Ablation for atrial flutter?

[ruffity]

Hi all, I’m Fran. I’m using my hubby’s account, who has had AF for about 9 years and has appreciated the wisdom found here. I’d be very grateful for your thoughts on my Atrial Flutter as I’ve found it very difficult to get the advice I feel I need.

(I hope this post isn’t too long, you might want to jump to the end.) For background, I’m 76, and about 3 months ago I saw my GP with pains in my chest and difficulty breathing. It was decided to refer me to the rapid cancer diagnosis service and for x-rays, and not to give any medication for my symptoms in case it interfered with the cancer diagnostics.

A week later, I saw the same GP again, who now suspected bone cancer (myeloma), which was pretty frightening. When I got home, my husband decided to check my pulse. It was just under 200 bpm. We tried phoning the GP but couldn’t get through. My husband meanwhile called 111 who were all great. I was called back by a doctor who was very concerned and told my husband to get me into A&E asap and he would call ahead.

There they confirmed my pulse to be 198 bpm and I was gently carted off on a trolley to the Resus ward. They struggled to get my pulse down with IV infusions and drugs by mouth, and though still higher than they wanted, I was discharged a week later.

The next day, I was phoned by the hospital, wanting me to come straight in. I was expecting to see a cardiologist, but it turned out to be an oncologist concerning the suspected cancer. To my relief she was puzzled as she saw no reason to suspect cancer. But she did find my heart rate was still much too high and I was readmitted to the Resus ward.

I think it was at this point where I first heard the term atrial flutter. I’m not sure whether it had been the untreated pneumonia, or the stress of being told I might have cancer, that triggered it.

My heart rate was brought down to around 130 or so but fluctuating, and, shortly afterwards, I saw a visiting electrophysiologist from a large central London Hospital who arranged for an ablation.

I then saw a different GP, who sent me back to hospital for more tests and x-rays for the lung problem. I was re-admitted again, put back on a drip, given a cocktail of drugs, and at the third attempt, my heart rate fell to around 45 bpm. I haven’t been back in tachycardia since and have an HR now of about 60 bpm. They now think I’d had pneumonia with “pleural effusion” which I now seem to be just about over.

The decision for an urgent ablation was made when they hadn’t been able to get my HR down. So the question that bothers me is, as I have had an abnormal heart rate, for almost 2 months now, how likely is the condition to return, and do I still need an ablation which is booked for about six weeks time? I am now just taking 3.75 mg Bisoprolol and a DOAC. The ECGs I had always showed what seems to be an even rhythm, unlike AF, but very fast.

I’m really sorry for the length of this post, which is a shortened version of what’s been quite a saga. I was discharged and re-admitted multiple times from the hospital and have 4 discharge letters signed by different members of the staff I saw, (2 nurses, and 2 junior doctors who were a nephrologist, and a rheumatologist I think). I’m not aware of ever seeing a cardiologist, apart from the single appointment with the electrophysiologist.

I have been told that I will be able to discuss it with the surgeon when I go in for the procedure, but it would seem a terrible waste of resources if it was decided to not go ahead at that stage.

I’d be very grateful for any suggestions on how to proceed.

Fran

[wilsond]

HelloSorry its been such a saga for you! I gas AF and Flutter, and like you,blue lighted a few times with the flutter.

Ablation is the best treatment for flutter rather than medication. It is a relatively simple procedure and has a much higher success rate than for AF. 95%+ success.

It forms a circuit of abnormal rhythm, and like breaking an electrical circuit with pliers,ablation follows the same principle.

It is easy to identify with a clear sawtooth pattern.

Good luck and I'm sure you'll feel far better for it. I have had no flutter since having mine done. Xx

[mjames1]

Are you in aflutter now or normal rhythm? What drugs are you taking? If you're in aflutter now, I would think electro cardioversion would be the first step. It may put you back in normal rhythm and the aflutter may never return. If it keeps recurring, then ablation would be a reasonable next step. A typical right-sided flutter ablation is successful over 90% of the time, however aflutter can sometimes come from the left side which would be harder to treat. Are you seeing an electrophysiologist (ep). They would be best to guide you here.

Jim

[ruffity in reply to mjames1]

Hi All. Thank you for your kind thoughts.

I saw the EP after the Resus unit had tried unsuccessfully for a week to get me out of tachycardia and so was then still in flutter with a still high HR. On that basis, he arranged for an urgent ablation. I was then on Amiodarone, Digoxin, Bisoprolol and Edoxaban (which made me feel awful).

But... the very next day my HR fell back to normal (hurrah!), and afaik, I haven't been in tachycardia since. I've been checking with a BP monitor and a Kardia.

The Amiodarone and Digoxin were stopped by the hospital few days later. I was phoned with an immediate appointment for the ablation, and explained to the appointments clerk that I was now feeling fine, but I was still given an appointment for September.

So now I'm wondering if I really need an ablation at all. I'd never had a problem until I caught pneumonia that went untreated, and don't know how likely I am to have flutter again. Is it normal to have an ablation on the basis of one incidence of flutter that has now gone?

I've never seen a cardiologist throughout, other than the EP from a central London hospital where the ablation is to be carried out. In Resus I saw nurses and non-cardio junior doctors, so I'm not sure who I can speak to.

[mjames1 in reply to ruffity]

I would get a second or third opinion before getting an ablation for flutter. Ablations are not without risk and your pneumonia might have been a once in a lifetime type of trigger.

Jim

[jeanjeannie50]

Last Sept/Oct pneumonia made my heart rate go crazily high, but I've had AF for many years. with three ablations and many cardioversions. I still have AF but my rate now is between 60-90bpm

Why rush into an ablation, your high heart rate could have easily been caused by your pneumonia! I'd say wait a while and see how you get on. Are you able to talk to your EP, or one of his AF nurses. Hopefully, the procedure could be had at a later date if needed.

Jean

[SeanJax]

they resorted to a very powerful cocktail of drugs to bring your hear rate down . So it is not a typical atrial flutter. At 76, high heart rate as yours will send you in heart failure pretty quick. With NHS system next time when you need an appointment for an ablation you might need to wait for 6 to 9 months. Your episode of pneumonia certainly played a role here. You roll the dice here and make your own decision. Let me explain my thoughts process. If your ep is a good and experienced one then go with the ablation because your atrial flutter can come from the left atrium and it requires experience and good mapping tools to detect the rogue source . Only an experienced ep can resolve your issue. Ask him point blank how he thinks and make a share decision with him to go or not to go. Best wishes.

[Cat04 in reply to SeanJax]

Agree about waiting for ablation. My EP worked with another cardiologist and a cardiac surgeon to bring all my treatments together into the OHS that I had earlier this year. (Combination of plumbing & electrical problems!) In fact my EP asked the surgeon to do both PVI & CTI ablations "in case it is RA flutter masquerading as something atypical left-sided".

[Ppiman in reply to Cat04]

I don't feel that you were given a powerful cocktail since the peculiar form of "stepwise" ventricular tachycardia that atrial flutter always creates, with its fixed ratio pulse (~300 / 150 / 100 / 75 / 50bpm, etc.), is hard to treat by either rate control or antiarrhythmic drugs. Also, these aren't always useable in certain scenarios (i.e. as they lengthen the QT interval). Digoxin is safe in this respect, and it worked well for me when I had Afl; amiodarone also, despite its reputation, is a relatively safe drug in the same respect. It was next for me, if an ablation had not come my way in 2019. In fact, the drugs you were given are, so far as I can tell, pretty standard for AFl.

I was told that atrial flutter tends to arise with a clearer cause behind it compared with atrial fibrillation, but does sometimes occur as "lone Afl", as mine seemed to be. If it was the lung infection that led to it in your case (and it won't now be known), then either this might never occur again, or it signifies that the flutter circuit in the right atrium is weak and might well be triggered again with a different cause, or none at all, and thus need further treatment or ablation. I doubt there is a way to prove this so - if this were me given the high levels of debilitation atrial flutter caused me - I would leave the decision to ablate to a cardiologist who has seen the echos, knows the history, and so on. It's a near 100% guaranteed successful operation, but not entirely risk free, A further complicating factor is that if you don't take up this particular offer of ablation, offered as an urgent procedure, you might get Afl in the future and have to wait and suffer much longer.

It's not easy to decide and I send you my best wishes for success, whichever way you go.

Steve

[Cat04 in reply to Ppiman]

Interesting, but was it in reply to ruffity rather than me. When I said "totally agree" I didn't really mean about the drugs combo but the acceptance of an ablation, I'll edit my reply to remove it.

[Ppiman in reply to Cat04]

Sorry, I wasn't intending that to be a reply to you Cat, but to the OP. These threads can be confusing at times. It was spurred by my feeling that certain phrases stir up more emotion than others and that the course of the treatment was likely reasonable given the complexity of things.

Steve

[Cat04 in reply to Ppiman]

No problem, I tagged OP so hopefully your post will get seen.

[Cat04]

You need to speak again with your EP (an EP is a cardiologist with extended training in the heart's electrical activity) but I doubt he would recommend an ablation if not required or anticipated to be of use to you.

I had a catheter ablation in 2018 and had remained free of arrhythmias until last year when I caught covid and went into atypical flutter which I stayed in for over 6 months. It was finally brought under control by trying multiple drugs.

I needed OHS earlier this year to replace my aortic valve and at the same time had a surgical ablation with a left atrial appendage clip fitted to prevent stroke causing clots.

[ruffity]

Many thanks everyone. Your comments have helped a lot.

I'd been thinking very much along the lines suggested and your views have firmed up my thinking. I feel I do need to speak to an EP, preferably the same one I saw before, who I liked a lot. When I saw him the first time, I was so euphoric but exhausted after learning I didn't have cancer after all, as the GP thought, that I hardly thought to ask questions.

It seems more difficult because he came in from a hospital in central London, and I've never seen or had a name for any cardiologist at the local hospital where I was treated. Just the staff in the Resus unit I was in.

Now I have to figure out how I can make contact with him. If necessary, I might be able to see him privately.

Thank you all.

Fran

[Cat04 in reply to ruffity]

If that EP is the one that has referred you for an ablation you should be able to track that down through the hosp a) that you were seen at b) where you are scheduled to have the ablation if that is a different hosp.The contact details should be on your appt letter for the September ablation.

[2learn]

Hi, has anyone mentioned cardioversion. Don't know how it works with flutter, but different medics have classified me as, flutter, AF and permanet AF. I've had 3 cardioversions all worked for over 12 mths.

[Cat04 in reply to 2learn]

As far as i understand it the original poster has had a chemical (medical) cardioversion and is no longer in any arrhythmia so there is nothing at present to convert. I think that is why she is querying whether she should still go ahead with the ablation.

[ruffity]

That’s right Cat. I did ask about cardioversion - as my husband had one about 8 years ago for AF that worked brilliantly until he needed a second one last year. They specifically said they wouldn’t try with me for some reason. Possibly because my breathing was still difficult from the pneumonia.

I’ve now spoken by phone to the arrhythmia nurse at the London hospital who was lovely and extremely helpful. So I know a little bit more. I didn’t ask how likely it was that I’d have tachycardia again as I thought it might be difficult for her to answer on the basis of a phone call.

She asked me to call her with any other questions I might have. I’ll be making my list.

Funny, you’re just minding your own business and these things come bowling into you to ruin your day. Suppose that’s what makes life so interesting.

Fran

[marcyh]

I had a second ablation two days ago along with a flutter ablation (right atrium). The EP wasn't sure whether he could treat my AFL but was able to trigger the small area that tends to be the problem so he treated it. So I'm thinking I should be fine now for both.

I'm doing okay. I'm glad I opted for this rather than rate meds since the chances for a permanent fix are better.