After a memorable vacation, my wife and I like to reminisce during the following weeks by saying something like "remember where we were two weeks ago?". Maybe we are not the only ones who do this. Tonight, as I think back to two weeks ago, it was the evening of my ablation procedure. Not really the same memories as a relaxing vacation. I do remember laying in the hospital bed, relieved that the procedure was over, and waiting for the healing to begin. Two weeks later I can say that the healing has been much quicker and easier than I expected.
So far I have not had any AF episodes or any other sustained arrhythmias. I have maybe a handful of single "skipped beats" per day. This is to be expected during the ablation recovery and hasn't concerned me. I had many more skipped beats before the ablation and it was when they would string together one after the other that I had to be worried about an impending AF episode.
I finally returned to work today. I was expected back two days ago but the New Year came complete with a head cold. Air travel this time of year has its drawbacks including lots of other folks with sniffles. I had to rely on rest and fluids to get over the cold as I always worry any extra meds or vitamins will throw my INR (Coumadin level) off. Maybe you have picked up on the fact that I will not shed any tears when the Coumadin therapy is discontinued.
That's all for now. Welcome to 2008.
Dave
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7 comments:
Dave,
Thanks for sharing your experience!
Are you going to have the follow-up CT scan? One of my major concerns is the amount of radiation received in the process of the ablation. How much radiation (in roentgens) did you receive during the procedure?
It is my understanding that radiation typically is received by Dr. Natale's patients:
1. from the CT scan prior to the ablation,
2. from the x-ray procedures administered during the ablation surgery,
3. from the CT scan after the ablation procedure.
4. is there any other radiation involved?
I guess you did not have the CT scan before the surgery, but all in all it looks like the process for most patients involves lots of radiation.
A. Do you know (or can Dr.N. tell you) how much radiation (in roentgens) you have received so far?
B. Do you know if there is any way to reduce the amount of radiation and still have a successful ablation?
C. Will Dr. N. require any additional radiation in your post-operative period?
I look forward to hearing how your af is during the months & years ahead and also any advice you can offer to those of us who are considering ablation. You are providing much help to others.
Back at work in two weeks! That is so incredibly encouraging.
I knew absolutely nothing about the radiation issue, as raised by the reader in the preceding post. I'm so appreciative that you are sharing your information. Any radiation information you have will certainly interest me too.
As to using Coumadin, apart from the daily small salad, what can you tell us? Are you counting daily mcgs, and/or keeping a food diary? What besides leafy greens are you careful about? Do you use the Coumadin Cookbook? Or did you find something more useful? This possibility of internal bleeding is so incredibly scary. How often are you monitored? Can a GP do it, or is it best to use a cardiologist? Or are you self-monitoring (I found an ad--apparently people can self-monitor, much as diabetics do--did you consider this?) If this INR number is something that changes daily, how can weekly checks--with a lag in finding out your lab results--possibly be reliable and useful?
We had been told several times that the important thing is to be consistent in your diet from day to day. After googling around, I read that ingesting a constant high daily amount of Vitamin K is supposedly healthier than a constant low amount--no doctor had mentioned that issue to us. Do you know anything about that?
How will you know when you can go off the Coumadin? I think, but am not certain, that you just drop it straight--right? Or do you have to taper it off? Does it have a long half life in your system after you drop it?
We live in California, so seeing Dr. Natale is much easier for us. I've scheduled a consultation with him, and we've a long list of questions. What questions were you glad you asked, and were there any you didn't ask, but wish you had?
Thank you,
Anne
I will do my best with the radiation questions first and then follow up with another comment for Anne's questions.
I have requested a copy of my procedure record and hope to have more details once I have it. I asked for and received this general guideline from the Director of EP Services at the hospitals where Dr. Natale performs ablation procedures:
We document the exposure in minutes and there is a physicist who monitors and audits the results by converting the minutes into dosages. In general, the modern equiment delivers pulse fluoroscopy that greatly reduce the exposure both to patient and operators. The minutes of exposure during an ablation procedure can vary 20-35 minutes.
Setting Dose Levels in Fluoroscopy
Maximum patient skin dose rates in fluoroscopy are set by legislative limits in both the US and Europe. A 5 R/Min patient skin dose is widely implemented as the maximum that a cardiac imaging system will deliver in its normal fluoroscopic operating mode.
I searched for and read just enough to get very confused on how skin dose might convert to Dose Area Product (DAP) and Effective Dose (ED). Hopefully this is what the physicist does and this info will be included in my procedure record.
I will most likely have the post-procedure CT scan. I'm not sure how much additional radiation this will involve.
Originally we had various concerns about having an ablation. We had a long list of questions for the first local EP that we saw. His relative inexperience (<100 AF ablations) and flippant attitude towards our questions did not help our concerns at all.
Enter Dr. Natale and his staff. They were all very willing to answer any questions we had but, to be honest, the list of questions we had was substantially shorter. For us, there was a immediate trust factor when you realize you are dealing with compassionate professionals who specialize in AF.
I am not aware of any additional radiation besides the fluoroscopy from the procedure itself and from the upcoming CT scan. I have seen it suggested that you can request a thyroid collar for x-ray procedures like a CT scan. I did not ask about a collar for the ablation as I figured the neck catheter would make one impossible.
I hope this info helps. I will try to post more once I have the procedure record.
Dave
Anne, good to hear you were able to get an appointment with Dr. Natale. Just to clarify, we may have referred to the ablation procedure as surgery a couple of times in the blog. Actually cardiac catheter ablation is considered a non-surgical, invasive procedure. In most cases it can be performed on an out-patient basis with a less than 24-hour hospital admission. They have you up and walking the day after the procedure before they will discharge you. Dr. Natale felt I could resume normal activities in 5-days. It was the holidays, air travel, and then a head cold that stretched my return to work to 2 weeks. Under normal circumstances I would think a one-week recovery would be more normal.
All together I have been on Coumadin therapy twice: the first time after my first AF episode and hospital stay, and the second starting this past October when an AF episode refused to convert to NSR. Between those two periods I was put on an adult aspirin per day. For people with AF, there are guidelines for which therapy, if any, is recommended depending on age and other stroke risk factors.
The first time I was put on Coumadin I was convinced that I was just one mistake away from having a brain hemorrhage or some other complication. In reality I have had no problems either time. Information is good but I have had to learn not to obsess about all the slim negative possibilities.
The required monitoring can be done 2 ways: a traditional lab draw that takes a few hours for results, or a point-of-care finger stick method that provides results in less than a minute. These tests are referred to as ProTime (PT) tests and the results are given as an International Normalized Ratio (INR). The goal INR range for AF or for the weeks before and after an ablation is 2.0-3.0. I thought I had read that risks for bleeding don't go up substantially until reaching an INR of 5+.
I have had both types of tests. My PCP/GP normally manages my Coumadin dose using the finger stick tests. Because I get results while still in the office, my insurance considers this an office visit so I have a $15 copay. This is actually cheaper than the lab draw because lab work falls under hospital services for me and the cost is $35+. Coumadin clinics have started up in some cities that also offer the finger-stick tests and management under one roof.
The frequency of the tests decreases as your INR becomes stable. They may start as weekly or bi-weekly until your INR is between 2.0 and 3.0, then every 2 weeks, and then monthly if your INR stays in range.
Self monitoring with the finger-stick testers is becoming an option for those on long-term Coumadin therapy (mechanical heart valves, etc). It usually requires a prescription and a medical necessity form for insurance coverage unless you want to pay the $1500+ out of pocket. I wish I could qualify for self-monitoring but it would be a stretch since the goal of the ablation was to get off the meds including Coumadin.
We have not had to do anything special with my diet other than what I mentioned. When I was first put on Coumadin they gave us a brochure listing what foods contained vitamin K and how much. They emphasized that I didn't have to avoid or increase my vitamin K, just keep my daily intake consistent. My salads are primarily iceberg lettuce which is relatively low in vitamin K.
The first time I had no problems obtaining and maintaining an average 2.2 INR. I skipped my normal salads 3 days or so and my INR went up to 2.8. I panicked and made sure I never missed my salads again. My INR went right back down to 2.2 and stayed there. The second time around I actually had a difficult time getting my INR above 2.0. Nobody has been very concerned since I'm no longer in continuous AF and my stroke risk is fairly low.
If you and your husband have a long list of questions, and some are easy to put into an e-mail, you may want to try e-mailing them to either Dr. Natale himself or, better yet, Ms. Salwa Beheiry, Director of EP Services. You can find both e-mail addresses at Dr. Natale's website. From my experience you should get a response within a few days or so, especially if you mention your upcoming appointment. This may get some questions out of the way ahead of time and help maximize your time with Dr. Natale.
This ended up being a very long response but I hope the info is helpful. Please let us know how things progress and if you have any other questions.
Dave
Hi, I noticed this was in 2008. I was wondering how you are doing now in 2011. I just had the Ablation for AFib 3 days ago and I've been reading about his medication they put me on and I find it quite scary the flicinaide and blood thinner. Also I have had a handful of skipped or premature?? Beats daily but no AFib. They kept me in the hospital a few days, I just got out today because I was having horrible chest pain ans shortness of breath due to inflammation then I got a pneumonia from not expanding my lungs enough because it hurt to breath. I'm feeling a little better but still having some discomfort, don't know if I'd do this again! I'm very nervous now abou these meds!
It has been a very long time since I have posted here but the good news is that is because my AF has become such a distant memory. I had PVC's following my ablation which seemed to get more frequent in the months following the procedure. They did calm down a bit maybe 6 months post-ablation but I still have a few daily PVC's now over 3 years later. Sometimes I have to remind myself that the PVC's are harmless (because they are) but I'd trade AFib for PVC's all over again in a heartbeat (bad pun included here at no cost).
I was on Flecainide and Coumadin both before my ablation for AFib maintenance and then after my ablation as part of the normal post-procedure follow-up regimen. I tolerated Flecainide very well both times where some of the other arrhythmia drugs didn't go so well. Flecainide has specific guidelines for patients where it is considered low-risk and I'm sure your EP has followed those. I would take it again if need be as long as I still met the criteria.
I'm guessing they still prescribe Coumadin/Warfarin for anti-coagulants (blood thinners). The key for safe use of Coumadin is routine monitoring and keeping your diet as consistent as possible, especially in regards to green-leafy vegetables. Things may have changed in the past few years but I believe the goal INR post-procedure was 2.0-3.0 (I never got above 1.8 after my ablation but nobody was too concerned). Keep your INR testing appointments and do your best to keep your diet consistent and you should be fine.
I had kept in touch with another Dr. Natale patient who dealt with chest pain after the procedure (I didn't have any). I'm guessing this is a somewhat common issue after an ablation but it should get better with time - hang in there.
I pray each day has you feeling better and years from now your AFib and ablation are distant memories.
God's Blessings,
Dave
Thank you for the reply and I'm glad to hear you are still AFib free! I am actually taking a new anticoagulant that doesnt have to be monitored. It starts with a p but I don't have it in front of me right now lol. These " skipped beats" or whatever I'm having are more frequent today and I scary because I think my heart us going to do something, maybe they will get better as I heal as I have still having chest discomfort. I've caused myself so much stress anticipating a episode of AFib and I'm hoping that gets better over time too. Thank you for your site and giving people hope. God bless you
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