Answer:

Theoretically, most patients with atrial flutter (>50%) will develop documented AFib after a successful flutter ablation, so it makes sense to do PVI with CTI early to prevent AF onset. However, unless you are willing to offer PVI ablation to a patient with 0% risk (impossible), then I would be cautious about ever doing PVI without documented AFib, or as you suggest, clear PV triggers for PACs during mapping. Of course if you are only figuring this out during the flutter ablation, you must have consented the patient for PVI upfront.

Answer:

Potential relation exists in the presence of a hiatal hernia. This is well reported and I have several cases where we ended up fixing the hernia first, and the AF improved, then performed PVI and it went away altogether. Large meals can often trigger AF by a vagal nerve stimulation reflex.

Answer:

Early in development still, but a very interesting approach. I think as the resolution of mapping improves, it will become an important adjunct to pulmonary vein isolation by wide area ablation. Right now, it is not clear who to use this in. I have seen several live cases in the EP lab at sites where they specialize in this approach, and it definitely can limit the amount of additional ablation performed. The question that remains is….does it really work longer term, or do you just make more rotors in new locations over time.

Answer:

Basic labs to exclude renal disease (BMP), coagulation blood tests and blood count, also, ECG and we recommend some type of imaging, either cardiac CT angio (gated) for LA and PV anatomy, or cardiac MRI. This allows precise anatomic location during mapping and ablation and can serve as an excellent guide and predictor of who is a good candidate for AF ablation. An Echo is not as helpful for AFib ablation, but if undergoing Aflutter ablation, it can predict who is at higher risk to develop AFib in the future. Mainly that would be LA volume or diameter, mitral valve function and ejection fraction.

Answer:

Yes. Flutter is often regular and at intervals of 300bpm. 2:1 atrial flutter would be HR 150bpm, 4:1 at 75bpm. Etc. 50% of patients with Aflutter will develop atrial fibrillation as well, so they are commonly co-existing. I typically monitor patients intermittently for up to 3 years after atrial flutter ablation, and will not stop blood thinners if CHADS 2 Vasc score 3 or higher out of concern for late Afib related stroke.

Answer:

There is a previously published randomized trial or Eplerenone after persistent AF catheter ablation and lower recurrence rates were reported with use of the medication. This may help with beneficial remodeling post ablation in sinus, and could reduce non-PV triggered AFib substrate. Interesting data, and I often place my persistent AF ablation patients on aldactone 25mg daily for 3-6 months post ablation.

Answer:

Its been shown that 50% of patients with typical atrial flutter ablation, develop atrial fibrillation within 3 years. This is NOT an effect of the flutter ablation, but rather, that it turns out, most patients who have been diagnosed with atrial flutter, also HAVE atrial fibrillation…but it may just not have been picked up yet on monitoring. Many experts think that perhaps we should target both Afib and atrial flutter at the same time when performing an ablation procedure for either AF or flutter.

Answer:

Great questions. At age 72, ASA alone may be ok, if you have no other known stroke risk factors. However, the NUMBER ONE risk for AF related stroke is age, and this is due to the decline in velocity of emptying of the left atrial appendage (LAA). I would not say that aspirin alone is the only therapy you need for long term stroke protection. As far as symptoms from AFib go, if tolerable, you can always continue as you are doing, and only intervene if worse. One consideration is that ablation is likely to prevent the progression from intermittent AF to persistent AF, and this may provide improved quality of life and in recent studies, reduced cardiovascular mortality.

Answer:

There is an isolated case report of saw palmetto interaction with Xarelto causing life threatening pericardial bleeding in a patient with a history of atrial fibrillation, thought to be from increased Xarelto activity (decreased drug metabolism). There are no reported associations of AFib with saw palmetto.