antiarrhythmic drugs or ablation

After spending hours 'n hours reading on medical sites and on forums such as affibers.org, those of us who have AF that comes and goes generally don't tolerate it well, and they often opt for catheter ablation. If the ablation succeeds, it's like being born anew. Ablation, the mechanical fix, is INFINITELY better than taking drugs to try to control the arrhythmia. Again...IF...it works. Failures for first ablations runs in the 30% range, depending on the patient and on the skills and experience of the electrophysiologist performing the surgery. Follow-up ablations enjoy about 85% success rates because most of the initial work was 'good' and useful. The EP just has to find the gap in the scarred endothelial tissue surrounding the pulmonary veins and close it with further burning. That's exactly what happened in my own case, and I am now five months on and doing well. Just got a call from my EP saying he was discharging me and wished me well because my Holter Monitor assessment showed no PACs or AF. Whew!!

Metoprolol is often combined with an anti-arrhythmic drug, but the heavy work is meant to be handled by the latter, not by metoprolol. Metoprolol is for rate control IF you have persistent AF and/or long runs of it while still in paroxysmal AF. It is also useful for lowering blood pressure due to its action on the myocytes. I happen to do poorly when the two are combined and was eventually in the ER just six days post ablation with a heart rate of 30, meaning my SA node was essentially shut down and my AV node was keeping me alive. In fact, the nurse in the ER came running in and saw me talking to my wife. She said they were watching and, holding her two index fingers six inches apart, said that the monitor showed no heart beat for that length of time. Needless to say, I had already had my last dose of metoprolol.

My only experience with a big hammer was with Amiodarone, and that was what replaced metoprolol on that occasion. It worked, but they try to get patients off it again as soon as their hearts settle down into NSR over the next six weeks or so. It is quite toxic. I advise you to google the drug you mentioned and read all about it, the good and the bad. If you want to balk, then get in line for an ablation...if an ablation is indicated for your particular case. Consult a really good, in high demand, electrophysiologist. Among the very best, if you can travel, is Dr. Andrea Natale at Austin Cardiology.

I had persistent afib for a year. I tried flecainide, but it did not work. So, I started on dofetilide. It put me into NSR after 2 doses. But then after about a year and a half of NSR, I started having break through afib. So, I then had an ablation, but stayed on the dofetilide until after the blanking period. We then held 2 doses of dofetilide and I went right into afib. I went back into NSR after resuming the dofetilide. I have remained on dofetilide since then and I am scheduled to have another ablation this fall because I want to get off of the meds. I don't like the way they make me feel. The initial loading process for the dofetilide was a piece of cake. I just sat around the hospital room in my pajamas for 3 days. The worse part was the boredom and the hospital food. I do wish I had gone straight to the ablation instead of trying meds. Good luck.

Thanks for sharing. Since I have persistent AF from the day diagnosed, rate control was tried first and has not been a success. Metoprolol caused headaches and extreme fatique, and since I have no hypertension, it lowered my systolic bp to 90s and 80s. Then diltiazem tried and dose increased once with same results. Rate still not down enough and often spikes and still fatigue (although not as severe) and bp often in 90s. Since I have HCM, I sought out a cardiologist at
a HCM clinic at a center of excellence for said disease. Have a wonderful cardiologist at Mayo Clinic and he referred me to the Mayo Heart Rhythm Clinic. Had my consult last week, really liked the electrophysiologist so am trying to relax and move to the next step. I can always decide to go with an ablation first, but it has its own risks.

Thanks for sharing your AF journey. I was diagnosed with Apical Hypertrophic Cardiomyopathy in Sept. of 2022. Until that time, I was very fortunate to have no health issues. My HCM required treatment at that time. When my persistent afib with rvr showed itself in March, that all changed. Rate control drugs have not worked well enough, so on to the next step. I do trust my Mayo Clinic cardiologist and the electrophysiologist/cardiologist that I have seen, so I guess I should try to relax until this next step. I hope my loading process is as uneventful as yours was. I have until early September, so I can still change my mind and have an ablation instead.

I was on propafenone and then flecainide for about a year after developing paroxysmal AFib about 3 years ago. I decided to go right to ablation before the meds failed. Unfortunately my ablation failed and I was back on flecainide for about 9 months and my AFib became more persistent. Another ablation was not an option due to complications from my first one. Two cardiologists recommended dofetilide (Tikosyn). I was very nervous, actually terrified, but decided to do the 3 day hospital stay and give it a try. It got me right out of Afib and has been very successful for a year now. No AFib for 9 months and now only very brief episodes less than 15 min about once every three weeks). When I got home from the hospital on dofetilide I was still very anxious for a few weeks but the anxiety went away and I am very pleased with how it’s going. I wish I had tried dofetilide before the ablation. That’s just my experience. I wish you luck with your decision!

Thank you for sharing your experience. I, too, am terrified of the loading process, but have to try the next step as rate control has not worked. I could not try either propafenone or flecainide because they are not used when you have hypertrophic cardiomyopathy. Glad to hear dofetilide is working for you. I am hoping for the same. Living with persistent AFib with rvr is definitely not fun.

I would definitely recommend that you go with an ablation. I had mine in January of this year and have had no issues with AFIB since. Did not realize how crappy I was feeling due to the AFIB went away. The actual procedure turned out to be a non event for me as I was put under in the morning and discharged that afternoon. Recovery went smoothly too. Will need to be on blood thinner forever but I don’t have a problem with that. Best wishes for a resolution to your condition.

I want to comment on the anti arrhythmic drugs or ablation discussion. I have reconciled myself to the fact that it is a no-win situation, as there are drawbacks for both options. I have chosen to stay on Sotalol (dofetilide is not available in Canada) for two years despite significant side effects of beta blockade because I think ablation is a greater risk for me. The success rate is not great, I have CAD, and stroke is my biggest concern (I am high risk and have abnormal cerebral arteries). It looks like everyone's risk calculation is going to be different, and no one's will be easy. I have appreciated everyone's comments on this issue, they have helped me to clarify what is best for me. Thank you.

The last five years I have been on all those drugs and even tikosyn . 3 ablations and several cardiversions . 8 weeks ago I got a pacemaker and I’m completely dependent on a pacemaker . I would skip the med s and go to the ablations . A lot of people sometimes need more then one . So please dont get frustrated Its like an emotional roller coaster .I felt lousy for five years and the drugs just weren’t helping. This doesn’t mean you need a pacemaker . That was my decision I was given . I wish you the best all the comments were all good . Find a good physician to do it . I’m 65 and it can be emotional.. good support on this connection . Take care my friend in my thoughts. Tara

The admin at affibers.org forum has had six ablations. Many need two or three. It cannot be emphasized too much that the skill of the EP performing the ablation matters more than anything. And, even the best EPs miss once in a while. I had a successful second ablation as shown by my Holter Monitor ten weeks out.

It is sometimes the case that a successful ablation of the pulmonary vein ostia in the left atrium reveals only after the blanking period and the subsequent Holter Monitor that there has been either a masked flutter, usually in the right atrium, or the flutter is new and subsequent to the successful ablation. If that happens, another ablation procedure must be done to completely stop the arrhythmia.

I dunno...I pointedly told my EP, when he came bedside prior to my ablations and pointed out the risks (about as low as having a stroke when on anti-coagulants...IOW...really low) and that drugs often control arrhythmias, that I wanted it 'mechanically fixed'. He nodded both times, immediately being assured that I know what's what, and I know that I would rather submit to his ablation procedure than to continue to roll the dice with an intractable and persistent arrhythmia. Ablation must be done, ideally, BEFORE the problem becomes persistent or permanent. You want an ablation as soon as possible, certainly well before your own paroxysmal AF evolves, or 'matures', into the more intractable kinds that are far more difficult to treat with ANY method...including drugs. In the final analysis, AF is essentially a progressive disorder for 85-90% of us. Even ablations have a life span. At some point, they'll have to be repeated...a touch-up, when AF appears once again. You can always elect to try drugs at that point, or try to stave them off by trying another ablation. They, too, tend to work around the 80% rate of success.