My Catheter Ablation at Bordeaux, March 2007
January, 2006 Wolf Mini-Maze performed by Dr Wolf in Cincinnati
One week later: Back in AF
Continuous until May 2006: Cardioverted, put on flecainide 50mg 2xday
August 2006: Risked a 1 1/2-hour bike ride+one mile run; went into Atrial Flutter
One week later: Cardioverted, put on flecainide 100mg 2x day
October 2006: Risked a second easy workout in one day; went into Atrial Flutter
Within a week: Cardioverted, back on flecainide 100 mg 2x day
By August, I had decided to arrange for a touch-up ablation.
I quickly decided where to have it done.
The most useful sources of information were:
It seemed clear to me that only Drs Jais and Haissaguerre at Bordeaux
offered the following combination of positive factors:
3) Published articles clearly describing their process and outcome (see the articles cited above). It is possible that others might be doing as well, but I did not run across any information from publications or conference presentations that indicated this.
I believe that the report on the proceedings of the 2007 Boston Symposium will bear me out, as it has been reported (at http://www.afib.com) that the success of the Bordeaux approach to continuous AF is beginning to sink in, and that more EPs in the USA will be doing their approach. (I will know more about this when the full proceedings appear on the above web site in early February.)
I inquired about making an appointment for the ablation (see the List of Doctors for contact information) Dr Jais emailed, asking whether my AF was symptomatic and whether I had failed antiarrhythmic drugs. When I answered in the affirmative to both, I was permitted to go ahead with the booking procedure. (I believe that the question about failing medications does not indicate that he thinks that he thinks that they are a good solution -- quite the contrary (see here ). It is rather a reflection of the reality that they cannot take everyone.)
They sent me a packet of information about the procedure and a list of hotels. Here are some things that I was to do:
>> Go on Coumadin 2 months before admission; stop Coumadin 48 hours before admission.
>> Have a TEE between 1 and 3 weeks before admission to check on the presence of blood clots, "especially around the LAA" (which the Wolf procedure removed).
>> The instructions said to stop AR medication upon admission. After I emailed Dr Jais asking about stopping the flecainide to see if possible side effects would stop (symptoms of Sick Sinus Syndrome, tremor and fatigue), Dr Jais said I could stop the flecainide four days before admission, which follows the principle of stopping five half lives before the procedure.
I learned that I will be in the hospital for 4-5 days, wearing a monitor, but wearing regular clothes and free to move around the hospital and grounds; they are more liberal with hospital days than here in the US. My wife, Marion, an RN, will stay in the room with me (which costs about $38 per day more).
I (we) will stay in the area for 2+ weeks to see if I stay in rhythm.
I am supposed be on Coumadin for at least 3 months pre-CA. After the CA, they usually put Continuous AFers back on AR medication for 1-2 months. After the hospital stay, I can return to my normal activities, but, since "normal" for me used to mean fairly intense exercise, I will be working gradually towards a higher level.
The cost was $18379 USD. There will be charges for any additional hospital stay, but I don't think an addition ablation will cost anything, but I am not sure about how soon a second ablation must be done to qualify for this.
I said that because some of the lesions that may be needed for my Continuous AF can be rather difficult, that I wanted either Dr Jais or Dr Haissaguerre to be the one(s) working the catheters, and that I would be willing to pay extra for this. Dr Jais emailed me back saying that either he or Dr Haissaguerre would do the procedure; he didn't say anything about any extra cost (perhaps this applies only to "public" patients?).
As I write this in early February, I have been on flecainide and in NSR (so far as I can tell) since the last cardioversion in late October. It seems that I am tired a lot more since I increased the flecainide. As noted above, I have developed a tremor, and bradycardia and other irregularities similar to Sick Sinus Syndrome. All these can be a side effects of the drug.
I have been very careful with my exercise, keeping my heart rate down around 100 bpm and keeping the duration of easy aerobic exercise to 20 minutes or less -- a far cry from my previous self! I know it is selfish, but I hate having to look over my shoulder when I work out, and I miss the feeling of, say, riding long distances on my bike or jogging up a mountain.
I have some PVCs that have been quite uncomfortable in somewhat the same way as AF was, although not nearly so bad. A small dose of taurine (500 mgs divided into two dose taken am and pm on an empty stomach) seems to help, but may depress me. I have tried magnesium a number of times through the years as well as now, but it also has always depressed me. Potassium may do so as well, although its effects are not as clear.
In late February, I noticed that my heart rate seemed rather slow (resting in the 40's instead of my normal 50's, and usually not going up as much when the demands on my heart would increase). The Holter monitor readout showed signs of sick sinus syndrome, which, as noted above, can be caused by the flecainide.
I believe that the Wolf procedure did not do a complete job, although it may make the touch-up easier. For one thing, the Mini-Maze does not deal with the area in the RA that can create Atrial Flutter -- and I have had this twice so far, post Mini-Maze (although there is an outside chance that this could have been caused by the flecainide). And there are other areas that are often involved in Continuous AF that it also misses. This is not to say the Wolf does not cure any Continuous AFer's. It's just that his approach would not ordinarily be the first choice of someone in this situation. (There is plenty more on these issues in the sections on lesion sets and on the Wolf Min-Maze in Choosing treatments... .)
Of course, looking back, I should have done things differently. Through a combination of naïveté and being mislead by estimates of success, I decided that the Wolf procedure was a reasonable compromise between what I believed to be the limited and potentially problematic process of ablation and the invasiveness of full Maze operation. If I were to choose over again, I would choose the Bordeaux approach ... for the reasons I list above, and because I could have both ablation touch-ups and even surgery if for some reason it were necessary.
Questions to ask Dr Jais or Haissaguerre after the CA
Here are some questions I plan to ask Dr Jais or Dr Haissaguerre after the procedure that I think will help me to judge how things went and my prognosis:
How long did the procedure take. (The shorter it was, the less that he would have had to do, either because of the work Dr Wolf did, or because my AF required less.)
Did the Wolf "minimaze" make your job easier, by doing a PVI which lasted, by deactivating ganglionated plexi and by excising the Ligament of Marshall?
Were there problems such as: difficulty making continuous lesions… in difficult areas such as the coronary sinus area ..in an especially thick atrial wall?
Were there other things that suggest possible failure: areas of rapid activity in the RA; were the AF cycles especially fast; did RA have the most rapid AF cycles?
At what point (i.e., after doing which lesions), did AF stop? (For example, did you have to make the Maze-like Pv-Mitral Valve lesion that is often needed to treat continuous AF?) Were you then unable to induce it? If neither of these things occurred, how much did the AF cycle speed lessen?
Was the area in the RA responsible for typical AFL ablated? Or was my AFL atypical; if so, was it possible to deal with it?
Do an elevated heart rate after the procedure indicate success?
My (our) trip was a series of new experiences, some good, others unpleasant, but always in the context of the hope that I could finally put my Continuous AF in the background. This hope was only partially realized.
Nothing about my Bordeaux experience would prevent me from recommending it to anyone with Continuous AF, or from having another CA there myself if it were needed.
In spite of having had a Wolf mini-maze (1/2006), my CA was long and extensive.
CA was successful in all areas except the last (the LA isthmus), where a complete block could not be achieved, leaving me with a 50% chance of arrhythmia recurrence, which in my case would almost certainly be atypical AFL and quickly taken care of once the edema created by the CA subsides.
No ARs post CA. If AF – or more likely – AFL recurs, I am to take 400 mg amiodarone, wait several hours, then call Bordeaux.
I had bad side effects from taking flecainide in the months leading up to the CA.
Post CA exercise: Nothing significant for one month. Then work up gradually.
We arrived in Bordeaux on Thursday, March 22, where we were to stay until checking into to Haut Levique Hopital Cardiologique in Pessac on the next Monday morning.
We took a shuttle bus from the airport to Grand Theatre, which is a short walk to Hotel Acanthe.
The Hotel Acanthe is in an excellent location in the middle of restaurants and shops. Walking is easy and very interesting because the streets in this part of the city are narrow, paved with ancient stones, with traffic limited to bicycles and scooter and the rare taxi or police car.
The Acanthe is also near a large square which opens onto the riverfront, which is being given a major makeover because (we heard) an ex-official in the French government is now the mayor and can call on his friends to direct money his way.
People are very friendly when asked directions, not like Paris (we heard) where they are more likely to walk on.
Guidebook French would be very helpful. Some people speak some English; very few speak it fluently; many more are (or seem?) mystified.
We had one of the Acanthe's large rooms with a balcony on the second floor above the street. It was not at all like what Americans are used to: Two beds, a small desk and chair, tiny TV, a good bathroom and plenty of floor space. There was considerable people street noise, which we mostly liked. There are people walking by a few feet down, whose conversations we could hear quite well. There I was, part of the scene in my pajamas getting fruit and yogurt for breakfast that were stashed on the balcony! We have a Marsona noise-masking machine, which was quite helpful at times.
The concentration of restaurants is amazing. We would go early for dinner as they would fill up after 8.
First thing Monday morning, we took a taxi to hospital in Pessac, which cost 40 euros. You can take the much cheaper tram and a bus, which we did when going back to Bordeaux The taxi pulled up in front of a large, dirty, concrete, glass and steel building surrounded by a portable construction fence – a totally unprepossessing mess! The first floor inside was not much better, with a ceiling that was only mostly there and a formidable portcullis that raised with an ominous groan at the opening hour of eight to reveal the admitting persons with their computers. After being admitted, we were taken to our room, which was very nice – by hospital standards extremely nice. It was light, spacious, with big windows at one end, two comfortable beds, a TV (which we didn’t use), a phone, and ample storage. WiFi is available but we were not able to get it to work because we could not provide a telephone number for their software to dial.
The nurses were extremely friendly, cheerful and competent. We came to feel like part of a family. Most spoke at least a few words of English, some much more. They do nothing but take care of ablation patients, who take up the western section of the third floor. This also means that the section is relatively quiet and relaxed.
Soon after we arrived on Monday, we were told that my CA was to be that day, instead of the next, as I had expected! Yikes! But I was very pleased and very ready to go! My waiting and wondering would be over! In this, I was only partly right.
I was taken to the ablation room, and lay around for some time as staff prepared for my procedure. It was frustrating not to be able to understand or converse. I felt rather like another a piece of equipment or a potted plant!
I had been told that Dr Jais was to do the procedure (I had asked for him or Dr Haissaguerre because I figured that my Continuous A would require some difficult linear lesions.) I wondered what his “entrance” would be like. Well, it was nothing at all. Out of the chorus of chattering voices, I heard a masculine voice my shoulder saying, “Hello, I’m Dr Jais and I am going to do your ablation.” I looked up and saw a young, slim, good looking man with dark eyes and short hair. I said I was very happy to be there, and very lucky, too. He smiled, chuckled and said “We’ll see.”
Over my chest was the fluoroscopy camera and ranged along the left side of the table was a bank of four monitors. By crooking my neck to the left, I would make out what came up on the screens (I ended up with a severe knot in my left trapezius muscle!) Dr Jais stood down past my feet on my right side, protected from the fluoroscopy by glass shields. I could easily hear him, however. There was another person at a console some way back of Dr Jais who would respond to requests for pacing and from time to time would respond to Dr Jais’ comments on the procedure.
I was given midazolam (known as "Versed" in the USA) to relax me and to help with discomfort and was told that if I experienced too much pain, to let them know and they would give me morphine. I never asked any but I believe they gave me some twice, perhaps because they detected some signs of discomfort. There was definite pain during the some of the burns – in my chest and right shoulder, but as you know pain is more of a problem if it is unexplained or indicates something dangerous or if it is sudden, none of which was the case here.
I could not tell as much about what was happening as I would have liked mostly because of the language problem, although Dr Jais spoke English some of the time. I had hoped that the Wolf mini-maze I had had in January 2006 would preclude the need for much work; that he would explore my atria for a few moments, make a few half-hearted burns in the RA to prevent typical AFL and then throw down the catheters (after removing them from my body, of course) saying, “Why are you wasting my time?”. Think again, Dick.
He seemed tired at the end of the procedure – and no wonder! It had taken over five hours. I asked him how things went, and he said that he had to do a lot more than he expected and that he would talk to me about it when he saw me – sometime before we left. This left me hanging, but he was tired and he has many other patients and things on his plate besides me.
I was also tired after the procedure and didn’t have much appetite. I also had noticeable inflammation discomfort when breathing deeply, which the intern said was normal. It subsided gradually and was gone in 3-4 days. If you want, they will give you something for inflammation from standing orders so they do not have to bother a doctor.
I was tethered to an IV, so, for that day, I walked around the room and stretched on the bed pull-up trapeze.
An intern who spoke good English came to see me (us) every day primarily to check on how I was doing. He was also able to answer some questions in a general way, such as what is sometimes done when such-and-such is the case… For questions specifically about my case, he would check with the doctor and get back to me.
Tuesday was spent mostly in CA ward routine: BP, temp, ECGs, heparin shots, no ARs (yet), meals (very good!). I did have an echogram, which seemed pretty good, with only a tiny bit of mitral valve regurgitation and an ejection rate of 70% (both of which I asked about).
Wednesday I was surprised by being taken down for the bicycle stress test that I hadn’t expected until the next day. I was quite nervous about this, and didn’t know what to expect either in terms of my stamina after the CA or, of course whether I would go in to AF or AFL, then or, more likely later, as I had previously during the previous months.
The test consists of being placed on a bike and going for about 3-4 minutes at a given rate of resistance, keeping RPMs between 60 and 65. Then, the resistance is increased. This happened, I think, four times. I could see the monitor more easily this time, and things seemed OK. I was working a bit during the last resistance period, but since I used to cycling and had kept up with minimal exercise-bike work while waiting to come to Bordeaux, it wasn’t very difficult. I was more worried about going into AF or AFL.
After my test, we went to see Laurence Deixonne, the person with whom I corresponded about setting things up, to give her my thanks and again pass on the best regards of a fellow AFer from Canada who had been here before.
The PVs needed to be isolated and Dr Jais did this successfully. (This was done previously by the Wolf “mini-maze” and the quieting confirmed. Perhaps some of the scarring had healed, or ?)
They always ablate the area in the RA from which typical AF can come (the cavotricuspid isthmus).
He did successful work in other areas, I assume as listed in the 2005 Bordeaux articles (see http://www.medscape.com/viewarticle/515973 ). I will give more details when I get the report. All went well for awhile and he might have been finished in 2-3 hours.
He was not, however, able to make a complete block on the mitral-valve-PV isthmus where it goes near the LAA.
I said, "Isn't this area easier to work on than the area near--or in-- the coronary sinus?" He said that they were not concerned about working in the CS area as many other EPs seem to be. He said they had been doing this isthmus lesion for eight years, which I would guess is much longer than others. I should add that they have reported finding that the isthmus lesion is very often necessary to do for Continuous AF. This experience in doing a difficult but necessary line was an important factor in my choosing to go to Bordeaux.
They DC cardioverted me at the end, as I did not go into NSR during the CA (although I am unclear as to whether I was in AF or atypical AFL). In one of their studies, they said that they found that whether or not this happens appears to make no difference in long-term (1-2 years?) outcome, although it may be correlated with short-term recurrence.
Of course whether AF could be induced at the end of the procedure was beside the point because I was in AF (or was it atypical AFL?). I think, however, that they have given up using the inability to induce AF as an endpoint because virtually everyone could be induced. They still use rapid pacing during the procedure, I think to determine the reduction in AF cycle length resulting from a particular burn or line.
He (and Dr Haissaguerre) explained that edema quickly builds up during a CA, making it difficult for them to know whether they have made an effective, transmural lesion, especially late in a long procedure. I am not sure when the edema is supposed to go down enough for them to do another CA. The fact that they will reportedly do another CA as early as a week for foreigners who are a long way from home suggests that the power of this aspect of inflammation to affect their work subsides quickly.
We will know better (they said) in the coming weeks or months (I am unsure of the timeline here) when the swelling goes down and the scars mature. Perhaps the incomplete block will open up; or, the scarring on either side may expand and block the opening. They said I have a 50-50% chance of going into atypical AFL.
This CA section of the hospital closes over the weekend, so was given heparin ampoules and syringes to inject into a pinched-up bit of skin (subcutaneously) on either side of my stomach 2x day. I also started back on warfarin ,which takes several days to build up, which I was to continue for at least three months after NSR.
(I had asked for a copy of the report of my CA, and after several requests, I finally received this rather sketchy account, which was a copy of that sent to my cardiologist. It was disappointing not to have more detail and to find a couple of mistakes: I did not have the paroxysmal form, and I had bad side effects with both sotalol and flecainide -- although either would be appropriate for a PIP (means "Pill-in-the-Pocket", a term for a relatively high dose of a medication used in trying to CV without having to go to the hospital and be converting electrically).)
What a disappointment!!! I do realize, however, that there are a great many people who are very much worse off than I am. I have heard their stories and read them on the IN, and any hospital stay will, of course, reinforce this feeling, as you look at the patients around you.
I could go into AF or -- most likely AFL (AT)-- at any time. (It seems that the likelihood of recurrence ordinarily diminishes with time; I am not sure if this applies to my case.) If that happens Dr Haissageurre instructed me to take 400 mg amiodarone and wait several hours to see what happens and then to contact them to find out what to do next. My question as to why amiodarone works as a PIP when it needs a large loading dose before it can affect cardiac functioning was brushed aside. Some who are self- or otherwise CVed at this point never have a recurrence. Other will need an additional CA.
(When I discussed this use of amiodarone much later with my cardiologist, he was as mystified as I was. He suggested that if there is a recurrence, either to wait, or to take propranolol to keep the rate at a more comfortable level, and then if I don't convert within several hours, to start taking flecainide twice a day in the hopes of conversion. He could not recommend the higher single dose used as a PIP (for example, 300 mg) because, strictly speaking, I would have to spend the night in the hospital because this would be an increase the dose that had proven to be safe for me. He said if I wanted to take the chance of doing so, this was up to me. I could then continue to take flecainide twice a day, and call he him if I didn't convert in a couple of days.)
If I needed another CA, the Dr Jais would know right where to go, and would be working and “seeing” before edema built up. Usually, this kind of touch-up takes a very short (RF-burning) time. They will work me into their schedule so I wouldn't have to wait as long as would a new patient.
The good news was that he didn’t have me on any AR medication, which surprised me. I assumed I would go back on flecainide, which kept me in NSR, but had bad side effects, including symptoms of Sick Sinus Syndrome and depressing fatigue. (I learned this when I went off it for several days before the CA, during which I felt very much better.) The other post-op possibility was amiodarone, which I predicted would bring me down. Dr Jais said the reason for no medication was that my AF was of such short duration (a total of about 6 ½ months in the last 2+ years). In any case, I was free of ARs and felt better than I had in a very long time.
As noted above, I am to stay on Coumadin for three months, and consider going off if there has been no AF – although the issue of silent AF and borderline risk factors complicates things
I asked about exercise, which has been so important to me throughout my life. They said no significant exercise for a month. They could not give exact guidelines. I will walk for a month, and then gradually work my way up.
I do not foresee getting back to doing what I call “Tier One” exercise, which would be doing triathlons, very long bike rides, or three-hour run-bike workouts. I do hope to do the next level down which would be occasional two-hour run-bike workouts, half-hour (mile) swims, jogging 10k, and strenuous hiking. The next level down which would be various weight routines and shorter runs or exercise biking.
Heart-relevant supplements I am taking include ribose 3-4 tsps, COQ10 (100mg), and a bit of taurine and a bit of Mg ; both taurine and Mg tend to depress me. I also drink 2-3 glasses of Low Sodium V-8 juice. Acetyl-l-carnitine seems too stimulating to be safe for people with AF potential, but I may be wrong about that. I also take pantethine and tocotrienols to help simvastin increase HDL, and vitamin K2 and vitamin D3 to fight calcification, some of which may be caused by taking Coumadin.
I am now two+ weeks in NSR. Apparently half the failures occur in the first week, although I do not know the exact figures for my situation.
I get tired more easily, but I feel very much better than when I was on flecainide or in AF. Before, I had to spend so much energy just getting through the day.
So far my heart has been remarkably quiet. I have had very few ectopics; I notice only because I am so aware of my heart, and I have the greatest sympathy with those who must put up with PVCs for weeks or months after their ablation.
Throughout my Bordeaux experience I believed that I was in good hands – although I was vigilant even there for omissions or slight bends in the truth to which all who spend their energies and talents in activities that involve reputations, status and the like are susceptible.
This is quite different from my Wolf experience, where I was given vague information that I irresponsibly failed to pin down and where for various reasons I was frustrated by lack of clear, helpful communication post-op and where I developed a vague feeling of mistrust.
So, I guess this won’t be the last chapter after all. Actually, second ablations are very common (although another one would be my third, counting the Wolf “mini-maze”). I know I will be very disappointed if (when) I go back into AF – or even if I have a lot of PVCs or PACs. My heart seems so quiet now; I have been aware of only a few 1-2 second runs of tachycardia. I will be waiting and watching anxiously as the edema disappears over the next three months, during which time the effects of the failed blockage may emerge…
I had just sent in my three-month report to Bordeaux, when I had an episode of AF, which was quite noticeable and which was confirmed by my Freeze Framer. It consisted of one hour of AF, followed by an hour of AT. I took 400 mg amiodarone, as instructed by Dr Haissaguerre, and 15 of propranolol. As indicated, I converted after two hours. My email describing the incident and Dr Jais's reply are included here.
Interestingly, the incident occurred after I went off a small dose of propranolol (5-10mgs) that I had been taking for musician's tremor (actually, a benign essential tremor that interfered with my woodwind playing) during a time that I was rehearsing for a musical. My internist agreed that going off a beta blocker "cold turkey" after 10 days of use can contribute to arrhythmias, and that a better strategy would have been to take the beta blocker every other day when I am not playing during the run, and then to lower the dose by 50% every 10 days.
I have had no further occurrences of AF/AT of which I am aware, although I suppose silent AF is always a possibility -- although if there were any indication of the heart inefficiency, I would certainly notice it.
At the end of June, I had a big drop in energy level, with severe fatigue and anxiety. I tentatively ruled out any heart issues, because I was able to exercise as usual, once I got started, and my heart rate and other cardiac behavior were not unusual. This left Chronic Fatigue Syndrome (CFS) or the like with possible adrenal exhaustion and/or other HPA or neurotransmitter problems, probably caused by- and causing sleep deprivation -- a vicious circle in which I had been involved before. To make a long and unpleasant story short, these problems have been pretty well handled for the time being by Remeron 15 mg at bedtime and Klonopin .25mq 2 or 3x per day (including a dose when I wake up early and can't get back to sleep -- which has been a life-long problem). Other measures that have been extremely helpful have been the use of the Resperate device and Dr Jeffrey Thompson's Delta Sleep System CD.
One reason I mention this is incident that dealing with AF can be terribly stressful and it would not be unexpected that sufferers would succumb to the results of severe stress with similar symptoms.
Another reason is that one way to check on adrenal functioning is to submit to a Cortrosyn challenge test, in which blood is first drawn to get a baseline cortisol level. ACTH is then injected to see if the adrenals will respond properly. I was concerned that the jolt of ACTH would cause arrthymia; however, my cardiologist assured me that this would not happen because the amount of ACTH injected is not that different than that which comes down the HPA axis during stressful parts of the day. Sure enough, all I felt when the ACTH was injected was a stronger, more noticeable heartbeat. I am only a case of one, however.
I will also mention that any AFer taking or considering taking an antidepressant should check to see if one of its side effects is heart arrthymias. There is not much information about this, but possibilities include tricyclic antidepressants, trazodone and fluoxetine.
So, things are going OK. I am hoping, of course, that the above incident was triggered by stopping propranolol, but there remains potential of the failure to complete the inferior PV-mitral annulus line ... We'll see.
Thanks for listening! -- Dick Inglis
I have had no further reoccurrences of AF of which I am aware.
Once in a while I notice 1-2 second run of tachycardia, as if some focus were shooting out an impulse to start AFL but it got blocked. I suppose there could be others that I don't notice.
Also, I notice an occasional PVC.
I am still very aware of my heart and still anxious about AF's recurring. I always carry my PIP (a beta blocker plus a choice of amiodarone suggested by the Bordeaux people and flecainide which I was on before and which is frequently used in this country).
A couple of months ago, I began taking taurine (c 1500 mgs) and magnesium (c 400 mgs) and potassium (c 2400 mgs) in doses recommended by other AFers and by integrative or functional medicine doctors. Previously, these dosage levels of taurine and especially magnesium would have given me a general "down" feeling (depression or tiredness). Now they usually relax me, and they almost certainly reduce the frequency ectopics.
The reason for this change might be that the Remeron (30mgs) I have been taking for sleep for about 7 months has begun acting as an antidepressant, as well as helping me to sleep over this period via its antihistamine-sedative effect.
The lesson here is not to give up on substances (or other measures) that have helped others. Give them a try from time to time, especially if something about your body chemistry may have changed.
-- Dick Inglis