Failed ablation, what next?

I just watched a video on YouTube presented by a physician who is an expert on A-fib and its treatment. The video is entitled "10 Things You Need to Ask Your Doctor Before an Ablation." I thought I was pretty savvy on what to expect but I had to admit that I did not know all the things I should have asked about the ablation I am going to have in the next 6 weeks. I'm a nurse but have no expertise in this area. I was surprised to learn that some electrophysiologists do mostly "standard" ablations which involve only the one wall with the pulmonary vein areas that are sort of the standard problem in early A-fib cases. I also learned that a patient should ask about the doc's success rate, whether he does more complex ablations, his level of experience with all types of ablation procedures. I want a pulse field ablation but this video suggests that this method is most successful with smaller areas of A-fib cells and that more chronic cases are not necessarily appropriate for this method. I think you should search on YouTube to see if you can find this information. I was told originally that I needed to be on an anti-arrhythmic before the actual ablation, but I found Flecainide very troublesome--with some side effects and then reading the Black Box warnings, I decided that since I was in NSR when I started that med, I wouldn't know if it was doing any good anyway! I told the APRN that I have been in NSR since June and I didn't want or need to be on that medication before getting the ablation (they want you in NSR for 3 months before the procedure apparently.) I don't have a problem with Cardizem but I am not ever taking Flecainide again. I, like you, want to be treated before the A-fib spreads any further. I hope you get your answers and that you look around for the best treatment source since there are many options out there. You don't have to take one opinion only; since I have been diagnosed, I have learned that there are experts out there with better results than some local options and I would be willing to travel to get the best options. Good luck to you! As the song goes: it pays to shop around!

Your ablation (may have) failed very simply for one reason, and that reason is that the application of energy did not neutralize the tissue housing the new rogue signaling cells that have grown in the walls of your left atrium. It got some spots, probably, but missed some. If you were deemed to be in persistent AF, meaning the second stage of progression, then you had at least two walls with the rogue cells (according to Dr. Scott Lee on Afib Education Center channel on YouTube.) Neither of us seems to know where the PFA was applied in your left atrium, but wherever it was done did not cover the entire affected substrate (tissue below the endothelium lining the inner walls of the heart's chambers).
I used brackets around 'may have' above because some AF happens once or twice during the blanking period, and may actually happen later. If it can be converted successfully, and you have no more for a year, then it technically is a 'successful' ablation: one full year free of the treated arrhythmia. In case you'd like some perspective from another patient, I was an obvious failure at the six day mark post ablation...if you can believe it. I had to be placed on amiodarone for eight weeks to get my heart to beat normally. Even then, after the Holter monitor, which showed many PACs, I reverted to paroxysmal AF and had a second ablation a few months later, So far, 30 months out, so good.
What this means is that a re-do is probably indicated, but your expert EP will be the judge....in his/her opinion. You might wish to look for a 'better' EP, or at least a second opinion. Perhaps the EP who did your procedure knows, or can guess, what failed and what he/she missed and would be willing to take another crack at you. Mine did.
Questions to ask:
Am I a reasonable candidate for a second attempt? Why, or why not?
Will you map the heart prior to ablating tissue to find where the rogue cells are? Are you averse to ablating the Left Atrial Appendage if it turns out that the cells are there? If they are there, will PFA suffice, or will you have to use RF energy? How far are you willing to ablate if the mapping procedure shows three or more walls are affected, including the septum and coronary sinus?
I'm no expert at this, but I personally think taking an anti-arrhythmic drug for more than a couple of weeks after an ablation is simply going to mask what effect the ablation has had. Some EPs prescribe propafenone or flecainide, and maybe some low-dose metoprolol as a prophylaxis against a cranky heart wanting to break into AF. The idea is to let the heart calm and to heal the lesions created during the ablation, especially if RF was used. But asking a patient to use them for eight weeks or more is just treating the AF with drugs if the ablation failed from the get-go. Maybe I'm unusual, but I'm a guy who wants 'to know'. I would like to have a pretty solid handle on success/failure within a couple of weeks, and taking a masking drug until a week or two before the Holter prevents that. My opinion.
Do, absolutely, take that second appointment with the other EP. Ideally that person would have access to records of your recent history, including a detailed report by the first EP of what he/she did.
Again with me thinking about what I would want to do and to know, I would consult the prescribing EP about reducing the anti-arrhythmic even more, right down to zero over the next two months. It might be unneeded after all, and wouldn't it be great to know that? Or, you may begin to get blips after a reduction and you'd know you definitely need another ablation. Maybe, if you put yourself in the hands of a new EP, that person would want to see for him/herself if that is the case. It's worth running that past the new consultant when you see that person. And also your current EP.
Good news is that you're still early in the AF game, relatively speaking, and the AAD is controlling the AF. With 75 days and counting free of AF, it means you have some time and can get to work finding someone who will try again. It's worth doing two, even three times, as long as each time the ablated tissue mounts to a third wall, a fourth, a fifth, and finally a sixth wall if needs be. Even the Vein of Marshall can be ablated (cryogenically with very cold saline) if that's where a gifted EP finds some rogue signaling.
Finally, please don't despair. I know, it's a bummer accepting that there are probably problems with the first ablation. Been there. So have about 25% of all index ablatees across all EPs all over the globe. It's a sad statistic, but it's not like it means you're a hopeless case. Just read a post over on afibbers.org of a guy whose first ablation lasted 13 years, second has lasted 5. Now.....think about that for a second. He found himself in AF again after a 13 year hiatus. Thirteen danged years! That's a loooooonnng time thinking you're home free only to find yourself on the down side of a wonky heart once again.

Thank you, Gloaming for your detailed reply. My doctor ablated the pulmonary veins and he said that he ablated the back wall because he saw some scarring there. In the procedure's chronological log it is written "intracardiac EP 3D mapping was performed and EP comprehensive evaluation with induction of Arrhythmia with left atrial recording". So whatever that exactly means...

Years ago (I had RF ablation in 2004 for Aflutter) the doctor must have injected something to try to induce the aflutter, my heart wouldn't stay in aflutter for long, so he didn't see much)... but no aflutter for over 20 years after that RF ablation. I wonder if my current EP doctor likes doing the new PFA and knows that he'd have to use RF on me for better results?

I consulted with an EP in 2023, before PFA was being used in his facility and that EP (at a teaching hospital) said, ideally, he'd like me to be in AFIB going into the procedure so he can see what's going on. I was in my first AFIB episode that I couldn't convert on my own, while sitting in his office! That's when I became persistent after about 16 months of being paroxysmal. Here I am 28 months later, three electric cardioversions later.

I wonder if my current EP doctor just likes doing the new PFA and knows that he'd have to use RF on me, in different areas of the heart, to get better results? Thanks again for all the information you've given me. I'll be better able to ask the important questions at my next appointments.

My husband had serious problem with flecainide- fainted while driving and crashed car into telephone pole and totaled it. It is indeed a dangerous drug and people need to be aware of that.

Hi sjm46. Thanks for the info from the YouTube channel. Good questions to ask. Yes, I believe my doctor might be one of them who is very good at fixing the easy cases by going after the pulmonary veins. But, when it comes to the more complicated cases, he might not be the best choice and hopefully can refer me to some doctors who can do the harder cases. During my follow up after the post ablation cardio version, my P.A. said "sometimes doing more ablations can make heart rhythm cases worse". Yikes, I didn't need to hear that! I am concerned with the complications that can arise from RF ablation.

Flecainide is keeping me in NSR, I don't have any immediate side effects and I'm using this time to find an EP that can say that they have success with persistent AFIB cases.

Thanks again and I hope you have great success with your ablation. Where are you having it done?

I initially agreed to try Flecainide but I was also in NSR at the time with only a very occasional PAC so I thought this option might be an alternative to ablation at this time. I found my chest pounding at night, constipation, vague headachy feelings--none of these were "normal" for me. I went to the drug book (I'm a retired nurse) and the first thing I noted was three (THREE) Black Box warnings about the serious nature of this medication. I started taking 1/2 doses for three days and then none. I almost immediately felt more normal for me. I am not saying this is a bad med, just a very serious med to be taking without any real valid ways to prove it is working. I am fine on a rate control drug and I am planning an ablation soon. I am sorry about your husband's experience. Even I was too trusting to try something without thoroughly checking it out. I hope your husband is okay and that he is able to take something else less "lethal". Physically and psychologically I just wouldn't ever be comfortable on this med.

Amazingly, though the car was totaled, he walked away mostly unhurt, probably bruised a rib, but never sought any medical attention (the dope.) His head was feeling funny and he should not have driven. He also had a bad reaction first time he took it, but thought it would help afib. He has had an ablation and has been fine since. But he had a super skilled doc. I try to mention the dangers of flecainide when I see it in the forum. It probably isnt really needed by anyone. For him it was prescribed to convert a heart in afib to NSR.

PFA is safer for the patient, and it normally doesn't require a TEE to ensure the energy isn't likely to damage the phrenic nerve and the esophagus, both of which run right behind the left atrium's outer rear wall. So, less to go wrong, less to do. It's effectiveness at 'success' is statistically insignificant at the moment between it and RF ablation. That may change, though, as more and more EPs become trained, acquire the equipment, and gain experience. It may be substantially better than RF, all things considered...just not at present.
A conscientious EP will challenge the heart in order to start AF or flutter so that he can map the rogue cell locations and zap them. They do use at least two chemicals, but even intravenous caffeine will do if nothing else. The two preferred are adenosine and isoproterenol. But more than that, before they release you to Recovery, they'll repeat that challenge. In my EP's case, he also routinely cardioverts the heart, even if it has turned to NSR by the time he's ready to call me done.
As a human being, if an EP is having poor success rates with PFA, you could appreciate that he would rather default to RF, certainly after a nasty run of failed ablations. I would. But considering that the failure rate for both techniques is about 25%, I would think that PFA would not have a higher rate of failures for any one (trained) EP than RF. I may be wrong, maybe only about your EP, but I don't think so. He would probably WANT TO do PFA because it presents less risk of damage to you on that basis alone.
If it helps, cardioversions have never worked for me. I know an aged woman who has had 50. !!! Obviously, none of them worked for her for more than a month or two. My longest lasting one was a whopping 16 hours. My first ever cardioversion never did work. To add insult to injury, I came to just as the tech pressed the button for the third, most powerful, jolt. That was NOT fun.
If you look for Dr. Lee's video channel on YouTube, and search for a recent one, 'Why do catheter ablations fail,' he goes into some detail about what is happening in the more complex cases and why some EPs are simply not experienced and/or skilled enough to do the job. So, if you have means and can afford to skip around looking for the very best EPs (that I have heard of in the USA, I'm Canadian), then you need to get in line behind Dr. Andrea Natale at the Texas Cardiac Arrhythmia Institute in Austin, or Dr. Pasquale Santangeli at Cleveland Clinic. They're worth the wait. Note that Natale has privileges in several mid-western and western hospitals, especially in CA. He often travels to them to perform in-situ operations for patients who can't travel much.
One last thing that I didn't get to, but as an afterthought: as it was in my case, sometimes the lesions created in a first PVI do not close properly against each other to create a contiguous 'dam' of fibrosis (over which the electrical impulses cannot pass, so no more AF!). If there is a sufficiently large, and clean, gap, those signals can escape the pulmonary vein ostia and do their worst. So, maybe a re-do of that simple and initial ablation is all that's really needed for you. Maybe. Your persistent category of AF doesn't bode well for that simple remedy, unfortunately, but with no experience as an EP, I can only guess. I think the EPs often redo the 'dam' of scarring, maybe using RF this time, and if the heart lurches back into NSR, then it's all done. Happened exactly that way for me on my second ablation, same EP. He was working around the third pulmonary vein when my heart suddenly resumed NSR as he did one zap. They stood back, watched, hi-fived, and he said he didn't even work on the fourth vein. He didn't even cardiovert me, which is his normal practice. He knew he had found what he'd missed the first time. As I said previously, I'm into my 30th month and going strong. Called his office on the first anniversary and introduced myself to Crystal, and said why I was calling, she actually laughed. I wanted them both to know how important their respective skills were to me.

So glad to hear that your husband is okay; that is one scary story! I personally think that Flecainide should be reserved for the most serious cases and not recommended for the "average" A-fib patient that is already in a fairly decent period of NSR. The Black Box warnings are pretty specific and the serious side effects are frankly very frightening. The EP cardiologist that prescribed mine did not really outline the problematic issues with this med; but most concerning was my regular cardiologist who listened to my concerns at a follow-up appointment and then automatically ordered a six month supply instead of letting me finish the "trial" period that I had agreed to. I now have a stash of medication I will never take again! Back to my original comment: listen to your own body, read and research your meds, make an intelligent decision for yourself! Not all physicians are willing to truly listen to their patients and respect their decisions! (It's your lungs, liver, kidneys, heart, throid!)

I was an "average" AFib patient with very infrequent episodes until the last year prior to my ablation. I took flecccainide for most of those years with no problems until it didn't seem to work any more. They then switched me to amioderone, which other than weight gain, didn't seem to cause me any side effects except mental worrying about side effects! It did nearly totally stop the episodes however. I stopped it the day of my ablation with dr.'s OK.