A-Fib Patient Story #84
PVC-Free After Successful Ablation at Mayo Clinic by Dr. Mulpuru
By John Thorton, as told to Steve Ryan, December 2015
“Well, I am now home from the Mayo Clinic. I cannot give high enough praise to the way Mayo treated me. The nurses were outstanding, and the delivery of care exceptional. The Mayo philosophy and attitude is far superior to the way the local hospital does things.”
Difficult Ablation with Multiple A-Fib, Flutter and PVC Spots
On July 27, 2015, John had his ablation procedure at the Mayo Clinic.
Besides A-Fib and A-Flutter, a particular problem for John was PVCs. Premature Ventricular Contractions (PVCs) are premature beats that occur in the ventricles, i.e., the heart’s lower chambers. (Premature beats that occur in the atria, the heart’s upper chambers, are called premature atrial contractions, or PACs.)
John’s ablation turned out to be quite an extensive procedure. Dr. Siva A. Mulpuru found two sources of PVCs, two spots A-Fib was originating from, and one where atrial flutter was found.
The ablation took six hours which was much longer than a typical pulmonary vein ablation/Isolation (PVA/I).
High Density PVCs and Low Ejection Fraction
John Thornton: “According to Mayo, if PVCs are over 20% of your heart beats, they are dangerous. Mayo calls that level ‘high density PVCs”. High density PVCs cause your heart muscle to weaken.
My high density PVCs were 30% of my heart beats, and my ejection fraction was down to 41%.
[An ejection fraction (EF) below 50%, means your heart is no longer pumping efficiently to meet the body’s needs and indicates a weakened heart muscle.]
After the ablation, my PVCs were down to 15% of my heart beats, and my ejection fraction was back up to 64%.”
[Spot on! A normal ejection fraction is in the range of 50 – 65%.]
My Heart is Beating Normally Now!
“It’s now December 2015 and I am still A-Fib free. I do have occasional PVCs still, but no where near the extent of what I had prior to the ablation. I am almost completely without symptoms of any rhythm problems. I’m still on a beta blocker and a blood pressure med.
Do NOT listen when doctors say PVCs are harmless.
The local MDs (about a half dozen different ones), cardiologists, EPs, and other local specialists, all told me stuff like, “Everyone has PVCs” and “PVCs are benign” and “It is just anxiety” and “You just need to learn to live with it” which was completely WRONG.
Be Assertive, Even Aggressive: I had to set up my own appointment at Mayo to get evaluated there. It was a lot of work, by me alone, to get in to see the doctors at Mayo, but it was worth it.
I honestly believe that had I not gone to Mayo I would have suffered some major heart event, or possibly death.
Follow-up and Changing MDs: Many of the local MDs are not receptive to me now. I had to change my local cardiology group to one where they would listen to the recommendations from Mayo.
I had to interview local doctors to find one willing to listen to Mayo’s staff and order follow-up tests for me. Simple things like ECGs, lab test, etc…
I am planning all my major follow-ups back at Mayo because of the stress between the locals (with the one exception) and the people at Mayo.
One Final Thought: If in doubt, go to the Mayo Clinic and get checked out. They know what they are doing and are the real experts.
Feel free to email me if you have questions about PVCs and/or the Mayo Clinic.”
John Thornton, Sioux Falls, SD
To learn more about PVCs, see my article: FAQs Coping with A-Fib: PVCs & PACs
Like John, don’t be afraid to fire your doctor! To learn how to interview doctors, see our page: Finding the Right Doctor for You and Your A-Fib.
PVCs aren’t always benign and, especially for people with A-Fib, should be taken seriously. Often they precede or predict who will develop A-Fib. They can increase chances of a fatal heart attack or sudden death. Sites in the heart that produce PVCs can be mapped and ablated just like A-Fib signals.
Kudos to John for being his own best patient advocate, for taking the bull by the horns and dealing with his PVCs which were destroying his life and driving him crazy. In spite of what he heard from everyone else, he persevered and went to probably the best center in the US for treating PVCs—the Mayo Clinic. Now he’s A-Fib free and only has occasional PVCs. Way to go, John!
In his 2015 AF Symposium presentation, Dr. Pierre Jais makes reference to the typical progression of a catheter ablation procedure. You may ask, what does he mean? What is the typical progression of an ablation?
Goals of Catheter Ablation for A-Fib
Just a reminder: the main goals of catheter ablation of A-Fib are to restore the heart to normal sinus rhythm and eliminate the symptoms of A-Fib. This also relieves the patient from the associated risks such as blood clot formation, stroke and increased risks of dementia and mortality.
The main goals of catheter ablation of A-Fib are to restore the heart to normal sinus rhythm and eliminate the symptoms of A-Fib.
Progression of a typical ablation for Persistent A-Fib:
• First, the sources of the rogue A-Fib electrical signals are mapped using a computerized system.
• The tip of the catheter is then maneuvered to the various sources of the A-Fib signals (usually starting with the openings to the pulmonary veins). Using RF energy (or Cryo) a tiny burn or lesion is made at each location to disrupt (or ablate) the electrical pathway.
• As the series of lesions progress, more and more of the A-Fib signals stop. OR, A-Fib signals may transition into Atrial Flutter which is a more stable and less erratic heart rhythm.
• At this point it is not uncommon for some A-Fib signals to continue. So, one or more rounds of mapping and ablation may be required to stop any remaining sources of arrhythmic signals.
• Finally, the heart typically transitions to either a stable atrial tachycardia (a fast, but regular heartbeat) OR transitions into normal sinus rhythm (NSR).
After the Ablation
While many patients will be in normal sinus rhythm (hurray!), some patients will be in stable atrial tachycardia (a fast and regular heartbeat)—but here’s the important part— they are NOT in A-Fib. This is still a good result!
Why? If you’re in stable atrial tachycardia, with rhythm or rate control medication your heart will typically heal itself over the following three months—called the ‘blanking period’ (or up to a year) and on its own return to normal sinus rhythm (NSR). (That’s why you shouldn’t rush to decide if your ablation is a success until several months post-ablation.)
For more about catheter ablation see, The Evolving Terminology of Catheter Ablation
See also, Dr. Pierre Jais’ 2015 AF Symposium presentation “The Spectrum of Atrial Tachycardias Following Ablation of Drivers in Persistent AF.”
Jeff Patten’s A-Fib started briefly in 2000, then returned in 2010 when his father-in-law died. The emotional upset, high summer heat, stress and accumulated age, followed closely by a bout with appendicitis, put him back into A-Fib .
In 2012, came a successful CryoBalloon ablation. But Jeff’s post-ablation recovery on Pradaxa turned into “alimentary torture” and burning diarrhea. Later came a Right Atrium Catheter Ablation for PACs/PVCs. Learn how Jeff emerged in 2015 healthy and A-Fib free.
A-Fib Patient Story #78
By Jeff Patten, Ashby, MA, January 2015
My A-Fib started about fifteen years ago.
That warm September day in 2000, I was tired, had a lot of coffee and was trying to finish a heavy shrub transplanting job. Sweating and breathing heavily, I noticed my heart was not doing what it should.
Alarming! Dehydration?? A couple of hours in ER and it normalized on its own.
After a couple more brief episodes, I decided to get back in better shape – slowly and judiciously! I’d always been active and couldn’t understand why the ole’ ticker was failing me now. They called it lone paroxysmal atrial fibrillation, so there was nothing else wrong.
Flecainide “Pill-In-The-Pocket,” Propafenone, Then CryoBalloon Ablation
The next decade saw no more episodes.
Then, in 2010, my father-in-law died. The recipe of emotional upset, high summer heat, stress (there was a lot of heavy “estate” to handle), and―as they tell me―accumulated age put me back on the A-Fib merry-go-’round.
My A-Fib was very symptomatic with erratic chest pounding, weakness and breathlessness. I took Life easier, and the A-Fib eased―until that autumn’s bout with appendicitis!
My EP put me on flecainide as a pill-in-the-pocket. That seemed to work for a while―until it didn’t
In December 2012, I had a pulmonary vein isolation (PVI). My EP used the newly approved CryoBalloon catheter.
Recovery: A-Fib free, but Pradaxa “Alimentary Torture” and Burning Diarrhea, Switch to Xarelto
After my ablation, I was put on a double dose of the proton pump inhibitor omeprazole (Prilosec), which is done on the theory it will help prevent the very unusual but deadly side effect of PVI known as atrioesophageal fistula by reducing erosive inflammation.
Since my INR numbers on warfarin were hard to control and there was concern about warfarin’s deleterious effect on vascular calcium through its action on vitamin K, I was put on dabigatran (Pradaxa) as an alternative.
Pradaxa comes in a special container to control moisture. The pills must be tossed if not used in four months once opened. They are awkwardly large. They must be taken twice a day. They are formulated with tartaric acid to help absorption. Everyone who takes Pradaxa must contend with all this.
Pradaxa was alimentary torture. Burned on the way down. Burned in my stomach and belly. Burned with diarrhea on the way out.
After six days I called for help and was switched to rivaroxaban (Xarelto). This is a small pill. Tiny, really. No particular moisture issues. No unusual expiration. Once a day. No burning. But the diarrhea continued for more than a couple of months.
Lymphocytic Colitis: From Taking Omeprazole (Prilosec) and/or Pradaxa?
As soon as my ablation was deemed ‘successful’, meaning that I was able to come off my doses of propafenone and Xarelto and omeprazole, I had a colonoscopy to check out the continuing diarrhea.
Diagnosis: lymphocytic colitis. I did a bit of research on this and discovered that very little is conclusively known about this increasing public problem. It is understood that there is an association between this colitis and the use of proton pump inhibitors among other meds such as non-steroidal anti-inflammatories. The diarrhea gradually subsided.
This Pradaxa/omeprazole story is one anecdote. No scientific conclusions can be drawn. I know what I personally conclude about it, however!
Ectopic Beats Turn into Flutter, RF Ablation
The ectopic beats following the ablation got worse.
PACs and PVCs are supposed to be normal and benign. Sometimes mine seemed to string themselves together for a bit. Then in July 2013, they didn’t quit. A heart rate of 130 at rest sent me to the E.R. where I got a diagnosis of atrial flutter, a successful cardioversion, and an appointment for another ablation.
An ablation in August addressed three flutter ‘circuits’. Careful electrical mapping was used this time, and RF-energy was used to break the ‘circuits’. Apparently flutter such as this often follows on the heels of an A-Fib ablation. Not fully understood. Yet.
So far, so good. I’ll let you know if anything more of interest happens.
Pradaxa and Stomach Problems: It’s unfortunately not unusual to experience the intestinal tract problems Jeff had when taking Pradaxa. Pradaxa’s own fact sheet states the common side effects of Pradaxa include:
• Indigestion, Upset Stomach, or Burning
• Stomach Pain
In Pradaxa’s clinical trials, nearly two out of five people (35%) could not tolerate Pradaxa, which is a high rate of adverse reactions. In an earlier post I wrote “Based on the clinical trial data, there is a danger that Pradaxa over time may cause long-term damage to the gastrointestinal system.” (See The New Anticoagulants [NOACs], 2013 Boston Atrial Fibrillation Symposium). This may be what happened to Jeff when he developed lymphocytic colitis, but we can’t say this for sure.
It’s unusual to be put on a double dose of omeprazole (Prilosec).
Switch from Pradaxa to Eliquis or Go Back to Warfarin: I’d recommend to anyone taking Pradaxa to switch to a different anticoagulant or go back to warfarin if it worked for you. Not only is Pradaxa associated with intestinal tract problems, but it’s been associated with people bleeding to death in the ER. There’s no reversal agent or antidote for Pradaxa as there is for warfarin. (See Stop Prescribing or Taking Pradaxa). Eliquis tested better than the other new anticoagulants and is safer.
With the new anticoagulants (NOACs) now available, no one probably should be taking warfarin anymore. Warfarin produces arterial calcification, and also puts patients at increased risk of osteoporosis and bone fractures. (See Stop Taking Warfarin [Coumadin]!!! Switch to Eliquis [Apixaban].)
Flutter after A-Fib ablation: Many EPs include a Flutter ablation along with an A-Fib PVI. It’s relatively easy to do compared to a left atrium PVI and only adds around 10 minutes to the ablation procedure. It involves making an ablation line in the right atrium (Caviotricuspid Isthmus line) either before or after entering the left atrium. But other EPs are reluctant to make any ablation burns in the heart that aren’t medically necessary. If someone isn’t in right atrium flutter, they wouldn’t do a Flutter ablation. (Personally if I had a choice, I’d ask the EP to do a right atrium Flutter ablation as long as they were already ablating inside my heart anyway.)
However, Jeff had three Flutter circuits which probably meant that some of these Flutter circuits did come from the left atrium. Flutter can develop after an A-Fib ablation or be found later after the inflammation of the ablation scarring settles down. That’s why Jeff needed a second ablation which was RF rather than CryoBalloon.
Oct 2015: FDA Aproves Reversal Agent Praxbind® for the Anticoagulant Pradaxa
The FDA granted “accelerated approval” to Praxbind®, a reversal agent (antidote) to Pradaxa®. Praxbind is given intravenously to patients who have uncontrolled bleeding or require emergency surgery.
If you find any errors on this page, email us. Y Last updated: Sunday, July 17, 2016
21. “Will an ablation take care of both A-Fib and Flutter? Does one cause the other? Which comes first A-Fib or Flutter?”
A typical catheter ablation can fix both A-Fib and A-Flutter at the same time.
It’s relatively easy to ablate for A-Flutter and it’s highly successful (95%). It usually involves making a single line in the right atrium which blocks the A-Flutter (Caviotricuspid Isthmus line).
Many doctors make this line while doing an A-Fib ablation (in the left atrium) even if you don’t have A- flutter at the time.
At the beginning of an ablation, doctors enter the heart through the right atrium. While in the right atrium they make the right atrium ablation line which usually only takes 10-20 minutes. Then they go through the wall separating the left and right atrium (Transseptal Wall) to do an ablation for A-Fib in the left atrium. (They can also make this right atrium ablation line at the end of an ablation when they are leaving the left atrium for the right atrium.)
But others say one should “do no harm” and not make this ablation line if there is no A-Flutter. It can always be done later at little risk to the patient.
Note: Most Maze/Mini-maze surgical approaches don’t access the right atrium, and therefore can’t fix A-Flutter. You have to have a catheter ablation to fix it.
While you can have A-Flutter without A-Fib, more often than not, they are linked. When you have A-Flutter, A-Fib often lurks in the background or develops later.
In a small study people did much better if they had an ablation for both A-Fib and a A-Flutter at the same time even though they only seemed to have A-Flutter.
But right now we can’t say for sure if one causes the other. We do know that A-Flutter usually comes from the right atrium, while A-Fib usually comes from the left atrium.
(I think of Flutter as a better or improved version or form of A-Fib. During an A-Fib ablation, as the EP makes ablation burns, the highly disorganized A-Fib signals turn into the more organized Flutter signals. As more burns are made, the Flutter turns into simple tachycardias. Once the tachycardias are stopped and can’t be induced, the ablation is usually considered finished.)
Kaarisalo, MM, et al. Atrial Fibrillation and Stroke, Mortality and Causes of Death After the First Acute Ischemic. Stroke. 1997; 28: 311-315 doi: 10.1161/01.STR.28.2.311 http://stroke.ahajournals.org/cgi/content/full/strokeaha;28/2/311.
Thanks to Olivia Levy Wallace for this excellent question.
Return to FAQ Catheter Ablations
8. “A-Fib and Flutter—I have both. Does one cause the other?”
You can have A-Flutter without A-Fib. And of course, A-Fib without Flutter. But more often than not, they are linked.
If you have A-Flutter, A-Fib often lurks in the background or develops later.
But right now we can’t say for sure if one causes the other. We do know that A-Flutter usually comes from the right atrium, while A-Fib usually comes from the left atrium.
(When Electrophysiologists do a catheter ablation, the first stage of success is to convert A-Fib into A-Flutter, the second stage is to convert A-Flutter into tachycardia. When the tachycardia is stopped and can’t be re-induced, the ablation is considered finished. You can consider A-Flutter as a more organized form of A-Fib.)
Atrial Fibrillation patients often have loads of “Why?” and “How?” questions. Here are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)
5. “What is the difference between “Adrenergic” and “Vagal” Atrial Fibrillation? How can I tell if I have one or the other? Does it really matter? Does Pulmonary Vein Ablation (Isolation) work for Adrenergic and/or Vagal A-Fib?“
14. “I have paroxysmal A-Fib with “pauses” at the end of an event. Will they stop if my A-Fib is cured? My cardiologist recommends a pacemaker. I am willing, but want to learn more about these pauses first.” NEW!
Last updated: Monday, August 8, 2016
4. “Is Atrial Fibrillation different from what doctors call Paroxysmal Supraventricular Tachycardia?”
‘Supraventricular’ refers to the upper part of the heart, the atria. “Tachycardia” means the upper part of your heart is beating faster than normal. “Paroxysmal” means occasional.
“Supraventricular Tachycardia” in clinical practice commonly refers to atrial tachycardia, atrioventricular nodal reentrant tachycardia (AVNRT). Atrioventricular reciprocating tachycardia (AVRT), an entity that includes Wolff-Parkinson-White syndrome. While Atrial Fibrillation is a distinct entity classified separately.
The term “Supraventricular Arrhythmia” most often is used to refer to Supraventricular Tachycardias and Atrial Flutter. In practice, “Supraventricular Tachycardia” is often used loosely to include all arrhythmias in the Atria, including A-Fib.
Thanks to Sol Yuyitung for this question.
FAQs Coping With Your Atrial Fibrillation: Day-to-Day Issues
Coping with your Atrial Fibrillation means a patient and their family have many and varied questions. Here are answers to the most frequently asked questions about dealing with the day-to-day issues of having Atrial Fibrillation. (Click on the question to jump to the answer.)
2. “Is there any way to predict when I’m going to have an A-Fib attack?”
3. “Should I exercise when in A-Fib or skip it and rest? Can I damage my heart if I exercise in A-Fib?”
4. “How long do I have before I go into chronic or permanent A-Fib? I know it’s harder to cure. My A-Fib episodes seem to be getting longer and more frequent.”
5. “They want to do an Atrial Flutter-only ablation, will that help if I possibly have A-Fib as well?”
6. “Is smoking medical marijuana or using Marinol going to trigger or cause A-Fib? Will it help my A-Fib?
7. “During an A-Fib episode, when should I call paramedics (911 in the US) and/or take my husband to the hospital? I’m petrified. I need a plan.”
8. “I have a lot of extra beats and palpitations (PVCs or PACs) They seem to proceed an A-Fib attack. What can or should I do about them?”
9. “How do I know which is the best A-Fib treatment option for me?”
10. “When my husband has an Atrial Fibrillation episode, what can I do for him? How can I be supportive?”
11. “How can I tell when I’m in A-Fib or just having something like indigestion?”
12. “What kind of monitors are available for atrial fibrillation? Is there any way to tell how often I get A-Fib or how long the episodes last?”
13. “I’m an athlete with A-Fib and have a naturally slow heart rate. My doctor says I need a pacemaker because my heart rate is too slow.”
14. “Can excess iron in the blood cause Atrial Fibrillation? How do I know? If I have Iron Overload Deficiency (IOD), what can I do about it?”
15. “Can too little iron in the blood (Anemia) cause Atrial Fibrillation? What can I do about iron deficiency?”
16. “Is it possible to have a single A-Fib attack and not have any others? I had a single episode of A-Fib and was successfully converted in the ER with meds.”
17. “My mom is 94 with A-Fib. Are there consumer heart rate monitors she can wear to alert me at work if her heart rate exceeds a certain number?”
18. “Can I have A-Fib when my heart rate stays between 50-60 BPM? My doctor tells me I have A-Fib, but I don’t always have a rapid heart rate.”
19. “I’m in Chronic A-Fib. Can I improve my circulation, without having to undergo a Catheter Ablation or Surgery?”
20. “In one of your articles it said that having an ablation was better than living in A-Fib. I’ve been taking 75 mg of propafenone 3X/day for seven years and have only had 5 A-Fib attacks in 7 years. If your article means all types of A-Fib [including Paroxysmal], then I will consider an ablation.”
21. “Both my uncles and my Dad have Atrial Fibrillation. I’m 50 years old and so far I don’t have A-Fib (yet), but I’m worried. How can I avoid developing A-Fib? Can dietary changes help? Or lifestyle changes?”
Last updated: Sunday, March 27, 2016
Return to Frequently Asked Questions
5. “I definitely have A-Flutter and possibly A-Fib as well. They want to do an A-Flutter-only ablation on me. Will that help me?”
Probably not. We now know that, in general, A-Flutter originates in the right Atrium, and Atrial Fibrillation originates in the Left Atrium.
A right atrium ablation for A-Flutter does little for A-Fib. If you have both A-Fib and A-Flutter, but only have and Flutter-only ablation of the right atrium, it’s estimated the success rate for curing A-Fib is only between 5% and 10%.1
You’re probably wasting your time and undergoing needless risk to do an A-Flutter-only ablation when you also have A-Fib. Some A-Flutter may originate in the left atrium, or the A-Flutter may mask A-Fib which may appear later after a successful A-Flutter ablation. As many as half of all patients ablated for A-Flutter may later develop A-Fib.
But what if you have Atrial Flutter only and don’t have A-Fib? A Flutter ablation in the right atrium is relatively simple and doesn’t take much time.
In my opinion, an A-Fib ablation in the left atrium should normally be done at the same time as a Flutter ablation.
- Takahashi Y et al. “How to interpret and identify pulmonary vein recordings with the Lasso catheter.” Heart Rhythm 2006;3:748-750. (Last updated 8/9/2010)↵