Atrial Flutter to Heart Pauses after RF ablation

[rdman]

I am a very active 68 year male. I've enjoyed bicycle riding for 30+ years. Until March 2009, I was riding challenging 30 mile rides every 2nd day (weather allowing) with an ex-pro bicycle rider neighbor friend. During a March minor pre-op examination EKG, an atrial flutter was revealed. I had no symptoms whatsoever. An RF ablation was performed on July 6, 2009 resulting in a strong, regular rhythm. Then during the second week of August 2009, on mild 2 mile walks, I began to experience waves of dizzines, faintness and lightheadness, accompanied by sweating and fatique. A Holter monitor revealed heart pauses to 4.2 seconds.

My question: How does a robust, active person go from an attrial flutter with no symptoms to a person unable to walk a mild 2 miles. I was told that RF Ablations were low risk and 95% successful. Does this indicate an incomplete ablation?? Is a pacemaker my only option??

Thanks in advance for your comments...  

[Gary3201]

An ablation procedure is the burning of the inside of the atrium chambers of the heart usually around the incoming and outgoing vessels, and the mapping and burning of hot spots to create non-conductive scar tissue in order to channel the electrical passage ways within the chambers. Any hairline crack or unscared break in the ablated areas can result in A flutter or ATACH. Thats why it is not unusaual to require a second ablation at some point in time. Sometimes the initial ablation is performed in the right Atrium and appears to have corrected the issue only to have the flutter pick up at a later date and often in the left atrium. In order to correct the left atrium it is necessary for the EP to punch a hole between the wall separating the left and right atrium. This of course increases the risk which is why they sometimes only ablate the left side first. Also are you on a supplemental antiarrhythmic drug  to help combat your condition they can sometimes zap your energy levels. Just stay the course keep up the exercising and talk with you cardiologist and EP guy about the changes perhaps another med would work better for you.
best of luck
gary

[rdman]

Thanks for your response... I appreciate it.

No, I was not prescribed any antiarrhythmic drugs. When the atrial flutter was revealed in March, I was put on Warfarin, nothing else. Without any medical experience, but reading up on the medical papers and studies on the internet, I kind of think that this might be an incomplete ablation (ablation was on the SA node side). The EP feels that I have sinus node dysfunction. Going from a asymptomatic atrial flutter to heart pauses up tp 4.2 seconds is problematic for me. I am scheduled for a pacemaker implant next Tuesday, Sept. 8., but I am wondering if there are other options to consider (I'm having a problem about wires embedded in my heart).  

[ptadvoc8]

That's a tough question -- and a tough situation to be in. I am NOT a medical professional, but I have lived with an arrhythmia problem all my life for which ablation has been recommended and after following the progress of ablation technology and researching it for over 20 years, my own personal opinion is that ablation for arrhythmia is as much an art as a science. Certainly the whole approach is very complex and subject to a wide range of variations in individual patients, based on their particular arrhythmia and individual anatomy, which makes each ablation unique.

The literature is full of cases where post-procedural problems include bradycardia, heart block, severe ectopics and sudden emergence of "new" arrhythmias -- and just as full of "explanations" for these problems, such as extended healing time, inflammation, patient "anxiety", "missed or hidden" pathway, unknown or unrecognized underlying condition, etc. But, if the "burns", or resulting scar tissue, are too near certain of the naturally occurring pathways, they can "block" or slow the normal conduction rate which may result in the requirement of a pacemaker, either during, immediately following or at some point in the post-ablation period may be needed. This is one the "known" risks they are supposed to warn patients about so that you can make an informed decision in consultation with your specialist.

It is my understanding that atrial flutter is usually not considered life threatening (except in rare cases) but that they worry about it leading to Atrial Fibrillation, which can be debilitating to some patients and also poses a serious threat to health from possible blood clots that commonly form during A-Fib, so some doctors and facilities "recommend" ablation to their patients as standard protocol in hopes of avoiding A-Fib in the future and improving their patients wellbeing. However, it is worth noting that "standard protocol" for when to ablate and when NOT to ablate, differs widely depending on the preference of the patient, the physician and the facility.

It is my opinion from looking at some of the research and talking to patients that the "95% success rate" for ablations that is so often quoted may well be somewhat inaccurate. For instance, in many studies your experience would be classified as a "success" -- the flutter is gone. The fact that you may now be facing pacemaker implantation possibly would not even be entered into the equation when the final research is presented for publication. Complications, even serious ones, do not necessarily detract from reporting a "successful" ablation IF the patient survives and the arrhythmia for which the ablation was intended, disappears. While physicians and scientists may be aware of this methodology in research, I doubt that many patients are and so quoting those stats with out further explanation may be somewhat misleading. Many, though certainly not all, of the success rates noted in research are based on this type of reporting and there is a type of "bias", even noted by some of the researchers themselves, in many scientific and medical fields known as "buzz bias" -- whatever seems popular, profitable or promising gains a sort of "push" for acceptance and implementation in the field. There have been surprisingly few long term, longitudinal studies on the outcome of ablation on adults as pertains to mortality, morbidity and quality of life -- partly because ablation technology is relatively recent and so there has not been adequate time for many of these studies. Also note that 95% success rate is based on OPTIMAL conditions which include appropriate patient selection, the most skilled specialists and highest volume facilities and specific types of arrhythmia -- i.e. ablations for WPW are reported to have higher success rates than those for A-Fib. While in the best of conditions there may be a 95% success rate, there are patients, physicians, facilities and types of ablation procedures that have much lower overall success rates.

Certainly there are plenty of people who have had miraculous "cures" from ablation procedures and I think this procedure has real merit -- in fact, I am scheduled for one myself in September after having declined this intervention for 20 years -- but I am still wondering if perhaps too many are done on the wrong patients for the wrong reasons by the wrong doctors at the wrong time and at the wrong facilities. On the other hand, there are many people living longer, better and more rewarding lives because of this technology, so it's a very difficult topic on which to provide a definitive answer.  

A pause of 4 seconds seems fairly long to me considering that the average "normal" heart rate is usually at least 1 beat per second so I would think it might leave you feeling pretty lousy sometimes! I totally understand your reluctance to have a pace maker implanted and your frustration with what has been happening, so perhaps if your current situation can stand it, you might consider a second opinion at a really top notch facility with a top notch specialist. If it does come to needing a pacemaker, it might help to know that tens of thousands of patients do very well with them, but it certainly does take some adjustment. Whatever happens, my best advice would be to hang in there, keep asking questions and demanding answers, find a specialist you feel comfortable with and confident in, and know that you can and will find a way to deal with this. Good luck and best wishes!