It is also our hope and prayer that this blog would be helpful to others dealing with AF or contemplating an ablation. I will try to provide some more detail in this post regarding my ablation and answers we got from Dr. Natale. We would also welcome any questions anyone might have. Leave any questions as comments to this post and we will do our best to answer them as a follow-up comment.
Here is some additional info in no particular order:
EP Study: I had read some ablation procedures are preceded with an EP study where lasso catheters are inserted into the left and/or right atria to map out the electrical signals inside the heart, including any abnormal signals. The doctor can use this mapping info to decide what areas need to be ablated. Dr. Natale said he would not need to do an EP study in my case. My guess is that was because my ablation was relatively straightforward.
CT Scans: The brochure we had gotten from Dr. Natale's office mentioned a CT scan would be performed before the procedure and again at 3 months post-procedure. There had been a discussion on the forum I watch about the risks of all the radiation from the multiple CT scans along with the fluoroscopy used during the procedure itself.
- Pre-procedure CT Scan: Dr. Natale did not ask for a CT scan before the procedure. I didn't think to ask why specifically but my guess is it was not necessary since I was not having an EP study.
- Post-procedure CT Scan: I did ask Dr. Natale if he thought a follow-up CT scan was necessary when there are no symptoms indicating pulmonary vein stenosis (narrowing of the pulmonary veins due to scar tissue or swelling). He felt it was very important to rule out stenosis as a complication for any future issues like pneumonia. He said otherwise you could be walking around with stenosis while not knowing it but it could be causing problems that would not immediately be connected to possible stenosis.
Vagal vs. Adrenergic AF: Dr. Natale said he felt the causes for AF were similar regardless and that vagal or adrenergic types described more the timing of AF onsets and not necessarily the cause. I definitely had vagal AF and my episodes were always at night usually following a late or heavy meal. Dr. Natale felt that the digestive process would cause an adrenergic response as extra blood flow is required to the gut. I'm not sure if we discussed it but I'm sure my sleep apnea events would also trigger an adrenergic response.
Pacing vs. Drugs to Induce AF: One local EP I saw said if I wasn't in AF for an ablation, he would electrically pace my heart to put it into AF. Dr. Natale said he could pace even a normal heart into some sort of arrhythmia and he preferred to use adrenaline like drugs to get the heart to reveal possible AF trigger sites.
The Ablation Procedure: Dr. Natale performed a variation of a PVI called a PVAI (Pulmonary Vein Antrum Isolation). My understanding is the "Antrum" part means the burn lines are moved further out into the atrium from where the pulmonary veins join the left atrium. Early PVI ablations placed the burn lines inside the pulmonary veins. Stenosis was a common undesirable result plus not all stray electrical signals were blocked. Dr. Natale's method reduces the risk for stenosis and isolates more of the potential AF triggers in and around the pulmonary veins. After the PVAI, Dr. Natale used adrenaline like drugs to reveal any other potential triggers. He found one other site in the coronary sinus that he ablated as well. I believe this would be considered a focal ablation.
Sleep Apnea and CPAP: I brought up my sleep apnea during the consultation with Dr. Natale as a concern I had while being sedated. He was more concerned that my SA might cause me to take deep breaths that could make keeping the ablation catheter in position with proper pressure more difficult. The easiest solution was for me to bring my CPAP machine and mask with me for the procedure. The morning of the procedure they called someone from respirtory to fit an oxygen feed inline between the CPAP and mask.
Boxers or Briefs: I understood from the brochure from Dr. Natale's office that there would be a total of 3 incisions made to insert catheters - two in the groin and one in the right side of the neck. I had never had an ablation before so I was not sure where exactly the groin incisions would be. The best way I can describe it is by saying you would not want to wear briefs anytime soon after an ablation. The incisions end up pretty much right where the leg openings in a pair of briefs would be.
Overall Impression: It helped me to read what others had said that had been through an ablation. Almost every account I read said the procedure was no big deal. While I hope and pray I do not have to have any more ablations, I would not hesitate to have another if I thought it would provide relief from AF or something similar. I would again seek the most experienced EP I could find and Dr. Natale would certainly be top on my list.
That is all I can think of for now. Submit any questions you have for me or Melinda as comments and we will do our best to answer. Happy New Year everyone.
Dave
8 comments:
Dear Dave and Melinda,
Thank you so very much for sharing your information.
A local cardiologist we have spoken with apparently routinely expects to need to perform a second ablation to cure his patients' AFib. Apparently, with Dr. Natale, you don't expect to have to return for a second round. Right?
What do you know about Dr. Natale's success rates, and how did you choose him? At what time interval would he consider his patients cured (or not)?
What about follow-up care, before (and after) the three months--for example, if accelerated heartrate suddenly recurs, or some unexpected symptom suddenly happens, what will you do--call him? Call his physician's assistant? Head for the local emergency room? Is he in ongoing contact with your local doctor? Are you now seeing a local cardiologist for any additional monitoring, or is the daily call-in replacing that?
Are you now on Coumadin? Three doctors we've talked with say Coumadin for at least 3 months post-ablation; does Dr. Natale agree? If you are on it, I would appreciate any advice on matching your diet with it. (My husband has, so far, opted for aspirin instead of Coumadin.)
Did you consider the Maze procedure? If so, why did you opt for ablation?
Thank you.
Anne
Hello Anne. I'll do my best to answer your questions.
Let me quote what the brochure said that I got from Dr. Natale's office about success:
"Success rates for PVAI are defined as restoring a patient's normal sinus rhythm while not being dependent on medications to control the heart rhythm. Pulmonary vein isolation has an 80 to 85 percent success rate with the first ablation. For those who have returned for further ablation, the success rate has been 95 percent."
Some doctors are vague about how they measure success so I was glad to see it well defined. I did not ask specifically but typically the endpoint for deciding success is 6 months to 1 year.
There has been some discussion on the AFIB Report forum about if an ablation is permanent or if AF might return in several years. I read more than one post where the person felt the ablation was still worth it for the several AF free years it had given them.
There was also a survey done recently about ablation outcomes. A large percentage of those who did not have complete success still felt the ablation improved their AF situation by shortening episodes or making the AF easier to manage with meds sometimes with lower doses. There was a small percentage that felt ablation made their situation worse. We considered all of this info and decided it was worth the possibility of relief from AF if we could get in with an experienced EP.
I had read a lot in the last 1-1/2 years that mentioned Dr. Natale. In my opinion he is among the top 4 doctors in the world and top in the U.S. for AF ablations. The backlog to see him in Cleveland was close to 18 months because of his success. It was the very day we decided it was time to consider an ablation that Dr. Natale made the announcement that he was now in California. This was too much of a coincidence to dismiss (we considered it an answer to many prayers). My guess is his backlog is longer now compared to when we contacted him.
Once I was scheduled for an ablation, we were given contact numbers for nurses to contact for questions, meds, and Coumadin monitoring. After the ablation we were given another set of numbers to call in case there was anything of concern.
Now that we are home we would head for the ER or my cardiologist for anything urgent. My cardiologist has copies of everything pertinent regarding my ablation. I am sure Dr. Natale and his staff would be available for any questions I or my cardiologist would have. We have not decided yet if we will travel back to California for the 3 month follow-up or handle it with my cardiologist. It probably depends on how things progress.
I believe the daily monitoring with the HeartCard is to show how often I am in NSR vs. AF or other arrhythmia. This info is used to gauge the success of the ablation as well to guide when to discontinue certain meds including Coumadin.
Dr. Natale also requires at least 3 months Coumadin post-ablation. He also wanted Coumadin at least 3 weeks pre-procedure. I was not in AF during this time so my ProTime/INR was not as critical as someone in AF. They did schedule a couple of ProTime tests the week of the procedure including the morning of and the day after as these times were more critical.
I was already on Coumadin before the ablation because of my last extended AF episode. Prior to that I had been on 325mg aspirin daily. I should be able to discontinue both if I remain AF free for an extended period. While on Coumadin we just try to keep my diet consistent in regards to vitamin K. Green leafy vegetables contain the most vitamin K so I try to keep my daily intake the same. In my case I eat one large or two small salads per day. It is not that you have to avoid vitamin K, you just need to eat the same amount every day. This will help ease the Coumadin dosing and keep your ProTime/INR in range.
My understanding of the various Maze procedures is they involve open-heart surgery and use of a heart-lung machine. It sounds like it is recommended if already undergoing other certain open-heart procedures (valve replacement, etc). I believe the Maze procedures have higher success rates but an ablation is much simpler and less risky. My health insurance also had a provision for ablation as secondary therapy for AF so it was easier to get it approved.
There are other new procedures including ablation techniques and equipment being developed. The decision when to pursue an ablation or other procedure depends on how badly AF is affecting your lives. There are also the concerns that the longer you are in AF, the more electrical remodeling and atrial enlargement can occur. Both of these can make curing or managing AF more difficult.
I hope this helps. Let us know if you have other questions.
Dave
Hello Dave. I have been following your posts here and on the forum. I am very glad to see that things are going much better for you.
I hope that's a trend to come!
As for me, I am scheduled to have an ablation with Dr. Natale on January 31st. I am wishing for the best but you know how thoughts can creep into your head. My biggest concern is if this makes things worse. I have heard that some people come out of this with a resting heart rate higher than before. Are you noticing this by chance? Also, when you were sedated, were you aware of what was taking place during the procedure or were you too far gone?
Being only 37, I feel I am relatively young for this procedure but I would like to get this taken care of now rather than later. I also don't want to be on meds the rest of my life. I know that nothing is for sure but everything I have read states that the least amount of AF a heart has gone through, the greater the chance of success.
Did you work with Salwa? I am assuming you did, isn't she great! I learned more from her than I did from my regular EP here in town! I am lucky that I live in California and SF is only about a three hour drive. I can't imagine having to take such a long flight. Well, I wish you continued NSR and I hope that your recovery continues to be smooth.
My thanks to you and your wife for sharing your story. It really does help those of us will soon go though it.
Erick
Hi Erick. Congrats on getting in with Dr. Natale, you won't be disappointed.
I went through the same exact thoughts you are describing. It didn't help that my weekly AF episodes decided to take a vacation for the month preceding the ablation. They actually wanted me to be in AF for the procedure and had me taper off and stop my Cardizem and Flecainide 5 days before the procedure. I tried all my normal triggers and even without the meds all I could muster was one 60 minute AF episode 4 days before.
I began to question if I really needed the ablation after all. I worried that it might make things worse (sound familiar). I eventually discussed this with my wife. We both had lived through the last 18 months and knew all too well how disruptive my AF had become. We concluded that my AF was not cured (perhaps it was playing a cruel joke) and that we had a once in a lifetime opportunity for a cure. The concern about making things worse was relieved by the fact that Dr. Natale would be doing the ablation. It was comforting to know he would be drawing on the experience of almost 3,000 procedures.
My resting heart rate before the ablation was in the low 50s and now is in the low 70s. I was on twice the Cardizem before which might make a small difference. I had read others whose RHR was higher for several months post-ablation so I was not surprised by this. I also know AF episodes are not uncommon but so far all I have had is a few skipped beats which are also to be expected.
For sedation Dr. Natale used Versed and Fentanyl which I had before for both cardioversions. Truly the best way to describe how it feels is like going to sleep and then waking up afterwards. You may or may not actually sleep but this is how it feels. I was very much out of it after they gave me the sedation meds except for the couple of times I remember "waking up" where my biggest concern was my dry throat. There was never any discomfort during the procedure at all.
One thing I forgot and may go back and add to this original post is regarding sleep apnea. If you have sleep apnea and use a CPAP machine for treatment, they will want you to bring your CPAP and mask for use during the procedure.
I decided the same as you that I was ready to be rid of the AF beast. I am more than ready to say goodbye to all the meds and the side effects and risks that come with them.
I spoke with Salwa a few times by e-mail and we met her when Dr. Natale made his rounds. Everyone we dealt with at Marin General were the greatest. It sounds like some of the contacts are the same at California Pacific Medical Center so I'm sure you will have the same excellent care regardless of where your procedure is performed.
I hope this info helps. You have our best wishes and prayers that everything will go smoothly.
Dave
Is all still going well? Hope so!
Anne
Hello again Anne. Today is one month exactly since my ablation and everything is going great! I will be posting a one month update later this evening.
Dave
Dave, thank you so much for your effort to post your experience. I followed all your post and comments where I get educated and much comfort. I scheduled the ablation with Dr. Natale on 7/23. I just wonder if possible i can get 3 hr ride to Lake tahoe which is 200 mile away from SF on 7/26. Again Thanks for all you have done and enjoy NSR.
Glen
Good to hear from you Glen and congrats on getting scheduled with Dr. Natale.
If your ablation is on 7/23, you should be fine to travel on 7/26. I was sent an info packet from the EP department about a month before my procedure that covered lots of details including traveling. They like to have you stay in the area for at least one day after you are released. The brochure said you should stop once per hour and walk 5-10 minutes if you live more than 2 hours away.
Walking was not bad even just 2 days after my ablation. I took small steps to reduce the movement of my groin area. I was afraid to overdo it but it felt good to get out and walk.
We have enjoyed doing the blog and I'm glad to hear it is helpful. I remember all too well the frustration of AF and trying to decide what to do. I do my best to remember everyone in prayer who has posted comments. I will be praying for you (and Dr. Natale and staff) on 7/23. Please let us know how everything goes or if you have any questions.
Blessings,
Dave
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