Atrial Fibrillation - Radio Frequency Ablation

[dsfbrit]

I am a 59 year old male with lone Atrial Fibrillation. This means I have a strong heart, no underlying heart disease, but it beats out of rhythm. In the 3 years since it was discovered, with just two 25 mg beta blockers (betaloc) and a 300 mg aspirin per day, this has been controlled very successfully - I have had no problems (feeling faint etc..). In fact today my daily Blood Pressure reading was 119/79 and heart rate of 59.

This heart defect was discovered when I went to India to have a hip resurfaced. I now have to go to India again to have the other hip resurfaced and the cardiologist is questioning my heart's ability to cope with a 2.5 hours operation.

I have offered to have the operation under local anesthetic. The hip surgeon says this should be OK, but the cardiologist has not come back with his approval to go ahead with the operation. Having waited a week for the cardiologist to OK the local anesthetic option, I am concerned he will not give the go-ahead.

I would consider going to another hospital, but the hip surgeon there is one of the best in the world and he is by far and away my first choice.

I have been thinking though, that perhaps I could use this opportunity to get the heart problem sorted out once and for all by having an RF ablation procedure.

So these are my options and any help anyone could give me would be greatly appreciated, as to be honest, my head is spinning with it all !!!

1. Have radio frequency ablation in Thailand now and get the heart beating again correctly. If so could anyone recommend a good 'non rip-off' hospital. I live in Pattaya and have contacted most of the hospitals here and in Sri Racha by email, and their replies, lead me to believe it would be better to go elsewhere.

I am awaiting a further reply from Gavin in Sri Racha as recommended in another thread, he has been helpful, but I don't think he will be able to provide me with what I am looking for.

2. If I had the RF ablation in India before the hip operation, would this be a good idea or can you not have surgery straight after the ablation

3. Would it be better to stick with my medication which has controlled my AF very well and suggest to the cardiologist in India that I go to a cardiologist in Thailand and get all the relevant tests run to show my heart is OK for surgery.

Like I say, I am totally confused and it is not helped by the fact that I cannot really see why there should be any problem anyway, as I have offered to have the surgery under local (epidural) anesthetic.

Thanks for your help

Edited August 31, 2013 by dsfbrit

[jrtmedic]

Here is a link you may find helpful.

http://www.mayoclinic.com/health/atrial-fibrillation/DS00291

Well controlled AF is not usually a barrier to undergoing surgery carried out under general or regional anaesthesia. However, your anaesthetist will usually proved guidance and advise. .

As you have an "established" AF it may not be possible for that to be converted to a normal sinus rhythm.

You would need to undergo some more investigation before it could be determined if ablation would help your particular case.

Investigations may include ECG, stress-testing, echocardiogram +/- a trans-oesophageal echocardiogram and chest x-ray and the usual blood investigations..

Hope this helps !

Best wishes

Jrt

[dsfbrit]

Dear jrtmedic

Thanks for the quick reply, the advice and the link. I had a read of that.

To be honest, one of the reasons I am so 'confused' is due to me spending so much time reading about how the heart works, AF, even learning how to interpret my ECG/EKG charts etc..

Like you, I did not think that controlled AF would prevent me having this type of surgery.

When I last went to see a cardiologist in Thailand 2 years ago, he confirmed the diagnosis of the cardiologist in India. He also confirmed the treatment.

He said I should not need to change my medication nor have ablation unless I felt faint etc...

I have felt great in the last 3 years, returning to playing regular sport. I have no desire to change my method of controlling my AF. I am very happy with it.

However, my right hip has now started to hurt, as I knew it eventually would and I need to have it 'fixed'.

Imagine my disappointment when I agreed the operation date with the surgeon (set for October 13th), but was then asked to wait for the cardiologist to OK everything before I booked a flight. Fair enough.

I emailed over an up to date ECG/EKG last Saturday and have heard nothing since.

Maybe the cardiologist will OK the procedure, but as I have heard nothing, despite contacting him during the week, it makes me feel uneasy as to what is going on.

I have to have this hip operation, so I am looking at ways to make sure it can go ahead if the cardiologist does indeed say it cannot go ahead with my heart's AF.

Thanks again for the reply.

Edited August 31, 2013 by dsfbrit

[jrtmedic]

Maybe a quick note to your Orthopaedic surgeon will produce results !

One point you could ask about is having a pre-op consultation with your Consultant Anaesthetist. If s/he has any concerns about your "fitness" to undergo surgery appropriate referrals will be made.

Anaesthesiologists are highly skilled Physicians who are very used to managing all manner of pre existing conditions whilst at the same time providing a good anaesthetic!

Best wishes

[dsfbrit]

I think my orthopaedic surgeon is a bit frustrated with the cardiologist. He made me have tests for 3 days to make sure I would be OK for the last hip operation.

In fact he started running the tests at 6PM on the Thursday and had not agreed I could have the operation at 9am Monday morning when the operation was scheduled for.

In the end I think it was my surgeon that 'encouraged' it to go ahead. I was really fed up as they would not even let me pay and I knew that meant the operation may not be going ahead.

I did not see the cardiologist once in this 3 day period, the nurses just put needles in me, connected me to machines and pumped fluid into me. I asked what each 'thing' was for and was just told 'Dr ****' said so.

After the operation, the surgeon inspected the wound and had a chat. He apologized for all the tests and the 3 day delay, and said my heart was very strong and I should not worry. He said that if my operation had been an emergency and not elective surgery it would have gone ahead without any tests at all - the anesthetist would have dealt with any complications.

At the end of my stay in hospital, I saw the cardiologist for only the second (or third) time during my stay. He told me I had AF and that ablation surgery would be an option and he could carry out an ablation procedure for me.

He then presented me with quite a sizeable bill!!

I was not really bothered by now, I was pleased my heart was strong if 'misfiring' a bit and I had my new hip!!!

I was only too happy to pay his bill and get home.

I guess that I am suspicious that this cardiologist is not entirely concerned with my health and may also be keen to make some money or something. Hey I could be wrong to be honest I don't really care as long as the operation goes ahead.

However, I did suggest to my surgeon I would have the local anesthetic, so maybe it would 'remove' the cardiologist from the 'loop'. My surgeon thought this would be an option and was going to discuss this with the cardiologist last week.

It is the fact I have heard nothing, when normally the surgeon replies to me within 24 hours, he even sent me an email last Sunday, that I think this cardiologist may be 'involved' in some way and the operation is in doubt.

I just want the operation to go ahead and is why I am looking at all options to make sure that this cardiologist cannot prevent it - if indeed that is what is going on.

Maybe next week I will receive the OK to book my flights and my concerns will be unjustified. Still, I used to be a boy scout and 'be prepared' is my motto!!.

Thanks again for your thoughts, it is helping me get my head 'sorted out' with all this!!!

Edited August 31, 2013 by dsfbrit

[jrtmedic]

If you lose confidence in a medical practitioner you have every right to "sack" that person and request another opinion

[bunnaag]

you have a heart rate of 59 which is normal.You do not have to take a lot of betablockers.For blood thinners aspirin is in your case sufficient.My heart rate is always above 90 heart beat irregular and I have to take additional to 100 mg aspirin warfarin 2.5mg per day 200 mg metropolotartrate and an other betablocker,Sport is not possible.I am thinking of ablation.With me it will not go away with medication it is chronic already.Some specialists in Bangkok?

[Sheryl]

Ablation is a highly specialized procedure, there are only a handful of docs in thailand with much experience in it.

And, most importantly - it is often unsuccessful.

Even when it does initially succeed, many people later revert to a-fib.

Personally if it were me, I'd leave it for now and await further refinements in the technique.

As others have said, a-fib with a well controlled ventricular response is not a contraindication to surgery, even under general, and certainly not a problem if spinal or epidural block used.

The problem in this instance seems to be with the cardiologist. The fact that he tried to "sell" you on the idea of ablation and is now dragging his heels clearing you for surgery raise some alarm bells in my mind.

I suggest you tell your ortho that you are not happy with this cardiologist and request a different one.

[dsfbrit]

bunnaag

Thanks for your feedback.

I see that you take more medication than I do. You are also considering ablation? I think that Sheryl's reply is very interesting for people in our position.

Edited August 31, 2013 by dsfbrit

[dsfbrit]

Sheryl,

Thanks for your thoughts on this.

I respect your opinion and will now adopt this as my position with regards to ablation. It is neither a 'cure' nor permanent solution to my situation.

I have read quite a lot about the heart, AF and ablation over the last period.

After reading so many blogs about ablation and the success rates and the need for second ablations etc... you have confirmed what I have been suspecting for some time, that ablation is not the answer to my AF.

I am quite 'happy' taking an aspirin and 2 beta blockers a day and for me it works, So why would I want to change it unless I have to. Certainly not just so I can have a hip operation.

Both you and jrtmedic have given me the confidence to 'stand up' to this cardiologist if indeed he is the person blocking my operation.

To be fair to him, it may be for another reason that I did not hear from the hospital all last week. Maybe someone was just on holiday. I doubt it though as 'alarm bells' have been ringing with this cardiologist ever since he suggested that he kept me in India when I had my last hip operation and performed the ablation procedure then.

When I do eventually hear form the hospital and if the cardiologist comes back with a scenario that seems like he is 'playing games' with me, could you please advise me what would be a reasonable way to side step him, would it be:-

1. to be blunt and say I cannot understand his concerns as my AF should not be a reason to stop the operation.

2. do 1 above and ask for a second opinion

3 do 1 above and suggest I go for a second opinion in Thailand - could a cardiologist runs tests on me in Thailand and give me the OK for the operation - maybe this would be a good option if it is permitted. Then could I avoid the cardiologist in India almost completely??

Thanks again for your help.

As you can see from the time I posted this (4.30 am) I am not getting much sleep at the moment thinking about all this. To be honest, it is not the hip operation that concerns me. I have had one before and know what it entails. It is the thought of this cardiologist 'messing' with my heart and my current treatment which has been so successful !

Edited August 31, 2013 by dsfbrit

[dsfbrit]

jrtmedic,

As you can see from my reply to Sheryl, I think sacking this cardiologist would be a nice idea.

If he does come back with what seems to be an 'odd' suggestion, what would be the best way to 'side step' him. I say side step him as I could see taking him on 'head on' could be a tricky thing to do. The surgeon that would perform my hip operation is my first choice to perform this operation and I don't want to put myself in a position that I cannot go to this hospital in India at all!!

Tricky isn't it???

Thanks again for your help - I know what I want to do now, I am just not sure how best to go about it.

It certainly does not include an unnecessary ablation procedure, so at least I have made that decision.

Edited August 31, 2013 by dsfbrit

[jrtmedic]

dsfbrit

I would write two letters.

The first addressed to this cardiologist in which you thank him/her for past advice but stating you have decided to seek a second opinion.

The second letter should go to your surgeon.

I would suggest in this letter you stress your trust in him and reiterate your desire for surgery ASAP. Go on to say that you have lost confidence in the cardiologist and ask if he could recommend a different doctor if he considers that a pre op cardiac assessment is necessary. Enclose a copy of the letter addressed to the cardiologist.

Hope this helps.

Edited September 1, 2013 by jrtmedic

[dsfbrit]

jrtmedic

Yes is does help, thanks.

I will wait now until next week to see what the cardiologist comes back with.

I have decided in my own mind that whether the operation goes ahead on the 14th October or not is not important. That way him delaying anything is no longer a pressure on me, as quite simply I would have a lot to organise in my personal life to go to India in October - and it is September already!!!

I waited 5 years before I had the left hip operated on, so I can wait a few more months to have this hip repaired if need be.

I think the trouble with people of my era, English and brought up in the UK, is that we were brought up to respect and not question doctors and the medical profession in general. So the thought of dealing/treating doctors like 'normal' people who are messing me about, is quite a paradigm shift in my mind.

Still you have encouraged me to be a bit more aggressive/assertive with them in future.

I wont contact him now until he contacts me - see who blinks first - I look forward to see what next week will bring!!!

Who knows, it may even be the OK to book my tickets for an operation next month!!!

Thanks again

Edited September 1, 2013 by dsfbrit

[Sheryl]

dsfbrit

I would write two letters.

The first addressed to this cardiologist in which you thank him/her for past advice but stating you have decided to seek a second opinion.

The second letter should go to your surgeon.

I would suggest in this letter you stress your trust in him and reiterate your desire for surgery ASAP. Go on to say that you have lost confidence in the cardiologist and ask if he could recommend a different doctor if he considers that a pre op cardiac assessment is necessary. Enclose a copy of the letter addressed to the cardiologist.

Hope this helps.

Agree with this but to #2 would add the offer to have a pre-op cardiology screening in Thailand and send him the results.

[dsfbrit]

Thanks Sheryl,

That sounds like a good idea.

Out of interest is, a 'pre-op cardiology screening' the same for purposes of a hip operation as it would be for any other operations. I guess I am asking if they are tailored to a specific operation? Or is it just on length of operation and whether it would be under local or general anesthetic.

I guess what I am asking is would I contact a hospital and just ask to see a cardiologist and then explain to the cardiologist that I wanted a 'pre-op cardiology screening for a 2.5 hour hip operation' ?

Any idea what a reasonable price for this would be as my initial 'googling' shows this is another area where unnecessary tests may be performed ?

I have a lot of question don't I???

I only want a hip operation!

Thanks again, your advice has been very helpful, I was at my wits end yesterday, I now have a good 'action plan' and maybe I will stop thinking about it all 24/7!!!

regards

David

edit: I have just looked at some of the (many) possible tests I could have in Thailand for a pre-op screening and think if I simply ask the hospital in India what they would want to have tested for the operation to go ahead would be the best thing to do.

Edited September 1, 2013 by dsfbrit

[Sheryl]

First of all -- the length of the surgery and type of anesthesia are key factors, but the type of surgery is also relevant, mainly in terms of the likely amount of fluid and blood loss. "Hip resurfacing undre general anesthesia" will be ample info.

Whether more tests would be needed for a cardiologist to feel comfortable signing off on you depends on your full medical history and what tests and records you have available. Obviously, you have a recent EKG and it sounds like some sort of cardiology assessment was done in India that concluded it was "lone" AF; do you have records from that? As a cardiologist's concern is not going to be so much that you have AF but why you have it, i.e. whether there is any underlying cardiac disease present.

A stress test might be recommended; it is not very expense, maybe 1000 baht or so, depending on hospital.

Make sure first that your ortho surgeon in India will accept the clearance of a Thai cardiologist.

[Sheryl]

P.S. Forgot to mention, but the aspirin is a definite issue as it increases risk of bleeding during surgery.Ask your ortho surgeon if you need to discontinue it and if so, how long in advance

[dsfbrit]

Thanks Sheryl

When the cardiologist does eventually contact me, still no contact - that is 10 days (6 working days) and nothing - no email at all - then I will follow your advice.

That is assuming that he comes back without giving me the OK to go ahead, then I will suggest I get the pre-op carried out over here and if that is OK, then I will ask exactly what he wants checked and the form of the letter he requires written by the cardiologist over here.

In fact, even if he OK's the operation, I may offer to have the pre-op check over here so he does not have to be involved so much - now that would be nice!

I assume then that I should book the pre-op test with a cardiologist ??- any cardiologist can do this I suppose.

Generally speaking, how long before the operation would the pre-op tests be valid.

For example if I do go ahead with the operation next October 14th, would I need to wait until a week before or could I do it a month before??? Would it still be valid?

The blood thinning is an interesting one, as before the operation last time I was given a blood thiinning injection each day, I have read of some people being given needles to inject themselves with blood thinning agent the week before.

It seemed odd to me, as when I recently had a vasectomy in Thailand, I had to stop taking my medication (aspirin and 2*25 mg beta blockers) a week before the procedure, due to the bleeding issue.

Mind you, as I was flying back from India after the hip operation, they were concerned with blood clotting, deep vein thrombosis. I wonder if there is much blood loss during the hip operation - I will look into that out of interest.

My heart is very strong, as the cardiologist in India knows all too well. I play a lot of sport and dont drink alcohol etc...so most of my body is in good condition, apart from the misfiring heart signals and the hips - worn out I expect due to too much sport over the years!

I still have all the results from all the tests - including the blood tests etc... there were lots of them - scanned into the computer as well in case I need to send them 'somewhere'.

That 'somewhere' may be a different hospital. I found another well recommended surgeon in India at a different hospital.

I used your 'guidelines' on choosing a surgeon, which I agree with, I would add to it though recommendations from Self-Help-Forums on the internet as being a useful indicator in conjunction with the other 'tests' of a good surgeon.

In my case I used some info on a Help_With_Hip_Resurfacing Website.

I have contacted this other hospital and they got back to me in about 4 hours and I have now given them my details, x-rays etc... and am waiting for some more feedback from them.

It s a pity I cannot find a good surgeon to carry out my hip resurfacing here in Thailand, it would save a lot of messing about. Sadly, none of the Thai surgeons have carried out enough hip resurfacing operations to make them experts in my opinion. Only several hundred. The surgeon in India has carried out over 3500 !!! Hence my desire to go back to him.

I cannot understand why this cardiologist has not contacted me at all - still for the next week I wont waste my time contacting him again - I will just wait for him to get in touch and pursue this other hospital option as well.

Thanks again for your help.

Edited September 2, 2013 by dsfbrit

[Sheryl]

The closer to time of surgery the pre-op assessment is done, the better.

[dsfbrit]

Just a quick thank you to jrtmedic and Sheryl.

I contacted the surgeon on Friday and he contacted me yesterday and said the cardiologist has OK'ed the hip operation - so I am off to India in 4 weeks time.

I cannot wait to get the hip fixed and then get back to my normal life - I won't be having any ablation procedure either unless there are problems in the future with my current simple medication.

So thanks for the advice, it was a great help and has helped me decide exactly what I want over the coming period.

[Sheryl]

Great. Thanks for the update.

Don't forget to ask the surgeon whether he wants you to stay in the aspirin prior to surgery.

[dsfbrit]

will do - thanks again.