Just (another) thought.......

We often hear from people who have infrequent episodes of paroxysmal AF who find it difficult to decide whether or not to have an ablation. It generates a lot of healthy debate about reasons for and against which is completely understandable. It occurred to me that those of us who were diagnosed with persistent AF and are unaware of having any form of AF prior to diagnosis most likely see things differently. Back in 2014, I was told I had lone persistent AF and had a CV which lasted around 9 months however, the first episode reverted naturally after 24 hours or so. When I saw my Cardiologist, he said “Ah, paroxysmal AF!”

I have since had two ablations and whenever I have had an episode, I rarely wait longer than 10/15 minutes before taking Flecainide as a Pip. I guess the point I’m making is that it seems more likely that someone in my situation is more likely to go for an ablation because we have started our journey from a different position. Although more recently, episodes appear to have reduced and it’s also possible that treatment for an overactive thyroid may have a positive impact as well. However, I am still due to have a third ablation later this year. At the moment, my thinking is to proceed because my fear is that if (or when) AF returns, it is likely to be persistent/permanent and the longer I can delay that the better. Then again, my thinking could be totally misguided..........

[Barb1]

I am with you here. In retrospect, I had undiagnosed PAF for years which resulted in my developing Dilated Cardiomyopathy, heart failure and eventually persistent AF. On diagnosis subsequent ablations and meds mean that my heart is now structurally normal, albeit a little 'stiff.' I am now in PAF again which I am sure will develop into persistent AF. If I am offered another ablation I will gladly take it to protect my heart as well as improving QoL.

[BobD Volunteer]

Interesting question FJ and since you know my position on this very well maybe some sideways thinking.

As we know any and all treatment for AF is only ever about quality of life (QOL). We also know that there is little if any lifetime difference in outcome between ablation and drug treatment. I'm not talking QOL here of course merely lifetime outcome and morbidity. Most of us choose ablation to avoid the side effects of drugs (not mentioning the need to remain on anticoagulation post ablation regardless of outcome. ) Nothing is without risk of course and one needs a logical discussion with your medical team in order to make the right choices. How possible that is in todays rush rush world only each individual can decide.

I know there are many on here who chose to avoid ablation since they are quite happy and for the most part trouble free on their drugs . Who am I to say they are wrong?

[sotolol in reply to BobD]

Thanks you have answered some of my questions that I’ve not even asked..... but in my thoughts all the time. Thank you.

[cuore in reply to BobD]

Two trials have concluded that ablation is better than drug therapy:

the CAPTAF Randomized clinical trial ( JAMA 2019)

CABANA Trial ( Cardiology Dec. 2, 2019)

But, yes the morbidity is the same, I think. AF can always come back.

[bennie06 in reply to cuore]

Dr. Milton Packer was "profoundly disappointed" with Cabana. So with a multi billion $ industry at risk "alternative facts" were created. Numbers do not lie but statistics can be massaged to fit a hidden agenda.

[cuore in reply to bennie06]

Thank you so much for introducing Dr. Milton Packer's viewpoint. I found this site:

medpagetoday.com/blogs/revo...

In this paper he does say:

"Throughout the planning and execution of the trial, the investigators stated that they were going to use an analytical procedure known as the intention-to-treat analysis. "

Now there were a lot of cross-overs in this trial (patients starting in drug therapy and crossing over to ablation). Thereupon , the CABANA results were deciphered by a "treatment received analysis" also:

practiceupdate.com/content/...

In the above first article , Dr. Packer substitutes "treatment -received -analysis" for "alternative facts" without even attempting to explain what these alternative facts are. In other words, he does not compare the two methodologies " intent -to -treat analysis" versus "treatment -received analysis, " granted the trial began with the objective of "intent-to-treat analysis. " I am not a medic, but I see the cross-over necessitating or precipitating a "treatment-received-analysis"also. Plus, there is a benefit to reviewing the latter analysis. The results are expanded and by expansion, they become more inclusive and fine-tuned.

Furthermore, Dr. Packer's paper focuses on "What is its financial impact?" arguing about money received by the electrophysiologists as opposed to medical benefits received by patients. ( I will not expand on that lest this post becomes too long).

I do not agree with Dr. Packer's incomplete flawed analysis of the results of the CABANA trial. Perhaps he was erroneously trying to make a name for himself plus trying to make money which he condemns EPs for doing.

Nevertheless , your reply was brilliant. and thought provoking . Thank you for allowing me to respond.

[beardy_chris]

I only realised I had AF when I started passing out (syncope). Before then I had, with hindsight, a number of episodes but I didn't know what it was. After it was diagnosed I had one cardioversion. It worked for a while but, at some point I went back into AF. I was so asymptomatic, I'm not sure exactly when that happened - though it was around 2 weeks later. So, I was in persistent AF. When my EP suggested ablation probably wouldn't be terribly useful, I was disappointed but not devastated.

Yes, ablation is about Quality of Life, if your QoL is not badly impacted by your AF, you have to decide whether the risk (and ablation is not without risk) is worth it. My EP 'guided' me in the direction of not having an ablation and I think he was right - and thank him for his guidance. I can live with my persistent AF and it really doesn't diminish my QoL by much at all. I'd say that, if you can tolerate your AF, you don't *have* to have an ablation.

[pottypete1]

I don’t think your thinking is at all misguided.

Pete

[buddje]

Hi

I wonder about any treatment really.my big prob on flecainide is weight gain but then again when I get my mindset organized i can lose weight so who knows?

It makes me lethargic but then again ...so does a fib..

....

A fib on the increase as obesity rises......and I wouldn t want an ablation

[Jhcoop55]

Similar situation as you. I had two failed ablations and was thinking about a third. However, my doctor and I decided to hold off and try taking a combo Flecainide/metropolol combo daily to see how that works (rather than on an acute basis after an AFIB event)

It's been two years since my last AFIB event and I've felt great. I'm also lucky that the meds cause no side effects for me. I would strongly suggest talking to your doctor (electrophysiologist) about the possibility of taking the meds chronically (daily) rather than when an AFIB event occurs. (This assumes you can tolerate the meds well). See how that works and if you still get AFIB, then consider a third ablation. As always, consult your doctor.

For me, as long as the meds work, I plan to hold off on an ablation (as some lucky patients can live the rest of their lives on meds). Hoping I'm one of them.

[Hidden]

You raise an interesting point. I’m not sure that my last ablation has failed as such. It’s nearly 3 month’s since I had my last episode but prior to that, I did have a few in relatively quick succession. During the period from 1 year after my CV to when I had the first Cryoablation, I was put on a daily maintenance dose of Flecainide and I remained on it for 6 months after, due I think to the problem he had ablations one of the pulmonary veins. Like you, there were no problems taking the medication, but my EP seems to prefers that I don’t take it long term. The other factor is age. At the moment I’m a relatively fit and active 73 year old and probably more able to cope with an ablation now rather than later. One thing’s for sure, you can only weigh up the pros ‘n cons and hope you make the right decision!

Thanks for your reply, hope things go well for you 👍