I’ve got the pre-ablation nerves for my Monday ablation…. The short story is over the last 3-4 years I’ve had worsening PAF which is brought on by higher intensity exercise, with red wine also contributing. I’m also 6ft 6, love long distance exercise and both parents have AF which appeared in early 70’s.
The threshold for entering has reduced, and last time it went for 5 days before reverting back into NSR. I’ve only ever had a couple of proper ECG’s, one at my cardiologist and one in a public hospital a few months ago.
My HR in AF when resting is around 60-70 (normal sitting HR would be 50-55). My single lead Wellue with the chest stickies tells me AF, with no p wave. It’s definitely not regular - feels like it’s skipping beats constantly then making up for it in runs, but it’s not chaotic either.
When in hospital they said I had atrial flutter with a 5.1 / variable block - this was a standard local hospital. I saw my cardio a few weeks later who knows my EP as I was concerned that the PVI I’m booked in for is different to a flutter ablation. The cardio did look at the Wellue trace on my phone and suggested that was definitely an AF trace not a flutter, but said they would follow up to get the ECG from the other hospital.
My Wellue definitely does not show any sawtooth pattern - but then not sure if it should. I haven’t pushed the cardiologist / EP, but short of drinking a few glasses of red then hammering the bike up a hill to get into AF I won’t know.
Couple of questions - what does flutter look like on a single lead? And secondly - could I have been confused about AF and actually have flutter the whole time? No one’s ever mentioned flutter ever - only AF until this hospital event.
Cheers,
Tom
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CyclingRunner
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Hi, you can have both I believe and some have an ablation for both at the same time. I’ve also read that an AF ablation can leave some with AFlutter and a follow up flutter ablation is required to fix it. Sometimes flutter is identified while doing the AF ablation.
Flutter is often described as a saw tooth pattern. I've had AF & flutter and have had 5 ablations , the last one in June this year. At least one of my ablations dealt with AF and flutter at same time.
Flutter is fast and regular. Atrial fibrillation is irregularly irregular. In other words chaotic. Not sure you can indentify flutter on a single lead trace to be honest. Since flutter normally occurs in the right atrium it is easy enough for the EP to deal with this on the way out from the fibrillation in the left.
Incidentally I guess you have already been told that your excercise regime has likely caused this? Very common problem for amateur endurance athletes. Maybe time to consider down grading your schedules.
Atrial Flutter with variable block can look very similar to Atrial Fibrillation on an EKG, especially a 1-lead EKG like most of use use at home. With variable block your heart rate can switch around between 150bpm, 100bpm, and 75bpm and maybe even 60bpm, corresponding to blocks of 2:1, 3:1, 4:1 and 5:1. It might stick on one of those rates for a while, maybe hours or days, but it can also hop around between them as quickly as every successive beat. When it does that, it looks quite like Afib, but it's not. At a quick glance you get the impression of randomness, and you can't see clear p-waves, so it looks like Afib. Even on a 12-lead EKG a cardiologist might think it was random, since you usually only have 10 seconds of trace. A longer trace shows it better.
If the intervals between beats all seem to fall into 2 or 3 possible values, especially if they correspond to approximately 150, 100, and 75bpm, rather than being completely random, then this is suspicious for fluttter.
You won't see any of the sawtooth waves clearly on a 1-lead. If you get a Kardia 6L you can see the sawtooth waves. This is probably the best way to diagnose yourself at home.
When I first got flutter I sent the EKG to the Kardia expert diagnosis service, which is supposedly a board-certified cardiologist, and they said afib. My cardiologist later looked at the same trace and said no it's flutter, for the above reasons. Had a flutter ablation a year ago and no recurrence since then. Ran the Boston Marathon in April with no issues.
Could you have just had flutter the whole time? It's possible. When I looked back at all my old "afib" EKGs, the vast majority now looked like flutter to me. But I definitely had some afb too. Will attach an EKG from a long flutter episode last August. Looks a bit like Afib, but this was flutter with variable block.
Atrial Flutter with variable block
In view of your impending ablation, your questions are irrelevant. The EP will deal with what he sees.
I had a planned ablation for longstanding AF,strong history of AF maternal sude. Mum and Granma died of AF stroke .
I had ablation for AFib and AFlutter at same time
AFib work much longer AFLUTTER minutes( although for me problatic due to mix up with pain relief.
While waiting for intervention, after a long trial of wait n see and medication, I was rushed in with crazy heart rate ( 230)
Apparently established AFib can trigger atrial flutter.
I felt awful in Flutter,much more than Afib.
NO flutter now,rare A,fib and much improved Ejection fraction( pumping action of heart..normal range 55 to 60,which mine is now post ablation, normal range.
I have heard that ablation for A Fibrillation, rarely, triggers Atrial Flutter.
But here's the good news. AFlutter is 95 to 97% sorted with a CTI line( heat made circuit breaker across the path, like cutting an electrical circuit)
Never had a single blip AFLUTTER since the same day 2022.
So I say, forget any meds offered fir Afl.pretty useless really.
AFib..flecanide can be our friend
So yes Afib and AFlutter can easily he done at same time, successfully like me
Thanks - appreciate all the replies. One more question which is more technical about the ablation and one of the replies hinted at this. So in the procedure do they excite the signals in some way to see the sources to know what exactly they are fixing?
Yes they electrically "pace" your heart at a range of high rates to see if the flutter will get going and self-sustain. Typically they go up to 300bpm.
I don't think you always see any sawtooth pattern on a single lead ECG, especially when other arrhythmia is happening concurrently. It sounds as if you are being well looked after by the doctor and specialist. AFl is a conduction issue in the right atrium, usually, with AF and ectopic beats from the left. The ablation will deal with both areas.
AFl at 5:1 induction would be around 60bpm, fixed and increasing non-linearly (i.e. in fixed stepwise jumps) perhaps from emotional stress or physical exercise to 4:1 or more, i.e. moving directly from 60 > 75 > 100 > 150.
I likely have both on occasions, and my son's colleague has been told the same.
I seem to remember that when I first was diagnosed, the doctor had to inject something called adenosine to allow the sawtooth pattern to show to confirm it was AFl.
I've just read that adenosine slows AF and AFl and allows a more accurate diagnosis to be made. It was when it first started in 2019 and I was admitted into A&E with very fast atrial flutter.
I was initially diagnosed by a cardiologist in hospital with flutter, my heart rate was very fast at 172bpm. I transferred to an EP who looked at my ECG reports and said I had AF and possibly flutter (apparently it can be confused and may look similar on an ECG - according to my EP). I suffered on and off for 4 years with meds not really working and episodes of AF for up to 36 hours.
I had an ablation in March this year (I was terrified and almost jumped off the trolley going down to the cath lab).
Whilst having the ablation I went into flutter and they ablated both at the same time, so I wouldn't worry too much, they will do whatever is necessary. Technology and the mapping due they use during ablation is very good in picking up any arrythmias I understand.
It's possible that you have AF and flutter, I certainly did.
I'm guessing that you've stopped the red wine? Alcohol certainly can trigger AF. I had to give up swimming as it would put me into AF. Are you saying that you still continue your cycling even though you know it causes your AF?
Artificial additives (especially sweeteners) were one of the causes of my AF but I'd had ablations before I realised that. Ablations are not always the wonder cure we think they will be, after each of my first two my AF became worse, a third did help but I'm now in constant low rate AF between 60-90bpm have been for almost 5 years. I totally avoid all of my known triggers.
I have moderated my exercise intensity, as it’s the high HR (160+) where I feel I start skipping beats. Also a beta blocker prior to going out as this also helps keeping it lower. On a high intensity ride I would previously come back with 140 avg and now would be 120. It’s a long way down from where I used to when running (in 2018 was 175 avg for the last 30 mins of a race).
I don’t drink much red wine anymore (maybe a glass a week if I’m lucky) and don’t exercise the morning after.
One other variable which is harder to judge is that any cold (including very early stages) seems to reduce the threshold.
I can live with the reduced intensity now and manage the AF - but I’ve seen how my Mum struggles with multiple drugs and side effects to manage hers - and it’s a well known progression from where I am to where I will be when I’m older. I certainly won’t be using this to go back to full intensity - hopefully I just won’t be so worried about whether I am going to go into AF and then how long it lasts for.
This forum is certainly one of the most useful to have ever come across - so really appreciate everyone’s input.
Yes, this is a great forum. It's often best to hear from members here who have experienced AF than someone who hasn't. Before my first ablation I asked my consultants registrar how long it would be before I could climb mountains again and was told the next day. Definitely not true, the heart has to heal inside and form scar tissue to block the rogue beats. Mind you my first ablation was 13 years ago.
I used to cycle with a group too and also did cross country running (hashing). Could never understand why I was always last! Once diagnosed I knew. My AF would last for days and knock me out energy wise. I'd also take days to recover from an attack. Am I right in thinking yours doesn't do that?
Hope this gets to you in time, as it's Monday a.m.PVI Ablation can do flutter and Fibrillation at the same time, I had this. Once they are ' in' they can thoroughly investigate odd behaviour and address it.
No flutter at all since 2022,touch wood. 4 or so episodes of AF which unfortunately means I stay on flecanide.
PVI done - on Monday morning and discharged late Tuesday. Apparently all went well - no AF and the odd lumpy beat but nothing out of the ordinary. Doesn’t appear to have affected my resting HR - still sitting here on the lounge at 51 bpm.
Still residual sore throat (feels like the food is slower to go down), groin a bit sore but otherwise ok.
Allowed to walk but no cycling or running for two weeks. Amazed at how high tech the operating theatre was. I think the total cost (most covered through insurance) was $27k - a bit more than the $8k or so I googled in the early days.
I’ll let you know how I go when I start doing some miles - looking forward to beta blocker free rides (zone 2 of course)..
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