Cardioversion before ablation?

[cuore]

Yesterday, March 7, after waiting 43 days, my cardiologist appointment materialised. The result was a DEPRESSING experience. I must have a cardioversion first before I can be referred to the electrophysiology department or "They will ask why it hasn't been done." In addition, he promoted that I should live in AF (I guess on rate control drugs) because if I didn't convert, then the success of an ablation would be unlikely, implying that I shouldn't bother with it.

My history, already organised by me in chart form, was obtained for him via his MD student assistant which was then conveyed to him during their very short private conference, as I waited. When he finally appeared, he asked me no questions as to how I was feeling so that specific first hand information degenerated into second generation (only that which the assistant told him). A PhD in Communication would fail a cardiologist on that point.

My chart had the headings: date, issue, days in sinus rhythm, days in AF, drugs, and GP Appointments. So, although atrial flutter was diagnosed February 3, 2016, atrial fibrillation start date was Sept. 26, 2016, and January 13, 2017 began persistent AF.

He had concluded that I was asymptomatic (even though I generally always have an aching, heavy chest, and sensations to my throat, with feelings of the heart pounding- stuff he did not hear or the assistant not conveyed ). Furthermore, he stated I had come too late. B.C., Canada runs on referrals and my GP didn't refer me earlier. And, I guess a cardiologist has to refer me to an electophysiologist.

Since I was taking only aspirin, I now have been prescribed Riveroxaban which I must take for three weeks in order to have the cardioversion, The literature I read also advises such.

I must add that I do have high blood pressure, so I don't know if that is the reason he said my atrium was enlarged or that would have had to have happened in just five months.

My question is must cardioversion precede ablation?

I left the office stressed and depressed as I felt a section of the "analysis" was second generation, and as his prognosis was steering me to remain in AF, a condition totally unsuited to my character. Today, I am still stressed and depressed. I will have to expend huge amounts of mental redirecting and reprogramming to supersede the bombardment of negative vibes which I equate to the rogue electrical impulses vagrantly firing in my atria.

[Hidden]

Hi, what a disappointing experience. In my opinion a cardio version would happen first as it is a relatively simple low risk procedure which could work so is worth trying. However, ruling out an ablation and not considering your symptoms is a load of rubbish. Keep fighting for your corner - good luck!

[cuore in reply to Hidden]

Thank you for your encouragement, I needed that! I am not adverse to trying cadioversion. However, it seems that after cardioversion, most do not stay in sinus for very long. So, I am really focused on ablation especially since I follow Steve Ryan and his annual presentation of AF symposium. The experts giving papers there advocate ablation especially since fibrosis increases annually. (See the Jan. 2017 papers). I did get from the cardiologist that even if the cardioversion did not bring me back to sinus rhythm, he would still refer me to the electrophysiology department. I went along with him because to go back to my GP to refer me to another cardiologist would take too long and I don't know how receptive my GP would be. But, the cardiologist did do a really big number on me that I should stop if I didn't convert to sinus. And, he was also encouraging me not to go for an ablation if the cardioversion was successful but I felt the same as if I were in AF. He also put a negative spin on ablation about how wires have to go into your body. What he did not know and failed to ask was that I have been thoroughly versing myself on ablations to the point that I am even aware of the sorts of cathers that are used and exactly how the procedure is done. I would also fail this guy on his judgement of people (patients).

[CDreamer in reply to cuore]

Don't worry if you don't stay in NSR after CV - you only need to be converted - even if it only stays for a few seconds it is proof you CAN be converted which is the difference between persistent and permenant AF - permanent meaning that there would be a very small chance of ablation working.

I had the same spiel from the cardiologist I saw - I now know that his training was so ancient he didn't have the relevant up to date information and hardly any experience of ablation, he had performed the odd one or two a year. A modern EP performs thousands and their training is intense and they are very knowledgeable and experienced.

[cuore in reply to CDreamer]

Thank you, thank you, CDreamer -- a bit hug to you. You have cardioverted me from my depression to optimism and hope.

[Hidden in reply to cuore]

The other advantage of a cardio version is it can prove you have a better quality of life in sinus. If you are only in a few days but your symptoms lessen it supports your requirement for an ablation. It's a shame some people in health care have a lack of communication skills - mine had an argument with his wife on the phone during my last consultation!

[cuore in reply to Hidden]

I found it astounding that my cardiologist would assume that I would have totally forgotten what it's like to be in sinus rhythm and that I could find AF to have the same feeling as sinus rhythm. But, he got his information second had from his assistant and had concluded before even questioning me that I was asymptomatic. Yes, ancient thinking cardiologists use "quality of life" as a criterion for ablation. The recent January AF Symposium in the U.S. uses the prevention of "fibrosis" as a criterion for ablation. According to Dr. Nassir Marrouche, a presenter and as reported by Dr. S. Ryan, "about 35% of patients with A-Fib will experience more than 5% - 10% of fibrotic changes within 1 year. (This is a frightening statistic, since fibrosis is currently considered irreversible.)"

[CDreamer]

In the U.K. A cardio version is often recommended for exactly the reason you were give, but not always, I went straight to ablation - but that was when I saw an EP. Cardiologists I saw (3 of them) were all useless, although one was kind, until I presented in clinic to his registrar who wanted to give me a CV there and then and he wouldn't because I had seen someone else and he said - let her go back to them then (!!!????!!!).

My faith in doctors was only restored after I saw my EP who was fantastic, knew what he was talking about and gave me the ablation 2 weeks later. I have since learned that EPs are the specialists, wait until you see the EP.

I found that sometimes you need to be quite assertive and very well informed to fight your corner so research, research, research so you can hold a sensible dialogue and play an active part in your treatment,

Best wishes CD.

[cuore in reply to CDreamer]

Again, thank you CDreamer. I absolutely agree with you that research, which I have done extensively, is super important. In fact, since the cardiologist didn't interview me at all, he knew nothing of my background. His presentation of a kindergarten analogy of ablation being Seria government forces fighting Isil made me spontaneously laugh. I must have irritated him for he said, "Do you want a technical explanation?" to which I replied, "Yes, please." There was nothing he said that I had not already read and absorbed. He posed a question by again bringing his Seria analogy, which I answered correctly, to his astonishment. Whereupon, he loudly blurted, "That is the right answer."

I drew the conclusion, via his pessimistic attitude about my condition, that we were not compatible, and I can hardly wait to see an EP.

[Hidden]

Hello Cuore, here in the UK it is quite usual to have a CV before an ablation and others have explained why this is the case. I was diagnosed with persistent AF and my CV lasted 7 months. I went back into AF, but after 36 hours I reverted back into NSR without any intervention and that stayed for a further 4 months. This indicated that an ablation was more likely to be successful. Canada may be different, but here there is a tendency to pursue all the options before an ablation is offered, especially if being treated by the NHS. Private care is probably different......hope things get sorted soon

[cuore in reply to Hidden]

Your story is encouraging for me. How long were you persistent before CV and were you on antiarythmic drugs before and after CV? You must still be on anti-coagulants. Canada is the same as the UK -- both socialised medicine. In B.C. there are court cases to get some privatised medicine established.

[Hidden in reply to cuore]

First diagnosed in May 2014 with lone persistant AF. Put on Bisoprolol, Warfarin and later Diltiazem prior to CV in September 2014 (would have been August but INR took a dive). After CV, remained on Diltiazem but stopped Bisoprolol. Almost a year ago, Warfarin changed to Apixaban. Also about a year ago, AF episodes started to increase. Prescribed Flecainide as PiP then a low daily maintenance dose of Flec kept AF at bay until ablation in July last year......so far, so good!! Still taking Diltiazem at the moment, but Flec stopped last January. Still taking Apixaban

[cuore in reply to Hidden]

Thank you for the details that do help me predict what may happen to me. Let us omit the anti-coagulants Warfarin and Apixaban. Your two rate control drugs were Bisoprolol (a beta blocker stopped after CV) and Diltiazem( a calcium channel blocker which you are still taking.) Flecainide, a rhythm control drug, was introduced after increased AF episodes prior to the ablation and up to 6 months later. You were almost in continuous SR for about a year. Your ablation was about two years after diagnosis.

I am one year into this journey. First, Metoprolol, a beta blocker, which I had a terrible reaction to, and am now on Verapamil -- both rate control drugs. My GP does not prescribe rhythm control drugs so he sent me to the cardiologist for an evaluation. The cardiologist has not prescribe rhythm control drug pre -cardioversion.

From other accounts I've read, these rate and rhythm drugs will become ineffective, leaving ablation. I wonder if the route cannot be short-circuited to ablation which some recent literature seems to suggest.

[Hidden in reply to cuore]

You need to be cautious about assuming that one persons treatment regime is suitable for you. There are so many variables with this condition and it takes time for medics to establish the best route for individual patients. That said, it is generally accepted that if ablation is determined to be the best route forward, the quicker it is done, the better. The normal process followed by the NHS takes time as we all know, but it is important that this proper assessment is made. I imagine that anyone able to have private healthcare would be referred to an EP on diagnosis and the route to ablation would be significantly quicker, but EP's like doing ablations!

Bearing in mind there are around 1 million folk in the UK, if each one was offered an ablation costing around £15,000....well it makes my eyes water! Also, we need to bear in mind that the majority of the 1m lead relatively normal lives and may not even want to pursue the ablation option. I don't know the answer, but I'm pleased I took route I did, but I was fortunate in that I belong to a support group. However, I know from posts in this forum, some struggle to get the help they need. Fortunately you are clearly able to fight your corner, so I hope you get the treatment that is right for you as soon as possible......best wishes.

[cuore in reply to Hidden]

Thank you for your wise counsel, Flapjack. The reason I am focused on the ablation route is because the latest literature from the US Afib 2017 Symposiums focused on fibrosis increasing at the rate of 5% to 10% a year(Dr. Nassir Marrouche) and also because I have a heavy chest feeling and lump in my throat in afib.a feeling I could get used to but prefer not to. I do acquafit that help decrease symptoms. If I let it go, and the symptoms get worse, which they will with more fibrosis forming per year, I will have lost my chance for bracing this disease. But, I have recently secured to be referred to an EP, but with socialised medicine, I have to go through the process, so I don't know the date.

[BobD Volunteer in reply to cuore]

Just to butt in here Cuore it is not the drugs becoming ineffective it is the AF progressing. there are no receptors in the body for these drugs so you can't become "used to them,"

In UK GPs are generally not allowed to prescribe rhythm control drugs without Consultant level instructions. Also there is no best treatment for AF and most are aimed at improving quality of life including ablation. (I had three.

I am delighted that you are now on anticoagulation (Rivaroxaban) and not aspirin as this has been shown ineffective for stroke prevention in AF and no longer approved for this purpose in UK. As others have said education is everything . One really does need to become an expert as few normal doctors other than EPs are.

[cuore in reply to BobD]

Thank you for pointing out drug effectiveness, BobD. I wasn't really looking at drugs from the right angle, so your explanation clarifies a lot. Yes, AF progresses, and mine suddenly took a leap. The literature that I have read points away from using aspirin for AF. However, I will not fault my GP; it was me. I was resistant to taking drugs, so I guess my GP followed the old rules for me. I always appreciate your knowledgeable insight on this blog.

[sleeksheep]

Even the Cardiologist (s) I have seen here in Australia dont like proceeding to an ablation without a cardioversion first. The way it was explained to me is an ablation has an initial success rate of 20% - 30% and in most cases needs follow up ablations.

Where as a cardioversion if successful shows that an ablation will be successful also.

( but still need follow ups in most cases)

If your atrial chamber is badly damaged an ablation is moot.

Try to feel positive that a cardioversion will work ,forget about focusing on a ablation till you

have the cardioversion and know more of what your hearts condition is.

My personal opinion is cardioversions are preferable to ablations .

Only because cardioversions have worked for me but I still had to take charge and not rely on the GP or first available Cardiologist opinion as the be all and end all.

[CDreamer in reply to sleeksheep]

I would challenge the stats you quoted - I haven't looked at the latest figures and there are a lot of factors which will influence whether or not ablation works but for PAF - more like 80-90% was my understanding with an EP with correct training and experience. Persistent AF is more variable for sure.

[sleeksheep in reply to CDreamer]

I,m only quoting what my cardiologist told me and going by what I have read it seems still to be the case for Persistent AF. Dr.Keren

perthcardio.com.au/our-doct...

He made a point of making me aware that ablations are usually at a minimum of 18 months apart ,so it is quite drawn out.

stopafib.org/catheter-ablat...

Generally with follow ups it does increase the success rate markedly.

[CDreamer in reply to sleeksheep]

That maybe the case in Australia (practices and stats will vary from country to country) but I had a follow up RF ablation 3 months after my first, which is not unusual in the U.K. - but it does depend upon the EP, of their expertise and experience.

[cuore in reply to sleeksheep]

Yes, sleeksheep, my records show you were diagnosed 7 years ago, and in that period you have had 4 cardioversions. You take 50mg Flecainide to keep you in sinus. However, I have read that the success rate of an ablation is dependent upon how far along in AF one is. I don't know if my atrial chamber was damaged due to high blood pressure, but I do know staying in AF since I am persistent is guaranteed to cause more fibrosis. Since you do drink alcohol, I toast a "wee" glass of wine to you.

[Robroy16]

You missed the opportunity to take your cardiologist by the arm, stop him from leaving the exam room, and explain to him that you don't understand. In lieu of this you must get a second opinion and this time take charge of your meeting, after all it is about YOU.

[cuore in reply to Robroy16]

Today I was successful in getting this cardiologist to refer me to the EP, the true specialist that can expertly deal with my AF situation. Now if I still have to remain under the care of a cardiologist, I will ask my GP to refer me to someone whom I would be more compatible with. I do thank you for your concern and advice.