EP visit at Dartmouth Hitchcock.

After 5 weeks since last episode and protocol of 75mg flecainide at bedtime, I took the 100 mile trip to explore options. Mostly what I expected. The fellow was 1 month from leaving and gave his opinion on 4 options. 1. If Im to continue Flec it will be with a BB even if its 12.5mg. 2. Full dose of Flec and Metop daily, not yet. 3. Tikosyn 3 day stay, no thanks. 4.PFA. Dr Sangha believes I am a good candidate for this and the failures he has seen are 80 yrs plus. Of course they only do PVI and only while in NSR. Ive read most on here from Careys explanation of why ablations fail to the many success and concerns, and have a pretty good idea of what I am facing. My thoughts are I roll the dice closer to home for 1st one with PVI only and hope that sticks, and next one to the rock star in Tx if necessary. They are 3-5 months out, so I did schedule with time to research while waiting. I have to say however, the Flec has done wonders for nighttime pacs/tachy and afib getting me thru the night with a few hiccups daytime I address with Potassium water. However, its early and meds could wain over time, possibly?

Of course they only do PVI ...

Don't know your AF history, but if it's your first ablation, especially for paroxysmal AF, a PVI only is not a bad thing. In fact that is probably what you want. It's what I wanted. My EP was highly qualified to do more, but he did a simple PVI because his experience showed that was the right amount of ablation in cases like mine. Going on 3 years AF free.

More burning does not automatically mean better results and can add risk without necessarily improving success. And just because something can be provoked during the procedure, does not mean it will be a problem when you go home.

And there is study data supporting both these points.

Yes, a simple PVI might not work, no guarantees with any ablation, but according to a couple of EPs I spoke to at top cardiac hospitals, if success is defined as a 95% reduction in AF burden, then the odds of a successful ablation can be close to 90%.

And if your're in the unlucky 10%, you can always go back later. But you can't un-ablate tissue that was unecessarily burned the frst time.

Additional burning outside of the pulmonary veins certainly has its place especially in redo cases, very persistent AF, flutter, identifiable left atrial fibrosis, or other documented tachycardias.

But what might be most important in your case is simply to find a high-volume EP you have confidence in, who works at a cardiac center of excellence. And not just assume that the most extensive ablation is automatically the best, especially for a first ablation for paroxysmal.

Jim



Edited 2 time(s). Last edit at 05/22/2026 08:30PM by mjamesone.

Thank you for that input. It did make sense to me. In year 17 and never on daily meds or ablated with average of two per year, now at 2 per month without meds and not converting easily and timely. At 72, and mostly healthy, I believe this may be my chance to have some peace of mind with moving/traveling soon. This is a teaching hospital so I would like some assurances before hand.

This is a teaching hospital so I would like some assurances before hand.

You should have the "talk" about who will do what. Some EPs will do all of it, especially if you ask, some will flat out say, I'll be there supervising, but this is a teaching hospital and we teach.

At the end of the day, teaching hopsitals like Cleveland Clinc and Sinai have very high success rates, so it seems to work. And remember, your success gets credited to the EP, so they have a real vested interest. So if you pick the right EP, you will be fine. I would not overthink.

The one caveat is do not schedule I think in August? I may have the date wrong, but I was told never to schedule an ablation the month the new cardiac fellows arrive and rotate, so find out when that is and schedule say 1-2 months after. This was told to me by an EP at a teaching hospital.

Anyway, for a basic PVI, it's pretty much by formula and if they're trained right, the results should be the same. Now, if they were hunting for an elusive tachycardia, then I'd want a solid assurance who will be looking.

Jim



Edited 1 time(s). Last edit at 05/23/2026 12:21AM by mjamesone.

I was labeled Paroxysmal years ago but Im not certain i fit that term, or really ever did. Given that my episodes are quite infrequent, 0-2 per year with a few years having 4-8, however without medical intervention of cardioversion or meds, I dont convert easily. The 2nd time was a 10 day stint with a TEE and a successful cardioversion. So I wonder if I am a good candidate for PVI-only PFA?

Yes, you are a good candidate for PVI only and by whatever method is most appropriate or likely to do the least tissue damage or offer the least risk of perforation and/or collateral damage. The current research shows PFA improving all the time in efficacy, but that it still doesn't enjoy a statistically significant success rate over RF ablation. Further, it requires more fluoroscopy exposure for the patient than RF does.

You are still in the earliest stage of AF, that being 'paroxysmal.' The reason is that your episodes are infrequent and can be terminated easily, whether on their own or with a cardioversion. Were you into the 'persistent' or 'long-standing persistent', you would be having more frequent bouts and they would be loath to self-terminate, or they'd be resistant to interventions. You'd be on higher doses of drugs, and the EP would know that you have at least two or more walls of the left atrium involved, and not just the rear.

This is my uneducated opinion; there would be others offered, I hope.

The 2nd time was a 10 day stint with a TEE and a successful cardioversion.

So technically you are "persistent" not paroxysmal, as you edged past the seven-day mark. Still, no worry, your chances of a succesful ablation shoud be he same as if you were paroxymal, according to the several EPs I consulted with. The problem is potentially when you start geting nearer long-term persistent territory, which starts at 12 months of continuous Afib. So technically you're persistent, but so close to the edge at 10 day, nothing really changes. My longest episode was 8 day, so I was technically persistent as well, and they did a basic PVI and I've essentially been Afib free going on 3 years now. You have to stop thinking more ablation is better for someone like yourself. Study data and the majority of EPs say it's not. And remember, a failed ablation isn't necessarily the worst-case scenatio. The worst case is coming out worse than you went in. So why increase risk without a proven benefit?

Jim



Edited 1 time(s). Last edit at 05/25/2026 10:42PM by mjamesone.

Gloaming and Mjames, That makes perfect sense. Yes, the fear is coming out worse than I went in of course, and deciding who will be the EP. I am flat out refusing a TEE for sure, my throat is more of a worry than the procedure itself. Im guessing they are concerned overall at this facility with stroke risk, but as Im never in afib constantly, I see little risk. Ill be asking for ICE.

I am flat out refusing a TEE for sure

I am very impressed your center is offering a TEE prior.

I would have thought unecessary myself until a recent trial was stopped because 6 of the first 183 patients had a stroke! The trial was continued after a stricter protocol was put in place, and paramount was a TEE 24 hours prior. No strokes after the new protocol was put in place. You can read my comments in this thread here: [www.afibbers.org]

Personally, if I ever needed another ablation, I would insist on a TEE prior. FWIW I've had several TEE's and no pain, no issue whatesover.

Jim



Edited 1 time(s). Last edit at 05/26/2026 05:47PM by mjamesone.

Probably because they did have 1 stroke out of all the PFAs the last 2 years. Its not the pain, it is years of strep and covid on top of that which gave me a very narrow esophagus and is irreversible. First and last TEE left me damaged for months. Not happening. Ill be glad to stay overnight for observation or do an ICE instead.

First and last TEE left me damaged for months. Not happening.

I missed that part. In your place I would also not have a TEE.

However, if you read the complete study, there were a few other tests/precautions they added to lower stroke risk, you might consider. As to only 1 stroke in the last six years from PFA, I'm skeptical because this trial had SIX. Anyway, you want to baby your esophagus as much as possible, and a stroke would would still be a fairly rare event.

Jim

I never said the last 6 years. 1 stroke in last 300 PFAs in 2 years fellow had witnessed. At any rate, I may not even be in the area by the time they are ready. Most likely I will be in Tx, 1 hr from Austin from Nov to May. That may be the better choice at this point if meds are keeping things in line presently.