Atrial flutter: Hi all. I'm a little confused... - AF Association

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Atrial flutter

Hi all. I'm a little confused about the need for an upcoming ablation.

I developed atrial flutter, following severe dehydration because of equally severe gastroenteritis.

A cardioversion was planned on an outpatient basis, followed by an ablation some time later.

I've been on Rivaroxaban and Diltiazem for around 4 weeks now. However, despite the Diltiazem, my heart rate periodically became very high. In the end, my GP arranged for me to be reviewed by cardiology at my local hospital.

While an inpatient, the cardiologists decided that I should have the cardioversion straight away. It was performed on Tuesday this week.

What I'm not sure about is my current situation, after the cardioversion. The consultant told me that I'm now in normal sinus rhythm, so now I just wait for the ablation. When I've looked online, I've read in a number of places that the ablation is done to stop atrial flutter. Does that mean to stop it reoccurring? If I'm in normal sinus rhythm, then surely it has stopped already.

Or is the ablation intended to reduce the possibility of AF developing?

Any advice would be appreciated.

Johnny

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Ablation would be to stop it recurring. Was there any discussion about rhythm control medication while you are waiting for ablation.

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Thanks for that. I've been told to continue on both meds until the ablation. Beyond that, I'm not too sure.

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Perhaps your GP has been advised about the meds you could have to prevent recurrence while you are on what could be a lengthy NHS waiting list.

Diltiazem won't do that, being for rate control rather than rhythm control.

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Oh right. Thanks for that. I'll check with the GP, as nothing was said to me about it in hospital.

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Much as I am a fan of ablation, to go this route after only one event does seem extreme. Were you in a different country I would start thinking opportunist money making but here in UK that is unlikely unless you are paying privately.

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OK. Thanks for that. The way it was explained to me by the cardiologists, it seemed that ablation following cardioversion is the normal route. I am in the UK and all the treatment has been NHS.

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Cardioversion is a useful tool to see if one can be returned to NSR. If not then ablation is probably a waste of time. If yes and you feel better in NSR (not everybody does) then should events continue ablation may be an option. Not many people are offered an ablation costing NHS upwards of £15k after just one event. Most people fight for years to get that kind of treatment.

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This is where I get confused. From the moment my AFL began, it was continuous. I didn't have discreet events. The cardioversion was successful and the symptoms of AFL haven't come back so far. Hopefully, they won't return, although I know that, statistically they could. What I don't understand is how events can occur, if I'm in NSR. If they do occur again, then am I not by definition NOT in NSR? By events, do you mean moving in and out of NSR?

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Paroxysmal AFl means that it comes and goes on its own yes. Persistent means that it lasts more than seven days and/or needs intervention and permanent can't be reverted.

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OK thanks. From the day mine began, two days after I was discharged from hospital (severe dehydration) it began and was constantly a big problem to me until the cardioversion. Altogether, about 3.5 weeks. Since then (only 3.5 days ago) it's been fine. So, putting it plainly, has it gone, or is it just not active at present? Thx again.

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Cardioversion is not a cure for anything so as I intimated it could come back anytime or it may just perhaps be a one off caused by your dehydration. There is no way of knowing and ablation is not a cure either, just a way of stopping symptoms and improving quality of life (QOL) . If you have the pre-dispostion to arrhythmias then anything can happen.

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Thanks for that. I suppose it could be a one off, due to the dehydration. I did have 2 ablations last October for a very high number of ectopic beats (around 15,000 a day). They solved the problem. In fact, when the recent episode began, I assumed that they had somehow returned until the consultant told me that this problem was completely different.

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what exactly are etopic beats? I keep hearing about those. I recently had an ablation for my A Fib which was happening more and more and lasting days at a time. I can feel the fluttering in my chest and know when I am in A Fib but what does an etopic beat feel like? Need to write that down so can ask my EP when i go in for my follow up on the 3rd.

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I think they're essentially extra rogue beats which occur very soon after a normal one. However, the person having them experiences a skipped beat. So if you check your pulse, it's as though a beat in an otherwise regular run, just isn't there. The frequency with which a skipped beat is felt, isn't constant either. I felt them sometimes every second beat, third or fourth etc.

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Here in the U.S. the new thought seems to be: the younger you are, go to the ablation sooner. I did 4 months ago, and my CP has called me a “posterboy” for the procedure. Fingers crossed!

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I agree about the school of thought in the US. I had one diagnosed episode of AFib, went to the ER, they gave me Metoprolol iv, it stopped immediately, referred to a cardiologist, then to an EP who said the earlier they do the ablation, the more successful it is, so I had the necessary tests to assure there was no other problem with my heart, and I had the ablation last Sept. The whole process took 4 months from diagnosis to ablation. I've had no incidents since then.

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The Doc not only knows of your condition best but also the best treatment for it, the ECG when you were in flutter would have given him the information needed along with your condition whilst in flutter would have indicated the priority. Flutter is the worst arrhythmia for your heart but thankfully the easiest to fix (it is the easiest of ablations to do) and it has a 97+% chance of success with low risk of complications. I suggest you have more chance of developing AF if you do not have the ablation but not knowing the state inside your heart it is impossible to say for definite. I have been suffering for 26 years and just had an ablation last February, I really wish I had it 26 years ago.

My advise is I would jump at the chance of an ablation for Flutter (I would not necessary get it for any other arrhythmia just yet as there is less chance of success and an increase chance of complications), you will also get an EP study which will inform your Doc of anything else and get treated accordingly (I had an ablation for flutter which was successful but they could not ablate the MAT they found which I have to take medication for). Right now I feel as good as I did 20 years ago. Unfortunately you will be having a battle between your heart (pardon the pun) and your brain right now, your brain telling you to get it done, your heart heart telling you that there is no need.

I will warn of recovery, it take a lot longer that the EP tells you, I would say 3 months before you can have a normal day to day life and up to 12 months for full recovery. That said some are like daisies after a few days.

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I would be reluctant to put myself forward for a procedure after only one event, however I would stay on the waiting list and see how things go in the meantime. Ask the consultant why they believe you need it. Is your quality of life affected?

I have had a flutter ablation, which has kept me in NSR for approx 18 months so far. That was following multiple events over a number of years including AF. I did struggle with the need to go for the ablation even while i was in flutter, as it had minimal impact to my quality of life. The main factors for me were to be able to come off the meds and be able to possibly return to cardio exercise.

There are always risks to having any invasive procedure and no guarantees to results, although the flutter ablation has less risks, shorter recovery period and better success rates (I believe) than AF ablation.

You said your flutter followed a period of dehydration. Even though I am "fixed" I try to ensure I keep hydrated on a daily basis (using electrolyte drinks following exercise) and a daily dose of Magnesium Taurate, to try keep the arrhythmia at bay.

Good luck.

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Hi. Thanks for your reply. I'm assuming that by a single event, you mean the whole of the almost 4 weeks of continuous problems.

I will check with the consultant why I'm down for the ablation. I've read that they are normally reserved for situations where cardioversion or medication haven't worked. However, mine seems to have worked fine.

Proir to the procedure, my quality of life was certainly adversely affected but now things are back to normal. For example my resting heart rate is back to around 55.

Thsnks again

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Yes, single event as you described. Ablation for me was only discussed when i was on my 3rd 'event'. Even then, to me, it seemed like the consultant was being hasty. Hence my long deliberation whether it was the right course of action for me.

Maybe this is the way the medical people are dealing with the condition now, but certainly the dehydration that you described does sound like a big factor/ trigger.

A successful cardioversion is usually an indication that an ablation will have success. However a successful cardioversion from a medical point of view means that the procedure puts the heart back into NSR at that moment. It doesn't matter how long that NSR lasts for ie it could be minutes, days, months etc.

I am by no means an expert on this, so please excuse me if i need to be corrected.

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I had my first episode of atrial flutter last year. My heart rate was 150bpm consistently for 3 days. I had previously been diagnosed with SVT so was on medication and extra meds wouldn’t help. I was hospitalised and doctors tried a chemical cardio version with adenosine (a drug often called ‘impending doom’). When that failed they organized an electric cardioversion the next day. I went back into sinus rhythm and was put on anticoagulants for 4 weeks. Two months later I went back into atrial flutter which then morphed into atrial fibrillation (my first known episode of AF). I had an ablation in September which fixed the flutter but not the AF but another ablation in March has now fixed the AF. Hopefully it stays that way. I can’t comment on the NHS as I’m in Australia. Good luck to you.

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I had ablation for fib then developed flutter as a result of the ablation, for which I had a 2nd ablation for that.

but tell me, a few questions:

- Is this the only arrhythmia you have ever had?

- What rate was it (did you say you were in flutter for 3-4 weeks permanently?)

- How did you "feel" whilst you were in flutter? completely normal or completely ratshit (like I did!)

- Are your echo's and ecg's since reversion to NSR completely normal or show any ongoing concerns?

I need these answers before advising you more.

I saw 4 EP's and got very different opinions!

my advice, if you have had 1 event, and your echo and ecg are totally normal, I would ask my EP these questions:

- If I have only had one event, is the long term prognosis for ablation at all reduced if I in fact wait to see if it happens again, then do it if it does happen a 2nd time?

- if the long term prognosis is not that much reduced, is it possible this is a one off event? or does it always come back soon with people that have had a single episode?

I would also consider seeing a 2nd EP (never hurts!)

I was NOT told of the complications ablation can result in (permanent HR of around 100 and in my case it induced flutter that did not exist before my ablation for fibrillation).

most patients really struggle to get an ablation despite major concerns for years, hence your situation is quite strange, and unique!

What country are you in?

Cheers,

Marcus.

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Hi. Thanks for your reply. Sorry all for the delay in getting back.

In answer to your questions:

Last October, I received 2 ablation for multiple ectopic beats - approx 15,000 a day. No particular cause identified. Post ablation, no further problems.

This time, my heart rate, on very mild exertion would rise to 165. In hospital it was between 120 and 170, at rest. At home before hospital, it was around 120 at rest.

For the whole period I felt dreadful. I was exhausted, dizzy and breathless with almost constant palpatations.

My consultants said that my ECGs post cardioversion were clear. However I have had right bundle branch block and first degree heart block for a long time and were still evident on those ECGs.

I'm in the UK

Thanks again

Johnny

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Sorry, I forgot to say: I'm possibly seeing the consultant next Friday. At that time, I'll certainly ask him the questions suggested.

Thanks again

Johnny

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I think with that extra history, well, you haven't just had an isolated episode or AFlut, you've had a history of significant electrical disturbances!

I had varied opinions, but ultimately the EP I went with was of the opinion that early ablation intervention gives a better chance of a result long term.

I still thinks ask those questions, but I would probably be earing on the side of action than non action given that extra history . I do know that flutter is worse than fibrillation in that it can be constant once it starts. Ask if they re intending to do left atrium or right atrium or both depending on what they find.

Good luck.

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Hi again. Something else has occurred to me! From when the flutter began, it was more or less continuous until the cardioversion. I am now back in NSR. Does that imply that my flutter was a one off, which may not need further treatment?

I wonder that, as it started immediately following severe dehydration, which was the cause, according to the doctors.

Or could it have been a long, single event, the first of potentially many?

I've now been asked to consider taking part in a clinical trial, which might involve either RF ablation or Cryoablation within the left atrium, piercing the septum in the process. Google "atrial flutter craft" for details of that. The process is randomised, so just before the procedure, I would be told I would have one or the other.

I can't help feeling that I've been put down for an ablation (which might not be needed) just so that I can be approached about the trial! Am I being paranoid!!!

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The doctor performing either of the procedures within the trial, is the same one who did my ablations last October. Regardless of the trial, I've been given a post ablation review eight weeks after the cardioversion. Half the normal waiting time for ablation, so presumably my ablation, clinical trial or not, will e done within around 6 weeks, not 16!

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Hi again. Sorry to bombard you with so many questions. The cardiology research nurse is ringing me on Monday to see what I feel about taking part in the trial. I want to make sure that I cover all bases during our chat.

After the cardioversion, I was told by a consultant that I was back in NSR. No one ever told me anything about the ECG which was taken a few hours before discharge. Presumably it was OK.

My question is, would that ECG look normal (as if flutter had never been a problem), or would it indicate flutter somehow, which was without symptoms because of the cardioversion? I hope you understand what I'm getting at!

Johnny

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I think you need to take a step back!

let me know if the following is correct:

- many months ago you were having huge numbers of ectopics, so had ablation for this, which was successful, no more (or very few) ectopics?

- However you do have some degree of "blocks" for which you are on medications?

- Then you had one episode of flutter which was cardioverted successfully?

- Now you " feel" normal, no chest concerns and back to being normal?

if above is the situation I would ask a lot more question about exactly what heart concerns you have now, why ablate again now if everything is seemingly OK? is it to prevent further flutter (which may or may not occur again?) or is to help these "blocks" that you do have currently? that's the main question I'm left with?

And again, would it be reasonable to see what happens for a few months before deciding on further ablation whether it be experimental or routine?

Then if no more flutter is occurring, at least wait until it does?

Ask their "best guess" as to whether there is a small chance it never occurs again, or highly likely, and if so in what time frame.

but....whatever the answer, what's the harm in waiting to see if a second episode of flutter occurs, and then act? Unless it is to address these "blocks" that you currently have.

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Thanks for getting back again. Much appreciated.

You're right about the ectopics. I haven't had any since the ablations in October.

I still have the blocks but I'm told much of the general population does too. I'm not on any medication for them.

I do feel OK after the cardioversion. No chest concerns. That said, I'm still quite tired but that could be a but of anxiety around this whole subject! I'm certainly not worn out like before.

I've put a number of questions (along the line of those you suggest) to the cardiology research nurse, with a view to speaking about them with the EP. She said initially that if I had questions about the trial, I could probably see him this coming Friday. While some questions do relate to the trial, others touch on the need for ablation at all and the statistics etc behind any reasoning put forward by him.

Thanks again for your insight.

Johnny

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No probs, good luck and come back to me if you need to after you speak to him.

may be worth a second EP opinion before you jump into trial ablations!

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Thx. I'll let you know.

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