Flutter & Afib

Hi all,

I have a cousin with afib & aflutter in the Fl Lauderdale, FL area. I'd like to post a recent email of his to me & my respose & get any comments from you. Especially those who've had flutter.

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Hi George,

I met with an EP. He said that the persistent Afib has become somewhat normal with mostly atrial flutter, and incidents of occasional Afib. I have a "normal" p wave. I re-explained how I am using the Polar heart monitor that you sent to monitor myself and he said that the monitor might not be able to differentiate between Afib and atrial flutter in my case. I asked how I might have gone from "persistent" afib to atrial flutter and he did not know. I explained that I have been using magnesium, potassium and taurine supplements...but he did not have any substantive ideas about my change, except that changes sometimes happen. He said that atrial flutter is sometimes caused by some of the rhythm meds and that medication was not a good course of action yet. The least risky and probably best course of action would be to do a right atrial ablation to try to remedy the atrial flutter. He said that he does these about 15-20 times per month and that it is very low risk, but with a success rate of only about 50%. He said that I could stay the course and stay on the corguard and coumadin for now, or that I could do aspirin therapy instead of coumadin. He said that by trying the right atrial ablation, we could see if we get lucky and solve the problem (atrial flutter and Afib) for always or now or that it might just solve the atrial flutter and make the Afib more noticeable. Then we could go after the Afib with rhythm meds or pulmonary vein ablation (which is more risky). I told him that I would think about it. Any thoughts or suggestions?

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My response:

First on the Polar, several guys have sent me Polar files for flutter. The
characteristic that I noticed is that flutter usually has much less variability
than afib or even NSR. In both cases, the atria are going at a high rate.
Flutter is usually described in terms of 2:1, 3:1 & etc. conduction. That is if
the atria are beating at 300 BPM the ventricular rate would be 100 BPM. I'll
see if I have some examples at home to forward to you. Even when the flutter is fluctuating rapidly between say 3:1 & 4:1 conduction, there is more order than in afib, as seen on the Polar.

From what I know, flutter ablations are easier than afib. However a flutter
ablation rarely fixes afib.

His quoted success rate is not very good, especially for flutter.

Afib ablations are much more difficult than flutter ablations. A question would be how many of those ablations a month are flutter and how many are afib.

The one thing I've learned from reading & participating in the afibbers forum is that success of afib ablation is highly dependent on the skill of the EP. My
number one best advice is to go to the absoultely best guy you can. My first pick in the US would be Andrea Natale formerly of the Cleveland Clinic (they parted ways in Sept because he had the audacity to teach others during his vacation time). He now practices in San Fran & Austin. His contact info is here: [andreanatale.com] He recently did a web seminar with his SF group. It is here [tinyurl.com]. You may have to register to watch, but it is free.

My local pick would be Dr. Pinsky whose contact info. I gave you the other day:

Sergio Pinski
pinskis@ccf.org
Head- Section of Cardiac Pacing & Electrophysiology
Department of Cardiology
Cleveland Clinic
Weston, Florida
Florida website: [www.clevelandclinic.org]

On the latest ablation survey from the Afib Report, the following is quoted: "Right atrial flutter ablations are generally successful in eliminating right atrial flutter, but only very rarely (5% of cases) do they cure AF as well."

I don't know what your insurance would allow but my first choice would be to go to either Natale or Pinsky and get a RF ablation and an afib ablation at the same time.

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I'd love your thoughts.

Thanks!

George

George,

I emphatically agree with your suggestion that your cousin get a second opinion from someone of the caliber of Dr Pinksi or Dr Natale.

I also agree that a 50% success rate is not the best -- although I am not sure what exactly is meant... I am assuming it mean that this was his success rate in solving the AFL/AF problem when he did a RA ablation for typical AF in cases like your counsin's?

... which brings up the question of whether your cousin's AFL is typical or atypical. The latter originates in the LA and is more difficult to ablate.

I have a vague nervous feeling (and it is *just a feeling*) about this EP from the things you have said... which means that I would want to be especially sure to ask him questions about his success- and complication rates, such as those provided at [www.af-ideas.com] before proceeding further.

-- Dick

George,

I don't think I could improve on Dick's advise. I, myself, had a right-sided flutter ablation with the intent that 'maybe it would eliminate the afib.' Well, the truth of the matter is that the flutter was masking the afib, and when the flutter was eliminated, guess what? The afib was even more apparent.

So, I went to Dr. Pinski, and now my afib is history.

Marian

George, I'm not sure I would have much confidence when a doctor makes a statement like this, "we could see if we get lucky and solve the problem (atrial flutter and Afib) for always or now or that it might just solve the atrial flutter and make the Afib more noticeable. " Sounds very iffy to me and this decision is not like rolling dice in Las Vegas. Just my opinion. I think your advise to your cousin was really good. Sharon

George,

A quoted success rate for a right atrial flutter ablation of 50% is very low indeed; in capable hands it should be at least 90%. However, if your cousin's doctor meant that the chances of curing both flutter and afib at the same time by just doing the right atrial flutter ablation I would say that he is being overly optimistic.

Hans

Hi all,

Thank you for your constructive comments!

George

George,

Stabbing in the dark without really knowing your friend, it really sounds like atypical flutter, with the close relationship to atrial fib. I had flutter mixed with atrial fib and both were stopped by a pulmonary vein isolation. My EP had diagnosed it previously as atypical flutter because it "seemed to behave something like atrial fib, except more rhythmic." I believe that she was right on the money and that a right atrial flutter ablation would have been useless.

Russ

Russ my E.p took about 30 seconds to read my e.c.g's and decide I had atypical AND typical flutter and a.fib (and I think some sort of pulmonary vein driven svt) Yes four different issues. Just for info since you were discussing this type of issue

Mark