“Wait and See” Approach to Atrial Fibrillation is NOT for Me; New Force Sensing Catheter Ablation by Dr. Vivek Reddy
by Jon Greenspan, New York, NY, November 15, 2013
I was first diagnosed with Atrial Fibrillation during a routine annual physical exam in 2003 (age 52) when my GP looked at the ECG he had just taken. He told me to take a baby aspirin daily and to go see a cardiologist. I experienced no symptoms or discomfort other than irregular beats when I took my pulse for the next few hours.
Atrial Fibrillation “Holiday Heart”
By the time I got to a highly-recommended cardiologist some 10 days later, I was in normal sinus rhythm and subsequently passed the prescribed stress echo test (walking on inclined treadmill while attached to monitor) with flying colors. In a follow up with the cardiologist, she mentioned that, given my history of ‘binge drinking’, the recent episode might have been triggered by some heavy drinking with business clients (sometimes referred to as ‘holiday heart’ in the A-Fib literature). She instructed me to continue taking a baby aspirin daily and to follow up with her if and when episodes recurred.
Compulsively Checking Pulse
Over the next 12 months, I didn’t think much of the incident. I stopped taking the baby aspirin (shaving nicks were bloody impossible to stop) and wasn’t concerned about the occasional, brief (usually less than 6 hours) irregular pulse I noticed after some hard drinking sessions. I did, however, become quite compulsive about regularly checking my pulse and gradually cut way down on the frequency of my alcohol consumption and the amount consumed. My ‘binge’ (7 or more mixed drinks with bad next day hangover) frequency declined from 1-2 x/month to about 1 x/year. And from late 2004 to 2009, I noticed no episodes of irregular pulse.
A-Fib Attacks More Frequent—Hot Tub
In May 2009, after consuming 4–5 beers one evening and spending a brief time in a hot tub, I awoke the next morning and found my irregular pulse was back. It went away in a short time, but over the next several months, the episodes came back about once every 6-8 weeks even when I had consumed no alcohol for a week or more. Usually, the ‘trigger’ was a session in a hot tub or sauna, and I would occasionally experience brief dizziness when getting out. I cut down my alcohol consumption further and made sure to keep my hot tub sessions brief. This seemed to help, and I remained unconcerned.
Longer A-Fib Episodes
By the middle of 2010, the frequency of the episodes had increased to about once every 4-6 weeks, occasionally lasting as long as 20-24 hours. 1 or 2 glasses of red wine became a guaranteed trigger. A hot, dry day on the golf range triggered an episode or two, and I finally became concerned enough to go back to my cardiologist. She was supportive, but fairly unconcerned since my ECG was again normal at the time of my visit. She had me wear a Holter monitor for 24 (or 48?) hours which proved negative, so we adopted a ‘wait and see’ attitude.
Shortness of Breath—Symptomatic A-Fib
Near the end of 2010, a ½ glass of red wine triggered an episode which for the first time was accompanied by a brief shortness of breath and coughing. I stopped drinking altogether. From my cardiologist’s viewpoint, it had not yet even been documented that I had A-Fib, a situation which persisted until another follow-up visit and Holter monitor (4 weeks this time) finally clinically confirmed that I indeed HAD paroxysmal (intermittent) A-Fib in March, 2011. It was only at this point that we discussed prognosis and possible treatment options for the first time. My cardiologist was again supportive but again we adopted a ‘wait and see’ attitude, with possible drug regimens on tap if and when the episodic frequency and/or duration increased further.
It was around this time that my friend’s wife (age 79), under a drug regimen treatment for A-Fib by my cardiologist, underwent ‘curative surgery’ (not recommended by the cardiologist) and abruptly died two days later due to complications from an intestinal blood clot.
I finally sat up and decided “wait and see” was NOT for me, so I began to search online and read everything I could find on A-Fib. Fortunately I came across Steve Ryan’s website A-Fib.com and Medscape.com’s The Heart.org /Arrhythmia & EP.
The bad news was that in many instances A-Fib progresses from intermittent to permanent, and that drug regimens are never curative, frequently became ineffective and at least occasionally have dangerous side effects. Furthermore, individuals with A-Fib are not only at much greater risk of stroke than the healthy population, but this risk increases when untreated A-Fib episodes exceed 24 hours in duration, occasionally to the point where in-hospital drug and/or electroshock regimens may become necessary to restore normal sinus rhythm.
A-Fib Anxiety and Depression
Discovering these basic “A-Fib facts” was a terrifying eye-opener for me. While it was by no means certain that I would follow the typical-to-worst case progression, there was a very real and significant probability that I COULD wind up undergoing electroshock (particularly frightening for me) treatment(s) and WOULD wind up on a lifelong drug regimen. Suddenly, each slightly unsettling A-Fib episode became a huge anxiety-provoking incident. Would the duration exceed 24 hours? Would I have to rush to the ER for drug or electroshock treatment? Would taking anticoagulants (Coumadin et al) cause dangerous bruising and/or bleeding? Would antiarrhythmics damage my liver and/or kidney function?… Luckily, the symptoms, frequency and duration of my episodes only increased very slightly and gradually over time, so the impact on my ‘quality of life’ was virtually exclusively emotional-psychological. I experienced brief, huge relief followed by several days of depression after each incident.
Potential Cure—Pulmonary Vein Ablation
Fortunately, as described by Steve Ryan’s website and confirmed by theheart.org, there was a potential, though by no means certain, cure—pulmonary vein ablation. The more I read about it, the more certain I became that this was the only option for me.
So I looked at Steve’s list for the most highly-credentialed (“FHRS”) Electrophysiologists near my NYC and Florida residences and scheduled consults in June and July 2011 prior to my next follow-up cardiologist visit. Both doctors confirmed virtually everything I had learned from my research on A-Fib, its prognosis and the possible risks and benefits of ablation. The first doctor was ready to schedule my procedure in 1 week, but this was way too fast for my comfort. The second left me convinced of my decision to schedule an ablation, but comfortable in feeling there was no downside in waiting several months or until I was completely comfortable going ahead.
Dr. Vivek Reddy at Mount Sinai hospital
When I met with my cardiologist in mid-July 2011, we discussed a few more details on drug regimens. I asked her for a “pill-in-the-pocket” prescription (Multaq in this case) I could take if my episodes threatened to exceed 24 hours and for her recommendations on who would best perform an ablation should I so choose to proceed. She thought an ablation was premature at that time but that I would likely wind up needing one eventually, and that Dr. Vivek Reddy of Mt Sinai was “the man”. Since I’d seen Dr. Reddy’s name on Steve’s website and in much of the literature as a leader in the field, and my cardiologist could coordinate pre- and post- op care, I knew I’d found the right doctor and facility.
Force Sensing Catheter Clinical Trial
I met with Dr. Reddy in September, 2011 and scheduled a procedure for January, 2012.
I was invited to be part of a study testing the latest RF (radiofrequency) ‘touch’ catheter technology, but in mid-December I found out that I was not eligible since I had not yet met the study’s prerequisite of having been on (and failed) at least 1 anti-arrhythmic drug regimen. While I could still undergo the procedure as scheduled, I would not receive the same intensive post-op follow up as study participants did. My cardiologist and I agreed to try Multaq (despite my fears and dislike of drugs in general and antiarrhythmics in particular, many of which were confirmed by reports and articles on theheart.org) in the hopes I might become eligible for the study. Luckily, my Holter monitor documented an A-Fib episode while on Multaq, and I became eligible for a last minute study opening.
After a sleepless night, I arrived at Mt. Sinai at 6:30AM, January 23, 2012. The Multaq had been discontinued about 1 week previously, at which time I was placed on a Coumadin regimen. After some paperwork and meeting the anesthesiologist, I was wheeled into the electrophysiology lab for the procedure and awoke very groggy after 4-5 hours (a bit longer than normal I was told), in absolutely no pain or discomfort. I was placed in a cardiac step-down unit with 3 roommates for a typical overnight stay. I had to remain motionless in bed for 3-4 hours (to allow time for the bilateral inguinal incisions to heal) before I could gradually, slowly sit up and then stand (it takes a bit of time for blood pressure to return to normal). I experienced some slight discomfort upon the removal of the urinary catheter and brief difficulty/pain in resuming normal urination, but the worst part of the entire procedure was a female roommate whose ‘drunken sailor-like’ snoring kept me awake for the second consecutive night. J
I was released from Mt. Sinai at noon Tuesday after visits from one of Dr. Reddy’s partners and my cardiologist. A concern post-op (other than cardiac complications) is that the bilateral incisions may rarely reopen, which would require an ER visit. This did not occur in my instance, and quite possibly my several days of anxiety in this regard were unfounded. Post-op, I was placed on prilosec (Nexium) and resumed Multaq for 4 weeks, while continuing Coumadin (requiring weekly blood test at my cardiologist) for 10-12 weeks.
I didn’t sleep well for the 1st few nights at home, and the incisions required some gentle dressing change and bathing care, but I was back to work 4 days post-op. I was told not to resume full physical activity for at least 1 week, but I chose to wait 15 days. Some bruising and discoloration persisted in the inguinal area for several weeks, but this was normal and disappeared as projected.
Life A-Fib Free!—No More A-Fib Anxiety
The study I was part of provided a monitor for initial weekly and subsequent monthly recordings which did not need to be worn. I had follow-up visits at 3 weeks, 10 weeks, 6 months and 12 months with my doctors who were wonderful throughout, particularly Dr. Reddy. Other than 3-4 brief (less than 15 seconds) instances of minor palpitations, I remain A-Fib free as of this writing, nearly 15 months post-procedure, taking no medications. I’ve consumed almost no alcohol since 2011, but a rare beer or glass of wine no longer acts as a trigger, nor does hot-tubing or golf on a hot day. The freedom from anxiety and improvement in my quality of life have been spectacular and wonderful.
In addition to the wonderful, compassionate care I’ve received from my doctors and the Mt. Sinai staff, I wish to again express my heartfelt thanks to Steve Ryan whose website provided me with the direction to empower myself to deal with this insidious condition which affects so many millions, and to my wife, Terry, for her love and support.
My Advice to You
I cannot encourage other patients/families/friends enough to be as proactive as possible in dealing with A-Fib.
I’m happy to answer any questions, and best wishes and luck to all who read this.
New York, New York
Jon is a textbook case of how A-Fib is a progressive disease that gets worse over time.
In the Force Sensing Catheter Clinical Trial Jon was enrolled in, he had to have failed an antiarrhythmic drug before he could have an ablation. That is not the case for a normal ablation. According to the most recent guidelines, catheter ablation is first-line therapy; i.e., you can choose to have a catheter ablation without having tried and failed antiarrhythmic drugs. Though most doctors will still encourage you to try meds first, you don’t have to go through the frustration of trying and failing different meds before getting a catheter ablation. See Amazing Evolution of Catheter Ablation Guidelines http://a-fib.com/2013-bafs-evolution-of-catheter-ablation-guidelines/
Note also that Jon did not follow his Cardiologist’s recommendation that “an ablation was premature at this time.” He instead chose to have an ablation by Dr. Vivek Reddy, Mount Sinai Hospital.
A special thanks to Jon for discussing A-Fib driven anxiety and depression. Much more attention needs to be paid to this aspect of having A-Fib. It certainly wasn’t “premature” of Jon to have an ablation in order to be freed from the anxiety, fear and depression A-Fib generates.