I'm considering pulse field ablation for my dad and he is 72 with persistent AF. EP has suggested that he is a candidate for ablation. The risks are high and success rate is only 60%. I just want to understand if it is possible to manage AF on medication for long term. He is happier not having to go through the procedure. He doesn't mind having a cardioversion so he will go ahead with that to try and bring him back to sinus rythm.
How many cardioversions can a person have in their life?
Cardioversion is not without risk. Nothing is! That said I had at least four over the years, some of which lasted for a few months, one over a year and there are members here who have had a great deal more.
Personally I don;t think ablation has any greater risk and had my last in 2019 at age 74.
Ablation is invasive so worried about oesophagus damage, heart perforation etc. Just weighing the options as it may reduce his quality of life if there are complications. I understand that taking all the drugs can take its toll on the body.
Doctors keep saying AF is not life threatening so that suggests meds could work long term.
I thought that PFA was said not to carry those risks as it uses no heat.
Steve
I believe PFA is selective so it has lower risk than other ablations for oesophagus damage and heart perforation but it still had a risk. It's only based on what I read so an EP would be able to confirm.
actually my GP told me that AF is life threatening I have permant af welll controlled withvapixoban and verapamil was diagnosed roughly ten month ago I feel perfectly well though have no other heart issues apart from AF but when I said well it's not life threatening he replied yes it is and went on to say do you want me to lie to you
That's interesting and worrying and is different from anything I have read before. So far as I know, AF is "life threatening" in one area only, and that is a "by product" of the AF itself in that it can cause tiny blood clots to form in a sac in the top part of the heart called the atrial appendage. This then carries the life threatening risk of stroke and embolism. That can be prevented by anticoagulants such as apixaban. I think only a very few sufferers have AF of a kind that risks causing their blood pressure to fall dangerously low so as to cause fainting and the need for IV treatment in hospital.
Steve
AF itself is not life threatening, it is what it can cause if left uncontrolled in some patients. I have experienced an episode of heart failure...pulmonary oedema....some years ago when I did not get a cardioversion soon enough. It could have been fatal.
I think he must be referring to stroke risk.
yes he also told me he also has AF
It also depends if your heart is healthy to begin with. Mine fortunately is. It’s important to keep rate under control and within range, so as not to put extra strain on the heart. My cardiologist told me it wasn’t life threatening. It’s important to keep it managed and controlled, as we all know.
Hi
You have not given us his delimma of AF.
High Heart rate or low? What drugs for control?
BP high or low ? What drugs does he have.
Side effects of AF and meds.
Do fill us in please. We can give our experiences.
BBs did not control my high Heart Rate. 186 on Metoprolol. Breathless, Pauses at Night with Heart Rate 47avg bpm.
Introduced CCB Calcium Channel Blocker Diltiazem to reduce Heart Rate. Bingo shot it down to 51 within 2 hours. But 1/2 dose 180mg AM too much.
Now
AM Diltiazem 120mg CD. controlling H/Rate Day to 60s.
PM Bisoprolol 2.5mg controlling BP. Now 120-135 /. 82
PRADAXA 110mg x twice my chosen anti-co.agulant
I have been on this regime for 2.1/2 years.
2 operations (not heart) urgent - later. Anaesthetists pleased.
cheri JOY. 75 (NZ)
Hi thanks for this. Sorry should have said that his details are on my profile.
As Professor Richard Schilling once stated, "Any and all treatment for AF is about quality of life. " I would add, "so long as rate is well controlled and the patient anticoagulated where appropriate,"
Uncontrolled rate in AF can lead to heart failure and lack of anticoagulant to stroke and possible death but as I said nothing is without risk. Not even doing nothing. Life is a risks/reward equation but I understand we are all different in how we view and assess that equation so it is up to your father , after due diligence, what he wants to do. That said, after seventeen years of AF Association the number of successful procedures reported far exceeds the number of complications. Consider too that you are only told of the possibility so you can't sue the doctor if it did happen.
How many cardioversions can a person have in their life?
Probably patient specific determined by the benefit as directed by the doctor. Some forum members have had several.
Cardioversons are not considered a permanent "fix" though a few may remain in NSR. Most often they restore to NSR with follow up antiarrythmic drugs to hopefully maintain the NSR.
As BobD often says, treatment is really is about quality of life and the fact that afib can progress. Often, more than one ablation is required.
Would encourage to do more research perhaps to include a second opinion, 72 is not considered a negative in being a candidate for an ablation depending on other health issues.
Best to your Dad !
You're probably speaking to the right person here re cardioversions! I had my 28th just over 3 months ago and I shall be 80 in a few weeks time. These cardioversions have been spread , albeit somewhat unevenly over 30 + years. I don't know of anybody whose has had more but I expect there are.
As far as ablations go I had my 5th ablation 3 months ago. This was an endo/ epicardial procedure where the EP accessed heart through keyhole in chest wall as well as catheter entry through the groin. It went well.
As long as you are reasonably fit there doesn't appear to be a limit but I accept that I've reached mine! If I thought there were high risks I wouldn't have gone through all this.
These procedures are common place nowadays. Just make sure that the person performing the ablation is experienced. I hsve been very fortunate in having the same EP for all 5 of my ablations and follow ups since my first procedure over 15 years ago.
Thank you for sharing. That's a lot of procedures! You must be an incredibly brave lady. Sorry for asking all these questions.Did the ablations keep you AF free for a few years?
Did you have persistent AF to have the cardioversions and ablations?
Were you treated on NHS and if so that gives me hope.
Good morning Priya!
Yes , I was treated on the NHS for all my Cardiac procedures. I'm very grateful that my EP never gave up on me. Bear in mind though that I was a difficult case and refractory to drug treatment.
The ablations left me mostly AF free for up to 2 years , some less . I was getting rates up to 240+ bpm before my 4th ablation so that kept the rates down to under 200, many 140 ish.
My episodes were persistent ie they would not revert to sinus rhythm without intervention. All of my cardioversions were ' emergency' as opposed to ' elective'. They were as a result of presenting at A&E with unrelenting fast AF (or flutter) which could not be brought under control. So no waiting lists for me.
Hope that helps with making a decision. I'm happy to answer any questions you may have!
Best wishes
J
Hiya priya_uk
I was diagnosed with paroxysmal AF in Jan 2010, aged 65. I have been following the medication line ever since. On discharge from hospital back in the day the Cardio Consultant who had been treating me discussed a number of ways forward - one was an ablation which I rejected out of hand. He duly referred me back to the care of my GP. Been on medication ever since. I was referred for cardioversion and on the day I was found to be back in NSR. Why not - its paroxysmal ! I was also originally diagnosed as being asymptomatic at the time !
At the time of discharge I was already on Simvastatin and Ramipril. The Consultant then added to the mix ... Warfarin ( in 2010 these NOAC's like Edoxaban didn't exist for patients, probably still in the laboratory ), and also Bisoprolol 5mg. In 2013 I was then prescribed an additional med ... Felodopine 2.5mg. after I moved to Cornwall.
Bisoprolol has been the only one to give me a really odd issue, ( violent. random, full flow nose bleeds - solved by changing the time I took the medication from morning to night ) even so I stayed on it for over 13 years and last year ( August ) my GP switched me to Nebivolol 5mg. ( still a beta blocker though ).
Earlier this year, March time, my heart started to kick off again and I went private selecting a South African Cardio Consultant who trained and qualified at Groote Schur Hospital, Cape Town. He elected to maintain the medication line I was on but replaced Nebivolol with Sotalol 40mg morning and night ( a total of 80 mg a day ). And so .... hey ho ... all is well .... the only side effect that I find annoying is the tiredness , but then, I've had that with Bisoprolol and Nebivolol too over the years.
Still alive to tell the tale despite my new Consultant still agreeing with the original diagnosis --- paroxysmal and asymptomatic. My Sotalol meds are up for review next month. I must say though, throughout my life I have never had side effects from any drug I've been prescribed ( except Edoxaban ) and I have made my GP very clearly aware that I will never take it or any of its 3 other buddies ever - so don't go there I told her.
Also, looking back on your post - I retired formally at 65, but got bored after a while and went back to bus driving..... I've remained a bus driver ever since finally retiring on 5 July 2024. Yes, even while taking all this medication - which as we write consists of Simvastatin, Sotalol, Ramipril, Felodopine and Warfarin ... basically all the same classes of drugs as I kicked off with in 2010 just changed with a slightly different emphasis to problem solving.
Like Jalia I turn 80 in a few weeks.
Good luck and success with your Dad. Any questions, ask away.
John
Hi John, thanks for sharing. You are amazing, driving a bus whilst on these medications is truly remarkable. The fact that you have managed with meds gives me a lot of hope and also gives my dad an option.
In a previous post you shared how you measure INR at home so that was very useful in case he has to change apixaban to warfarin.
Hi priya_uk,
I should have said that right from the get go I declared my AF to DVLA and my medication. Life got more tedious as I shifted into my 70's as I then had to have a medical annually ( a DVLA requirement for bus drivers ) , but even so everything was declared to DVLA, including the name and address of my GP and my employer. My only medical conditions were and still are AF ( al beit, highly controlled ), and osteoarthritis in both shoulders.
If you go down the Warfarin road you will need to find an INR Clinic near you, ( in my case my surgery has its own INR clinic staffed by two nurses who do all the work on their computer ). Maybe your own GP Surgery has its own INR clinic but you just don't know it maybe because it has never been a concern in the past.
In my case my INR clinic establishes a base line INR test date. I do the test, first thing in the morning, phone the result into the Clinic. The Clinic phones me back a few hours later, tells me the new dose and the next test date. Every 10 weeks we agree that I take my device into the INR Clinic and we do a joint test .... I do a pin prick on a finger and squeeze drop the blood onto the Clinic Test Strip and from the same puncture wound on the finger of choice onto my Test Strip. We then compare the reading results ... historically the difference is usually +/- 0.01 between the two devices. So that way we keep a check on the accuracy of my device.
The cycle just keeps repeating over time. I do suggest you 'Google' a subject such as Food and Warfarin or Food and INR and have a look at thoughts on diet. I'm very fortunate in that food and drink, particularly alcohol, have no bearing at all on my INR test results. (I'm as normal as a grumpy 80 year old git can be 😂😂😂 ). The UK website BANT have useful stuff on diets.
Roche are the manufacturers of the Coaguchek XS PT system that is pretty universally used these days and you may wish to do some research online through their website ( or any other for that matter ). Once you get used to it, its as easy as falling off a log. After all these years and study of Wafarin and how it behaves I can now confidently self dose and determine my own test dates. As I may have said previously I have had three medical procedures which have required me to stop and restart Warfarin ... again, no sweat.
Anyway, going forward I wish you well in any process you opt for.
John
I have been on Flecainide - metoprolol for 9 years. I'm 69 now. I have an episode on average every 8 months. But if I was having episodes every week I would get an ablation and hope for the best.
My dad was on flecanaide for 7 years. Now that it is persistent we have to decide what to do.
I was getting AF 3 to 4 times a week, sometimes lasting hours or even days and my quality of life was very poor, so had an ablation in May 2018 and have not looked back since, still AF free now 70, my meds for heart related problems is rivaroxaban, which I was informed I would now take for life now, so ablation for me was a no brainer.
Thanks. Good to know you would recommend it.
Had my ablation in March 🤞 still AF free, long may it continue had awful episodes previously
This is the stance of EP John Mandrola, who has performed hundreds of ablations himself:
“AF ablation is a big deal. It is not for the faint of heart.
• It requires 3-4 hours of procedure time with either general anesthesia or significant sedation and an considerable dose of harmful radiation.
• A harpoon-like needle has to be poked across the beating heart in a patient on blood thinners.
• Over a hundred burns are made in the most sensitive of the heart’s four chambers.
• In low-risk young patients–a minority of AF patients–the procedure successfully eliminates the AF in only a modest two-thirds of cases.
• Almost half of these successes need to have a second procedure to touch up areas that “grow-back.”
• Complications are real. There is a risk of stroke, heart attack, perforation of a perfectly good heart, pulmonary vein stenosis, air embolism, esophageal damage, and of course death. The overall complication rate is low, but since AF is not immediately life-threatening, any major complication becomes even more magnified.”
Thanks for sharing this. When it goes well it's amazing but when it doesn't we don't know how it's impacted quality of life for patients.
Gosh, if everyone read and believed all of this I would think no ablations would be carried out I had a long discussion with my 'highly regarded Professor EP' who informed me of the risks and benefits. I decided I couldn't continue with severe symptomatic episodes lasting 36 hours, it was controlling my life.
I had the ablation in March and whilst the first few weeks were uncomfortable with some digestive issues things settled down and I have been AF free ever since.
Yes, it's not for the faint hearted but give me one procedure/operation that is without risk
Thanks for sharing your perspective.
My EP told me that age 70 in their team was considered young and they perform many cryoablations for people in their 80s. I was glad to get out of persistent AF and have been enjoying NSR ever since. If I ever need another ablation I’ll take that tiny risk. In the end we can only face those tiny risks involved in every medical procedure for ourselves.
it’s harder to answer not knowing his background but I’m still exploring Ablations. The PF ablation is newish and approach lot quicker and less risks. I’ve read that results are on par but not better than RF ablations. When they did the Study I believe it was Generation one technology, some manufacturers are now on Generation 3 models. It would be very interesting to see comparisons if other studies are done. In addition there is an Australian company Imracor that had developed an MRI guided Catheter which promises to be far more accurate than the current methods I think using Xray. It has commenced trials in a major US Hospital on patients with Atrial Flutter and also in Europe. I am watching keenly and waiting to see results. The idea being the doctor can see much better detail and therefore 2nd and 3rd ablations might not be required
I am 66 and have had 3 episodes since 2022 and 3 cardioversions, prior to that the previous 30 years one AF episode on average every 5 years. So the point is my triggers were and are alcohol caffeine over eating and stress. I’ve managed that now and have always kept fit which could be the reason my episodes were so spaced out or I could be just luckier than some. After the last episode end of January I decided to try very low dose Flecainide and low dose metoprolol, so far so good. My doctor jokes that I’m just above homeopathic doses!
I also checked my bloods and was low on Vitd3, magnesium and coq10 and after speaking to Cardiologist he was ok for me to supplement. I now wait and see the advancements in these new methods. Your father will be told if his heart is structurally sound and if so the medication route maybe an option. Certainly the PF appears to have less risks if he decides that route
I have been taking bisoprolol since about 2015. No other interventions. I was put off an ablation at the start by a consultant who told me in a doubtful tone “that ablation was not without risk”. They clearly wanted to put me off and I am not a risk taker. I didn’t want my heart zapped either. So I have pursued the meds route. No regrets at the moment. Hope you work out your way forward.
I'm 73 and awaiting my 1st ablation after cardioversion onlyvwirked for a few days....prev one had lasted 7 years.
My cardiologist said 60% of ppl stay in sinus for a year or more which is different to a 60% CoS. That said all are different so only your fathers cardiologist can verify that. That figure can apparently be improved on with weight loss/exercise, tho again cardio advice may vary depending on other conditions.
I have mistakenly replied to Bob (whose opinions I always value) in this thread but I meant to reply to you!
hi I agree with leechg I permant AF well controlled with med feel perfectly well no other heart issues never had ablation or any other procedure mentioned to me personally I'd avoid surgery unless it was absolutely necessary
Thanks for sharing your perspective.
This is such a tough decision for you and your father ...
I personally have an aversion to invasive procedures, neither am I keen on medication, however I can see from these posts that for many there comes a time when AF is too frequent and intolerable, or the drugs are intolerable .. so the choice is a matter of QOL ...
Would I want to stay alive feeling horrible all the time, or take that risk? It's a hard one, many on this forum are lucky and have a positive result from ablation, some not so much ...
I don't know what the statistics are of success and failure, if they exist?
For me PAF happens every month or two and is horrible. The PIP Flecainide that gets me out of it, has a disturbing after effect. Reading these posts I realise if the episodes were more frequent or lasted longer I would also be pushed to consider ablation.
Thanks for your post, and to everyone for sharing their experience - it's helpful.
Bear in mind Priya that anticoagulants in PAF reduce the risk of ischaemic stroke by only 60%. Ischaemic strokes are considered the most disabling.
With time, a consensus will form around surgical intervention in AF.
Until then, my opinion is that patients need the very best available advice from EPs in the USA, Bordeaux or Japan.
There is no substitute for the accumulated expertise in a particular technique of a given top EP who I imagine is driven more by reputation than revenue.
The stamina demanded for 3-4 hour procedures will take a significant toll on a man older than 55.
Gosh I wasn't aware antocoagulnts only reduced stroke risk by 60%. Thanks for sharing that.
I have expanded on my post above and would be glad of any further comment.
Forgive my presumption, is your father’s reluctance to engage with the forum a reflection of a decision in his mind already taken?
What is your own instinct?
Only reason for him to not engage in the forum is that he is quite frail. He is coping with Psoriatic arthritis without meds since he started Apixaban which is debilitating. His worst health problem is psoriatic arthritis as its an autoimmune disorder. His quality of life has already been greatly impacted by it.
I'm just helping out to make sure he has different perspectives before he makes any decisions. His mind is not yet made up.
He is concerned about any risks from the procedures further debilitating his life. I don't think he would cope if it did hence all concerns.
Arrhythmia after ablation
Persistent AF(ib) after Ablation
Afib 4 days after ablation
Feeling rubbish after ablation
