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A-Fib Free Again: My 3rd Ablation for “Very Late Recurrence” by Dr Natale
The return of my A-Fib was captured by my Medtronic Reveal LINQ loop recorder. I was asymptomatic, often referred to as Silent A-Fib. (For more about my recurrence, see my earlier post: My A-Fib’s Back: Need a Touch-Up This Week)
A Medtronic Reveal LINQ Insertable Cardiac Monitor (ICM) is one of the world’s smallest cardiac monitors—inserted just under the skin near the heart.
Medtronic Reveal LINQ IHM
Each night my Reveal Linq wireless monitor transmits that day’s data by wireless connection to my EP, Dr. Shephal Doshi.
I’m 80 years young and a very active runner, high jumper and weightlifter. While many EPs would likely prescribe A-Fib drugs, I chose a third “touch-up” ablation instead.
Very Late Recurrence: This ablation was for the condition called “Very Late Recurrence” where someone who has been A-Fib free for years develops A-Fib again. (Previously these cases were considered very difficult or even impossible to fix.)
Why does A-Fib sometimes recur many years later? We can only speculate. Perhaps the evolution or development of A-Fib silently continues during the years of being A-Fib free. Is it age-related? Does genetics play a role? Obviously more research needs to be done in this area.
Pre-ablation, Steve Ryan with Dr. Natale and his surgical nurse.
But thanks to the excellent research of Dr. Andrea Natale and his colleagues, “Very Late Recurrence” can now be fixed.
To learn more about Very Late Recurrence, see our article: After Two Years A-Fib Free, What Causes ‘Very Late Recurrence’ in Post-Ablation Patients?
My Third Ablation: My re-do catheter ablation was on August 19, 2021 and was performed by Dr. Andrea Natale at Los Robles hospital in Thousand Oaks, CA.
Research has shown that “very late recurrence” of A-Fib is primarily driven by non‐pulmonary vein triggers especially from the left atrial appendage and coronary sinus. Isolation of these triggers results in a high success rate.
Beautiful quilt, Los Robles Hospital Cardiac admittance; Handmade by two staff nurses.
During my ablation, this is exactly what Dr. Natale found. Therefore, he isolated both my left atrial appendage and my coronary sinus to eliminate the locations of these triggers. (My pulmonary veins had remained isolated.) He also made a roof line and an “infero-posterior” line with RF to isolate the posterior wall of the left atrium. He found non-PV electrograms/potentials in the left atrial septum, the floor of the left atrium, the left atrial lateral wall, and the anterior roof of the left atrium which he eliminated with RF ablation.
I was in the hospital overnight. Everything went fine. The only complication I had was irritation of the throat from being intubated. I had to return to the Los Robles emergency room, but they took care of that with medication.
A-Fib Free (Again): I’m temporarily on Multaq and of course the anticoagulant Eliquis.
I am in the three-month blanking period. This is the period when my heart is learning to beat normally again.
For now, I’m A-Fib free.
After Two Years A-Fib Free, What Causes ‘Very Late Recurrence’ in Post-Ablation Patients?
Even though catheter ablation is remarkably successful in restoring most paroxysmal A-Fib patients to normal sinus rhythm, a small number of these patients do have relapses (recurrences) sometimes many years out.
The main objective of this study was to understand why Atrial Fibrillation relapses years after successful electrical isolation of the pulmonary veins (PVs) in paroxysmal patients and whether the presence of comorbidities influence recurrence.
These are the questions Dr Andrea Natale and his colleagues at the Texas Cardiac Arrhythmia Institute were looking to answer.
Study Parameters
In this observational study, researchers at Texas Cardiac Arrhythmia Institute looked at 1,633 of their paroxysmal patients who had been A-Fib free for two years after their first or second catheter ablations, then suffered recurrences years later (i.e., Very late recurrent).
The patients were divided into two groups based on the presence or absence of comorbidities (presence of two or more diseases). The groups were:
Group 1: 692 patients with no comorbidities
Group 2: 941 patients with comorbidities
A-Fib and Common Comorbidities
The Group 2 patients had one or more of the following illnesses/conditions (comorbidities):
• Moderate to severe sleep apnea
• Diabetes mellitus
• Body mass index 30 kg/m² or higher (obese)
• Hypertension treated with multiple anti-hypertensive agents
• Low left ventricular ejection fraction (lower than 45%; normal is 50% to 75%)
Quality of Previous Ablations
The patients who experienced recurrences had been previously well ablated (one or two procedures.) Standard ablation procedures included PVI plus isolation of the left atrial posterior wall and the Superior Vena Cava (SVC):
• Their pulmonary veins were completely isolated of all PV potentials as confirmed by entrance and/or exit block. The electrical isolation was extended to the posterior wall contained between the PVs.
• Posterior wall isolation was performed using multiple ablation points covering the whole posterior wall.
• The SVC was mapped and isolated circumferentially in all patients. The atrial myocardial sleeves extend into the SVC for up to 2 to 5 cm. thus harboring ectopic pacing cells that provide the substrate for atrial arrhythmia. The Superior Vena Cava (SVC) is a known source on non-PV triggers.
Patient Follow‐up
Follow‐up was performed at 1, 3, 6, and 12 months with office visits, cardiology evaluation, 12‐lead electrocardiogram (ECG) and 7‐day Holter monitoring at 1, 6, and 12 months. After 1 year, patients were followed up annually with a 7‐day Holter and were asked to check their pulse regularly to monitor rate.
Ablation success was defined as absence of arrhythmia off antiarrhythmic drugs.
Ten-Year Recurrence Findings
At 10 years of follow-up, median time to recurrence was 7.4 years. The recurrence rate among the study patients was:
• Group 1 patients: 31.1% experienced recurrence (215 of 692)
• Group 2 patients: 51% experienced recurrence (480 of 941)
Redo Ablations
Patients with recurrence of their A-Fib, underwent a ‘re-do’ ablation:
• 201 in Group 1 patients
• 456 in Group 2 patients
Ablations targets at re-do:
• 561 patients received isolation of the Left Atrial Appendage (LAA) and Coronary Sinus (CS); 96 patients received left atrial lines and flutter ablation; 9 patients received re‐isolation of PVs;
• PV reconnection was not noted in any of the patients with two prior procedures. The SVC was found to be permanently isolated in 642 (97.7%) and no reconnection of posterior wall in 611 (93%) cases.
Top: Representative images showing a patient’s lesion sets during initial ablation. Bottom: 5 years later during the same patient’s re-do ablation.
Two-Year Results After Redo Ablation
At 2 years, 91.1% (134) of Group 1 and 94.4% (391) of Group 2 remained arrhythmia free! These patients received left atrial appendage (LAA) and Coronary Sinus (CS) isolation.
Of those who received left atrial lines and flutter ablation, results were poor with around 7% arrhythmia free.
Study Conclusions
The main objective of this study was to understand why Atrial Fibrillation relapses years after successful PV catheter ablation in paroxysmal patients and whether the presence or absence of comorbidities influence very late recurrences.
Despite permanent pulmonary vein isolation (PVI), very late recurrence was primarily driven by non‐pulmonary vein triggers especially from the left atrial appendage and coronary sinus. Ablation of these triggers resulted in high success rate (regardless of the comorbidity profile.)
The median time to recurrence was significantly shorter in patients with cardiovascular comorbidities.
Editor’s Comments
These study results are remarkable! The study findings reinforce the crucial role of non-PV triggers in the relapse of A-Fib. Knowing how comorbidities shorten the timeline to A-Fib recurrence can motivate patients to improve their overall health.
If You’re Having an Ablation or Re-do Ablation: Besides isolating the Pulmonary Veins, talk with your doctor about mapping and isolating non-PV triggers i.e., from the Left Atrial Appendage (LAA) and Coronary Sinus (CS).
How can You Avoid Recurrence? Get rid of comorbidities. Even after the establishment of sinus rhythm, comorbidities contribute to the progression of A-Fib and its recurrence.
While patients in Group 2 (with comorbidities) were able to be cured and restored to sinus rhythm just as well as patients without comorbidities, recurrence occurred sooner (5.6 years versus 7.4 years).
To postpone or avoid recurrence of your A-Fib, do what you can to get healthier. Lose weight if needed, get treatment if you have sleep apnea, address hypertension issues, manage your diabetes, stop smoking, moderate your consumption of alcohol.
Why Does A-Fib Sometimes Recur Many Years Later? We can only speculate. Perhaps the evolution or development of A-Fib silently continues during the years of being A-Fib free. Is it age-related? Does genetics play a role? Obviously more research needs to be done in this area.
Last Thoughts: Have researchers like Dr. Andrea Natale discovered how to cure even the most difficult A-Fib cases? Isolating the LAA and the CS seems to be the key.
Are we close to a time where even the most difficult cases of A-Fib can be cured by the right EPs using the right ablation techniques at the right time?
My A-Fib’s Back: Need a Touch-Up This Week
On August 19 I’m scheduled for a touch-up ablation by Dr. Andrea Natale at Los Robles hospital in Thousand Oaks, CA.
Dr. Shephal Doshi and Steve Aug 1 2019
I’m symptom free. But my Medtronic Reveal LINQ loop recorder shows I still have some A-Fib after a catheter ablation by Dr. Shephal Doshi at St. John’s hospital in Santa Monica 24 months ago (August 2019).
Background: My first catheter ablation was in 1998 by Drs. Michel Haïssaguerre, Pierre Jais, and Dipen Shaw in Bordeaux, France. Though it was relatively primitive compared to what EPs are doing today, it kept me A-Fib free for 21+ years.
Steve with Dr Häissaguerre who cured Steve in 1998.
Left Atrial Appendage: During the touch-up ablation, my Left Atrial Appendage (LAA) may have to be electrically isolated. If that’s done, and my LAA doesn’t empty of blood properly, I may have to have a Watchman device inserted to mechanically close off my LAA. As an enthusiastic runner/sprinter, I don’t want to have my LAA closed off as it can reduce blood flow. But at 80 years old, I may have little choice. I’ll post again after my redo ablation.
A “re-do” catheter ablation is nothing to be frightened of. My procedure this week, like last time, will be as an out-patient. For my 2019 touch-up procedure, I arrived at the hospital at 5am and was back home at 5pm. In and Out. Lickety-split!
Magnesium IV to Stop A-Fib
We have long advocated the benefits of Magnesium for A-Fib. (See Magnesium Long-Life Insights for A-Fib Patients.)
Intravenous Delivery: A recent randomized controlled double-blind study found that Magnesium delivered directly into the bloodstream (Intravenous, i.e., IV) can produce both rate and rhythm control when used for A-Fib patients in the emergency room (ER).
The Good News: This study from the University of Monastir, Tunisia, found Magnesium IV is the fastest way to improve Magnesium levels and is very effective in restoring A-Fib patients to normal sinus rhythm.
The Bad News: In U.S. emergency rooms, Magnesium IV is not a standard treatment for A-Fib patients (though it may be used prior to cardioversion). (Dr. Julian Whitaker in Newport Beach, CA performs this therapy (www.drwhitaker.com).)
One of our Advisory Board members wrote me about his large facility’s experience with Magnesium IVs, “A few years ago we tried and stopped because of futility.”
Bottom Line: So it’s an interesting research study, but don’t look for a Magnesium IV if you end up in the ER with an A-Fib episode.
Side Effects of Flecainide: An A-Fib Patient’s Perspective
Carol, from Salem, Oregon, wrote me to share how taking the antiarrhythmic drug, flecainide, affected her.
Flecainide, an antiarrhythmic medication, works by slowing electrical signals in the heart to stabilize the heart rhythm.
“When I initially started taking flecainide for my A-Fib, I experienced annoying visual disturbances, especially when there was a difference between a light and dark environment such as a stage or when going from a light to a dark room. I would see afterimages, many of them. For example, in a theater I’d see my hands clapping, but I’d see many of them as if in a time lapse still photo. Over time that effect got better.
But other side effects developed.
…Here it goes again. I plan to call the Cardiologist as soon as the office opens. I have the following symptoms:
• Irregular heartbeat
• stomach discomfort (bloating)
• rash and hives
• hair loss
• anxiety (my shoulders are practically making contact with my ears)
• sleep problems
• increased sweating
• annoying visual disturbances
These are all listed on the package insert as possible side effects.
However, I am not ready to say they were caused by flecainide as I have had lifelong problems with allergies and digestive issues. Except for the visual disturbances…
I was on flecainide for 12 years―and it mostly worked well―until it didn’t anymore.”
Carol Baumann,
Salem, Oregon
Editor’s Comments
One of the most frequently prescribed antiarrhythmic drugs is flecainide acetate (Tambocor). Flecainide has been around a long time (1985) and is only available as a generic drug.
Instead of a daily dose, fecainide can be used as a “Pill-In-The-Pocket” treatment i.e., taking an antiarrhythmic med at the time of an A-Fib attack.
Flecainide carries an FDA “Black Box Warning” which is the most serious the FDA issues. A Black Box Warning alerts doctors and patients that a drug has potentially dangerous effects.
As with almost all antiarrhythmic drugs, flecainide is known for bad side effects.
To read a detailed description of flecainide, its uses and side effects, see fecainide at MedlinePlus/Drugs, Herbs and Supplements (U.S. National Library of Medicine).
Don’t Want to Take Anticoagulants? Three Alternatives for A-Fib Patients
With Atrial Fibrillation, you are 4–5 times more likely to have an A-Fib (ischemic) stroke. Taking an anticoagulant helps prevent an A-Fib stroke and may give you peace of mind.
The negative side is that all anticoagulants are high-risk medications and inherently dangerous. You bruise easily, cuts take a long time to stop bleeding. You can’t participate in any contact sports. There is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. See Risks of Life-Long Anticoagulation.
(Most EPs are well aware of the risks of life-long anticoagulation.)
Don’t want to take anticoagulants? What’s the alternative? Remove the reason you need an anticoagulant!
Three Alternatives to Taking Anticoagulants
Anticoagulants are used with high-risk Atrial Fibrillation patients for the prevention of clots and stroke.
The best way to deal with the increased risk of stroke and side effects of anticoagulants is to no longer need them. Here are three options:
RF Catheter ablation
#1 Alternative: Get rid of your A-Fib.
As electrophysiologist (EP) and prolific blogger Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”
Action: Request a catheter ablation procedure. Today, you can have an ablation immediately (called ‘first-line therapy’). You don’t have to waste a year on failed drug therapies. See Catheter Ablation Reduces Stroke Risk Even for Higher Risk Patients
Placing Watchman in LAA
#2 Alternative: Close off your Left Atrial Appendage (LAA).
The Left Atrial Appendage is where 90%-95% of A-Fib clots originate. Closing off the LAA provides similar protection against having an A-Fib (ischemic) stroke as being on an anticoagulant.
Action: Request a Watchman device. The Watchman device is inserted to close off your LAA and keep clots from entering your blood stream. See Watchman Better Than Lifetime on Warfarin
Natural blood thinners
#3 Alternative: Consider non-prescription blood thinners
Perhaps you can benefit from an increase in natural blood thinners such as turmeric, ginger and vitamin E or, especially, the supplement Nattokinase.
Action: Ask your doctor about your CHA2DS2-VASc score (a stroke risk assessor). If your score is a 1 or 2 (out of 10), ask if you could take a non-prescription approach to a blood thinner. See FAQ: “Are natural blood thinners as good as prescription blood thinners?”
Bottom Line
Whether or not to take anticoagulants (and which one) is one of the most difficult decisions you and your doctor must make. To stop taking an anticoagulant, talk to your doctor about alternatives:
• Catheter ablation
• LAA closure (Watchman device)
• Non-prescription blood thinners
These options may help you to no longer need an anticoagulant. As Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”
As an A-Fib patient, don’t settle for a lifetime on anticoagulants or blood thinners. Remember: You must be your own best patient advocate.
Unsafe Interaction Between Pradaxa and Common Calcium Channel Blockers
An observational study published in 2020 found that people with A-Fib taking two common rate control calcium channel blockers along with the anticoagulant Pradaxa had higher bleeding rates (GI bleeding, minor bleeding, and minor GI bleeding).
The study was an analysis of the potential drug-drug interaction between verapamil or diltiazem and DOACs.
The term DOAC has replaced use of NOAC.
The study was conducted using US population-based data (2010-2015) analyzed between January 1 and July 15, 2019. Data were obtained on 48,442 patients with nonvalvular atrial fibrillation who had received an index prescription of dabigatran, rivaroxaban, or apixaban.
Analysis was restricted to individuals with no history of kidney disease who were receiving standard doses of the DOACs.
Drug-Drug Interactions Found When Co-Administered
Researchers found that taking the drugs Verapamil and Diltiazem (rate control calcium channel blockers) along with the anticoagulant Pradaxa had higher bleeding rates.
Other anticoagulants such as Xarelto and Eliquis didn’t cause more bleeding. (Apixaban [Eliquis] had consistently lower bleeding event rates among all DOACs.)
(For you technical types, Dabigatran functions as a P-glycoprotein inhibitor (P-gp), an important protein that pumps many foreign substances, such as toxins and drugs, out of cells. Verapamil and diltiazem are also P-gp inhibitors.)
Pradaxa Data Compiled and Compared to Four Calcium Channel Blockers
The investigators compiled data from IBM Watson MarketScan Databases.
Comparisons were made between 1,764 Pradaxa (dabigatran etexilate) users taking verapamil or diltiazem versus 3,105 Pradaxa users taking amlodipine (a calcium channel blocker used primarily to lower blood pressure which isn’t a P-gp inhibitor). The overall bleeding rate was 52% higher compared to amlodipine.
In addition, comparisons were made between 1,793 Pradaxa users taking verapamil or diltiazem versus 3,224 Pradaxa users on metoprolol (a beta-blocker which isn’t a P-gp inhibitor). The overall bleeding rate was 43% higher compared to metoprolol.
Avoid Mixing Pradaxa with Verapamil & Diltiazem
The message of this study is clear. “Clinicians and patients may need to consider alternative DOAC therapy other than dabigatran” when using P-gp inhibitors such as verapamil and diltiazem. (Amiodarone is another P-gp inhibitor.) “It is not safe to combine dabigatran (Pradaxa) with P-glycoprotein (P-gp) inhibitors in people with atrial fibrillation (Afib)” regardless of kidney function.
What This Means to Patients
If you are taking the anticoagulant Pradaxa, along with Verapamil and Diltiazem (rate control calcium channel blockers), talk to your doctor about changing to another DOAC (and take a copy of this article with you).
Happily, there are several DOACs, so there’s seldom an overwhelming need to continue on Pradaxa (dabigatran). Eliquis (apixaban), for example, tested the best and is the safest of the DOACs.
Gastroparesis: a Rare Complication After A-Fib Ablation
Gastroparesis is a condition in which your stomach empties into your small intestine more slowly than it should. It can be either temporary or chronic. Gastroparesis can occur after surgery or another medical procedure that interrupts your digestion.
Symptoms of Gastroparesis
When you have Gastroparesis, you feel bloated after eating, you may have stomach pain, or you may be vomiting. You may lose weight, your blood sugar levels may fluctuate, you may be dehydrated, your esophagus may be inflamed and you may experience malnutrition because your stomach isn’t absorbing nutrients.
Gastroparesis After Catheter Ablation
Gastroparesis is a rare complication of A-Fib ablation. It’s a condition that affects the stomach muscles and prevents proper stomach emptying. If after your catheter ablation, you experience any of the above symptoms, you may be experiencing Gastroparesis.
The cause can be damage to the vagal nerve which controls the stomach muscles. This can happen when ablation at the right inferior Pulmonary Vein (PV) affects the esophagus. The distance between the right inferior PV (RIPV) and the esophagus is an independent predictor of gastroparesis. … Continue reading this report…->
Post Surgery―Develops A-Fib, Drug Therapy & Supplements Restore Sinus Rhythm
My name is Richard, male, and born in 1945. I am 5′ 9’’, weigh 167 lbs., and am a non-smoker. My exercise is walking about 1.5 miles a day, and I have a healthy diet.
Complications from an Appendectomy Surgery―Develops A-Fib
In April 2018 I was in the hospital for three weeks. I had two surgeries, first an appendectomy and 10 days later correction of a problem caused by the first surgery.
After the second surgery I developed A-Fib, with no prior history of it.
The only drug to bring me back to sinus rhythm was Amiodarone. I left the hospital with prescriptions for Amiodarone 100 mg a day and Metoprolol Tartrate 25 mg twice a day.
Amiodarone Damages Thyroid
Everything was under control for several months. Until I had blood work that revealed my Thyroid was not functioning. Amiodarone was removed, and… continue reading Richard’s personal A-Fib story.
ADVENT Trial of Pulsed Field Ablation (PFA) for Paroxysmal A-Fib! PFA a True Game Changer
Fundamentally different from traditional methods for cardiac ablation, I expect the FARAPULSE Pulsed Field Ablation (PFA) will change the way catheter ablations are done and will become an innovative and most effective treatment option for Atrial Fibrillation.
U.S. Trial of Pulsed Field Ablation (PFA)
The U.S. trial of the FARAPULSE Pulsed Field Ablation (PFA) system is underway. The first patients in the ADVENT Trial were treated at New York’s Mount Sinai Hospital by Vivek Reddy, M.D., Director of Cardiac Arrhythmia Services.
” I believe PFA will define a new era in the ablation of AF and possibly other arrhythmias.” – Dr. Pierre Jais, French Bordeaux LIRYC
The ADVENT Trial is a prospective randomized pivotal trial of the FARAPULSE Pulsed Field Ablation System compared with standard of care ablation in patients with paroxysmal atrial fibrillation.
“…We look forward to how our study can move adoption of this procedure forward,” said Dr. Vivek Y. Reddy.
ADVENT Trial is Recruiting: You May Quality
There are 37 study locations participating in the ADVENT Trial (see the list). Recruiting is underway and you may qualify.
Key inclusion criteria: Patients are required to meet all the following inclusion criteria to participate in this study (there are also exclusion criteria):
• Age 18-75
• Paroxysmal atrial fibrillation
• Anti-arrhythmic drug failed for efficacy or intolerance
Learn more about the ADVENT Trial on the FARAPULSE website. Prospective patients of The ADVENT Trial should contact their physician.
How PFA Works
As an emerging technology, there are many concepts and treatment strategies that will be brand new to you (they were for me).
Pulsed Field Ablation (PFA) is fundamentally different from traditional methods for cardiac ablation. PFA is very tissue selective.
PFA is Tissue Selective; Green labels are Preserved tissue; Red label is Ablated tissue
Through a process called irreversible electroporation, cardiac tissue targeted for ablation is rendered electrically inactive while collateral tissues are spared.
Unlike traditional thermal methods, PFA works on the selected cell types while leaving others alone.
Based on European clinical trials, these electric fields have proven very effective in durably “silencing” abnormal heart signals, while reducing the risk of damage to other nearby tissues.
For more on how PFA works, see my report: 2020 AF Symposium Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.
First Approved in Europe
In March 2021, Pulsed Field Ablation (PFA) from FARAPULSE, Inc. received CE Mark approval and can now market in the Europeans Union and other CE Mark countries. FARAPULSE plans to launch by first partnering with a select number of physicians, then move to a broader rollout.
Boston Scientific has expanded investment in FARAPULSE, Inc. and secured an exclusive option to acquire it.
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