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.
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.
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.
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.
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.
Answer:Simpler question please.
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.
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.
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.
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.