated. I don't know what they ablated in your procedure, but if it didn't include the posterior wall then that would be a likely suspect. That's the kind of thing that leads to so-called touch-up ablations. On the other hand, if you can get to year 2 with no further episodes, that probably indicates your episode was a one-off, perhaps caused by electrolyte disturbances, and the ablation was successful. All you can do is wait and see.

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Carey
If you have no more episodes in the next month your ablation will "officially" be a success.

I was under the impression that the "official" pass/fail was no events >30 seconds in months 3-6, so by that criteria, I
already "failed" or came close to failing, have to check the exact dates.

Your other points are well taken. I had a straight Cryo PVI and no posterior wall work was done per the institution's paroxysmal afib protocol, although I was told if they saw any scar tissue they would then ablate the wall as if it were "persistent", but they found none.

Should I go back into the lab, I assume they will look all over on both sides, as I have also other tachycardia's going on besides afib, although not bothersome to the point of dealing with them yet.

My trigger this time was one of those tachycardia events with a severe case of GERD/heartburn on top of it. Hopefully that apparent perfect storm will not repeat, as this was the only tachycardia during the post ablation period that converted to afib. Prior to the ablation, most of my afib episodes were preceded by tachycardia -- either flutter or some other SVT, the ep's seem to disagree on what it is.

Jim

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gloaming
However, if one gets runs LATER in the blanking period, or after, then one should assume that the ablation or other remedial measures have not succeeded in isolating the focus/foci re-entrants and that AF will continue, even if at a greatly reduced frequency. And we should remember that there is only as predictive coefficient, not an absolute here. Individuals vary greatly. But from there, I assume that 'triggers' become more important to the sufferer.

Well said. One ep I spoke to mentioned that if we used the normal criteria of no events after blanking, then his success rates were only 50-60%, but if one considered success (no need for further ablation) a significant reduction in afib burden, then his success rates were closer to 90%. Hopefully, my afib burden will remain significantly better than before. Just looking for anecdotals here on post blanking events and how things eventually turned out.

Jim

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mjamesone
I was under the impression that the "official" pass/fail was no events >30 seconds in months 3-6, so by that criteria, I
already "failed" or came close to failing, have to check the exact dates.

I've never heard of that criterion. The most common criterion I've seen used is no sustained atrial arrhythmias at 12 months post ablation without the use of AADs. By the standards used in most research studies, yours would be considered a success. But like I said, that episode wasn't a positive indicator. Six months is a long way out.

During a repeat procedure a good EP would look everywhere for afib sources and would try to provoke them with electrical pacing and with isoproterenol. I know that Natale does a prolonged isoproterenol challenge at the end of all his ablations, which the average EP does not do.

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mjamesone

... Just looking for anecdotals here on post blanking events and how things eventually turned out.

Jim

Sorry, I completely forgot that part of your question. As briefly as I can do it:

Had an index on July 27/22, and was in the ER six whole days later, put on Amiodarone, told to stop metoprolol completely. Went on to within two days of completing my 8-week regimen of Amiodarone, including a two week taper. With two days to go, more AF.

Holter two weeks later showed a ton of PACs, but no AF according to the outreach nurse who kindly offered to call me and tell me what the results were.

I was free of AF until two weeks after the Holter, but broke into AF while visiting daughter and her very young family...toddlers. It was during the telephone call with the outreach nurse for the Holter results that I told her about breaking into AF again. She asked if I had an EKG, told her only from my Galaxy watch. Could I download it and send it to her...she'd show the EP. Did that, and she called back and said the EP agreed with the Galaxy watch and would call me to discuss where to go. It happened about three weeks later, and he agreed to try another ablation.

Had the ablation mid-February last year, with one rather nasty intervening bout of flutter which had me into the ER three consecutive days over New Years. Luckily, even though a cardioversion each time failed to last more than a few hours, the metoprolol kicked me out of flutter, or my heart did it on its own, which is somewhat rare. Flutter tends to stay there.

So, second ablation mid-February, and I went two weeks. Suddenly, I went into AF. I was greatly dismayed, thinking I had lost the fight again. I felt almost as badly for the kindly EP as for myself. To the ER I went, but they conferred amongst themselves and said they didn't want to offer me cardioversion in view of the three failures six weeks earlier. Not knowing any better, I had to agree, and they sent me home, but not before I converted about an hour after that conversation. Amazingly, I haven't had a single missed beat, to my knowledge, ever since.

Last thing, the nurse, when I called to ask her advice, said very emphatically that the decision not to cardiovert me was a mistake. Each time you heart is messed with, whether open heart or by catheter, it gets something like a new manual and a new warranty. She said that I should absolutely have been given a cardioversion. I offered that I was fearful that I Dr. Novak and I had lost this round as well. She waved me off immediately and said, again emphatically, "You do NOT have atrial fibrillation!" I couldn't argue, but that recent run spoke volumes to me. Still, it turned out she was correct, and as I stated, my heart has been perfect ever since that one weird oddity.

So, it happened to me, twice. The first time was unmistakably a failure, but while the second ablation's rogue AF took a week longer to manifest, it was indeed just that....the typical rogue run of blanking period AF that comes, goes, and that's it until more interventions years from now...with any luck.

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Carey

I was under the impression that the "official" pass/fail was no events >30 seconds in months 3-6, so by that criteria, I
already "failed" or came close to failing, have to check the exact dates.

I've never heard of that criterion. The most common criterion I've seen used is no sustained atrial arrhythmias at 12 months post ablation without the use of AADs. By the standards used in most research studies, yours would be considered a success.\

I think we're on the same page. My ep mentioned 6 months, but the endpoint of most trials is still as you mentioned -- no afib episodes lasting more than 30 seconds for months 3-12, where the first three months don't count because of blanking. But by that criteria, I still technically failed as I had a 3 hour episode at the six month mark. That said, even though still used, many think the current endpoints derived from older studies need rethinking in terms of what is a success or failure.

Jim

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gloaming

Sorry, I completely forgot that part of your question. As briefly as I can do it:

Thanks for the detailed story. Very helpful. Our afib journeys are not often easy ones!

Jim

Hi Jim, I've had a similar experience as yours 7 months post ablation. Hope it was just a one-off. In the meantime, avoid triggers as much as possible would be helpful.

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Yuxi
In the meantime, avoid triggers as much as possible would be helpful.

I think you've got it spot on. Either that and/or the 3 month blanking period is not one size fits all and for some of us, may be longer.

Since posting, I've heard from another person who also had a post blanking episode within the first year and only one episode the next. I would be very happy with only one or two episodes a year!

The trigger for my sole afib episode was a short tachycardia episode intermixed with heartburn. I can't control the tachycardia episodes without another ablation, however I am treating the heartburn more aggressively with PPI's and PIP Rennie's.

Jim

There's something to this questioning of the blanking period criteria. I believe that the best evidence is in the anecdotal information about the odd run of AF later on, but also in how long it takes for the resting HR of some patients to return to something akin to 'normal'. Many people report that their resting HR is still in the high 70's or low 80's up to nearly a year, while a great many of us have returned to our normal 55-65 range inside of a few weeks where the bulk of the population, male OR female, happen to lie under the standard normal curve.

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gloaming
There's something to this questioning of the blanking period criteria. I believe that the best evidence is in the anecdotal information about the odd run of AF later on, but also in how long it takes for the resting HR of some patients to return to something akin to 'normal'.

While it may seem counterintuitive, (An) increase in HR more than 15 bpm has a positive association with remaining free from atrial fibrillation at 1 year.

[pubmed.ncbi.nlm.nih.gov]

Jim

Very interesting. Thanks, Jim. I'll keep this reference tagged for subsequent discussions.

I've had 2 ablations for afib. The first in August of 2021 and the second on 2/22/22. I had a few episodes during the blanking period after the second ablation, the last being on 5/25/22, just at the end of the 3 month blanking period. I then contacted EP about whether another ablation was warranted, but told to wait a while and see what happened. I was afib free until 6/6/23, just over a year, when I had a 5.5 hour attack. Since then, no further attacks to date. At this point, I am more interested in a LAA occlusion, but haven't been convinced the current devices are ready for prime time. Perhaps the latest watchman FLX Pro will be it; at least I'm hoping. Hope this helps. Good luck!!

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Jasams
. At this point, I am more interested in a LAA occlusion, but haven't been convinced the current devices are ready for prime time. Perhaps the latest watchman FLX Pro will be it;

What are your reservations on the Watchman? Quite a few of us here have them if you have questions about our experiences with them.

Hi and thanks for replying. I know that many here are happy with the watchman and I don't want to say anyone should not be. I have 2 main concerns. The first is that I believe an occlusion device should have no leaks and that small leaks are not OK. Once the device is implanted, the blood left in the LAA coagulates and any size leak will allow a piece of that clot to dislodge. The US originally arbitrarily decided leaks under 5mm were OK, while the EU said less than 3mm should be the standard. More doctors seem to be coming around to the idea that no leaks are acceptable. Since the occlusion devices are round and the opening to the LAA is ovalish, that seems like a tall order! The second is the need to stay on an anticoagulant or antiplatlet after the device is implanted, which means I will still have a bleeding risk.



Edited 1 time(s). Last edit at 03/09/2024 01:30PM by jasams.

Carey will chime in before long, but my understanding is that, all other risk factors aside, if the Watchman is deemed to be closed, no further requirement exists for anti-coagulant. It seems as if many do leak, but minor amounts, and the clots would still form eventually, even with anti-coagulant medication. The drugs delay, but do not prevent, coagulation.

JASAMS: At this point, I am more interested in a LAA occlusion, but haven't been convinced the current devices are ready for prime time.

Have you looked into a surgical solution such as the AtriClip LAA exclusion device? Unlike Watchman, the LAA is permanently excluded from the outside (versus inside with Watchman) with minimally invasive surgery. A bit more of an aggressive procedure than Watchman, but you will not have the same potential leakage issues and no requirement for anticoagulation either before or after the procedure. Watchman often requires low dose aspirin for life. It is often done in conjunction with Maze or Mini Maze, but now being offered as standalone at many top cardiac centers. May not be mentioned by your ep, as they don't do them. You need a cardiac surgeon here.

Jim



Edited 2 time(s). Last edit at 03/09/2024 02:45PM by mjamesone.

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jasams
The second is the need to stay on an anticoagulant or antiplatlet after the device is implanted, which means I will still have a bleeding risk.

Good points and you are correct that there is more to learn about the Watchman and that the fit is vital. Mine was implanted in April last year by Dr. Natale. He is monitoring his Watchman patients more closely than many EPs, most recently asking us for scans at 6 weeks, 6 months, 1 year and 2 years. He just extended his monitoring to 2 years because two patients developed clots at that late date. His Institute probably puts in more Watchmen than any other US practice, so statistically that is not a lot, but I was told in my last followup that he feels that it warranted extending the monitoring period. After 6 months or a year he gives patients a choice about continuing anticoagulants—you can stop them, take a continued half dose of Eliquis or take a baby aspirin every other day. Of coarse he gives individual recommendations on this. I am going with a half dose of Eliquis.

I have the Flex model but the newer Flex Pro has some new features:

“The latest WATCHMAN FLX Pro device is enhanced with a coating designed to reduce device-related thrombus and enable faster, controlled healing and endothelization of the device surface. In addition, newly added visualization markers are intended to enhance device placement for optimal sealing around the LAA. This device is also available in a new 40mm size option, which will enable physicians to treat a broader range of anatomies with the WATCHMAN technology.” [news.bostonscientific.com]

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mjamesone
Watchman often requires low dose aspirin for life.

Subtle bit of distinction is needed here. Aspirin isn't required per se. That's the FDA's recommendation, but the truth is there's no good evidence to support it. As the implanting EP told me, the FDA recommends it mostly because they felt like they had to do something, not because there are good reasons for it. Notably, there is no such recommendation in Europe and patients there usually stop all aspirin and anticoagulants after the initial period.

I have a Watchman and don't take aspirin. I take half-dose Eliquis simply because I'm a CHADS-Vasc 2 (arguably 3) and the LAA isn't the only place that clots can form, not because I have a Watchman. That was Natale's recommendation, and my local EP and PCP both agreed with it. I can also stop Eliquis any time I want. I recently stopped it for a full two months because I was taking hefty doses of a prescription strength NSAID for a pinched nerve in my neck that produced excruciating shoulder and arm pain. A cortisone injection in my neck finally relieved the pain sufficiently that I could stop the NSAID, so I've resumed my daily Eliquis.

We should know by December 2027 if the Watchman is a reasonable alternative to NOACs or a possible supplement to NOACs.

CHAMPION-AF trial