Rate and rhythm meds pre ablation

[KiwiBlake]

Hi all.

I am booked in for a touch up RF ablation on 7th May.

Briefly my back story. Diagnosed with AF 5 years ago. Fit male 52 years old, 70kg.

I had a cryo ablation of the 4 pulmonary veins September 2022. Attempted weaning off both the rate (Bisoprolol 2.5) and rhythm (Flecainide 100) at 4 months post ablation, I went into AF 10 days later, so returned to the daily meds.

Subsequently approx every 6 months I tried again to stop both the daily Bis and Flec, stay in NSR, only to lapse into AF after 10-14 days which reverts within the hour of taking Bis and Flec. Stress is my main trigger.

If I take both the Bis and Flec daily I remain in NSR, no hint of AF, no ecotopics, strange sensations, so meds are controlling the AF nicely. I feel good as.

My question (I've yet to discuss with EP, but I like to go along to meetings well informed)....prior to a touch up RF ablation do you remain on both the rate and rhythm meds, or do you stop taking the Bis and Flec a couple of weeks prior to the operation so that they are out of your system?

When doing the touch up RF ablation do you need to be in AF so they can find the rouge signals and burn the tissue at that spot, or do they induce AF to track down the source, if so how is this done. If on the Flecainide will this mask finding the source of the rouge signals?

Cheers Blake

(New Zealand)

[BobD Volunteer]

You do not need to be in AFat the time of the ablation as they have some clever drugs which can bring it on as and when they need to infuse such. Regarding what you may or may not be told to stop that is something for your EP to decide as there are plenty of different strategies. Generally these days anticoagulants are continued throughout .

[KiwiBlake in reply to BobD]

Thanks Bob. Yes last time I was put on the AC's 4 weeks pre, and 12 weeks post ablation (dabigatran). Was told I could stop after that due to CHADs score evaluation. I didn't get any bruising or excessive bleeding if I cut myself. In work I manage a farm, so I'm often losing skin on machinery etc, but am conscious of the stroke risk. I think I will run it past my regular GP again re AC's.Cheers

[mjames1]

Every ep has their own way of working. Some will ask you to stop anti-arrythmic's "x" days/hours before and some "y" days/hours before. Personally, I was told to only hold my Flecainide the night and morning before. Go with what your ep suggests.

Jim

[KiwiBlake in reply to mjames1]

Thanks Jim. I've long deliberated with myself as to whether to have the touch up RF. As I say, if I take the Bis and the Flec daily, absolutely no AF or inclings of it, but if I stop it returns one or two weeks later following a stress event. I have absolutely no side effects from either of the meds, but wonder what they are doing to me long term.

I will follow the advice of the EP regards if and when to stop meds pre op.

[trevs7]

Hi Blake,

You are probably suffering from rejoins from the PV which is what can happen once the heart heals after an ablation. This means that some of the rogue signals are no longer isolated from the PV and are causing the afib episodes once triggered (in your case by stress).

My understanding is... during the ablation the EP stimulates each of the PV's in turn to identify where the rejoins are and re-isolates them (with RF or Cryo). This is why the 2nd (or 3rd) ablations are sometimes referred to as "touch-ups". The EP can see these signals live on their monitors during the procedure and can also see them disappear as they are ablated.

As others have said, each EP has their own preference about medications, but that doesn't impact they way the EP performs the ablation.

[KiwiBlake]

Thanks Trev. With the first (Cryo) ablation I was awake and was able to see the monitor screen (from an angle lying down on the operating table) for the first freeze. I found it quite fascinating watching. I however started feeling uncomfortable so they put me under.

This time I've been told it will be GA, so I won't be conscious at all, which is a shame as I would love to watch, while they have a good poke and search around inside my heart.

I think something worked with the first ablation as if and when I do go into AF it is far less chaotic, and reverts quickly with the flec and bisoprolol. Sometimes within 15 minutes.

Prior to the ablation I could go into AF even on daily Flec, so hopefully they can find those rejoins with the touch up.