Why is it bad to be in flutter?

[Madsometimes]

I know this must seem like a really daft question to most people.

I'm 4.5 months post op, and for the past 4 months I have been in flutter, non-stop. My surgeon referred me to an EP, who has recommended ablation as the best way to permanently take me out of flutter.

The combination of warfarin, pacemaker and betablocker means that my flutter is not bothersome, and my pulse is between 60-75. I know my surgeon wants me out of flutter, and I have had some sudden vision loss problems, but only in the early days when my INR was too low. Flutter also makes it hard for the pacing techs to check my pacer and leads.

However, I am cross that I forgot to ask the EP why my flutter needs to be treated, given that I feel well. Does anyone know?

 

[Bill B]

You're tolerating the flutter better than others, perhaps due to the pacemaker and/or some pre-existing degree of heart block that prevents the ventricular rate from following the atrial rate 1:1. Although you are not feeling it, the longer the atrial flutter goes on, the more damage it is doing to the underlying function of heart muscle. And even with your normal ventricular rate, the ineffective atria are reducing your cardiac output. You may not feel that now, but you could later. There is still some risk of emboli that warfarin does not completely eliminate and the possibility of the flutter degrading in the atrial fibrillation and the ventricles may start to respond 1:1 and present a real problem. Your EP should be explaining this to you. Ablation is very effective in restoring normal rhythm and eliminates these problems.

 

[Madsometimes]

Hi Bill, and thanks very much for your reply.

I'm sure the EP would have explained, if I had asked him the question Why am I seeing you today? It was only the following day that the thought occurred to me.

Essentially, my post operative care is being managed by my surgeon. Surgeons are not the greatest communicators, as a general rule, and mine adheres to that rule. Her registrar organised an echo after my visual disturbances, and the tech let slip that he had seen an ASD, but I needed to get the result from my doctor. I spent a month trying to find out the result, and getting nowhere. My GP had not been told either, so she chased it. Next thing I knew, the registrar was on the phone saying he was presenting my echo at a multi-disciplinary team review, and he would let me know the outcome. He didn't.

When I saw the EP, he said that he had been at the case review. As he was the first doctor that I had seen since my echo, I pumped him with questions about that, and completely forgot to ask about the flutter Then, when I got home, I realised that I had signed up to an invasive procedure under conscious sedation, and that it would be painful in parts. Suddenly I wanted to know why I had agreed to it!

I really need to see my ordinary cardiologist, she's a great communicator, always writes letters to my GP and sends me a copy.

 

[Bill B]

Ah, your case seems complicated, but it looks like that, other than some failures to communicate, your doctors are on top of things. Keep us posted on how things work out.

 

[Bryan B]

You're tolerating the flutter better than others, perhaps due to the pacemaker and/or some pre-existing degree of heart block that prevents the ventricular rate from following the atrial rate 1:1. Although you are not feeling it, the longer the atrial flutter goes on, the more damage it is doing to the underlying function of heart muscle. And even with your normal ventricular rate, the ineffective atria are reducing your cardiac output. You may not feel that now, but you could later. There is still some risk of emboli that warfarin does not completely eliminate and the possibility of the flutter degrading in the atrial fibrillation and the ventricles may start to respond 1:1 and present a real problem. Your EP should be explaining this to you. Ablation is very effective in restoring normal rhythm and eliminates these problems.

This pretty much covers it. I was in constant a-flutter the summer before my last surgery. They were going to do a cardioversion on me but found a blood clot in my atrium (don't remember which side) and had to abort. I was put on coumadin, a high dose of metoprolol and a high dose of enalapril. Even with that my heart rate was in the 110-120 zone (was ~140 before the meds). I DID NOT feel good with my heart rate that high. It felt like I was running a marathon 24/7. After 6 weeks on coumadin I went back in and they decided on doing an ablation instead of the cardioversion. They rolled me in with a heart rate of 120 and rolled me out with a heart rate of 70. I have been in sinus rhythm ever since.

BTW Bill I'm not stalking you LOL!

 

[Madsometimes]

I don't think that I am complicated. I suspect the ASD is just a common PFO, but the doctors want to cross the t's and dot the i's. I feel great anyway. My ablation will probably be done in June because it is not urgent, so it will be a while before I can give a proper update.

 

[Eva]

You're tolerating the flutter better than others, perhaps due to the pacemaker and/or some pre-existing degree of heart block that prevents the ventricular rate from following the atrial rate 1:1. Although you are not feeling it, the longer the atrial flutter goes on, the more damage it is doing to the underlying function of heart muscle. And even with your normal ventricular rate, the ineffective atria are reducing your cardiac output. You may not feel that now, but you could later. There is still some risk of emboli that warfarin does not completely eliminate and the possibility of the flutter degrading in the atrial fibrillation and the ventricles may start to respond 1:1 and present a real problem. Your EP should be explaining this to you. Ablation is very effective in restoring normal rhythm and eliminates these problems.

As Bryan said: Bill has covered it all!

 

[Greg a]

There is an ICD'Pacemaker support site that may offer more information

 

[Madsometimes]

Thanks everyone for your replies. The EP said that he was not going to stop my warfarin before the ablation, but that I should try to keep it in range. Luckily, my ACT is behaving well at the moment, but I'm a bit nervous about bleeding.

 

[Bryan B]

Thanks everyone for your replies. The EP said that he was not going to stop my warfarin before the ablation, but that I should try to keep it in range. Luckily, my ACT is behaving well at the moment, but I'm a bit nervous about bleeding.

I wasn't on warfarin for my valve but i was on it when they found a clot in my atrium (not sure which side) due to the a-flutter. I had to be on warfarin for 6 weeks before my ablation and my range was 2.5-3.0. They brought me down to 2.0 to do the ablation and I had no bleeding issues. After the ablation I took warfarin for 6 more weeks at the 2.5-3.0 range.

 

[AgilityDog]

There's a little area in your left atrium (I'm not sure about the right atrium) called the "atrial annex." It's like a side room to the big room, and when you are in a-fib or a-flutter, the blood tends to pool there. This can cause a clot. A big one, that can lead to a massive stroke! That, plus the fact that your heart is not pumping properly when you are in flutter or fib, is why they want you out of flutter.
When I had my maze procedure and mitral valve replacement, they closed my atrial annex, too. Sewed it shut, I believe.

 

[Bryan B]

Thanks for the explanation Laurie. I knew that fib/flutter could cause clots but I didn't know the details of why and exactly where in the atrium.

 

[Bill B]

Actually, for what it's worth, I think it's called the left atrial appendage if anybody is trying to look this up. The right atrium has one as well, but it is not involved in clot formation during AF, like the left is, as Laurie mentioned.