A-Fib Patient Story #78

15 years in A-Fib: CryoBalloon Ablation, Pradaxa Problems, Second Ablation (RF) for Flutter

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!

Time to see an electrophysiologist. My newly acquired EP put me on flecainide as a pill-in-the-pocket. That seemed to work for a while―until it didn’t. Episodes got worse. I was put on propafenone and warfarin while waiting for my ablation.

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.

For me, Pradaxa was alimentary torture. Burned on the way down. Burned in my stomach and belly. Burned with diarrhea on the way out. The label suggests you’ll accommodate.

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.

Jeff Patten
jedapatten@yahoo.com

Editor’s Comments

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. (Added Oct. 26, 2015: The FDA approved a reversal agent for Pradaxa on Oct. 26, 2015. See https://a-fib.com/fda-approves-praxbind-reversal-agent-for-pradaxa/)

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

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