Regression toward a-fib/flutter after a successful ablation.

I was successfully ablated by Dr. Natale on 10/13/05. Since then I have done a 24 hour Holter about every ten days and have plotted the resulting data on a single large graph. The important cumulative Holter data plot observations are:

(1) Average irregular rhythm time per 24 hours is increasing (now averaging about 30 minutes per 24 hours) (range 5 minutes to 300 minutes per 24 hours). This is (normal sinus rhythm) atrial based irregular rhythm, and not the result of a-fib/flutter)
(2) Supra ventricular tachycardia (SVT) time per 24 hours is increasing and now averages about 120 seconds per 24 hours)(range 10 seconds to 400 seconds per 24 hours). The tachycardia bursts typically last only a few seconds.

Since the successful ablation I have experienced seven short episodes of a-flutter.

(1) (06/04/07) Apparent a-fib/flutter like symptoms on a trip to Elmira, NY. Terminated with oral K.
(2) (10/07/07) Recorded a-flutter termination by Holter. A-flutter trigger likely food related. Terminated with oral K.
(3) (10/15/07) Recorded a-flutter termination by Holter. No known trigger association. Terminated with oral K.
(4) (12/20/07) Documented presence of a-flutter by Holter before leaving on trip to Fort Collins, Colorado. Oral K did not terminate a-flutter after three hours. Flecainide/Toprol, taken prior to leaving for airport, terminated the a-flutter three hours later.
(5) (05/04/08) Recorded both the initiation and termination of a-flutter by Holter. A-flutter trigger likely food related. Flecainide/Toprol terminated a-flutter after one hour.
(6) (05/05/08) Recorded a-flutter termination by Holter. A-flutter trigger almost certainly the same food as on previous day. Flecainide/Toprol terminated a-flutter after three hours.
(7) (06/13/08) Episode of a-flutter. No obvious trigger. Terminated with Flecainide/Toprol.

For the mathematically talented:

I played with graphing the above a-flutter dates to find out what kind of graph seemed to produce the most useful data display.

I found that a graph with the vertical axis being logarithmic and measuring the "time before the next a-flutter episode" in days, and a linear horizontal axis measuring calendar time in months, produced a downward sloping straight line, showing the time between episodes is shortening with increasing calendar time. There is no reason to expect the correct curve to be a straight line on a semi-logarithmic graph, so the resulting straight line is probably just a coincidence. Extrapolating the straight line predicts that I will be experiencing an a-flutter episode every ten days one year from now (about four years post-successful-ablation), and will be experiencing an a-flutter episode every day three years from now (about six years post-successful-ablation).

However, note that the first three episodes were convertable with oral potassium. The last four episodes required Flecainide/Toprol for conversion. I wouldn't be surprised that the above predictions will be too optimistic because the "Pill in the Pocket" Flecainide/Toprol dose will eventually cease to convert my a-flutter episodes, and I will need a touchup ablation to remain in nsr.

Sobering report. My most sincere sympathies. Food diary, Fitday, all nutrients in good supply?
PeggyM

Ah, Wil . . .

Probably the result of too little extended endurance exercise!

Interesting data. I will watch with curiosity and empathy to see longer term trends.

Wil - as we know, often one ablation is not enough. I'll be interested in your updates. Have you sent your data to Dr. Natale for an opinion?

Jackie

Thanks for your , as always, honest report. You are willing to look as things straight on - to a remarkable extent. Not all readers will know what a staunch advocate you have been for catheter ablation, though. Since you are willing to to a touch-up, it is obvious that you remain realistically committed to that procedure.

Keep posting your findings, please.

Hi Wil,

Given the likely lengthing of the queue once Natale gets established in his new surroundings, are you inclined to schedule a touch up at say a year from now, then push that date further out if the outcome is better than predicted by your data?

George

Wil,

If this is right-sided flutter it shouldn't be too difficult to ablate.

Marian

I am grateful for having been granted years of nsr, thereby avoiding the accelerated heart deterioration that would have resulted from ongoing 24/7 a-fib.

The accumulating evidence is that a successful ablation blocks numerous possible mechanisms that can initiate a-fib/flutter. Some of those blocks will prove to be permanent; and/or some of those blocks will only be partially effective; and/or some of those blocks will become ineffective in time; and/or some new mechanisms will appear in time.

If all the above is true, a successful ablation will normally be followed by an indeterminate, but finite, period of reliable nsr; followed by a period of a-fib/flutter episodes, characterized by exponentially decreasing periods between episodes; followed by a need for a touchup ablation to start the sequence over again.

The heart's electrical system behaves very much like a non-linear oscillator. That makes studying the system's response, to internal heart changes and external changes, difficult. While I am comfortable adopting the received wisdom advocated here, my long term study, during which I have added and subtracted various parts of that received wisdom (external changes) for periods of time, has not identified any evidence that the long term "normal" progression (of internal changes) has been affected. Obviously, the progression (of internal changes) could be aggravated by external changes, but I've not been interested in intentionally studying that possibility.

I have been sending my data to Dr. Natale quarterly.

My inclination is to allow Dr. Natale to determine what should be done next. He possesses an instinct for what is best, based partly on his knowledge about thousands of ablation outcomes.

After my first ablation (for permanent a-fib) I maintained nsr only with ongoing Flecainide/Toprol, after the termination of which I went into a-flutter that could not be converted with medication. After the second ablation I remained in nsr without medication for essentially two years, after which I am experiencing a form of a-flutter treatable with medication (so far). My guess is that another ablation will result in a longer period of nsr before a-fib/flutter reappears, because each ablation will have to deal with fewer and better defined problems that can be more successfully treated.

Oops - I forgot you had the second. Sorry. J

Wil,

Thank you for sharing your most interesting observations. The curve you describe sounds very similar to the curve (line) you would get if you were to plot damage caused by oxidative stress against time on semi-log paper - except the curve would have a positive slope; ie. damage increasing logarithmically with time. Do you supplement with antioxidants? Also, in the early days, how much potassium did you need to stop the flutter?

Hans

The only anti-oxidants I take come from a nearly daily fish portion, usually as salmon or similar.

I have no idea how much K I took in episode (1). I was at a meeting to be inducted into a national scientific society. The a-fib like symptoms took me completely by surprise and I wasn't very scientific about about my response. Guessing from the physical symptoms experienced as the K level peaked, given the symptoms experienced during later episodes, I'd estimate I'd taken about 4 gms of K.

The second episode involved 3 gms of K, and that dose did not produce noticeable physical symptoms as the K level peaked and the a-flutter died.

The third episode involved 4 gms of K initially, and because it seemed to be having no effect, a little over an hour later I added 3 gms more. That did accomplish the conversion, but it also generated an uncomfortable nausious feeling as the K level peaked and the a-flutter died.

The fourth episode probably involved 5 gms of K, based on my memory that I didn't want to repeat the third episode's physical symptoms, but concerns about the upcoming flight distracted me and I didn't record what I took. I'm sure there was no conversion after three hours and I took 200 mg Flecainide/50 mg Toprol before leaving for the airport.

The data is consistent with a progressively lesser ability of the K to accompish conversion over the six and a half month time span from episode (1) to (4).

I've limited myself to supplementation with magnesium, potassium, and more recently taurine. The opportunity for changing this minimalist program of supplementation exists, and such a change might prove something.

Hi Wil,

First, your data driven, analytical approach appeals to me as the engineer. I commend your rigor.

So, in the for what it is worth categor, here is another thought on your minimalist approach. I recall that you mentioned that you reached bowel tolerance on magnesium with a relatively low doseage.

After doing a lot of reading, it is hard to find studies showing increases of intracellular magnesium into the normal range. Certainly PC, here, tried very hard with little success. On the Exatest site, they reference a paper [www.exatest.com] wher they gave heart patients oral mag citrate for 6 months. The patients averaged 33.2 mEq/L before starting and 35.5 at the end. I don't have the reference, but as I recall, 35.5 is just at the bottom of normal.

I had an Exatest before starting my supplement program nearly 4 years ago. The result was at or near the low end of normal. I've not retested, but I'm guessing that the results would be no different that PC's.

After reading "The Magnesium Factor" by Mildred Seelig, as well as much of the material on the [www.mgwater.com] site, I decided to play around with this a bit more. On the mgwater site, a prostate section, [www.mgwater.com], talks about using oral magnesium chloride.

In searching for successful ways to raise IC mag, I came across a site where "magnesium oil" was used transdermally to raise IC mag levels from 35 to 42 (from memory - unfortunately didn't save the reference). Now this is a huge increase in IC mag. Looking into this further reveals that "magnesium oil" is just mag chloride in water. In this state, it "feels" oily, but has no oil in it. The transdermal absorbtion of mag has the advantage of not causing bowel issues.

Remembering that the Japanese use mag chloride, from sea water, to coagulate tofu (called Nigari), I found a site for to purchase Nigari in bulk [www.simply-natural.biz]. I've purchased 10 pounds, and been playing with it

Apparently it can be used as a foot soak, in the bath water, or just topically. I've tried it in the bath & it is quite relaxing. Topically, it sometimes starts to itch after a while, so I'll wash it off after an hour or so. I have not pretested, nor have I had my supply long enough to really evaluate it. In its hydrated state, it does feel quite "oily."

So, as I said, this is just a thought on a possible way to increase your IC mag levels, other than the oral route with its potential bowel issues.

Georeg

Wil,

I feel very strongly that antioxidant supplementation is an absolute must in this day and age. I began supplementing myself more than 40 years ago when I discovered that alpha-tocopherol is highly effective in preventing the breakdown and cross-linking of long-chain molecules similar to those making up the human body. I have some 20 patents on various antioxidant compositions and in 1995 wrote an article about the importance of antioxidants. You can find it here:

[www.yourhealthbase.com]

The article is still reasonably up-to-date except that it is now clear that the optimum vitamin E supplement is a mix of the four tocopherols and the four tocotrienols with gamma-tocopherol being the dominant component. Also, it is now evident that supplementation with synthetic beta-carotene on its own is a bad idea. It sould be taken only as part of a natural (algae-based) carotene complex.

Vitamin C (with its naturally occuring bioflavonoids) and vitamin E (whole complex) are the foundation of any antioxidant program. You can certainly add alpha-lipoic acid, blueberries, coenzyme Q10, NAC, selenium, glutathione, etc., etc., but vitamins C and E are still the mainstay with vitamin C acting in the aquous phase and vitamin E acting in the lipid phase of cells and vitamin C also playing a very important role in the regeneration of vitamin E. Most qualified nutritionists recommend 500 mg of vitamin C three times daily plus 400-600 IU of vitamin E taking with a meal containing some fat. I would highly recommend that you try it. Please not that it is pretty well impossible to obtain these amounts from even the most healthy diet. You can read more about vitamin C and E here:

[www.yourhealthbase.com]

[www.yourhealthbase.com]

Hans