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July 28th, 2015
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I am a physician in Boston. I have paroxysmal a fib and I am contemplating an ablation, but Boston is a little backward and no one is doing a Topera. In fact at MGH they insist on using high frequency ventilation for their ablations. Talk about unproven entities! The closest place to go for a Topera is Hartford or Yale. When they do a Topera do they look for rotors in the right and left atrias then do the PV's, or do they do the PV's first and then look for additional rotors. Would you wait for the Topera to come to Boston? My history I'd I have had paroxysmal a-fib for three years. At first I was on atenolol and a propafenone pill in a pocket. My EP didn't want to put me on chronic propafenone because I have CAD. I now take 160 mg. of sotalol bid. I am still getting a-fib 2-3 times a month but it has never lasted longer than 3 hours and I have never had to be cardioverted. With my CAD I had a stent placed in an OM 11 years ago and have a normal Echo and stress test. Incidentally at cant they found a 0.8 cm aneurysm in my LM. They wanted to place me on warfarin, clopidogrel, and aspirin for life. I said n, so I am on clopidogrel and aspirin for life. I have a cardiac MRI every 2 years and the aneurysm has not changed in size. I am a CHAD 0 and my a-fib burden is relatively low so contrary to what you might think I think I am fairly well protected for embolic phenomenon. My question is would you wait for the Topera to come to one of the backwater Boston hospitals, go to Yale or Hartford for the Topera,or just get an old fashioned PV ablation. My EP is best friends with Dr. H in Bordeaux and if I was Donald Trump or if my insurance covered it I would go there. thanks

2015-07-27 Answered By : Dr. Edward P. Gerstenfeld,MD

Answer:Thanks for starting me off with a provocative question! Topera (recently purchased by Abbott) is a mapping system developed for targeting rotational activity (\"rotors) and focal triggers of atrial fibrillation in the right and left atrium, rather than the triggers in the pulmonary veins. Typically, rotors in the right and left atrium are ablated first, followed by standard PV isolation. In my opinion, while the approach holds promise for improving the outcome of AF ablation, particularly in more persistent forms of AF where some of the triggers/drivers may lie outside of the pulmonary veins, the results remain unproven. the initial studies arise largely from the center where the system was developed, and have not yet been validated in a prospective multi-center trial. So the first question for you is whether your symptoms are bothersome enough to warrant an ablation. If you are having recurrent bothersome episodes on Sotalol, it seems appropriate to me. Even in \"backwater\" Boston there are several excellent centers and operators. You should find an experienced operator with low complication rate. Yes, I would go with the standard PVI, using either an irrigated contact force catheter or the second generation Cryoballoon. Either should have excellent success rates for paroxysmal AF. If you are CHADS-Vasc=0, then I agree ASA/clopidogrel should be sufficient, although you would likely need additional anticoagulation before and after PVI. If you would like specific recommendations in the Boston area, please email me personally. Best of luck.

Welcome Dr. Gerstenfeld. What is the latest theory on the cause(s) of typical atrial flutter? Among them, which would you classfy as primary (and as secondary) causes? What is the first-line treatment for lone, persistent, typical atrial flutter in a middle-age athlete? Thank you.

2015-07-27 Answered By : Dr. Edward P. Gerstenfeld,MD

Answer:There is not much new regarding typical atrial flutter, which is a macro reentrant circuit that revolves around the tricuspid valve (valve between the right upper and lower chambers of the heart). Most patients with atrial flutter have some atrial fibrosis and/or dilatation of the valve annulus, which can be related to multiple factors including leaky valves or a weakened heart muscle. Most patients with atrial flutter also have atrial fibrillation, which then organizes and sustains itself as atrial flutter. The recurrence rate of atrial flutter, once it occurs, is quite high and control with medications is difficult. Catheter ablation is quite safe and considered first line therapy. I would also perform some monitoring to exclude atrial fibrillation, in which case a more complex atrial fibrillation and flutter ablation procedure would be required to completely resolve the arrhythmia.

Good afternoon Dr. Gerstenfeld. I am in the process of evaluating ablation cryo versus RF as well as trying another rhythm drug after cardioversion for persistent A-FIB. I understand the success varies with the procedure and possible multiple ablations may be necessary. What is the common practice of determining the best treatment plan based on ablation versus the use of medication. Is it worthwhile to try medication prior to ablation to see what the future holds. I know that there are a lot of ongoing studies that may provide better information for the physician and patient to make an informed decision between them. Please advise. Thank you.

2015-07-27 Answered By : Dr. Edward P. Gerstenfeld,MD

Answer:The decision of whether to try another drug vs. ablation is up to you and based on personal preference. For persistent AF I often consider dofetilide if your kidney function is normal, as it works quite well and has few side effects. The only downside is the need for a 3 day hospital stay to monitor your heart rhythm during drug initiation. Cryoablation is only approved for ablation of paroxysmal AF, though some also use it for persistent AF. For persistent AF, if you choose ablation I would recommend a wide antral pulmonary vein isolation using an irrigated contact force catheter. Targeting non-pulmonary vein AF triggers may also be helpful. If your persistent AF has been present for < 1 year, the outcome of ablation will be better. If you remain unsure what strategy is best, there is little downside to trying a drug first, and then if you have recurrence or drug intolerance, proceeding with ablation.

Good afternoon Dr. Ellis. My question involves the treatment plan for persistent A-Fib. I understand there are hybrid and only ablation procedures. Based on your technical expertise and experience what would be your advice for treatment of this condition. I have read that multiple ablations may need to occur for some patients. Another concern is the issue of scar tissue that develops and the rigidity of the Atrium based on the number of burn sites in the future. Please advise. Thank you very much. Take care.

2015-07-25 Answered By : Dr. Christopher R. Ellis,MD, FACC, FHRS

Answer:The truth is that there are no randomized trials of hybrid ablation versus catheter ablation published. There is one ongoing with N CONTACT approach that looks promising (better results with hybrid), but I don\'t know what the safety data would look like, we will wait and see. Our experience with Atricure hybrid has been very positive, patients feel great even 4-5 years later and are typically off all meds including OAC, because we also ligate the left atrial appendage. There is a very important trial about to start combining the LARIAT with ablation for persistent AF and should answer more questions about the importance of LAA ligation. On average persistent AF will require 2-3 catheter ablations to fix, and sometimes it just won\'t work. The largest total area of ablation that would casuse scar is N CONTACT, but the posterior wall of LA doesn\'t really do much functionally, so patients seem to do fine if it (posterior LA) is completely ablated.

How often does polyuria occur following a successful CTI ablation of typical atrial flutter? What is the relationship between polyuria and aflutter or afib?

2015-07-25 Answered By : Dr. Christopher R. Ellis,MD, FACC, FHRS

Answer:Its most likely that was from saline irrigation from the ablation catheter. If its a longer ablation you could get 2-3 liters of saline and then your body will urinate that out over a few days post procedure.

Hello, perhaps you can put a professional backing to what I have been trying to tell my doctors. In 2013 I went in for an abdominal hernia repair, it had been caused by emergency surgery through the stomach and all went fine. 11 days later while driving my wife to work I was slammed into from the rear while at a dead stop. Needless to say we were slammed back and forth in the seat since we were sitting still with my foot on the brake. Now I never had any heart issues of any kind, no high blood pressure, or any kind of fast heart rate, afib, aflutter or palpitations. I experienced discomfort and abdominal pain immediately, within a minute or so of being hit. The incision from the repair was fine. Within a couple of months I was experiencing enough heart rate and speed symptoms that I took myself to the ER. Now right after my surgery they said I had what was commonly called post op afib that went away before I was sent home and it was not much. The rate that took me to the ER was 160 bpm or faster. I have lived with the symptoms of a hiatal hernia for some years. However since the accident my reflux and heartburn had increased drastically. I also happened to get checked by a general surgeon that found me to be suffering from an inguinal hernia. I was told I could have had this weakness from birth and it finally manifested itself. I told him that I have worked construction most of my adult life (50 now) and had always been able to lift with absolutely no issues of any kind. The surgeon repaired the inguinal hernia that was on the left. I go back for a follow up and tell him that I am had been hurting on the right side and he checks me out and tells me I have an inguinal hernia on my right side. It was not there when he checked me or did the previous repair on the left side yet while at home doing nothing I develop a second one? He told me that there we definitely "seat belt hernias" this was HIS term that he used. He said that when you get jerked back and forth in the seat belt it can cause enough compression that it compresses the stomach thus stretching the diaphragm of the stomach making it weak at particular locations allowing the development of inguinal hernias. Prior to these surgeries I had 3 ablations for Afib and Aflutter. Following these I have been on Tikosyn, Eliquis and Metoprolol for speed, rhythm and clotting control. Now to the crux of the issue. I believe that the same force that compressed my abdomen and stretched out my lower diaphragm also stretched out my upper diaphragm thus enlarging my hiatal hernia and allowing the stomach and esophagus to intrude into the hearts space also into the space for the lungs. it also seems to be worse after I eat. It seemed that if I sat down and would bend over to tie my boots that I would get the afib or aflutter to act up and get so short of breath you would think I had just ran 3 blocks. The afib and aflutter are under control and my breathing is fine for the most part but if I bend over I get out of breath immediately and have only about 25% to 30% of the lung capacity that I normally have. I have had a lung function test done and the technician was extremely impressed with my lung function. However they do not do the test with you bending over. I believe the the accident increased the size of the hiatal hernia causing the heart and breathing issues. And now having suffered the ablations will I have to keep taking the meds forever? And I suffered the 2 inguinal hernias and the repair surgeries. I also had to have catheters inserted 3 different times during the ablations. And would you know it my luck held out and I developed chronic epididymitis with no infection of any kind. I know this seems to be a lot to try and attribute to a single accident but I had no issues with 90% of this until the accident that knocked us approximately 80 feet and it was in a 97 ram pick up truck, which has no crumple zone, thus all the force was transferred to us in the passenger compartment. It is very hard to get my own doctors to listen and understand the connections to these issues and how they are connected. I watched a Dr Suraj Kapa whom I believe is a colleague of yours in a video describing some of the correlation between the issues. Is there a way to get documentation or anything I can from you to help me out? See I am 50 years old and have always worked in the construction field. We were hit in an accident caused by a city dump truck driver who was pulling a large trailer with an even larger piece of equipment on it, who I can only guess was texting and driving because I cannot imagine anything that would have a driver of a big truck like that not paying any attention because there were no sounds of breaks at all. As you can imagine I am trying to get back to working but it is difficult with the shortness of breath at times, especially if I have to bend over, and in construction you can imagine it is often. And with the epididymitis it is quite difficult to function at times also. I am accepting the fact that I need to train for some career or job that is not as physically demanding but this takes time and money and I have to be able to live and exist in the mean time. Please help me out in any way you can. Just a little guy trying to go up against the city of Indianapolis and its team of lawyers and the city protects itself by being self insured under guidelines that the city writes. I am being forced to play a game that they dictate the rules in and play at their park. Please help me. Thank You

2015-07-24 Answered By : Dr. Christopher R. Ellis,MD, FACC, FHRS

Answer:Simpler question please.

Can the vagus nerve be damaged/irritated during a RF abalation for typical atrial flutter? Is abdominal discomfort (i.e., bloating, distention, etc.) a possible complication of a RF ablation for typical atrial flutter? It appears as though post-operative abdominal discomfort is associated with PVI (given the proximity of the vagus nerve to the left atrium?). Does any such association exist in the case of CTI abalation?

2015-07-24 Answered By : Dr. Christopher R. Ellis,MD, FACC, FHRS

Answer:I have never experienced this as a complication of CTI ablation, no. If the tricuspid valve was severely damaged and leaking for some reason, the liver could enlarge from congestion, and cause GI symptoms. Some patients may have pain from ablation down to the IVC which could also cause some abdominal symptoms.

Is persistent left superior vena cava (PLSVC) a potential trigger for atrial flutter or atrial fibrillation? What challenges, if any, does the presence of PLSVC pose in performing a CTI and/or PVI?

2015-07-22 Answered By : Dr. Christopher R. Ellis,MD, FACC, FHRS

Answer:Yes it can. I have a few very nice cases of L SVC triggering AF and this can be isolated by circumferential ablation within the coronary sinus. Should not affect the ability to perform a CTI ablation for typical flutter, but it may be challenging to isolate as a source of paroxysmal atrial fibrillation.

What can an otherwise healthy 58 year old lifetime athlete who undergoes a CTI (for aflutter) and/or a PVI (for afib) expect in terms of post-ablation pain and recovery? How soon can he/she get back to a regular cardiovascular and weightlifting routine? Are any exercise restrictions recommended. i.e., maintain exercise heart rate below a certain number of bpm; restrict the number of minutes/hours per week; etc.?

2015-07-20 Answered By : Dr. Christopher R. Ellis,MD, FACC, FHRS

Answer:I generally counsel patients to take it easy for a few days when going home. By 1 week post ablation if feeling well, I would be ok with a patient resuming full activities including exercise. This may be a physician specific recommendation so you will need to ask the performing MD.

Can a patient scheduled for a CTI and/or PVI continue to take rivaroxaban during the 2-day period prior to the procedure? Or should they be transitioned to another anticoagulant during this 2-day window? If transitioning is necessary, what anticoagulant is preferred and why?

2015-07-15 Answered By : Dr. Christopher R. Ellis,MD, FACC, FHRS

Answer:The trend amongst high volume and experienced AF centers is to perform left atrial ablations on continuous anticoagulation. This means not interrupting Xarelto, or Eliquis at all. Continuous Pradaxa was associated with a higher bleed rate and is under clinical study. The standard practice and recommendation if patients are on Coumadin is to perform the ablation with INR 2-3.

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