For those who were interested in the outcome, I won't be having an ablation in Moscow for now. They insist on stenting a coronary artery and waiting some time after this is done. So I'm now deciding on whether and where to have this done. As a general observation it's been difficult here because doctors expect patients to do as they are told and not ask too many questions and also I don't have a translator in constant attendance. They assigned me a very junior doctor on grounds that she spoke the best English but I did not find her very satisfactory.
I have a question. Having doubts about the success of a ablation I consulted, privately by Zoom, a cardiologist in the UK who told me that the purpose of a cardioversion was to see whether you felt better in NSR and would benefit from an ablation. This begs the question, if you feel better after your first cardioversion why do the NHS insist on a second before giving an ablation?
Thanks in advance for any answers.
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Ivan_the_Terrible
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I don't know that they do insist on a second cardioversion - I only had mine because I was ignorant of the fact that I could have an ablation as I believed and was hoping that the object of this was to see if a CV alone would be sufficient? It was after my second cardioversion that I conversed with a nurse and asked why an ablation wasn't considered and she said if cardioversion didn't work they would try medication - but I pointed out it was because rate control - beta blockers and calcium channel blockers made me feel worse than the AF that I had gone for a cardioversion - If the medication had worked or I felt OK with medication I would have stayed don it. I was then put in the process of referral for an ablation. They were not done at my local hospital so had to go to a different hospital.
Am I right in presuming you're on the NHS? If you are then your experience surprises me as I thought there was uniformity of practice within the NHS, following NICE guidelines.
Not sure that you are correct about a second cardioversion but agree with the prime statement. Cardioversion is a test really and always has been.
The NICE guidelines are that ablation may be offered when two drug regimes have failed to maintain NSR. Nothing about cardioversion. Many EPs feel ablation should be a first line treatment and ignore that anyway.
I've never been offered cardioversion. Have had AF now for almost 2 years and 1 ablation.
One answer may be that when the CV fails, it could take over a year before you can have an ablation especially here in the UK and this could have a major impact on the success of the ablation. A second CV is easy and quick or alternatively, an Arrhythmia drug could be used to maintain sinus rhythm until an ablation becomes available……
The private cardiologist appeared to say that cardioversion normally last for only a few days at most. I think she was trying to stress that they are not a cure but primarily diagnostic.
It all depends two of my 3 CV's lasted over a year the other one 6 months - this was while waiting on list for ablation and I know of someone whose first CV lasted for 2 years and second lasted 4 years.
In 7 years of AF I have NEVER been offered a cardioversion. Drugs yes, ablation yes but never a cardioversion and I’ve had several admissions to hospital with AF.
NHS has absolutely no uniformity and it will depend very much on EP/Cardiologist opinion and the Trust’s/Commisioning Body’s funding. NICE are guidelines.
When in AF I tried to /was offered a a DC CV on 4 occasions but never got one, twice owing to lack of anaesthatist, once I cardioverted myself before the time planned.The first one was a comedy of errors. I was in hospital with high rate AFib the CV was arranged for a certain time to get within the 48 hour window( I was not on A/C) , then they fed me! I was not aware of the procedure, no one told me it was 12 hours nil by mouth until they came to check me over by which time I eaten the meal ! Happily 12 hours or so later I reverted to NSR.
The only cardioversion I ever had was by flecainide infusion after 8 days in AFib at high rate.
It appears to vary world wide. I'm in South Africa and my symptomless AF was diagnosed by chance, although I have to add that AF runs in my family - I have 4 sisters in the UK who are each treated differently! I won't bore you with the whole story, suffice it to say that a few months later when I saw the cardio for a check up he told me I was in AF, would I like a cardioversion, I said since I'm here why not, but I asked if I could have an ablation, as my son , an extreme athlete, had had one a couple of years before. he said I was not a candidate as I have mild asthma and COPD. I was admitted to the cardio ward (his offices are at a private hospital) had the conversion that afternoon - one shock resulted in NSR. I have annual check ups with the cardio and 6 monthly ones with my GP, I really don't know when I'm in AF. I just take the medication as prescribed and carry on. It appears to me that some people who are not ablation candidates do benefit from a cardioversion.
Certainly no uniformity. I was put forward for an ablation and had never had a cardioversion. It didn't happen though as they cancelled because I was anemic.
Re NICE guidelines- they are just that- guidelines snd been written following pioneer ing work done by cardiologists and good for cardiologists to follow , but ding fitter that healthcare is changing all the time and new treatments constantly being developed by pioneering doctors. Healthcare is not the same across the uk snd there are specialist centres of excellence I would say - discuss with your cardiologist.
They were originally designed for Best Practice. Costs factors got involved later when NHS looked at treatments that were given but with low efficacy so, as far as I can tell, they are guidelines to signpost doctors to what factors to consider. The REAL cost factors come in when you look at the Regional and Local Commissioning Bodies - can’t remember what they are called now as they re-brand every other year it seems. They dictate to NHS hospitals but not Trust hospitals. Then you get into GP practices and their commissioning bodies but it’s a minefield the last time I looked there are something like 500 QUANGOS which operate within the NHS.
I think that changed and about 4-5 years ago and now the Department of Health and Social Care (DHSC) oversees 19 quangos. NHS England is the largest of these (and indeed in Europe, funded to the tune of over £100 billion per year)
People imagine the NHS is one organisation but it is FAR from that!
It strikes me your artery situation is life threatening, Afib a major annoyance assuming you’re properly monitored on blood thinners. In either case a major hospital heart center is needed, easier in the US with Medicare. In my case an ablation was delayed a year and I took an aggressive anti arrhythmic amiodarone, waiting for a couple of scans to see if a pseudo aneurysm was stable.
Yes I am concerned. The hospital in Moscow were prepared to operate this week and it wouldn't be expensive but the medical culture here is different to Britain, you are expected just to trust the doctor and not ask any questions. They did not want to tell me what would happen if I was allergic to the drugs I needed to take after the stent is fitted. The lack of a good translator did not help. I plan to return to London and take my chances with the NHS. Hopefully I will not have to wait too long.
I think the point that might be being missed here is that we AFibbers and sufferers of other arrythmias cannot reasonably expect our treatment plans to be identical. Whilst recognising that Electrophysiologists inevitably have slightly differing approaches, it's not so much a postcode lottery as a mongrel condition lottery.
We all have different causes, triggers, symptoms and allied conditions.
We all react differently to medical procedures and drugs.
The NHS do not insist on two cardioversions before ablation. But if AF has broken through again after your first, your chances of a successful ablation are reduced and that's where the insistence on a second cardioversion may come into the equation.
For the most part it's a positive that we aren't all being treated in an off-the-peg set of protocols because each case requires a tailored response.
AFib came back after 4 days when I shared a bottle of 16 per cent wine with a friend in belated celebration of my birthday. I had asked the cardioversion nurse if I should avoid anything to stay in NSR and she said just live normally, nothing about alcohol. You might say I'm silly but I know that if she had warned me, as, she should, I'd never have opened that bottle. I don't drink much at all it was, a special occasion. So really no chance to judge if I felt better after CV. When I raised the issue the hospital found a pretext to discharge me and I got caught up in a queue at another hospital and came to Russia where treatment is cheap, but there's a language and culture barrier.
Red wine triggers all sorts of arrythmias for me, but it's fine for others - too much beer caused me problems, but 2 or 3 pints seem ok - which makes my point really. It's not really for the hospital staff to tell you specifically what not to eat or drink, as every patient is different. However as a previously heavy drinker and carefree scoffer of any food I fancied, I didn't touch alcohol, caffeine, sugar, bread, red meat or dairy for several months after my cardioversion, which at the time of writing is still holding me in NSR (with ectopics) over a year later.
The reason I was so strict with myself was that I, like so many on here, had read 'The AFib cure'. I suspect if you'd been lucky enough to have been made aware of this book at the time, you may have avoided that wine!
I suspect so too. After I lapsed back into AFib I did some googling and it's well-established that drinking too much alcohol can cause relapse. In fact when I complained I wasn't warned the hospital said that there should be plenty of discussion about lifestyle. However the nurse in question appeared to be clinically obese and the only advice she gave me was not to put on more than another 7 kilos or the Rivaroxaban might not work, this when my BMI was 29. I've never mentioned this to anyone before, but it has bugged me.
Yes, you touch on an important point there, I think. Every AF patient should leave hospital/GP clutching a factsheet on lifestyle, diet and suggested reading.
To be fair to them there were BHF booklets in a rack in the waiting room and the cardioversion nurse did send me a link to a video. But none of these substitute being told clearly face to face and/or being handed a factsheet.
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