Flutter for 5 months now back in NSR

Hi All,

I am pretty happy right now but now it can/may be short lived. Long story short I had a mitral valve repair and cryo maze a year and a half ago. I was in NSR for a whopping 5 days and went into persistent atrial flutter. I had an ablation for the flutter (right sided) a year ago. I maintained NSR for about 7 months, with a couple of short AFIB episodes in between.

Right around April of this year I started fluctuating between AFIB AND FLUTTER. I have some 12 lead EKGs that are Afib and some that are Flutter. I would Wake up in Afib and sometime throughout the day go into aflutter. This lasted months up until about two months ago where I was 100% Persistent Atrial Flutter. In two months I've only seen Flutter not Afib. Because I am mostly asymptomatic and just don't have the desire for another ablation at the immediate moment I had intended to just stay in flutter for the time being. The Persistent Flutter this time lasted 5 months had a rate always around 107BPM. The flutter on the right side I had ablated in September was about 138bpm. So this flutter is 30bpm or so less than the flutter I had ablated.

Anyway, today I was off from work and did a lot of cleaning and carrying of things almost non stop. I worked up a good sweat more than I had in months. I carried a few heavier things around and when I finally sat down many hours later I felt GREAT. I decided to check my EKG on my watch and it showed NSR! I then went and grabbed my kardia and it too showed NSR!

I was very happy to see this as I've been in an arrhythmia non stop for 5 months. I also know I've read flutter is extremely difficult to convert on its own. Is this unusual that after 5 months I'd just convert to NSR? Is there a high likelihood I'll go back into Flutter? I am thinking either way my ass better start exercising a lot more again. I've gained weight over the years when I used to be extremely fit and I've been apprehensive because of the flutter. I think no matter what I better start exercising a lot more as there's no way it's a coincidence I did non-stop lifting and moving of things all day work up a serious sweat and convert to NSR.

Any thoughts on this?



Edited 1 time(s). Last edit at 09/29/2025 05:07PM by cornerbax.

I suffered from flutter for a couple of years, and I learned I could often terminate it with strenuous exertion. Not 100% but maybe 90% of the time. My usual go-to solution was to run laps up and down a flight of stairs if I was at home or work, or walk briskly up a hill if I was outside. Maybe the same will work for you?

Hey Carey thank you as always for your response. When you were able to run laps up and down a flight of stairs to terminate flutter.... How long did NSR last?

I was set for an ablation with Dr. Natale for early December but quite honestly, right now I am truly ''over it''. I've had the mitral valve repair. I've had cryo maze. I've had my laa sutured. I've had an ablation after all of it on the right side for flutter. A coworker died getting an ablation as I've posted here. Right now I am OVER IT. The chance I get a another ablation with anyone the rest of my life is slim. I am mostly asymptomatic but I did sweat much easier always in flutter.

I wanted a semi miracle and working my ass off 7 straight hours carrying 60+ pounds throughout the day. Squatting. Lifting moving fast and all of a sudden I'm in NSR! I guess I should of pushed harder in flutter earlier on. With that said I assume it's a good sign after 5 months in flutter mostly that I can convert on my own?

Quote
cornerbax
With that said I assume it's a good sign after 5 months in flutter mostly that I can convert on my own?

Of course!

But you need to see if you can repeat it.

I understand where you're coming from with all the procedures and being done with it. So if you can't reliably terminate your episodes, all you really have to do is keep your heart rate under 100 bpm. Letting your heart rate stay above 100 for prolonged periods is the one thing that will be your undoing.

Carey, do you think it would be beneficial to start an anti arrythmiac medication for a period of time now that I'm back in NSR? I have amiodarone and diltiazem. Do you think it may be a good idea to start either of those for a period of time or just leave it?

I was prescribed diltiazem and then amiodarone while In the arrythmias and neither converted me to NSR. Because I was in mostly flutter I was told flutter doesn't usually convert with medication like AFIB and that was true for me. But now that I'm in NSR, what do you think?

It's worth asking your doc about, but diltiazem isn't an antiarrhythmic and I would avoid the amiodarone due to all the nasty side effects. I would want something like flecainide. I also found that my flutter wouldn't convert with any sort of antiarrhythmic but flecainide did a decent job of preventing it.

Thanks again Carey for the response. A few years ago when I found out about my mitral valve and afib one of the medications subscribed was flecainide. It caused me into the WORST episodes of either Afib RVR or Flutter. I had never actually felt as though I was going to pass out but on Flecainide I almost did. My rate also shot up over 180bpm. My doctor immediately stopped the medicine and said in some people it can be Pro-arrhythmiac. In my case I'm one of them. They never did say if it was 1:1 conduction I had but did say something to the effect of if my flutter was ablated then I could take flecainide again if AFIB came back. I know I just got out of Flutter after 5 months so I'm thinking I could still have the same issues with Flecainide?

You're thinking of taking an anti-arrhythmic as a prophylaxis against future bouts of arrhythmia. It's not a bad idea per se, but most of us find it isn't a sure thing, not by any means. It might work well for 95% of the time, or we think it's working, and then BOOM...back into an arrhythmia for a while. And it seems to defy the whole point of an anti-arrhythmic drug. It was this uncertainty, as well as knowing that AF, the problem for me, is generally progressive that gave me the most anxiety. The disorder is going to get the upper hand eventually for most of us. That was why I pushed for an ablation.

As for your reaction with Flecainide, I can see your reluctance in view of your history. It's like getting drunk on Mai Tais that one time, a real bender in our youth. From then on, Mai Tais are verbotten. Of course, had we not drunk maybe a liter of the stuff...................and this may be what is at play for you. Your initial dose might have been twice what your heart needed. I can think of a dozen people who were simply getting too much metoprolol at one time and were getting pauses and bradycardia all the time. So, yes, I understand your reticence about Flecainide, but maybe Flec wasn't the real culprit. If it is, then there is dronedarone (Multaq), or the often-iffy Tikosyn (Dofetilide) but which needs to be loaded in a hospital. Maybe propafenone, which they give for cranky hearts after an ablation (so I was informed by a reputable source) also called Rhythmol.

That is amazing that you could convert on your own . I developed flutter in October of 2023 and it lasted 4 and a half months to February 24.The Holter indicated.100% burden with an average rate of 97 bpm and going up to 140. For me any physical exertion, such as running a snowblower or carrying things up the stairs or right before my cardioversion just walking up the stairs, would increase my rate and would become an SVT of around 225. Meds kept things under control after the cardioversion until my ablation. What a blessing for you. Hope you have continued success.

@ Gloaming, my initial medicine to attempt to convert from AFIB was Amiodarone. This was for about a month, it didn't work so the EP at the time prescribed Flecainide. This caused THE WORST symptoms I've ever had TO DATE. Flecainide was stopped and don't ask me how but Propafenone was prescribed in its place. The same EXACT symptoms occurred. Severely out of breath, dizzy, heart rate higher then it had ever been at that time, massive, MASSIVE sweats. I immediately switched EP's and my new EP said they can't believe the prior EP would of prescribed propafenone after the issues I had with Flecainide, as they are in the EXACT SAME 1C CLASS of Anti-arrhythmiac medications.

Both of those medications caused what I believe to of been 1:1 Conduction but it was never confirmed. I since found an EP at Cedars-Sinai and they said those medications can be PRO-ARRHYTHMIAC in some people and I am one of those people. They said if my flutter was ablated then those medications should be fine afterwards. Over the last couple of years i've been on Amiodarone, Diltiazem, Sotalol,and NONE gave me any issues that i'm aware of. And as of September of last year I did have the FLUTTER ablated. It was right sided flutter and my EP said it was a relatively easy case.

Many months in NSR, and out of nowhere, the Arrhythmias came back. Thanks JDfiB, I appreciate that but I am not getting my hopes up. I am more elated that I know I "CAN" convert to NSR, which I am still in right now at a rate of 65BPM! I have learned so much over the years with the help of this forum so I am definitely not thinking I am out of the woods or that I will definitely maintain NSR. Of course I hope I do and will do things to try to maintain NSR, but again, I am more happy with the fact that I now know that I "CAN" convert to NSR.

What I was most frustrated with was that both my Left Atria (which was severely enlarged prior to my Mitral Valve Surgery) and my Left Ventricle which was moderately enlarged, BOTH, within a year after my Mitral Valve Surgery remodeled to normal size! I was extremely happy about this and my EP said my chances of mainaining NSR were much greater in my case because my Left Atria had remodeled to normal size. Well, that was the case for 7 months but then the Arrhymias occurred again. I feel very fortunate, but like many, this thing has been quite the journey. Even in Flutter I was extremely thankful that the rate was never usually more than 110BPM and almost always right at 107bpm, and that I had absolutely no symptoms at all except for ONE case early on of AFIB/RVR back in May when I got out of a Sauna and my heart shot up to 200bpm. Definitely wasn't smart to go into a sauna in AFIB, and won't do that again, but that was the only issue I had. The last 2 months have been all flutter with no symptoms at all. I actually feel the same right now at 65BPM in NSR then I did in Flutter at 107. At this point I'm gonna take it day by day and just hope for the best. I do definitely want to get an echo scheduled to see what it looks like the last 5 months in these Arrhythmias.

I've had 3, 12 lead EKGs the last 5 months. The 1st back in May was AFIB, the last 2 were Flutter. Dr. Natale confirmed this as well. The flutter was listed as "2:1", where my Atrial rate was twice what my Ventricular rate was. I'm hoping this didn't cause my Left Atria to enlarge too much over the last 5 months as it had remodeled to normal size from being SEVERELY enlarged as mentioned.



Edited 1 time(s). Last edit at 09/26/2025 06:02PM by cornerbax.

@ Carey, I have a couple of quick questions for you.

1) The first time I had Flutter and had an ablation for the right side, September of last year, my Flutter rate was always upper 130's, typically around 138. This time the Flutter is almost never more than 110, and usually right at 107BPM. I know the Rate is still over 100, but not by much and it's certainly a lot better then nearly 140 with the Flutter I had previously. With that said, would a rate just over 100 still cause issues long-term, when a normal rate is considered between 60-100? I'd certainly prefer to stay in NSR permanently at a rate of around 60 or so like I am now, but if I did revert back to Flutter, I'd think If the rate were lower 100's as it has been this time around, it would be much better then a rate significantly higher, right?

2) When the Arrhythmias started back in May, they alternated between AFIB/AFLUTTER. When it was AFIB the rate would sometimes get in the mid 80's and it was easy to see on the Kardia beat to beat. When it was Flutter, it looked like Tachycardia and the rate was usually right at 107BPM. So for a few months i'd alternate between AFIB and AFLUTTER during the day. Over the last 2 months it has been strictly AFLUTTER with no signs of AFIB at all. It's like the Flutter just trumped AFIB out of the picture entirely. I've done many Kardia EKG's over the last couple of months and they are definitely Flutter. Not a single one classified as AFIB and you can see where each one looks like Tachycardia. The question is if this is common? Is it common to alternate between Arrhythmias and all of a sudden just have one Arrhythmia be present and the other completely gone?



Edited 1 time(s). Last edit at 09/26/2025 06:16PM by cornerbax.

A rate of 107 isn't going to do you any harm in the short run, but I wouldn't allow that to continue for weeks or months.

Having both flutter and afib is very common and so is alternating between them. I did. One reason you may be seeing all flutter now is because your heart tends to follow the fastest pacemaker, which would be the flutter.

You didn't experience 1:1 conduction except possibly that time when you hit 225. You can call it SVT if you like but flutter actually is one type of SVT. It's a pretty general term. I think that 225 bpm was still flutter.

When you're in flutter (or afib) your atria may actually be contracting at anywhere from 200-300 bpm. But the AV node can't usually transmit a rate that fast, so it may only pass every second beat to the ventricles, giving a 1:2 conduction. That would produce a rate of 150, which is an extremely common rate for flutter. Unfortunately, my AV node can transmit rates that high which is why my flutter was consistently 225-250. I was always in 1:1 conduction. (My EP at the time once said half-jokingly that what I needed was a little heart disease to slow my AV node down.)

As for meds, I think you're right to avoid flecainide, and propafenone is in the same class so I'd avoid that too. That leaves you with sotalol, Tikosyn, and Multac. Personally, I would ask my EP to try Multac. It's very low on side effects and doesn't require being started in the hospital like Tikosyn does (and some very conservative docs will also start sotalol in the hospital).

But mainly, I would have that flutter ablated. Ablating flutter is much easier than afib, and never requires as many burns. If you're lucky, the flutter is typical so it's on the right side, which means they won't even have to puncture the septum and go into the left atrium.

Thanks, Carey. That is crazy about your issues with 1:1 Conduction. Those symptoms i'd imagine were horrendous! Thankfully that is no more and hopefully never will be. That's funny about the "heart disease" comment, but I get the doctor saying that jokingly to avoid such super high rates. Again, thankfully those days are long gone for you.

I think I'm gonna just stay away from the meds. You are saying that even if I remain in NSR I should get the Flutter ablated? Thanks for the explanation on the "fastest pacemaker," that makes sense for persistent Flutter and AFIB not appearing for 2+ months. If I did have an ablation, it would be for Flutter AND AFIB, right? Because AFIB did occur that would mean it "CAN" occur and it came from some area which I would think is still could still produce AFIB.

But even if I were to remain in NSR for months continuously, you think an ablation is still necessary?



Edited 1 time(s). Last edit at 09/26/2025 10:35PM by cornerbax.

Quote
cornerbax
But even if I were to remain in NSR for months continuously, you think an ablation is still necessary?

That's your decision to make. You could quite possibly spend years or even the rest of your life living in NSR with meds, but I think that's unlikely and even if it does happen you'll be dealing with the side effects and expense for all that time.

Yes, a good EP would address both the flutter and the afib in a single procedure. I'm guessing you know who I would recommend to do that procedure. He did mine and I had both, and I've been in NSR for 8 years without drugs ever since.

I definitely want off of all meds and do not want to be on them the rest of my life or at all for that matter. One thing that is extremely interesting (besides the fact that I self converted after 5 months) is that I don't have any PVCs.

After my right sided ablation for flutter at Cedars-Sinai where I was in NSR for about 7 months, I still had many PVCs. Fortunately, again, I was asymptomatic to them. I do not and never have felt my heart beating unless it's over 145 or so. AFIB with RVR I always felt, but AFIB, FLUTTER and PVCs I never felt.

But after my right sided ablation and even though I was in NSR for 7 months I almost always had a lot of PVCs. My Kardia will almost always say NSR with PVCs. On my physical last year with a 12 lead with my PCP he said if he didn't know I already had a cardiologist he would of immediately suggested I see a Cardiologist with the level of PVCs from the EKG. I believe it was around 30% or so.

Its only been a day since I have been in NSR but the EKGs show absolutely NO PVCs and always just say NSR. I am extremely happy about this but again it's only been a day. If I do end up needing another ablation it will 100% be with Dr. Natale.

Thanks again for all the great info and help with responses to this thread.