Ablation - what to do?

[Jafib53]

Okay a bit long so please bear with me. In Early October 2022 I was diagnosed with hyperthyroidism and one symptom of this was Afib. Now, I was being treated by a cardiologist and an endocrinologist both of whom agreed that my heart rate and rhythm were unlikely to improve much before my thyroid levels were under control. I was on bisoprolol and an anticoagulant and, at first, some thyroid drugs. However it soon turned out that my thyroid issues weren't caused by the usual culprits of Graves disease or toxic nodules but it was a temporary problem and it was thought that it would self resolve, so I came off the thyroid drugs. My thyroid levels came down to near normal in January / February but I had been in persistent (mostly asymptomatic) Afib all that time. My thyroid seemed pretty normal a few weeks ago but my Afib was still there so I saw an EP and he suggested an ablation and put me on rhythm drugs. Nothing happened for a week and then I fell back into NSR. I went back today to see both the thyroid doctor and the EP. My thyroid levels are now normal and my heart rate and rhythm are, too. I have an ablation scheduled for end of May but there is a lot of information online suggesting that patients with Afib caused by temporary thyroid problems that self resolve often fall back into NSR 6-8 weeks after the thyroid levels are normal. (something like two-thirds off such patients) My thyroid doctor had hinted he didn't think the ablation was necessary but would leave that to the EP and me to decide. The EP, too, after initially thinking the ablation definitely was for the best agreed that it might not actually be strictly necessary. This was after he realised that my thyroid issues were temporary and not ongoing. The thyroid was almost certainly the cause of the Afib. He cut my bisoprolol and I remain on the anticoagulant and the rhythm drugs and will see him again in early May. The thing is, I will have remained on the anti-rhythm drugs from now until the time I see him, so we won't know if it was the drugs that brought me back into NSR or whether I was just falling back into it as many do after temporary self-resolving thyroid issues. So not sure whether I should go ahead with the ablation or not. I am quite happy to have it if it is needed but obviously would rather avoid an unnecessary procedure.

I am in Japan, so cancelling it wouldn't be the same as if I was in the UK in that I wouldn't go to the back of a huge waiting list. I could maybe have it a couple of months down the line. I suppose my question is this: Is there any problem with having an ablation that might not strictly be necessary?Also, I know people say staying in AFib longer makes the success of an ablation less likely, but if my drugs keep me in NSR is waiting longer going to do me any harm should I eventually go ahead with it?

I don't have any other heart issues and have been told my heart is generally in good health. I am 53 years old.

If you managed to read all this, thanks!

[CDreamer]

Hi Jafib - Making the decision to have or not have an ablation is always a difficult one but in your situation I think I would not go ahead yet, especially as you will have access to the procedure in the future.

A couple of questions - which antiarrythmic? How symptomatic were you in AF?

I ask because all treatment for AF is generally considered for relief of symptoms and AF often returns a few years down the road so I would ask myself what are the advantages of having an invasive procedure for something that may resolve itself with medications and keeping a watch on Thyroid levels? Consider the risk:benefits.

I do not believe there is a right or wrong answer, only a personal choice and I would suggest that you ask the question because you feel quite ambivalent about having the procedure ie: feelings about both having or not having the Ablation - and they cancel each other out so you find it difficult to make a decision - but only you can make the decision.

Hope that helps.

[Jafib53 in reply to CDreamer]

Thank you very much for your reply. The anti arrhythmic is called bepricor and my doctor told me it was one which is only available in Japan. I wasn’t very symptomatic at all - just a few palpitations now and again, although my heart rate fluctuated a lot. It was generally in the 80s but would sometimes pop up to 135 or so. But even when it did I wouldn’t have known had it not been for my devices! And it would only stay at that rate for minutes at most, usually seconds. Since taking the anti-arrhythmia meds my heart rate is steady in the 50s and so I think that is why I am cutting my bisoprolol down from 3.75 to 1.25 a day..

[Hennerton]

since it is your thyroid that has caused all the trouble, my thoughts are that you should be addressing that problem. Do you have Hashimoto’s disease? This slowly destroys the thyroid but while doing so will cause high levels of thyroid hormone that can then settle down but will happen again and again until the gland is destroyed. Has your endocrinologist made any comments? There are treatments you can take to stop the thyroid being overactive but they are not necessary when everything is normal, so it is a tricky problem and one that your endocrinologist could and should be addressing.

Another reason for high thyroid levels is Graves’ disease, which I had and resolved by having my thyroid removed - not a great solution but the only way forward with yo yo ups and downs. I now have to take thyroid hormone every day to replace my thyroid.

If I were you I would ask to see your endocrinologist again and learn more about your particular thyroid problem. Which kind is it? Will it most likely return and if it does, can you take anti-thyroid medication to calm it down and let the heart settle itself again?

There is a thyroid site for Health unlocked and you also could get help from members there. It is the site I mostly use and has many excellent and helpful members, just as this one has.

[Jafib53 in reply to Hennerton]

thanks. Yes the thyroid has been what I have mostly been dealing with and has been well treated. As I mentioned in the post it wasn’t graves or nodules, but probably painless thyroiditis which seems to have resolved, although the endocrinologist is still keeping an eye on it just in case. The thyroid treatment has been excellent and so now we are focusing more on the AFib.

[Hennerton in reply to Jafib53]

Sorry, I missed that they definitely said the thyroid problem was not an issue any more and if that is the case, I certainly would wait and see and not rush to have any heart treatment. Thyroids can be a huge nuisance when they take it into their heads to go over active so I am delighted for you that yours is back to behaving itself. I do wish mine had been as well behaved as yours. It is my greatest regret that I had to have mine removed. One is never the same person after the operation, as it is a vital part of the body, yet little is known until it goes wrong.

[BobD Volunteer]

I concur completly with CDreamers thoughts and cards on the table I am a great fan of ablation!. Any and all treatment for AF is only ever for quality of life (QOL) so since yours is not at all bad I would hold off a while and see what happens when you stop the anti- arrhythmic drug.

[Jafib53 in reply to BobD]

Many thanks. Well, I guess if I fall back into Afib the decision will be easier, but if I stay out of it until my appointment in May, I guess I could try coming off the anti-arrhythmic drug and see how I fare. Lots to think about and appreciate the input!

[KMRobbo]

I am a fan of ablation over drugs, now over 5 years past my AFib ablation and no Afib.

However I would ask the EP about stopping the Anti arthythmic drug first. If AFib does not return, no point in having an ablation.

,

[Jafib53 in reply to KMRobbo]

yes, I think that’s what I’m going to do. Thanks.

[MaryCa]

Has the EP suggested trying to stop the rhythm drugs? If he does, then please taper them off very gradually, as there can be a huge rebound if you just drop them.

Worth discussing in my opinion with your EP, now that your thyroid levels are normal.

At least you'd know if your AFib is here to stay or was just visiting.

[Jafib53]

Not yet - I’ve only been on them for two weeks. But will continue on them until our next appointment and then maybe try a reduction.