1. < Heart Rhythm Conditions

Should ablation be one’s first attempt at conversion of a fib?

Posted by clayart @clayart, Mar 21 11:21am

I’m 74 year-old male ex distance athlete in very good health. Barely one week after very first a fib diagnosis a cardiologist is strongly recommending pulse field ablation. Seems to me this should be more of a last resort. Apparently, for any other less invasive methods he considers amiodarone essential, which to my mind should also be kind of a last resort. Currently on metoprolol and Eliquis, Heart rate and blood pressure relatively normal, No symptoms to speak of. I’m trying to understand this peculiar malady.

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gloaming | @gloaming | Mar 21 12:32pm

This is strictly my opinion from having read a ton of posts by patients, watched many videos by electrophysiologists, and from having done a lot of research and advanced reading:
If you are content with the way things are going, not suffering quality of life degradation, not losing sleep, and feel relatively secure with how things are being managed, there is no rush to jump onto an operating table in a cath lab. Your caregivers know that AF will not kill you. It can make you miserable, though, in which case it is your symptoms that matter most and that will be the reason your EP agrees to treat you. Of course, some patients' hearts do very poorly and they can go downhill quickly, so that would be another urgent reason for an intervention. Flutter cases, and cases of ventricular fibrillation would be more urgent than someone who is 'paroxysmal', where their arrhythmia comes and goes on its own accord, as yours does.
Further, most EPs and cardiologists would want you to attempt a cardioversion as a first step, especially when acute enough that you called an ambulance and were taken to the ER, or if you went their on your own. Cardioversions work for some, even sticking for many months or forever afterwards, whereas people like me were a bust...none of them lasted more than 16 hours (I have had four spread over two years).
Amiodarone, when I googled it three years ago with that very syntax 'is amiodarone the drug of last resort', the answer was immediate and positive. Even so, I had to be placed on it for eight weeks in total after my first ablation failed and I ended up in the ER with an erratic heart. I went off it, was happy until the Holter monitor at 10 weeks post ablation, and then learned the Holter had detected many PACs. From there, with yet another bout of AF over the New Years, and sending a Galaxy watch ECG to him, my EP agreed to try another ablation. I have been free from AF for just over two years now. But, to return to amiodarone, it's not everyone's fave until you really need it, and then it's your best bud. It worked for me, and I knew it was meant only to stabilize me and to get me to the Holter at 10 weeks out. I was advised to go off it about two weeks prior to the Holter so that the Holter got me a pretty accurate picture of my heart's state of disorder....which was unfortunately still quite wonky.
This is getting long...sorry...I do go on...but I would not agree to amiodarone unless I was highly unstable, under great emotional and cardiac duress, and could not be ablated any time soon. To me, a cardioversion should be tried first, then flecainide or some other anti-arrhythmic that fits your circumstances well (they're not all the same chemically). I don't feel there's a rush to an ablation. Once again, it's the patient, in concert with the physician, who negotiates what happens next with 'the system'. You should NOT dismiss the cardiologist's or EP's advice, certainly not on my account...or on my opinion..., and you will ultimately need that person in your corner, so-to-speak, so be careful pushing them away from you. You want an ally, and in this case, a highly skilled and friendly ally. If you'd like more time to think and to research, why not ask for that consideration in so many words? Ask if you can pose three or four telling questions to help you to figure out your way ahead. And then, stick to it, and go for it. As I said, I have had two ablations, no regrets whatsoever. Some, whose EP was unsuccessful for whatever reason, say they do regret it. If you get the best EP around, ideally someone who has already performed several thousand ablations (IOW likely to be in his late 40's or early 50's), your odds of success rise measurably. My EP was frank and up front, and told me in our first meeting that his success rate was running at 75% for an 'index', or first, ablation. I knew I could trust him right away. It took him two tries, but he got 'er done.

REPLY
1 reply
Mentor
Sue, Volunteer Mentor | @sueinmn | Mar 21 12:42pm

@clayart Any episode of Afib, or atrial fibrillation increases your risk of heart attack and stroke. Early management and intervention can stop progression. The recommended treatment depends on your specific diagnosis, but a single episode is all that is needed to tell the cardiologist you are at risk - and once your heart begins having faulty electrical pulses, it doesn't just go away. I also note that you are already on Eliquis -is this new, or have you had blood clots in the past? If so, afib increases your stroke risk even higher.

What testing has been done to determine the source of your afib? Have they done a complete risk assessment?

Here is the current American Heart Association information about Afib:
https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af
Why do you amiodarone should be a medication of "last resort"? As far as I know, it is typically prescribed for medically-managed afib.

It sounds like you are little like me - last September, at Urgent Care, the treating Advanced Nurse Practitioner didn't like the explanation that my shortness of breath was from Covid & Asthma, so she ordered a new ECG on the spot - it showed an irregular heartbeat that was not on my previous tests and she sent me right to the ER, where they found a significant heart blockage. I had been ignoring my symptoms for over a year, and the cardiologist got me right in for testing and treatment. After much discussion, he agreed to watch and wait for a year before surgical intervention -IF I added 3 medications and agreed to monitoring by the cardiology lipid clinic where they cover lifestyle issues. So far, so good - I will see him in May for a follow-up.

Did your cardiologist explain their reasoning for the ablation? Can you compromise on a watch-and-wait period if you take the additional medication?

REPLY
2 replies
jc76 | @jc76 | Mar 21 6:06pm

@clayart
Very hesitant to give you any information other than my experience with this. My question to you state you are seeing a cardiologist. Have you requested to see a EP (electophysioloigst)? EP are specially trained cardiologist that deal with the electrical functions of your heart.

I am not sure if you have access to them but if possible look into it. An EP could easlily answer some of your questions and have access to your complete medical history. Your questions which you want to have answers you have that should be answered by a medical professional with expertise in that field of medicine.

I have off and on AFIB but nothing sustained. My EP said biggest concern with AFIB is the threat of strokes from blood clots. So you can see the concern of your cardiologist. I take medications for my PVCs and PACs which really helps but that too should come from a experienced cardiologist in electrical functions of heart or a EP.

I had one ablation in my right ventricle that fixed PVCs in the RV. However lately the LV had increasing PVCS. I asked about ablation again but my Mayo EP stated wanted to try medication first. They put me on a medication that requires I take it every 8 hours (has a very low toxicity and leaves body quickly) which made dramatic improvements in my PVCs.

My last pacemaker check showed no AFIB episode and a 50% improvement in PVCs.

REPLY
clayart | @clayart | Mar 21 8:33pm
In reply to @gloaming "This is strictly my opinion from having read a ton of posts by patients, watched many..." + (show)
@gloaming

This is strictly my opinion from having read a ton of posts by patients, watched many videos by electrophysiologists, and from having done a lot of research and advanced reading:
If you are content with the way things are going, not suffering quality of life degradation, not losing sleep, and feel relatively secure with how things are being managed, there is no rush to jump onto an operating table in a cath lab. Your caregivers know that AF will not kill you. It can make you miserable, though, in which case it is your symptoms that matter most and that will be the reason your EP agrees to treat you. Of course, some patients' hearts do very poorly and they can go downhill quickly, so that would be another urgent reason for an intervention. Flutter cases, and cases of ventricular fibrillation would be more urgent than someone who is 'paroxysmal', where their arrhythmia comes and goes on its own accord, as yours does.
Further, most EPs and cardiologists would want you to attempt a cardioversion as a first step, especially when acute enough that you called an ambulance and were taken to the ER, or if you went their on your own. Cardioversions work for some, even sticking for many months or forever afterwards, whereas people like me were a bust...none of them lasted more than 16 hours (I have had four spread over two years).
Amiodarone, when I googled it three years ago with that very syntax 'is amiodarone the drug of last resort', the answer was immediate and positive. Even so, I had to be placed on it for eight weeks in total after my first ablation failed and I ended up in the ER with an erratic heart. I went off it, was happy until the Holter monitor at 10 weeks post ablation, and then learned the Holter had detected many PACs. From there, with yet another bout of AF over the New Years, and sending a Galaxy watch ECG to him, my EP agreed to try another ablation. I have been free from AF for just over two years now. But, to return to amiodarone, it's not everyone's fave until you really need it, and then it's your best bud. It worked for me, and I knew it was meant only to stabilize me and to get me to the Holter at 10 weeks out. I was advised to go off it about two weeks prior to the Holter so that the Holter got me a pretty accurate picture of my heart's state of disorder....which was unfortunately still quite wonky.
This is getting long...sorry...I do go on...but I would not agree to amiodarone unless I was highly unstable, under great emotional and cardiac duress, and could not be ablated any time soon. To me, a cardioversion should be tried first, then flecainide or some other anti-arrhythmic that fits your circumstances well (they're not all the same chemically). I don't feel there's a rush to an ablation. Once again, it's the patient, in concert with the physician, who negotiates what happens next with 'the system'. You should NOT dismiss the cardiologist's or EP's advice, certainly not on my account...or on my opinion..., and you will ultimately need that person in your corner, so-to-speak, so be careful pushing them away from you. You want an ally, and in this case, a highly skilled and friendly ally. If you'd like more time to think and to research, why not ask for that consideration in so many words? Ask if you can pose three or four telling questions to help you to figure out your way ahead. And then, stick to it, and go for it. As I said, I have had two ablations, no regrets whatsoever. Some, whose EP was unsuccessful for whatever reason, say they do regret it. If you get the best EP around, ideally someone who has already performed several thousand ablations (IOW likely to be in his late 40's or early 50's), your odds of success rise measurably. My EP was frank and up front, and told me in our first meeting that his success rate was running at 75% for an 'index', or first, ablation. I knew I could trust him right away. It took him two tries, but he got 'er done.

Jump to this post

Thanks so much for your input. I appreciate it and I’m reading and probably will have more comments later.
Thanks again

REPLY
clayart | @clayart | Mar 21 8:36pm
In reply to @sueinmn "@clayart Any episode of Afib, or atrial fibrillation increases your risk of heart attack and stroke...." + (show)
@sueinmn

@clayart Any episode of Afib, or atrial fibrillation increases your risk of heart attack and stroke. Early management and intervention can stop progression. The recommended treatment depends on your specific diagnosis, but a single episode is all that is needed to tell the cardiologist you are at risk - and once your heart begins having faulty electrical pulses, it doesn't just go away. I also note that you are already on Eliquis -is this new, or have you had blood clots in the past? If so, afib increases your stroke risk even higher.

What testing has been done to determine the source of your afib? Have they done a complete risk assessment?

Here is the current American Heart Association information about Afib:
https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af
Why do you amiodarone should be a medication of "last resort"? As far as I know, it is typically prescribed for medically-managed afib.

It sounds like you are little like me - last September, at Urgent Care, the treating Advanced Nurse Practitioner didn't like the explanation that my shortness of breath was from Covid & Asthma, so she ordered a new ECG on the spot - it showed an irregular heartbeat that was not on my previous tests and she sent me right to the ER, where they found a significant heart blockage. I had been ignoring my symptoms for over a year, and the cardiologist got me right in for testing and treatment. After much discussion, he agreed to watch and wait for a year before surgical intervention -IF I added 3 medications and agreed to monitoring by the cardiology lipid clinic where they cover lifestyle issues. So far, so good - I will see him in May for a follow-up.

Did your cardiologist explain their reasoning for the ablation? Can you compromise on a watch-and-wait period if you take the additional medication?

Jump to this post

Thanks very much for your comments. I am reading and appreciating and soaking it all in and may have more to say later. Thanks again.

REPLY
harveywj | @harveywj | Mar 22 10:04am

I think your first impressions are correct both about the ablation and the amiodarone. Any EP that has only a one week waiting period for an ablation is not a very busy EP. I would at a minimum want some time to see how frequent my events are happening. You didn't say if you are still in Afib or if you had a cardioversion or self-converted. I assume you are on some sort of anti clotting agent at least for the moment that will at least minimize the risk of clots.
Not to scare you but Afib can and does kill or cause damage from clots as well as heart failure from long term untreated chronic Afib. Anybody who says otherwise is totally misleading to say so. I only bring this up because there is someone on this list that continues to mislead people that Afib doesn't kill.AFib is a serious diagnosis. While this condition isn’t fatal in itself, it can lead to potentially life-threatening complications. Two of the most common complications of AFib are stroke and heart failure, both of which can be fatal if not managed quickly and effectively. But with care one can usually avoid those serious consequences. You need more information on how often you have events: whether they are self-limiting (self-conversion) and if cardioversions give you sustained relief. Also of importance is how fast your heart rate is when you are in Afib. The further above 100 BPM the greater the risks of complications.
See https://www.hopkinsmedicine.org/health/conditions-and-diseases/atrial-fibrillation/afib-complications.

REPLY
1 reply
harveywj | @harveywj | Mar 22 10:57am
In reply to @sueinmn "@clayart Any episode of Afib, or atrial fibrillation increases your risk of heart attack and stroke...." + (show)
@sueinmn

@clayart Any episode of Afib, or atrial fibrillation increases your risk of heart attack and stroke. Early management and intervention can stop progression. The recommended treatment depends on your specific diagnosis, but a single episode is all that is needed to tell the cardiologist you are at risk - and once your heart begins having faulty electrical pulses, it doesn't just go away. I also note that you are already on Eliquis -is this new, or have you had blood clots in the past? If so, afib increases your stroke risk even higher.

What testing has been done to determine the source of your afib? Have they done a complete risk assessment?

Here is the current American Heart Association information about Afib:
https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af
Why do you amiodarone should be a medication of "last resort"? As far as I know, it is typically prescribed for medically-managed afib.

It sounds like you are little like me - last September, at Urgent Care, the treating Advanced Nurse Practitioner didn't like the explanation that my shortness of breath was from Covid & Asthma, so she ordered a new ECG on the spot - it showed an irregular heartbeat that was not on my previous tests and she sent me right to the ER, where they found a significant heart blockage. I had been ignoring my symptoms for over a year, and the cardiologist got me right in for testing and treatment. After much discussion, he agreed to watch and wait for a year before surgical intervention -IF I added 3 medications and agreed to monitoring by the cardiology lipid clinic where they cover lifestyle issues. So far, so good - I will see him in May for a follow-up.

Did your cardiologist explain their reasoning for the ablation? Can you compromise on a watch-and-wait period if you take the additional medication?

Jump to this post

You comment "Why do you amiodarone should be a medication of "last resort"? As far as I know, it is typically prescribed for medically-managed afib."
Amiodarone is not considered a first or front line therapy for Afib. It has a lot of serious side effects.
https://medlineplus.gov/druginfo/meds/a687009.html

REPLY
milkmaid | @milkmaid | Mar 22 11:58am

I think you need to talk to the cardiologist frankly. Have your questions written down before you
Go in. He may see something you don't. Hearts are kinda like an engine
They compensate very well but an alternative rhythm is a compensatory mechanism that an lead to problems already discussed and also heart enlargement, than leaky valves ect.
Talk to cardiologist first, if do not get answers get second opinion. It's your own body you only get one.

REPLY
clayart | @clayart | Mar 22 12:57pm
In reply to @harveywj "I think your first impressions are correct both about the ablation and the amiodarone. Any EP..." + (show)
@harveywj

I think your first impressions are correct both about the ablation and the amiodarone. Any EP that has only a one week waiting period for an ablation is not a very busy EP. I would at a minimum want some time to see how frequent my events are happening. You didn't say if you are still in Afib or if you had a cardioversion or self-converted. I assume you are on some sort of anti clotting agent at least for the moment that will at least minimize the risk of clots.
Not to scare you but Afib can and does kill or cause damage from clots as well as heart failure from long term untreated chronic Afib. Anybody who says otherwise is totally misleading to say so. I only bring this up because there is someone on this list that continues to mislead people that Afib doesn't kill.AFib is a serious diagnosis. While this condition isn’t fatal in itself, it can lead to potentially life-threatening complications. Two of the most common complications of AFib are stroke and heart failure, both of which can be fatal if not managed quickly and effectively. But with care one can usually avoid those serious consequences. You need more information on how often you have events: whether they are self-limiting (self-conversion) and if cardioversions give you sustained relief. Also of importance is how fast your heart rate is when you are in Afib. The further above 100 BPM the greater the risks of complications.
See https://www.hopkinsmedicine.org/health/conditions-and-diseases/atrial-fibrillation/afib-complications.

Jump to this post

Thanks for your input. This is a brand new diagnosis for me. The EP I spoke to was just leaving the country for a week, Which is partly the reason why I am here seeking answers to my questions. He has been managing my wife’s afib for years apparently sees cardio conversion as contingent on including amiodarone, and is apparently recommending ablation as first conversion attempt for me.

REPLY
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