First degree heart block

[KiwiBlake]

Hi all. I had a cryo ablation last September (2022). Following the procedure I stayed on daily meds of 120 Diltiazem and 100 Flecainide controlled release capsule. At my 4 month review and being in NSR (no AFib) and feeling great, I was advised to stop taking the Flec.

Over the course of 10 days I weaned myself off the Flec, while continuing the Diltiazem. I then went 8 days no Flec, only to go into AF after a hectic day at work. Took a PIP Flec, rested and went back into NSR approx 3 hours later. I resumed the Flec for a week, and then tried going without the Flec only to go back into AF, this time after only 2 days. Once again reverting back to NSR a couple of hours following PIP Flec. Therefore went back to taking the controlled release Flec. However feeling fragile, ectopics, palpitations and feeling that I could flip back into AF at any time.

Spoke with specialist at at Cardiology dept, who increased my daily dose to 200mg Flec in the controlled release capsule. I have been on this now for last 3 months, feeling good, just a bit fatigued at end of day (physical job, farming). Wore a holter for 5 days. This has come back with NSR for the whole 5 days but a diagnosis of borderline first degree heart block. I have been advised to go back to the 100mg Flec.

Therefore is this first degree heart block a result of the Flec? Does borderline mean early stages?

The other change I've noticed is that my HR while sitting quietly used to be approx 65 bpm. Now it's approx 55bpm. During sleep, my wearable device says I go down to approx 47bpm through out most of the night. I'm getting a good 6 to 7 hours sleep every night.

I'm 51 years old (male) weighing 69kg. During the day my pulse goes up to mid 140 when doing physical work, but quickly drops back to 55-65 when I take a breather.

My specialist at Cardiology has put in a request for a touch up ablation (RF this time to try and zap any rouge signals) with aim to stop the Flecainide. New Zealand public hospital system is very similar to UK system, so likely a 6 month wait if referral is accepted.

Any comments or advice would be greatly appreciated.

Thanks Blake

[CDreamer]

Good Morning - here at least - night for you I guess.

Yes to the first part of your question, Flec can cause 1st degree heart block and like any compound which can ‘cure’ has the ability to also cause. It is a very toxic drug and one many of us had to cease because of complications or contraindications with other drugs.

As to the second part - impossible to say as potentially if you stop the drug entirely it may be reversible. If you continue to take it at all then you would need very careful monitoring, I would think - not medically trained so cannot give advice, only opinion having been in a similar position but in my case it caused wide QRS and exacerbated another condition so having to stop Flecainide.

If I were in your position I would put these questions to your doctor and really drill down and ask for numbers. You may find that your doctor is reluctant to answer those questions so then you have to assess the risk v benefit of continuing to take the drug if it is going to cause harm.

Certainly go for the ablation ASAP because if you HAD to stop Flecainide you would then have reduced any other drug options such as Amiodarone which has worse potential affects taken long term.

I would really look at your lifestyle and if hectic work is an underlying cause of your AF then you really need to consider and know that you cannot continue to do that, hard but believe me, speaking from experience we have to slow down as we get older and it really doesn’t get any easier so we have got to reduce our expectations of ourself in order to live a more comfortable life.

We all need to think through the consequences of our options for future life, hard to accept I know but absolutely true.

Best wishes and hope that helps.

[BobD Volunteer]

All sounds fairly normal and yes flecainide can simulate heart block.

I'm sure you will know that cryo ablation has limitations. It can only deal with the four pulmonary veins if they are nice and symetrical so an RF abalation is often needed to deal with any missed areas or other parts of the atrium firing off.

Sounds like you are doing well so well done.

[KiwiBlake in reply to BobD]

Thanks Bob and CDreamer for your prompt response.

In terms of my job, the work load is relatively steady for about 6 weeks, easy to cope with, but then followed by a 2 week busy period where it gets hectic. I'm trying to resolve this by delegating more of the work load to my staff during this period. I'm my own worse enemy, try to do it all myself. I'm a slow learner in this respect!

Fingers crossed that my referral for touch up ablation is accepted. The public health system here in NZ is plagued by chronic Dr and nurses shortages, and decades of under investment by both sides of the political divide - sound similar?!

[mjames1 in reply to BobD]

Bob, we've had this discussion before, but while you are technically correct, I think you may inadvertently be misleading people and preventing them from having effective treatment with cryo ablation.

Yes, the cryo balloon only deals with the four pulmonary veins, however what is termed a "cryo ablation" (or let's say what is included with a cryo ablation) often includes not only the cryo balloon for the PVI, but also includes RF for what you call "missed areas or other parts..."It would also include RF for anything on the right side of the heart, such as the flutter line.

So instead of just assuming a cryo ablation does not incorporate RF, I think much better to ask the ep something like "Do you use RF in addition to the Cryoballoon if necessary".

In the US, it's standard for ep's who do cryoballoon PVIs to use RF when needed, outside of the PVI. Studies have shown both RF and Cryo ablations have identical results, and anecdotally, those I have spoken to at Johns Hopkins, a leading cardiac center in the US, prefer cryo because of its even coverage and less dependency on the operator.

I have also spoken to an EP in the Uk, who also exclusively uses Cryoballoon, but also uses RF when necessary outside of the pulmonary veins, and his results are excellent. You know his name.

I am not saying that every ep in the UK will use RF along with the cryo balloon as in the United States, but don't you agree it's better to ask the ep in advance what he will use and not use, rather than just assume he doesn't use RF?

Lastly, RF is not necessary in the majority of afib procedures and recent studies have shown that additional burnings that many ep's use are not superior to PVI alone. That said, personally I would want any ep performing a cryo balloon to have RF capability just in case.

Jim

[Hidden]

I had a very similar experience after my Cryoablation although it was about a year before AF reappeared. I knew that my EP had problems treating one of my pulmonary veins, so it was no surprise when a second RF ablation was recommended. I did experience some AF episodes about 7 months or so after this ablation but I was also diagnosed with an overactive thyroid. I was on the list for a third ablation but this was postponed whilst the thyroid was treated. I’m pleased to say that normal rhythm has continued since 2018…….🤞

[mjames1 in reply to Hidden]

First, happy that your second ablation held.

Don't want to go over everything I mentioned to Bob, but Cryo seems to be getting a bad rap and I think unnecessarily.

Second ablations or touchups are just as common in cases where the RF was the first as when Cryo was the first. Spots are missed. The technologies are imperfect. The success rates of the two procedures -- cryo and rf -- are identical per studies.

Jim

[Hidden in reply to mjames1]

I don’t know about you Jim, but I tend to limit my responses to situations as they affected me. I certainly don’t think I should take it upon myself to refer to results from trials etc as I am no where near qualified to make such comments. I think most people recognise that we are all different and therefore what happened to me probably will not apply to someone else. The fact that over here, many EP’s will tell their patients exactly what Bob and I have said so that their patients hopefully, will not be too disappointed if the same should happen to them suggests that we are doing the right thing by explaining why their Cryoablation might be faltering. I certainly never have nor never will, be critical of the Cryoablation procedure, on the contrary, it is generally quicker, safer and all things being equal, equally as effective as an RF ablation but thank you for your observations………..

[mjames1 in reply to Hidden]

I think one of the wonderful things in forums like this is that you get anecdotal accounts outside of the literature, i.e how "situations affected me", what my ep said to me, etc.

Well, cryo PVI and rf PVI affect me as well. And I also have spoken to several ep's, including an eminent one in the UK. And I am relating what they told me, just like you were relating what your ep told you.

As to study data, that also is very important. Don't we quote the study data all the time on the CHADS2 Vasc score?

I know you are not knocking Cryo. And I am not knocking RF.

Just trying to point out that: (1) many ep's who do cryo balloon PVI's, will also use RF for other areas, if necessary during the same prodcedure; and (2) Studies show that both cryo and rf PVI's are equally successful and equally safe.

How can someone know if this pertains to their ep? Don't ask me. Don't ask another member here. Just ask the ep who will be doing your procedure.

Jim

[Hidden in reply to mjames1]

I think you are making a bit of a mountain out of a molehill. If someone writes in experiencing problems with AF after a Cryoablation then I will continue to reply in the same way I have always……simples!

[mjames1 in reply to Hidden]

After re-reading your first post, I'm going to apologize, as you were simply relating your experience with your ep, as you should. And I should have responded to you differently, if at all.

My objection was to Bob's initial post where he appears to state as a matter of fact that "cryoablation has limitations". Limitations which I tried to explain in the following post, are at best misleading.

Jim

[KiwiBlake in reply to mjames1]

Hey Jim. Thanks for the comments. Can you clarify something. Are you saying that in the US it is common to do RF during the same time as doing a cryo (go searching for rogue signals). Or are you saying the RF touch up is done some period later e.g. 6 months once the cryo scar tissue has formed, healed to get any area missed due to the pulmonary veins not being perfectly round. Cheers Blake

[mjames1 in reply to KiwiBlake]

Maybe this will help.

In the US, ep's in almost all cases do either an RF PVI or a Cryo PVI. They don't do both. In 95% of afib cases, a PVI (pulmonary vein isolation) is all that is necessary.

In cases of right sided arrythmia's like typicsl flutter or SVT, or in the other 5% of left sided issues like atypical flutter, only RF will work.

So let's say you have both afib and aflutter and want them treated at the same time which is now recommended.

The RF PVI guy will use RF for everything. The Cryo guy will do a cryo balloon PVI and then they will ablate the flutter line using RF. All in one procedure.

And in this example, in spite of the fact that the Cryo guy has to switch catheter instruments, he will probably complete the entire procedure faster than the guy who only uses RF. That's because the Cryo PVI, by it's nature, is significantly faster than the RF PVI.

Jim

[KiwiBlake]

I've got an under active thyroid- hypotherydism. I'm on Levothyroxine.

[Hidden in reply to KiwiBlake]

Both an under or over active thyroid can have an impact on AF but I believe an under active thyroid is easier to manage. I suggest that you discuss this with your Doctor if only to make sure they are aware……

[mjames1]

Yes, most probably because of the Flecainide. Probably not to worry, or you would have been taken off of it completley. Same thing happened to me. My flecainide was reduced from 100 twice a day (fast release tabs) to 50 twice a day. This is why ekg monitoring both at rest and during exercise is important on Flecainide. Many doctors seem to fall short here.

Jim

[KiwiBlake]

Thanks to everyone for the interesting discussions. We are all different, there is no single silver bullet. Lifestyle, diet and getting into the right headspace, are all important. It was explained to me both pre and post procedure that the cryo ablation may need to be followed up with a RF to get any areas missed. The post procedure report I was given stated (with times) that all 4 sites had good freeze times.In terms of the hypotherydism, I have been advised to continue taking the levothyroxine, I get my bloods analysed every 3 months which shows that the meds are keeping it under control.

Gotta keep going

Blake

[2learn]

Hi, I was recently told I had 3rd degree heart block, worried me. Don't know where that came from, but if you google heart blocks it seems pacemakers are the solution. I've got pacemaker and consultant put in writing my heart block is of no clinical concern. So as others say just keep asking questions. I don't take flecanide, ablation has worked and now weaning off bisoprolol.

[KiwiBlake in reply to 2learn]

Thanks 2learn. Can I ask in your case how long did it take to progress from 1st degree to 3rd degree. My prognosis is "borderline 1st degree " which I'm assuming is very early stages. I'm hoping if a touch up RF is sucessfull and I drop the Flec, that it doesn't progress any further.

[2learn in reply to KiwiBlake]

Hi Kiwi Blake, wish I could tell you, but I've had heart surgery, 3 ablations and 3 cardioversions and lots of ECGs and no doc ever mentioned it. Then about a month ago had an annual check up and consultant said in follow up letter the ECG showed level 3 block. So it came as a complete surprise to me. I'm still checking my past heart correspondence to see if I missed it in past. Good that you've been told so early, you can make sure the docs tell you how its progressing and if and when you may need any treatment. I'm bit older than you at 74, so it may just be slow progress or hopefully not. Good luck.

[JOY2THEWORLD49]

Hi

I'm Kiwi too. I did the majority of my education at Tawa (Tawa Flat). Lived at 1 Victory Crescent!

Seems as if your first ablation has not worked. Why because the ain re ablations is to get you off meds.

On Diltiazem 120mg AM my H/R is controlled. I also take 2.5mg Bisoprolol PM for BP control. And both help rythmn.

My night h/R avge has always been 47. Never changes.

I've never had Flec. Always in AF but since controlled H/R no more sweating or breathlessness.

I look forward to what they do with you next.

I haven't had cardiversion ot ablation cause my ECHO shows an enlarged chamber.

In Sept 2019 I had an Ischaemic Embolic type stroke with AF caused by undiagnosed Thyroid Papilary Cancer (foud 4 days later during a carotid scan). Removed 4 months later.

I have persistent rapid H/R with AF which eeds to be controlled.

cheri JOY. 74. (NZ)

[KiwiBlake in reply to JOY2THEWORLD49]

Thanks Joy. hope you are doing OK. Next time I'm in northland, put the kettle on and I'll pop in for a cuppa!

[JOY2THEWORLD49 in reply to KiwiBlake]

hi

the kiwi comradism continues and me too if i come down. i stay at a coupe where one is a fellow classmate.

off to have my 5th jab this am via free bus.

cheers JOY

[KiwiBlake in reply to JOY2THEWORLD49]

Hi Joy. I was being a bit cheeky saying I'll pop round for a cuppa. In all seriousness though, I wish I knew a few people locally who have AF. While the forum is great, nothing beats meeting in person. I've asked at my local cardiology dept if there was anyone keen to start a local support group, meet for a coffee once a month. Share notes, experiences, have a few laughs. I'm in the Taranaki if anyone out there local sees this post.Cheers Blake

[JOY2THEWORLD49 in reply to KiwiBlake]

Hi

I know you were being an open kiwi.

I know someone in Kapiti region but not in Taranaki.

You could put an open invitation in this forum - you might stumble on another in your area.

In this day of privacy .... it is sometimes annoying. Perhaps start a group walking and go from there. Ask your clinic and chemist.

I know only one other in my area because his wife is my EPOA. But his diagnosis is different. I'm trying to get him to read more about side effects of Beta-Lok (metroprolol) but he won't tell his doctor that he is breathless. Yes older than me.

It's good that you want to join a group .... next to get them to open up and perhaps encourage 'speakers' on the subject. We have 'Retire and Live' here but I don't feel old enough to join.

cheri JOY. 74. (NZ)

[Banquo]

Hi Blake,I had very similar results in my attempt to go off the meds after my first ablation blanking period. I made it less than two weeks off meds before having to go back on. In fact my dosage of flec was increased..much to my chagrin. I also was put back on anticoagulant. Yuck! My flec and beta blocker are about double your dose! After about a month in that I'm holding on for now, so I have that going for me. I'm about 5 months post ablation. I have a second ablation set for late August. My ECGs show wide QRS but they don't seem to be overly concerned. I can exercise but overall feel a bit lethargic. Interestingly, my heart rate experience is opposite yours...before ablation (and before meds even) my resting heart rate was low mid 50s, and overnight sometimes mid high 40s. Since ablation it is mid 60s to 70s. I'm happy to not be in AFib for sure..but the meds aren't wonderful either. Lesser of two evils I guess? Sounds like we are similar age and activity and lifestyle.. I wish you well!

[KiwiBlake in reply to Banquo]

Thanks Banquo. In the first month post ablation my resting HR changed to mid 70s. Over the last few months it has slowly been dropping to now be mid 50s. I haven't noticed any impact on how I work. I do sometimes have a little "siesta" mid afternoon, but I've always down that since my mid 20s years of age. Ive always been a good night sleeper as well. Maybe I've had a heart rhythm issue much longer than I've realised, just that it wasn't diagnosed until I was 48 years old.