Another cry out for help…Ablation or no ablation!

[Eva]

Last Sunday (8/18), my iWatch alerted me at 1 p.m. that my pulse was over 100 for ten minutes while inactive. Although this was the fourth time since 2019, I was again taken by surprise because I felt fine and normal like the previous times!
I had no symptoms—my blood pressure was normal, no dizziness, no chest pain, and no unusual fatigue.
I waited until Tuesday to go to the emergency room, hoping my pulse would drop to normal with the extra 100 mg of Metoprolol I took over 12 hours period. Unfortunately, it was still at 118.

Note: When I had a similar A-flutter episode of 120 bpm this past March, the emergency room around my area resolved it with a drip of Cardizem and Metoprolol.

1. Despite sharing that I took a total of 100 mg extra to my usual daily 100 mg of Metoprolol over 12 hours, this emergency doctors insisted on giving me three shots of Lopressor, which had no effect and to me it was just a waste of time. My pulse then went up to 120 bpm. I asked for Cardizem, but received no response.
2. Cardiologists who saw me wondered why I was taking Digoxin and thought I should not have been on it. Yet, after two hours of discussing this with me and the failure of the Lopressor shots, a nurse brought a Digoxin pill!. I mentioned I had taken one that morning and that doctors didn’t want me on it, yet nurse insisted it was the doctors’ recommendation. (This was very confusing to me). I took it.
3. One hour later my pulse rose to 135 bpm and stayed between 135-145 bpm until I had my Cardioversion on Wednesday around noon.

Doctors are keen on ablation “to know why this is happening”. Though I mentioned that: (1) my electrophysiologist told me when the first time this happened in August 2019 that ablation is risky in my condition and he did Cardioversion. And (2) the second time this happened in June 2022, he said, “if this happens again, we’ll zip you again.” Still recommending ablation. Did they hear anything I said. I don’t think so.

In my heart, I feel the risks are greater than the benefits especially that ablation has not always been a successful solution. I plan to ask all these questions when I see the electrophysiologist who the emergency room made an appointment with for me. (I’m not sure why my appointment was not made with my original electrophysiologist…maybe he refused to do the ablation.)

So, I am really scared of ablation: I have two mechanical valves, my left atrium is severely enlarged, my aortic root is 4.2, I have PFO, and I’m 73 now and maybe facing a fight with cancer!

Please, if you have any advice and any questions to ask the electrophysiologist, please share them.

Since I never had any of the symptoms associated with A-fib/A-Flutter, what if this is caused by stress? I asked the doctor in charge. I explained how emotionally stressful these last two weeks have been with the need for a breast biopsy, stopping warfarin, taking Lovenox shots, needing surgery, stopping warfarin again, and going back to Lovenox. It was too much on me emotionally! No reaction if stress could cause this or not or a combination!! I know stress can cause many things!

I am stressed I’m not getting direct answers!

My apology I could not make this shorter. And many thanks in advance. Stay well and healthy.

 

[pellicle]

Hi Eva

sorry to read of your plight. So as you know we're not in my lane on this one, so given that I would echo your concerns about ablations; to me it seems that they are a path of increasing application.

I would if I could seek alternative chemical approaches before going to the "scorched" approach.

The second time this happened (June 2022), he said, “if this happens again, we’ll zip you again.” Did they hear anything I said. I didn’t feel so.

it would seem not. I'd shift back to whoever was doing your cardioversion.

Also, I find this curious:

Doctors are keen on ablation “to know why this is happening”.

as ablation is not to my knowledge a diagnostic tool. So getting the "why" from basically burning tissue is a bit weird.

what if this is caused by stress?

to me I would suspect that too. Have you ever done any mediation classes?


Best Wishes

 

[dornole]

Hi Eva, I'm sorry you're going through this with so much stress. I have some similar issues right now. Short version, I have severe mitral stenosis with my native valve and I had afib for the first time at the end of March. Went to the ER and was cardioverted after the IV meds did not work. I had about 8 additional afib with RVR episodes in April through mid May which resolved on their own after 4-10 hours. Unlike you I DEFINITELY knew they were happening. My heart was racing (like 140 - 250 HR), pounding, totally chaotic and irregular, and I felt very "tired and wired." I saw electrophysiology in late May (two weeks after the last episode) and he said we can do an ablation, or try metoprolol and flecainide. I went for the meds. No afib episodes on those but my BP was pretty low (88/55) and I had dizziness, fatigue and vision problems. They took me off those in early July, still no further afib episodes.

I am seeing the valve guy on Thursday about a number of things but specifically I want to ask about the afib:

--How dangerous are these infrequent episodes, given that I am anticoagulated ? Are they damaging my heart? Are we controlling symptoms for quality of life here? Preventing heart damage or disease progression? What are the risks of having occasional afib?

--Is it reasonable to NOT treat this paroxymal afib (neither meds nor ablation) given its rarity?

--Does the fact I have valve disease change the equation about recommending an ablation or not?

--Does this new afib indicate progression of valve disease and make you want to do any other tests?

FWIW, I was extremely stressed in the months prior to the episodes because my son was suicidal and that was a huge emotional load keeping him safe 24/7 plus I was very sleep deprived due to comforting him in the night and mental health ER visits. When I went in with afib they directly asked me in the ER if I had been stressed. (He's doing well at the present which I am grateful for every day.)

 

[3mm]

I would if I could seek alternative chemical approaches before going to the "scorched" approach.

Eva - A drug may be a viable option for you. But some of these drugs have serious risks.

I currently have Premature Ventricular Contractions (PVCs) 19% of my heart beats, which is slowly damaging my heart. Long term we need to eliminate these PVCs. I was offered an option to try Sotalol, which requires a 4 day stay in the hospital because sometimes Sotalol causes cardiac arrest. Please carefully research any drugs they offer you!

I don't like the risk of Sotalol, so I will have an ablation Nov 6th.

 

[Woodcutter]

Doctors are keen on ablation “to know why this is happening”. Though I mentioned that: (1) my electrophysiologist told me when the first time this happened in August 2019 that ablation is risky in my condition and he did Cardioversion. And (2) the second time this happened in June 2022, he said, “if this happens again, we’ll zip you again.” Still recommending ablation. Did they hear anything I said. I don’t think so.

In my heart, I feel the risks are greater than the benefits especially that ablation has not always been a successful solution. I plan to ask all these questions when I see the electrophysiologist who the emergency room made an appointment with for me. (I’m not sure why my appointment was not made with my original electrophysiologist…maybe he refused to do the ablation.)

So, I am really scared of ablation: I have two mechanical valves, my left atrium is severely enlarged, my aortic root is 4.2, I have PFO, and I’m 73 now and maybe facing a fight with cancer!

Please, if you have any advice and any questions to ask the electrophysiologist, please share them.

Stress is definitely a known contributor to arrythmias. I was going to try to find a useful quote from a book I like to reference ["The Haywire Heart"], but instead will simply share that when I started by looking up "stress" in the index there were at least 25 references. I figured that make the point!

Regarding 'ablation to find out' . . . . that definitely does not sound right. Your EP can certainly clarify this but I suspect they are referring to the EP lab (electrophysiology lab) which is indeed where ablations are performed. However, the initial steps are often referred to as an EP study. This is the process used to identify at a local level (i.e. specific location in the heart) where problematic signals are occurring. Performing an actual ablation is not necessarily the outcome of an EP study.

 

[Eva]

Stress is definitely a known contributor to arrythmias. I was going to try to find a useful quote from a book I like to reference ["The Haywire Heart"], but instead will simply share that when I started by looking up "stress" in the index there were at least 25 references. I figured that make the point!

Regarding 'ablation to find out' . . . . that definitely does not sound right. Your EP can certainly clarify this but I suspect they are referring to the EP lab (electrophysiology lab) which is indeed where ablations are performed. However, the initial steps are often referred to as an EP study. This is the process used to identify at a local level (i.e. specific location in the heart) where problematic signals are occurring. Performing an actual ablation is not necessarily the outcome of an EP study.

Thank you for responding. Yes, they want to perform EP study “FIRST” to know which side is causing this. The doctor didn’t clarify that they may not do ablation…my understanding was once they verify which side is causing this arrhythmia, they’ll schedule an ablation. Even this procedure is a bit scary for me due to its risks.
Stay well and healthy.

 

[Eva]

Eva - A drug may be a viable option for you. But some of these drugs have serious risks.

I currently have Premature Ventricular Contractions (PVCs) 19% of my heart beats, which is slowly damaging my heart. Long term we need to eliminate these PVCs. I was offered an option to try Sotalol, which requires a 4 day stay in the hospital because sometimes Sotalol causes cardiac arrest. Please carefully research any drugs they offer you!

I don't like the risk of Sotalol, so I will have an ablation Nov 6th.

Thank you for sharing your thoughts, 3mm.
I’m sorry you’re going through this and wish you best outcome if this is the only solution. I’m sure you havre done your researches.
I like to share with you there was a time I had lots of PVCs. In my case, (1) they were caused by the energy drink “Bull”. I stopped that drink, no more PVCs.
(2) There was a time after my surgery when I could not concentrate, a psychiatrist prescribed “Adderall”. PVCs returned. I stopped those pills. PVCs were gone!

Stay well and healthy and keep us updated.

 

[Eva]

Hi Eva, I'm sorry you're going through this with so much stress

. I’m sorry you too are going through this too.

…..I had about 8 additional afib with RVR episodes in April through mid May which resolved on their own after 4-10 hours. Unlike you I DEFINITELY knew they were happening. My heart was racing (like 140 - 250 HR), pounding, totally chaotic and irregular, and I felt very "tired and wired."

. When my pulse went up to 134-144, I felt it too. The bed was shaking with each beat.

I had a short episode in July of 110 bpm. I took an extra 25 mg of Metoprolol and it was resolved itself after 4 hours.

I saw electrophysiology in late May (two weeks after the last episode) and he said we can do an ablation, or try metoprolol and flecainide. I went for the meds. No afib episodes on those but my BP was pretty low (88/55) and I had dizziness, fatigue and vision problems. They took me off those in early July, still no further afib episodes.

After my second cardio version, my BP was low like yours. My electrophysiologist adjusted my dose of Metoprolol.

I am seeing the valve guy on Thursday about a number of things but specifically I want to ask about the afib:

--How dangerous are these infrequent episodes, given that I am anticoagulated ? Are they damaging my heart? Are we controlling symptoms for quality of life here? Preventing heart damage or disease progression? What are the risks of having occasional afib?

--Is it reasonable to NOT treat this paroxymal afib (neither meds nor ablation) given its rarity?

--Does the fact I have valve disease change the equation about recommending an ablation or not?

--Does this new afib indicate progression of valve disease and make you want to do any other tests?

Good luck on Thursday. Keep us posted what your doctor says. Hope you get honest helpful caring good answers. A-fib unfortunately, if untreated, may cause heart failure, clots, stroke, but, we are anti-coagulated. So, I hope we’re protected.

FWIW, I was extremely stressed in the months prior to the episodes because my son was suicidal and that was a huge emotional load keeping him safe 24/7 plus I was very sleep deprived due to comforting him in the night and mental health ER visits. When I went in with afib they directly asked me in the ER if I had been stressed. (He's doing well at the present which I am grateful for every day.)

I’m VERY SORRY. This is extremely stressful . I hope your son will continue to do well and that your episodes will stop with no returns!
I know it in my heart that it’s stress in my case too. My oldest sister (92) who taught us so much about everything in life, sacrificed so much, and whose company I and everyone who knows her enjoyed much started dementia seven years ago and I have been struggling seeing her going through these changes!

Stay well you both and keep us posted.

 

[Eva]

Thank you, pellicle, for responding.

This whole experience at this hospital emergency was more stressful than assuring. But, I’m happy my cardioversion was done just in time and performed by my trusted and admired cardiologist. However, I couldn’t help but wonder why my electrophysiologist wasn’t involved!
Fortunately, my return visit with my cardiologist has just been confirmed. I’ll be seeing him before my scheduled appointment with the newly assigned electrophysiologist, and I’ll take it from there.
I pray a lot and meditate while praying. I eat well and healthy. I was exercising regular until now.
You stay well and safe. And thanks again.

 

[Protimenow]

In 2020, I had multiple SIMULTANEOUS arrhythmias. My cardiologist didn't know what to do about it - he installed a stent that I'm sure I didn't really need. Otherwise, my angiogram looked fine.

I was sent home with Amiodarone - a nasty medication that did nothing to my arrhythmias, but sure did a number on my digestive system, turning everything to concrete.

The arrhythmias continued, and I was back in the hospital with the nasty effects of Amiodarone, and still having arrhythmias.

I was eventually visited by my current electrocardiologist. He originally tried to tame the arrhythmias with medication - but eventually decided that the best course of action was ablation of the nodes that were causing the arrhythmias.


I had a long string of PVCs - hours of PVCs that I really couldn't stop. I was sent to the hospital for a chemical cardioversion - atropine shocked my heart into a reboot.

The doctor was going to find the node causing the PVCs - he searched for an hour or more, tried everything he could to get the nasty node to act up - but couldn't - because it didn't exist.

I was referred to a heart rhythm center at UCLA, where I got a heart MRI studying heart function and looking for a cause of the PVC - the doctor thought that it was due to cardiomyopathy - and not a node.

I now have a pacemaker, keeping my heart rate from falling too low.

I've had ablations for what is called 'sick sinus.'

Medications have been helping, mostly.

In November, I think, my heart rate jumped into the 130s after practically no exertion.

The doctor said that I was having aortic tachycardia. He defibrillated my heart, the rhythm returned to normal, and he told me that an ablation would prevent this from happening again. It would also make me pacemaker dependent.

Getting the ablation was no big deal - a few hours in the hospital -- an outpatient procedure. I was released about six hours after I went into the hospital.

For me, it didn't seem to be the final answer - when I saw the doctor last, he said that my pacemaker was picking up continuous aortic fibrillation (maybe too mild for me to notice?).

Ablations are easy. They're irreversible. They're not diagnostic per se - other than of the type that suggest that if you 'remove' a bad part, and the problem doesn't come back, you've done the right thing. Personally, if I had a choice whether or not to do the ablations again - I'd probably have had them done.

You may want to be sure that there is no appropriate prescription (or non-prescription) medication you can take to deal with the problem. If you're really concerned, you might do better to get a second opinion from a physician than getting information here (although there are experts and physicians here).

One odd thought -- are you getting enough sodium in your diet? In my case, some of my problems occurred when I was cooking at home, using almost NO salt. When I had a hot dog or two, over a few days, some of my cardiac symptoms cleared up. This isn't a suggestion - just an observation. If you've had a recent blood test, you may look at your sodium levels out of 'curiosity.'

 

[Eva]

Thank you, @Protimenow.
I hope ablation will be easy if decided on! My top-notch electrophysiologist in 2019 and again in 2022 told me that ablation in my case is risky (though doable)! He gave me literature to read about it where there’s a mention that ablation may not be successful! And I read here some members who had this repeated.

My electrolytes are all good, according to my latest lab test. I’m sorry for what you’re going through.
Regarding sodium, my doctors always advise me to keep it low. I take 40 mg of Furosemide daily to manage fluid retention and an extra 20 mg when I consume salty foods.

I’m seeing my internist tomorrow, and I have appointments with my cardiologist and electrophysiologist next month.
I love our website because the members’ answers, based on their experiences, are more reassuring and caring to me.
Hope you stay well and healthy.

 

[pellicle]

He gave me literature to read about it where there’s a mention that ablation may not be successful! And I read here some members who had this repeated.

I've noticed that some interventional cardiologists are quite cavalier (verging on irresponsible). I also think I see you becoming more questioning, more ... having expectations and seeking information. Analytical. I think that's great. We absolutely should not just be "subjects" but more "project managers" who are charged with a complex task and gather experts to inform, explain and execute what we think then needs to be done.

I mentioned meditation to you earlier, I've found that a valuable tool in my life (started on that path early). I think Sam Harris explains the premise of it quite well here



I find it calming and helps me maintain a view point.

I hope that it can perhaps bring you some calm and perhaps that will help.

Best wishes

 

[vitdoc]

Having undergone three ablations and many cardioversions for A. Fib I can give a little perspective. The questions you should ask are what is the best guess on the effectiveness of the procedure. There are a few parameters that may help in the guesstimate. The duration of the rhythm problem, whether it is intermittent or continuous whether it is A. Fib vs A. flutter and possibly some characteristics of your heart such as size of the atrium. With this info a guesstimate might be given on the likelihood of controlling the problem with a single ablation. So if they say 90% I would consider it. If they say 50% maybe not. Also ablations may work initially but the effect wears off and often the arrythmia returns. Hence the repeat ablations.
There are some differences in technique in performing ablations such as how the tissue is ablated. Electro cautery , cryo techniques and other methods. Also the pattern of where the tissue is ablated my be different. The classic approach is to ablate the tissue around the pulmonary veins as they enter the heart. But sometimes the posterior atrial wall is ablated.

Generally these procedures are relatively safe but they can have complications. Aggressive ablation may injure the esophagus causing a fistula from the heart to the esophagus. Clearly this is very bad and often fatal. But rare. Emboli can occur leading to stroke again relatively rare.
So the decision to consider ablation depends on how the rhythm problem bothers the individual. If there are frequent bouts of rapid heart rate that is disabling and they can't be medically controlled then perhaps ablation. In certain people they don't do well with A. Fib compared to normal sinus rhythm especially if they are involved with sports so they may want ablation and also since the drug approach may limit their heart rate. That was my reason. Also as mentioned some of the rhythm drugs have a narrow therapeutic window and can lead to bad lethal arrythmias.
If you already are anticoagulated then the risk of stroke from A. Fib is already being addressed.

The actual procedure can take some time. I was under general for my procedures. You are up and around fairly quickly in as much as the procedure is done generally through the groin
.
For me I was free of A. Fib for perhaps 5 yrs but it returned. My guesstimate of success with further ablation treatment was no better than 50% which I think the cardiologist plucked from air. I declined. Since I have 3rd degree heart block my heart rate is controlled by a pacemaker and the A. Fib is ignored. What I lost was having my heart rate going up and down with exercise, controlled by my heart in normal sinus that was picked up by the pacer, to a rate controlled by the pacemaker and dependent on motion and movement. It is a bit bothersome but I function pretty normally with it.
Good luck on your decision.

 

[Eva]

Yes, @pellicle. We have to step in and question why and how. My sisters and I learned to research, question, and analyze at a very early age after a doctor mistakenly gave our mother a medicine that could have killed her.

Sam Harris does have some great insights. I’ll be listening to him. Thank you.

I’m planning also to try out UCLA’s free guided meditations.

Thank you again. Stay well and healthy.

 

[Eva]

Thank you, @vitdoc.
Thanks for the information about the different techniques, which I hadn’t heard about before.
I’ll listen carefully to how the electrophysiologist rates the success of the procedure, hoping I won’t need any further intervention.
The rhythm problem doesn’t bother or disable me; it just scares me. These are the times when I’m grateful to be on warfarin!
I’m glad to hear you’re feeling and functioning pretty normally!