Scheduled PFA at Keck Medicine of USC, and questions about amiodarone

After fighting afib for 8 years, I finally gave in and I'm scheduled for pulse field ablation at Keck Medicine of USC in mid-July. EP is one of their leading professors and EP. Has anyone had their ablation there?

I was put on flecainide 100 mg twice a day, eliquis 5 mg twice a day and metoprolol 25 mg twice a day. But after 3 days free of afib, I had breakthrough of afib, so I took one more flecainide together with one metoprolol tarate 50 mg as PIP, but that triggered a sinus but fast heart rate. My heart kept beating at 130 - 140 bpm for 26 hours, and even I took an extra metoprolol tarate, the heart rate was not lowered. I found the fast pounding heart is harder to tolerate than afib.

Now the EP took me off flecainide and wanted to put me on 400 mg amiodarone twice a day. After reading the serious complications and side effects, I am feeling very hesitate to take amiodarone. But EP said I need to start it, and continue through ablation, then will do so after a period of time after ablation. Does this sound normal?

I truly wanted to see Dr. Natale at Austin, but my busy life and work schedule made me hard to travel over there.

He wants to put you on amiodarone and continue it through the ablation?!

I would refuse that plan. It doesn't make me comfortable with his skill and experience. You really can't find 2-3 days off to travel to Austin or Los Robles?

Yes, he wants to put me on 400 mg amiodarone twice a day for 2 weeks, then 200 mg twice a day for 2 weeks, thereafter 200 mg once a day until ablation, and after ablation will continue the course and adjust or reduce, then eventually took it off. Is there any problem with this? I haven't heard of a lot of people used amiodarone in this forum, and I'm really concerning about the adverse effects.

Yes I can find a few days or even 2 weeks to stay in Austin, but worry about the regular check ups. Do I also fly to Austin for check ups? If I need to be seen for any reason, do I fly over there each time?

Yes, there's a problem with that. In addition to the side effects of amiodarone, it conceals your afib. If you go into an ablation on amiodarone, how is the EP to know if they've actually fixed your afib? All he can do is a PVI and hope for the best. That's not the mark of a well-trained, experienced EP these days.

If you were to do an ablation with Natale or someone like him, he would stop all antiarrhythmic drugs well before the procedure because he wants your heart to reveal all the afib sources it has. And when the procedure was nearly complete, he would then administer isoproterenol to try and provoke afib. Isoproterenol basically just amps up your heart and makes it produce any arrhythmias that might be lurking. If any are revealed, he finds them and ablates them. If you were on amiodarone at the time, that wouldn't work. Amiodarone is a last resort for top EPs.

As for doing the procedure in Austin or Los Robles, no, you don't need to return there for follow-up visits. They have their system down pat and deal with out-of-town patients all the time. You'll need to spend about 3 days there for the procedure, and then never go back again. You'll be assigned a nurse practitioner who will be your point of contact and you'll be able to deal with everything remotely. If you want to keep seeing your local guy, that's fine as long as he recognizes that Natale is calling the shots on major decisions such as drugs used.

Thank you so much for the details, totally makes sense. I thought about how they can induce afib to pinpoint the abnormal cells too. But I haven't got the chance to ask the EP. In fact, after the first consultation, I wouldn't have another visit with him until the ablation day, which makes me think shouldn't they at least run some testing or mapping beforehand? I will definitely ask the EP how they will induce afib during the procedure, and also try to get an appointment with Dr. Natale.

Do you know if Dr. Natale is using Pulsed Field (PFA) or Radiofrequency Ablation (RF)?

Yes, Natale uses PFA. He was using it during clinical trials before it was FDA approved. He also uses RF as-needed because PFA still can't deal with everything.

Some EPs want their patients, some of their patients, to remain on flecainide or diltiazem or propafenone for a week or four AFTER their ablations....depends on the patient. But, as Carey has said, it's somewhat unusual, especially with amiodarone. HOWEVER........I was one such patient. I was heavily ectopic in the five/six weeks leading up to my ablation, and apparently headed for persistent/permanent AF in a hurry. My first ablation failed and I was in the local ER inside of six whole days, and quickly placed on amiodarone due to my erratic heartbeat and heavy bradycardia with long pauses. Naturally, I knew all about amiodarone and objected, but my attending had consulted my EP before coming back to me and my EP wanted me on amiodarone. He was the top cardiology student in Canada in 2001, so I figured I had better accede to his prescription. To make this short, amiodarone worked, and for that I was most grateful. I immediately set out to get off it, as you would understand, but ended up on it for a total of 8 weeks with a two-week taper at 200 mg PO. I experienced no undesirable side-effects. I believe that amiodarone is a safe drug for most patients for a few weeks, especially if it takes the edge off a cranky heart and settles it down. However, I would insist on frequent tests/monitoring to ensure my lungs, liver, and eyes were not being unduly affected.

“due to my erratic heartbeat and heavy bradycardia with long pauses”

Your SN might had been slightly heated but not enough to cause permanent harm.



Edited 1 time(s). Last edit at 06/08/2025 12:59PM by susan.d.

I believe you mean the SA node, Susan...the 'sino-atrial' node...? I don't see how because the SA node resides high and medially in the right atrium, whereas my left atrium was being ablated at the pulmonary vein ostia. The burning lesions were being created about 5-7cm distant from the SA node. The second attempt, seven months later, was successful. My EP reported that he was in the process of isolating the third pulmonary vein (I'm not entirely clear which is the 'third', and I don't know if he started at the third or had just done the first and second...) when my heart began to beat normally immediately after one application of the RF tip. He had found the gap in what was intended to be a closed loop of lesions, it had just been closed with the last application of the RF tip, and my heart has played nice ever since.

I'm keeping my fingers crossed for you, Susan. I'd like little else except to see you post in a few weeks that you've had a complete turnaround.

Amiodarone may be justified in your case, provided the symptoms as described. But for me, although I almost have episodes everyday, but they lasted couple hours to a few hours. Actually, I function best by taking PIP instead of on regular flecainide. But I’m still worrying about taking amiodarone from now on till 3 months after ablation, that would be almost 5 months.

I know going to Austin for ablation by Dr. Natalie is the best bet. But he also see patience in La Jolla 2 days and La Robles 3 days per month. Does either of these 2 places have equivalent environment/equipment like Austin? If I do ablation in either of these 2 places, would it affect the outcome compared to going to Austin?

Yes and no. Austin has a lab that was brand new in 2019, so everything in it is also brand new. It's huge and it's beautiful and has all the latest whiz bang toys. Their old lab was in the basement and kind of cramped. So for Natale and the rest of the staff, it's a big improvement. Will that actually make a difference for you? No, not really. Natale's going to do the same job no matter where he is. The only drawback to Los Robles and La Jolla is that it might mean a longer wait for the procedure.

Here are some photos of the Austin lab I took when it was almost complete. As you can see, there's equipment that's not fully set up yet.

Thanks a lot for the information. It is very helpful! I have reached out to Dr. Natale's coordinator and hopefully I can be seen soon.



Edited 1 time(s). Last edit at 06/11/2025 10:45PM by kong2018.

Quote
kong2018
I know going to Austin for ablation by Dr. Natalie is the best bet. But he also see patience in La Jolla 2 days and La Robles 3 days per month. Does either of these 2 places have equivalent environment/equipment like Austin? If I do ablation in either of these 2 places, would it affect the outcome compared to going to Austin?

I had 3 ablations at Los Robles. Dr Natale suggested I get the second ablation done in Austin because the equipment is better (imagining). It was during Covid so I regret my choice.

I will say Austin has multiple NPs on call. At Los Robles be aware he is gone 27 out of 30 days. If you have issues with tachycardia, etc, there is only one NP at his Thousand Oaks satellite. If she is on vacation, holidays etc, nights, materity leave, you won’t get the luxury of getting someone on call-like Austin.

I know because I had problems a week before thanksgiving during her two week vacation, and Christmas during a holiday and when she was on leave. So you don’t want a random hospitalist at Los Robles (hospital is fantastic, food perfect, private rooms, I recommend getting yourself established with the chief of cardiologist (he is great) as a backup just in case…or any attending. Ask if they work weekends or nights. I had an assigned EP that had a solo practice and didn’t work weekends nor nights.

Ivan Ho?

I was just there in March for a flutter ablation......back next week for a
Watchman. I was told that Natale now implants a Watchman with every ablation. He does not do it in one procedure......waits three months.

Believe there are now six labs in the new facility versus two labs previously.
The place is impressive!!!!!!

Steve