Is a second ablation advisable if the AFib is controlled by flecainide

Hello. Since you were on flecainide and the Afib returned, my guess is, how can you be sure the Afib won’t happen again? also shouldn’t you be on a anticoagulant? I also know that after an ablation is quite common to have arrhythmias. How long has it been since your last ablation? I would suggest talking with a reputable cardiologist and your EP. Also, I’ve heard of people who have had several ablations… I believe the rate of success with the first ablation is about 80%

If you are having a “standard” heat or cold ablation, I’d suggest that you look into the newest cutting edge ablation: pulsed field ablation developed by Boston Scientific. The clinical trial through Johns Hopkins Hospital, Hugh Calkins, MD, in Baltimore has ended and the results are expected soon.

I have talked to people who have had several ablations and some of them have gotten to a such a low heart rate that they then need to have a pacemaker. Just remember every patient is unique and what works for one does not work for all I do think age is a factor and how long you have been in AFib and how often you're in AFib. Have you had the v i o heart monitor I wore for one week.

Oddly enough Hopkins does not do the PFA ablation the only hospital in Maryland that does it is MedStar.

PFA has been approved for a pulmonary vein isolation (PVI) since early last year, and it has been used for LAA isolation as of last summer. The outcomes in terms of ridding the patient of AF are, still early in PFA's history, no better than it is for cryo and for RF ablations, that being 75%. However, the risks to the patient are considerably less, notably damaging the esophagus, and the phrenic and Vagus nerves. I believe the risk for pulmonary vein hypertension is also lower.

Below is my (now) stock answer when dealing with considerations about AF:
It's strictly your call. Obviously, I don't know a thing about you, and can't do more than to point out the possible outcomes of not controlling it better. If you're okay with that, then here is my counsel, which you must have seen in other replies to people by now:

a. AF is a progressive disorder. The more you have, the worse it gets. The worse it gets, the more problems will happen as it evolves;

b. A percentage of your time, your oxygenation is poor(er) than when your heart is in NSR. As you age, all sorts of things deteriorate. Now you're adding a deficit, even if mild, of oxygen to the mix;

c. Many people feel that, if it isn't so bad, or not the least bit intrusive, what's to worry about? I feel fine, and I have the two meds, sssoooooo........ That's good, but it isn't stopping the progression of your disordered heart toward more intractable forms of the arrhythmia, and it might go on to result in mitral valve fibrosis and prolapse, and it could end in 'heart failure';

d. Did your various blood tests happen to show any insufficiency of electrolytes, and how about troponin? If the electrolytes were lowish, and if troponin is higher than normal, you have options with the electrolytes (supplementation daily), and the troponin is a marker of myocyte death, probably due to the stresses of the arrhythmia on heart muscle;

e. An ablation, in the right hands, is now considered to be the 'gold standard' of care for AF. It has the best outcomes and the least morbidity between other options, including just controlling it with medication. Your burden suggests that, at the very least, you should be on an anti-arrhythmic drug (to be determined by a competent physician based on your genotype and phenotype), and if it were up to me, you'd be in line with an electrophysiologist now. The idea is to control the onset of AF, to prevent it, and to stay out of it for as much as is possible without making your life truly miserable. For me, being in AF was indeed truly miserable. It was bloody awful. So, soon after my diagnosis, and after reading about things like amiodarone, I knew an ablation was my goal. It took two rounds of it to work, which is the case for about 25% of all first-time ablatees, but I am three days away from my second anniversary completely free of AF. If you'd like to be where I am, you have two options....get on an anti-arrhythmic or get an ablation.

Dr Calkin did mine at JHH 12/14/23, I’ve been off Flecainide Acetate for over a year and have been in sinus rhythm since 11/12/23. I know he’s been in touch with Boston Scientific as he was part of the clinical trial, so JHH may be on their radar for PFFS soon.

My reasoning would say go for the ablation because flecainide causes fatigue and it is not necessarily controlling Afib. That you are now seemingly under control is a "tweener". So it is sort of maybe yes or maybe not. You initially showed a failure of ablation albeit you were maximally stressing your heart during a race. It sounded rather soon to put that kind of stressors on your heart so close to an ablation ( you said "A few months after an ablation the AFib returned after I did some heavy exercise (swimming race). I am assuming you are good athlete and know how to train. What was your training period like? It seems that during your training period you would have also had the opportunity to maximally stress your heart but it didn't go into Afib during you training period?? One could argue it both ways. What you have left out is what was your experience with Afib before you had an ablation? As for PFA it is not the be all to end all: at least right now. Results really will not been known for a couple of more years. So far its biggest + is that there is less trauma to the heart. But the long term results are not here now. My EP wants more results before he jumps in and it sounds like Hopkins is in the same mind set.

I'm on the anticoagulant Eliquis. My last ablation was April of 2022. I've discussed this with my EP and he says he doesn't want to pressure me into another ablation. He also did an ECG and said it was sinus rhythm. I feel better than I did previously on flecainide so I'm hesitant to have another ablation since I'm in sinus rhythm, feel good, am exercising more and there are some risks with the procedure.
Thank you for your reply.

The Afib did not return while on flecainide. It returned when I tried to stop it. I'm on flecainide now and am in sinus rhythm according to the last ECG the doctor did and according to my Apple watch.

I've not had the heart monitor: only an ECG in the office. That sounds like an excellent suggestion. Thank you.