A-Fib ablation day for daughter

[tom_h]

We are currently in the short stay unit at University of Pennsylvania Hospital awaiting the call to take my daughter away for her A-fib ablation.  Sheis going to be under general anesthesia for the procedure and the electrophysiologist days it will take about 2 hours.  Interestingly, she will have temporary sutures, something I did not experience 7 years ago for mine.  Less chance of hematoma and no weights.  More later...

[tom_h]

My daughter is 44 and lives 250 miles away, so it hard to keep up with what she has been on.  But I know she on Xarelto of course, and Flecainide.  But Metoprolol Tartrate was added after she went to the ER with the messed up rhythm upon returning to work a week after the ablation  procedure.  There's another anti-arrhythmic that Im forgetting... I can't remember now.  The UPenn staff was great.  The electrophysiologist, Dr. Jeffrey Arkles was just fantastic too.

[tom_h]

Atenolol is the other.  Don't know dosages.  She was also on Cardizem back in November when this all started.  Not sure if she is on that now.

[2210485]

Examples would be:

*Rhythm control agents*
Propafenone
Sotalol
Amiodorone

*Rate control*
Digoxin
Diltiazem

Any familiar?

[tom_h]

Update: My daughter's recovery was not without its problems.  After 5 days at home, she returned to work.  After only A couple of hours at her office, she experienced what she described as a jumbled up heart rhythm, and afterb10 minutes of that, was transported by ambulance to the nearest hospital.  The attending physician conferred with her electrophysiologist at Penn, and they could see that arrhythmia which was NOT afib.  They increased her meds to pre-procedure levels, and it slowly went away.  She was released by days end.
Since that episode, she has not had any more incidents, or any episodes of afib.  Her life is slowly returning to normal, and the fear of afib incidents is slowly receding.  She has a follow up appointment in early April where they are going to set up a plan to
wean her off all cardiac related meds she has been taking for afib.

To be honest, we are all delighted with the results.  She continues to have some PVC's, but it appears (knock on wood) that the afib was eliminated.

[2210485]

Im glad to see that this is working out so far tom!

I am also glad to see that the electrophysiologist is still pursuing rhythm control over just throwing in the towel! Going after rhythm has higher risk and lower success rates, however its really such a better result when the patient has their own healthy, natural rhythm coming in as opposed to winding up with a pacemaker!

What meds is she on at the moment? I expect she'll be on anti-thrombotics (blood thinners) a while. However I am interested in what UPenn is using as that safety net to keep the AFib from returning or to support rate control until her heart finishes the healing process.

[2210485]

Updates?

[tom_h]

My daughter is all finished and in recovery, a 4 hour procedure.  The electrophysiologist did a pulmonary vein isolation on the 4 veins. And said it was pretty much textbook a-fib.  The 2 left veins were a little difficult to isolate, but he got them, and thinks her prognosis looks excellent.  The staff at UofP in Philadelphia were excellent, and I can't day enough of the electrophysiologist.  Ok, at 67 I think he looks like Doogie Howser working on my daughter, but he knows his stuff.  Good luck to whomever is dealing with A-fib and is researching how to deal with it.

[2210485]

Glad it worked out ok.. 2 hours is an absurd underestimate for afib ablation.

4 hours is the absolute best guess, with many procedures going as long as 12 hours.

Good news is; 4 hours means the procedure probably went smoothly.

[2210485]

In fact I doubt they had any difficulty working around the 4th vein.

Likely the 4th vein hes refferring too lies near the Phrenic Nerve. It is always difficult to isolate. :p

Sounds like your doc is just being humble and trying to reassure you regarding the time she'd be under actually. Alot of patients are naturally worried about going to sleep for that long. So it makes sense to give an unrealistic estimate.

[tom_h]

Thanks for your reassurance.  The problem we're having now is the recovery period.  She's been in recovery for nearly 3 hours now, and we've been here for 12.  She had general anesthesia.

[2210485]

This is why we hate AFib ablations Tom..

No amount of insurance compensation can make up for all the late shifts/time lost with my family that AFib brings to the table.

Its the longest, riskiest and just generally annoying procedure we have to be a part of.

Fear not though.. The biggest risk is induction of anesthesia not recovery.

There are some complications that can occur but nothing beyond what can be managed. Worst case scenario you're there for a few days. At least on the anesthesia end.

Monitoring for Pulominary Venous Stenosis is much more critical.

[2210485]

In fact AFib is the only condition in interventional EP with stern cautions against ablation as a first line treatment.

Notwithstanding the 30% overall complication and failure rate (SVT ablation stands at 4% for perspective); not only are you and your family stuck there, but the providers responsible for the procedure and recovery must stay nearby as well..

If recovery takes 24 hours, chances are the electrophysiologist and anesthesiologist will be spending the night on a cot somewhere..

It's just so burdensome for everyone involved... Literally the worst day at work I've experienced was walking in and seeing 4 AFibs on the schedule.

Myself and everyone I came in with turned around and had to step into the hallway to collect ourselves and come to terms with what was ahead of us.. There just isn't enough coffee in the hospital for that kind of nonsense..

[tom_h]

So my daughter was finally returned to her room after over 3 hours in recovery.  They had a bleeding issue after removing an internal blood pressure monitor which was inserted in her arm.  When pulled it out, she bled badly.  She has been on Eloquis, and was given Heparin during the procedure. So they made her last dead flat for 6 hours.  She was in a lot of back pain, but made it through.  They also temporarily sutured the entry points as they've found that it works better than the traditional weight on the groin.  They were removed the following day.  She's home now and doing good.

[2210485]

Yes. Specifically what they likely use is a product called "perclose"

https://youtu.be/ugJebd5DweU

It is highly effective. Over here we don't use it for ep as much because it is very expensive/fancy.

Thebaccess sites used are venous, so theyre alot easier to control. They would rather just pay a grunt worker to put pressure then spend the extra cash lol..

We utilize the system for large lumen femoral artery sites exclusively.

Its interesting that such systems weren't in use during your time.

[tom_h]

No, in 2010 I had a large sand bag pressed against my groin which put a lot of pressure on the point of interest as well as the mmmm... boys.  The pain the next day was what only a male cpuld described.

I spoke for a bit to the electrophysiologist who told me that in the coming years, cardiac ablation will be done on the outside using a stereotaxis(?) device that directs multiple beams at a pinpoint location.  He said that they're experimenting with it now.  Also interesting is the fact that magnetically controlled catheters have fallen out of favor and he's using what he described as spring tipped catheters which give him a lot of tactile feedback.  Lots of cool stuff!

[2210485]

Steriotaxis systems are magnetically controlled, but I see what hes getting at. Upenn are the best at what they do, so I defer to them ofc.

I think what he was trying to bring up however is not only the exciting advances that are being made but also challenges we've faced trying to refine the technique. So many great ideas, such as basket catheters or cryroablation had great theory behind them but fell on their face in practice.

Its very difficult to develop a replacement for contact force or irrigation catheters. You can place a lesion sure, but will that lesion be sufficient to hold in the long term? Thats where the experimentation comes in and why its unlikely to see anything go into widespread use in the next few years at least.

Ultimately the goal is to burn the heart and make a scar. Right now we do that primarily by taking an electrified metal stick and making it really hot while a doctor pushes it into the muscle. Its basically a cattle prod and we're tryna replace it with a space age laser. Its a pretty big leap in technology. It takes alot of time to convince the farmers that their cattle prods are old news!

Once we're able to make the leap however it will be exciting. It is indeed forseeable for some of this tech to revolutionize the industry. Its just a matter of ensuring it is reliable and cost effective.

Thankfully; my primary focus in this field is the software that drives the mapping systems. Mathematics is alot of theory and once you work it out there are less challenges in terms of cost or practicality. I'm glad we have UPenn to work out the more mind bending problems.

[tom_h]

4 hours since she went into the lab.  The report is that 3 of the 4 veins have been worked on and all is going as expected.