Ablation for Persistent (Chronic) A-Fib at Chapel, Hill by Dr. Paul Mounsey, UNC
by Wesley Dukes, 2008
Wes lives in Cary, NC. He worked as a programmer for IBM and RTI International and retired in 2008. Gardening and home projects are his hobbies. He is married (39 years) with a son and daughter living in the area. He grew up on a farm in South Carolina and still owns 14 acres of that land.
Wes first developed A-Fib in October 2005. He was electrocardioverted in November 2005. He still had a few episodes of A-Fib that reverted by use of Rhythmol and a good night’s rest. (In Feb 2007 he decided to lose weight and joined Weight Watchers at Work. He lost 30 pounds to reach his goal, and became a lifetime member. He considers it the best money he ever spent.)
In June 2008 he reverted back into A-Fib due to an adrenaline rush. The rush came from a dream in which he was in a vehicle accident. He woke up at 120 bpm. His cardiologist concluded he was in persistent (chronic) A-Fib, and that he should consider an ablation procedure where they zap parts of the heart to stop the A-Fib. His Cardiologist, Dr. Sunil Desai, recommended he contact a “new guy” at UNC HealthCare in Chapel Hill, NC. That was Dr. Paul Mounsey. It took 6 weeks to get an appointment with Dr. Mounsey and another 6 weeks to get the catheter ablation scheduled. He searched the web on A-Fib and found A-Fib.com to be the best overall site for information.
Why Wes Decided on Pulmonary Vein Ablation
I went a total 360 degrees in my decision making process. I was geared up for ablation and was armed with A-Fib.com‘s questions when I met with Dr. Mounsey. Dr. Mounsey answered most of the questions before I could ask them. I felt comfortable with the ablation, but the doctor’s discussion of Tikosyn had me leaning toward the medication route.
I slept on the decision over the weekend which was good. By chance I emailed Steve at A-Fib.com because the site still had Dr. Mounsey at the University of Virginia Medical, and I wanted Steve to know he was now at UNC.
I told Steve I was leaning to medication, and Steve provided information that convinced me to go the ablation route. I agreed that I had not considered there was no long term data on Tikosyn, and that it could always be a second option if the ablation was not successful. My wife had not let her feelings be known until the decision switch. She told me she thought ablation was the best first choice. That’s why I finally decided on having an ablation.
I had considered going to Dr. Wharton in Charleston, SC, because I met someone locally who had it done in Charleston. But my meeting with Dr. Mounsey convinced me that they both used similar if not identical techniques. Traveling to Charleston would have been a 250 mile trip and a lot of inconvenience for my family. I decided that UNC was my best option. Dr. Mounsey was quite candid and informed me that no procedure was fool proof, and all had risks. He said that what was done during the ablation depended on what they found once they reached the heart and began the mapping.
I recommend the following book as a great help in making medical decisions. THE PATIENT FROM HELL (How I worked with my doctors to get the best of modern medicine and how you can too) by Stephen H Schneider. While it concerns the author’s battle with Lymphoma, it offers a lot of insight into how any medical issue can be customized to a real patient and not a statistical average.
I began writing this account after I returned home from the hospital, but I did not finish it until today. Now it is 7 weeks today since I had my ablation.
I had a Catheter Ablation to eliminate my Persistent Atrial Fibrillation and restore me to Normal Sinus Rhythm at UNC Hospital in Chapel Hill, North Carolina on Tuesday Sept 9, 2008. Dr. J. Paul Mounsey and his team performed the procedure. He had worked at The University of Virginia before coming to UNC Hospital to build an electro-physiology program there.
The Ablation Procedure
I checked in at 7 AM. The last thing I remember is having all these monitoring leads put on me around 8:15 that morning. (I had about 30 extra leads added mainly to my back since I agreed to take part in an A-Fib study that Dr. Mounsey was doing.) They said I was being injected with a sedative to relax me, and man did it. The next thing I know I was having wild dreams and I could hear the recovery room people telling me to keep my legs straight. I kept trying to bend them, and they must have had one person on each leg holding my knees down.
It took me maybe 5 minutes to be able to settle back to reality. I asked the time, and it was 5:30 PM! I had slept the whole day away. I was taken way out with anesthesia and had a breathing tube while unconscious. I probably should have required more information about the anesthesia and breathing tube, but I had been under the assumption I would have something like Versed where I was semiconscious. While they keep some A-Fib patients awake because they have to map areas and induce A-Fib, I was in A-Fib all the time with a mix of normal and fast heart beats. I do remember asking if my anesthesia was all IV, and the Nurse-Anesthesiologist said it would be a mix of IV and gases.
On my Oct 15 follow-up visit, Dr. Mounsey explained that it was desirable to have as shallow breathing as possible during the ablation, and that they did this by using general anesthesia and a breathing tube. I also had a Foley catheter inserted to collect urine. I did have a sore throat for a week or so but nothing excessive. One night I got some Halls cough drops to soothe the throat, and I still have half the pack I was given.
On my follow-up, I asked Dr. Mounsey if I could have had a sedative instead. He said yes, but that there were drawbacks such as if I dropped off to sleep I might snore. The vibrations from snoring could affect the ablations or at least postpone some work until I stopped snoring. I finally decided that though I did not want general anesthesia which may have some increased risk, so did ablation isolations where my movement or reactions could affect the isolations.
All I can say is to be sure before hand what kind of anesthesia you will be having so you will not be caught by surprise as I was a day before the procedure. At the follow-up visit he also informed me that at the end of the procedure they can also increase the depth of the breathing to exercise my lungs to help clear them and improve function before I was awakened.
In The Recovery Room
I remember talking with the recovery room staff, but not a whole lot of detail. They let my wife have access at some point in time, and shortly thereafter I was taken to my hospital room. I arrived and got the regular meal. I don’t remember what it was, but I wolfed it all down with no problem while still being almost flat on my back.
That Tuesday night I was wired, I suppose because I had slept all day. About 9 that night I told my wife to go home as I could get to the bathroom on my own and felt fine. The groin was sore, but once I had reached the required time on my back to insure the catheter punctures were healing and getting the Foley catheter removed, I could move around very well although I was still attached to one IV drip. I asked for an icepack for my left groin. Their “icepack” was very creative. They took two new zip lock bio-hazard bags and double bagged the ice and wrapped it in a towel, which was probably better than the cost of a regular icepack like I bought when I got home.
I had a heparin drip which was removed the next morning. Then I started getting Lovenox injections until my Coumadin level built up. The Lovenox injections are done in belly fat and will leave some bruising. You only get 2 shots a day for 3 days. They made me give myself one injection, because sometimes you are discharged before the last shot is due. I was kept two extra days, so self injection was not necessary. I had given myself allergy injections years ago so it was not much different from those. The needle is very small, and the needle slides in with hardly any sensation. The injection is a good amount though and it mildly stings for a minute or so once injected. On a scale of 1-10 it was a minor irritation at a 2 or 3 at most. These belly bruises were slowest to fade and left a tiny knot where the needle was inserted.
I don’t know if it was the Foley Catheter for urine, or just the effects of anesthesia, but I did not start producing large amounts of urine, and I really had to strain to urinate. I am not sure how much saline I got during the procedure, but I figure it was at least 5-7 liters. When I entered the hospital I weighed around 165 in shorts and T shirt, and by Thursday morning I was weighting in at 187 pounds. Anyway the excess fluid diluted my potassium. Since oral lasix was not working as well as expected, I was put on 80 mg IV Lasix as a diuretic, and potassium was added to replace what I lost. Man did that lasix work. I got the injection at 6 am and by 8 am I had produced 2 liters of urine and lost 4 pounds in 2 hours. I could almost hear the water filling my bladder. The Sodium is not excreted as much, so as I lost fluid my sodium level rose to normal. According to Dr. Mounsey, the saline IV helped keep my heart plump and stable to facilitate better ablation isolations. I have to stay on Lasix because the HCTZ (Hydrochlorothiazidg for fluid retention) I had been taking cannot be taken with my new antiarrhythmic medicine Tikosyn.
Ibutilide, Tikosyn and the Recovery Plan
My ablations alone did not return me to normal sinus rhythm, so Ibutilide (Corvert) was used to convert me. At my follow-up visit I asked if it was preferable to an Electrical Cardioversion, and decided that considering all the ablations it was probably better to get the drug instead of a shock to the heart. Dr. Mounsey also wants to keep me on Tikosyn for 6 months to give the heart a chance to relearn a normal rhythm. I plan to stop it after 6 months to see if I can stay in normal rhythm on my own, but I may have to remain on Tikosyn if I revert. Either that or another ablation. I have 6 months to think about it and I am hopeful I will not need it.
I was started on the largest dose of Tikosyn 500 mcg; but my Q-T interval got too long that they cut the medication down to 125 mcg. I don’t think I was ever on 250 mcg. Going to that level got the Q-T interval back in control. Tikosyn must be taken at fairly strict 12 hours intervals (8 am and 8 pm is my schedule), so I use several alarms to remind me—two cordless phones, the cell phone and a watch with alarm. It works so far. I missed only one dose. I had to modify my rules to take the pill before turning off any of the alarms. One evening I got so obsessed with resetting the alarms that I forgot to take the darn pill. I keep a glass of water ready so all I have to do is grab the pill and swallow it. I was supposed to be released on Friday, but I did not get released until Sunday. After 3 doses of Tikosyn at 125 mcg, my Q-T interval was steady and at an acceptable value.
The Hospital Stay
I ended up being in the hospital five nights instead of the originally planned 3 nights. Because of the two extra nights, I ended up celebrating my 62nd birthday in the hospital. All the hospital personnel were great. The food was institutional though. What really got me was the “standard diet” breakfast meal was eggs, hash-browns, 2 sausage patties and a plain white flour biscuit with white gravy. Not even a whole wheat biscuit! I have to put in a jibe that this was a substandard not a standard diet.
Another aggravation was the mattresses were very uncomfortable, and the bedsore prevention made for random compressor noises all night. Fortunately one nurse told me where the switch was to stop that aggravation. If I have to return to that hospital for any reason, I will be taking my own memory foam mattress topper with me unless the hospital provides a better mattress. Lying on my back, and I think the lack of give in the mattress gave me back spasms that have not totally healed yet. The cure has always been hamstring stretches on my left hip; but that was the leg where most of the catheters were located, so stretching was limited until the catheter punctures healed.
Groin Bruising from the Ablation Catheters
I knew my groin was going to be quite bruised, but I did not really understand how sore it was until it actually happened. The left side was dark purple, and there were some small knots where the catheters were inserted. 7 years earlier I had a catheter experience about 7 years and I kind of knew what to expect. There was pain – spasm like – that I attribute to the bruising, but ice-packs, warm packs and Tylenol kept the pain bearable. The spasms were not constant, but correlated to the amount of time I was not lying fairly flat. Once I got rid of all the fluid, then being on my sides was preferable to my back. After the procedure I had to be careful to not sit or stand too long. Getting horizontal at regular intervals helps. I also found this thermal pad that uses some kind of clay encased in plastic, then fabric that works well to apply heat – much better than a heating pad. You microwave it for about a minute and a half and it stays warm for around 2 hours.
I went on a 4 hour car trip 17 days after the procedure and did not walk much that weekend, so I ended up with fluid retention and some shortness or breath.
Before the ablation I did have hamstring problems in my left leg. The bruising aggravated the hamstring and contributed to my discomfort. Most of it is gone now. The bruising slowly drifted to my inner thigh, calf and down to my ankle as it slowly faded. The bruise was the size of my hand on my thigh, but down to the size of my index finger after it reached my ankle.
Editor’s comments: It’s somewhat unusual to have this much bruising and pain at the catheter ablation site.
One personal account said they were up mowing the lawn in 3 days. I read more accounts and the worst case was about 3.5 weeks to get back on a bike, so I knew the range of recovery was wide. After about 8 days I felt well enough to slowly take a mile walk at about 2 mph. from my house I can walk a gentle grade about half a mile and then turn around and the rest of the mile is down hill. I have been trying to maintain two round trips each day. I was progressively getting better when all of a sudden I started getting a mix of fast and slow beats. I was relieved when they told me that part of the variation is the heart tissue healing after the ablations. That can take a month or so to get back to “normal”. Last Friday I checked with Dr. Mounsey to reassure myself that the fast and slow beats were normal to the healing process.
On day 13 after the procedure, I went to get my electrolytes checked with my GP and my BP was 140/86 and my heart-rate 106. My GP took an ECG, and the rate was a normal sinus rhythm. A call to the cardiologist reassured me that this was part of the healing process. After a nap it dropped back to the 85-90 level. So the range of heartbeat since the ablation has been as low as 55 and as high as 103. Later that third week my heart rate dropped back to the 64 to 72 range which is when I took the car trip.
I have randomly checked my heart rate since the procedure, and it has been from 55 to 115. This cuff can detect irregular heartbeats, but not NSR. The last reading of over 100 was on day 24 following the procedure. The last day over 80 was day 26. I am now at day 30 and my goal is to walk 3 miles per day at 3 mph. I will break that into two walks. For the past 4 days my rates have measured 63-68. For as long as I can remember I have a rate in that range (lower when I was still jogging). I will warn you that it is easy to get obsessed with taking your BP and pulse. I logged mine. Some days I didn’t take any measurements, on other days I measured my pulse and BP 25 times per day depending on how concerned I was.
I was never given specifics on how to regain conditioning after an ablation, but I have listened to my body. I go for my one month follow up next week and will ask for more exercise specifics then. I really thought I would be back 100% pre-A-Fib by now, but I feel I am more like 80% but feel poised to get back to being in condition. I asked Dr. Mounsey how to best condition myself, and he told me that what I was doing was fine. He said to compare my current capability to walk that half mile grade to how I walked it while I was in A-Fib. That was a reassuring measure since my first walk after the procedure was so much better than during A-Fib. During A-Fib I would have to rest once or twice in that half mile.
Follow-up Meeting with Dr. Mounsey
I had my follow-up on Oct 15 which was 5 weeks and one day after the procedure. I think I got most of my questions built up over the last 30 days answered to my satisfaction. Dr. Mounsey said that my procedure was not the most extensive he has done but it was on the extensive end of the scale. He said I was still healing, and it may take a few more weeks. He explained that some of the isolations may cause irritation on the outside of the heart wall which may cause the heart to rub against the containing membrane and cause brief discomfort. I had experienced some of this soreness in my chest over my heart – it seldom lasted more than 10-15 seconds. It no longer seems to happen when I walk, but I do notice some if I use my upper body more.
My arms and chest are out of condition but I am regaining conditioning by doing 10-15 minutes of yoga and stretching each day. I will add some weight lifting beginning tomorrow (Oct 20) to build upper body strength gradually. I have done some house projects that required lifting enough to get a bit sore, but I am not ready to hammer re-bar in landscaping timbers or dig post holes yet.
At 7 weeks, I have not done weight lifting regularly, but my house projects and chores cause me to use my upper arms more and more. Today I did 25 minutes of yoga stretches and poses that exercise the upper and lower body. I walk 3 miles per day.
In the last 10 days I have had two episodes of rapid heart beats which lasted an hour or two. Both incidents coincided with drinking at least 16 ounces of southern style iced tea. Since backing off on such jolts of caffeine I have not had a recurrence.
So far I have not regretted the procedure and am optimistic that the odds of reverting to A-Fib are low but realize it could happen. I would go back and have a second ablation if necessary. It has taken me longer to get to this point of recovery than I had initially hoped, but I feel so much better than when I was in persistent A-Fib. While in A-Fib I estimate I was at 50% of my pre-A-Fib condition and was moderately depressed for 3 months. Now I estimate I am at 80+% of pre-A-Fib and the blahs are going away. I feel feisty enough to argue with the insurance company over the statements and to check the hospital bills versus the statement. You will find errors, so monitoring the hospital bills and insurance statements is essential.