Ablation for Flutter

Hi all, I have an ablation scheduled for a flutter and have a couple of questions I wanted to ask here first. Cliff notes version is I had robotic mitral valve repair and a cryo Maze procedure end of February and was in NSR for about a week. After a week I was in sinus tachycardia or a flutter most of the time. I have had ZERO issues of dizziness, palpitations, excessive heart rate or anything else. If I didn't have a number of 12 lead ekgs done I wouldn't even know I wasn't in NSR.

With that said, my resting heart rate is in the 80s to 90s most of time time and my EP thinks it would be better to ablate to maintain NSR vs any arrhythmia. My question is does it matter if my a flutter is on the left side, ride side or possibly both sides? I remember reading a needle is needed to get to the right side of the heart. I don't know if that was from another procedure or a catheter ablation?

And would there be any reason to NOT do an ablation for the Flutter since my rate isn't that bad and I have zero symptoms since surgery? Thank you in advance for any suggestions and advice.

All arrhytmias can lead to heart failure in time. Just because you are asymptomatic doesn't mean your heart is having an easy time of it. So, I would counsel getting it fixed...soon.

The catheter is pushed through the septum during an ablation for atrial fibrillation. it might not be required to fix right atrial flutter, for example. but maybe the locus of the flutter is in your left atrium...?

Thank you for your response. The heart having an easy time of it is where I'm a little confused as many things I've read talk about rate being more important than rhythm.
One thing I should of mentioned in my first post is in the 6 months since surgery my left atrium has gotten smaller and gone from severely dilated to now moderately dilated.
And my left ventricle has gone from moderately dilated to mildly dilated. My ejection fraction has gone up 11% as well since surgery.

With the severe mitral regurgitation I was in Afib 100% of the time. Every ekg always showed afib and the Zio I wore for two weeks said 100% Afib. I don't know if any of this matters in terms of surgery but my heart is much better since surgery even being in A Flutter most or all of the time. This is what I read:


Typical atrial flutter occurs in the right atrium, while atypical atrial flutter occurs in the left atrium or other parts of the right atrium.

Typical atrial flutter is more common and often responds better to treatment. On an electrocardiogram (ECG), typical atrial flutter appears as continuous negative modulation in the inferior leads (II, III, and AVF) and flat atrial deflections in leads I and aVL. This is due to the way the macro-reentrant circuit propagates and activates. Typical atrial flutter can be cured with a short outpatient catheter ablation procedure.

Atypical atrial flutter can have a variable appearance on an ECG. It can be caused by scarring on the left side of the heart from previous procedures, heart surgeries, or heart disease. The scarring can stretch and damage the upper heart chamber, which can lead to problems like valvular heart disease or heart failure. Most types of atypical atrial flutter can also be treated with catheter ablation, but the procedure is longer and more involved.

It seems right side Atrial Flutter is referred to as TYPICAL and is usually caused from scarring on the left side from surgery, etc. My ekgs all say Atrial Flutter so I have no idea if it's from the left or right side or both. I will ask My EP but if I understand what I read correctly it's more likely on my right side?

It's most likely on the right side and is caused by scarring on that side. But there's no way to be 100% sure until they actually get in there and can map the source of the flutter (AFL). If it's on the left side, yes, they have to go through the septum so the procedure is longer and more involved, but whichever side it's on, the procedure is shorter and easier than an afib ablation.

@carey,

Thank you again as always. It looks like I got it reversed. So you're saying the flutter is most likely on the RIGHT side, but if it is on the left side they have to go through the Septum to correct. Is it possible it can be on BOTH sides? Also, is it possible to have BOTH Afib and Flutter at the same time or regularly between each other? And do you think it would make sense to wear a Zio monitor for two weeks prior to the ablation to get a better idea of what's going on first as I did last year where it showed after 14 days 100 Afib? You think that is better before the ablation?

Yes, it's possible it's on both sides (mine was) but odds are it's just one side. Yes, you can have afib and AFL together (I did). Zio might be helpful but I'm not sure it's going to tell the EP a whole lot more. I think you'd be wearing one now if they thought they needed it.

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cornerbax
Also, is it possible to have BOTH Afib and Flutter at the same time or regularly between each other?

Can a person be diagnosed with afib & flutter at the same time? Yes. Any episode could be one or the other, or switch between the two in an episode. Years ago, my cousin was diagnosed with both and the EP wanted to ablate only the flutter & see if the afib went away. I suggested he go to a Natale protegé, Dr. Sergio Pinski, at CC Weston, FL. My cousin lived near there and I knew Pinski would fix both in the same procedure. That is what my cousin did & he's been happy since.

Thank you Carey and George this is very helpful info. The reason I asked on both afib and aflutter is it seems anytime my heart rate is under 100bpm it shows as AFIB. Anytime it has been over 100bpm it shows as sinus tach or Flutter.

I've had 3 (12 lead) ekgs on follow up doctor visits and each of them have showed my heart rate just over 100bpm and one was listed as sinus tach but can't rule out aflutter the other 2 were listed as Aflutter. It's been bad luck that those three visits I was just over 100bpm as anytime I'm under 100bpm and where I'm usually 80bpm or so my kardia shows Afib. I am gonna post the 12 lead ekg from a few days ago and a Kardia I just took to show what I'm saying.

But if I understand this correctly and am going between AFI and Aflutter the likelihood is that the Afib is on the left side and the Aflutter is on the right side and that it would be best to have them BOTH ablated at the same time, correct? Or are you saying Carey that it's more likely the Aflutter AND Afib are coming from the right side? Again, remember I had a maze Cryo ablation in February where from my understanding the ablations were done around the left atria the pulmonary veins and the mitral annulus.



Edited 3 time(s). Last edit at 09/01/2024 04:26PM by cornerbax.

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But if I understand this correctly and am going between AFI and Aflutter the likelihood is that the Afib is on the left side and the Aflutter is on the right side and that it would be best to have them BOTH ablated at the same time, correct?

I had both Afib and Aflutter going on during my ablation with Natale (no previous ablations). Both were in the left atrium and he took care of them both--but he had to chase them!

There's no way to know which side these things are coming from but the afib is most likely on the left. The AFL could be either side. I would definitely want both addressed in one procedure. Half the risk, half the cost, and half the downtime.

Thank you Susan, thank you Carey. I wanted to ask thoughts here BEFORE I see my EP this week. @ Susan, i'm glad Dr. Natale got everything ablated for you. Have you had any further issues of Afib or AFlutter since? I had my mitral valve robotic surgery with one of the top surgeons for Mitral Valve Repair in the USA and who had done over 550 Mitral Valve Repairs, Robotically, prior to mine, which was 2nd in the USA. My EP is also at Cedars-Sinai, but I had a video call with Dr. Natale last year where HE said to get my Mitral Valve repaired FIRST before considering any ablation. My EP is apparently one of the TOP EP's with Cedars, but I still want to know how MANY total ablations they have done, and confirm 100% they are a Bi-Atrial Ablationist, etc, just as Carey and others have recommended in other threads.

I have one last question, and Carey will likely be the one who answers it, but Carey, when you say there's no way to know which side of the Atria the Arrhythmias are coming from, a seasoned EP would see this exactly where they are coming from while doing the Ablation, correct? I think the biggest thing for me is exactly what you said. Having BOTH addressed in one procedure, so I will ask all the questions I need answered, and if there are any issues, I will reach back out to Dr. Natale.

Yes, during the ablation a good EP will know where it's coming from. In the office all they can do is a 12-lead ECG, which can provide hints as to the source, but no definitive answers. But during the procedure they can put mapping catheters anywhere they want in the atria and literally see a real-time graphical display of where the errant signals are coming from. You can find videos of those displays on youtube. Pretty cool to watch.

For example, in my ablation Natale found the source of my 250 bpm flutter was the LAA. So he isolated the LAA and that immediately stopped it. However, instead of reverting to NSR I went to AFL at 120 bpm. He went looking for the source of that and found it way over on the right side in the coronary sinus. A single burn there put me back in NSR, where I've been for the last 7 years (anniversary was last week).

That's an example of his mastery. A local EP with great credentials and experience had been unable to even find the source of my 250 AFL, much less the 120, precisely because most EPs don't know how to isolate the LAA and are afraid to try so they tend to stay away from it. Mapping is a difficult skill that takes years of experience to master.

That's fantastic Carey, HAPPY 7 YEAR ANNIVERSARY! NSR for 7 Straight years is awesome. Hopefully you stay in NSR permanently. After 7 years i'd think that's a very high chance. These mapping Catheters you mentioned seem beyond incredible. But as you said, you need a real expert with thousands of ablations to be a true pro to master the Mapping. This is all of what I will find out this week and if anything concerns me, I'll just set the appointment with Dr. Natale whenever he can see me which is probably months down the line.

One last question for you Carey, because I have had my LAA Closure during my Mitral Valve Repair and along with a Cryo-Maze, do you think this will be EASIER during the ablation process for a top-tiered EP? What I mean is, it is better that I had a Cryo Maze and an LAA closure prior to this ablation? I'm thinking it definitely would be but I figured i'd ask out of curiousity. Again, from what I was told by my surgeon, my LAA was closed (sutured with goretex I believe), and the Cryo Ablation Ablated Pulmonary Veins, Left Atria and Mitral Annulus. I asked if anything on my "right" side was ablated and was told that they didn't see any issues on my right side, but even if they did, the Left side was showing as the problem and being on Lung Bypass for 70 minutes or so, they didn't want to take more time "trying to trigger" things they didn't see on the right side. The response was something to this affect.

The last thing i'll mention is that even though I am in either AFIB, Aflutter or Sinus Tach most of the time, I have no Symptoms at all, and I haven't seen my heart rate at rest exceed 112 or so. My average RESTING heart rate is around 85-90bpm, and in the 6 months since my Surgery, my Left Atria has reduced in size by over 1cm, as has my Left Ventricle. The reason I mention this is even being in an arrythmia most of the time I have no symptoms at all, a respectable resting heart rate, and my left atria and left ventricle reducing in size, while my ejection fraction has increased 11%. I would think since the Mitral Valve has trace regurgitation vs. the 50% or so Severe Regurgitation is allowing my heart to recover and relax so to speak vs. getting a thrashing with 50% or so regurg back to the left atria with every beat when I had the severe regurgitation.

So all in all even with the arrythmias, my heart is much healthier 6 months since surgery, and I am hoping that the Cryo Maze wasn't a complete waste and will HELP prior to this ablation. What are your thoughts?



Edited 1 time(s). Last edit at 09/01/2024 10:55PM by cornerbax.

Oh, I think the Maze helped without question. It got you most of the way there, but flutter is actually a common complication of Maze procedures, so it's not a big surprise you're dealing with it. I don't think it will present any particular difficulty for Natale. It's just something he'll need to be aware of and take into account. I think Daisy probably presented a more complex case for him than you will and she got great results. I think you probably will too.

Cornerbax, even though your LAA was sutured, from what I remember, it is still possible to have arrhythmias coming from the tissue surrounding it – check me on that Carey. And yes I have been Afib and Aflutter free since my ablation.

Thanks Carey, good to know that flutter isn't that uncommon after a Maze procedure. I had read that prior and expected it may occur and it has. I think I'm more concerned with the Afib as I had the CryoMaze to prevent it. Hopefully, as you said it won't be a very difficult case.

You think even if my current EP has done thousands of ablations it would be better to see Dr. Natale? Daisy, thanks for the helpful info. I actually do recall reading something about that here with tissue surrounding the LAA possibly causing AFIB. As Carey mentioned though, there's no way to know exactly where it's coming from until you're actually there. I'll report back after I speak to my EP.

Daisy, yes, I believe you're correct. Even with the LAA excised the tissue surrounding the mouth can still produce afib. When Natale isolates the LAA he doesn't burn inside it. He doesn't even put a mapping catheter inside. He burns around the mouth of the LAA to block errant signals coming from it much the same way they isolate the pulmonary veins by burning a circle around them.

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cornerbax
You think even if my current EP has done thousands of ablations it would be better to see Dr. Natale?

Depends on whether he has the skills to work on the LAA, if that happens to be the issue. Not all experienced EPs do.



Edited 1 time(s). Last edit at 09/03/2024 02:29AM by GeorgeN.

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Depends on whether he has the skills to work on the LAA, if that happens to be the issue. Not all experienced EPs do.

My LAA was sutured/closed, but as mentioned, the tissue surrounding that area can still allow for Afib. Are you saying that not all experienced EP's can ablate the tissue "around" the LAA? Because, again, mine is closed. If this is the case, this will be, yet, one more question I will ask my EP this week when I meet with them. Thank you.

Most likely my last question in this thread is what questions would anyone here ask an EP prior to an ablation? I know from previous threads, Carey was adamant on THOUSANDS of ablations, NOT hundreds, as well as an EP that is a Bi-Atrial Ablationist. As George mentioned, work on/around the LAA is of importance. If Dr. Natale were retired, what questions would you ask an EP prior to an ablation? I really am more considering Dr. Natale anyway, but my mind is saying I had the Robotic Mitral Valve Surgery at Cedars-Sinai, with one of the best in the USA, and very likely the world, and I'd be doing the same with Dr. Natale. But since all of my follow-up appointments are at Cedars, it would seem to have some benefit to have my EP there as well. However, if my EP isn't skilled in areas Dr. Natale is, then I don't owe them anything and I'd rather see Dr. Natale at Los Robles, locally.

Any suggestions/thoughts on the questions you would ask to determine the best fit for the ablation?

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cornerbax
My LAA was sutured/closed, but as mentioned, the tissue surrounding that area can still allow for Afib. Are you saying that not all experienced EP's can ablate the tissue "around" the LAA? Because, again, mine is closed. If this is the case, this will be, yet, one more question I will ask my EP this week when I meet with them. Thank you.

When we discuss isolating the LAA, that is exactly what it means—ablating outside the LAA on the surrounding tissue—and yes, only a relatively small number of top EPs will go near the LAA. The fact that you no longer have an LAA as such, is a variable you would need to ask about.

cornerbax,

FWIW, I just returned to Los Angeles from Austin where I got my second ablation with intent to 'isolate' the LAA. My understanding from the Austin team was that often, especially in women, the tissue around the LAA can be very active in producing arrthymias, especially if the areas aorund the pulmonary veins had already been ablated at a first ablation. On his morning after round, Dr. Natale said there was a lot of activity around my LAA that he had to ablate. So likely it was causing my extra heart irregularities since my intial ablation in May of '23. But additionally, he ablated the tissue also with intention to place a Watchman in a few months.

Good luck Californiagal!
I wish you a lifetime of nsr!
I’m happy you went to Austin instead of CA near you. I was told his imaging equipment is better and I like the idea of rotating NP on call.

What is your flutter burden right now? Flutter is very common after a maze type procedure, but usually resolves by itself in time with treatment. The person most knowledgeable about this would be your maze surgeon not your ep. So if you haven't already, I would ask them for input before going ahead with a flutter ablation, as you're still in the healing period from the maze. It may turn out that a wait and see strategy is the best for now. Typical right-sided flutter is more common, however, since you've had a maze, it very well may be coming from the left side.

Jim



Edited 2 time(s). Last edit at 09/06/2024 08:30PM by mjamesone.

My Surgeon and EP are both at Cedars and work with each other's other regularly. My surgeon said flutter is common and if it goes away it's typically within 3 months. It's been nearly 7 months and every ekg I've had since has shown flutter or sinus tach which may be flutter. My surgeon and EP think it's in my best interest 7 months in to have an ablation to likely correct any remaining issues of afib or flutter. My appt for ablation is end of the month and I'm hoping this is the end of all these arrhythmias and issues.