Brief Answer:
Have you got your ECG?

Detailed Answer:
Hi,

I am so pleased that you wrote to me,

I have read your question, and will try to further explain things to you...

Yes I do remember you, it is hard to forget such kind people, now that I know, you are quite well aware of atrial arrhythmias and treatments and you have gone through quite much of the literature and videos.

I will touch some technical things in this conversation for your better understanding but it will be great if you can upload your ECG to this conversation. I want to see if there was any flutter wave in ECG or not... If you have 10 ECG's, I am ready to go through all ten, any reports you want to share.

I am happy to go through them and I hope I will be able to explain every thing in detail... what was it...what could have been done and what should have been done..

Hope to hear back from you.

Dr.Muhammad Ahmad
Resident -M.D (Cardiology)

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Brief Answer:
No unfortunately I did not get the images.

Detailed Answer:
Hi,

Thanks for writing back,

I apologize for inconvenience.

Unfortunately I did not get the ECG'S thanks for detailed list of contents you tried to send to me, when you post a question you can find "choose file " tag bellow click on it and chose picture or you can see upload feature on right side of your dashboard and scanned ECG files in proper chronological order as you mentioned in the list.. You can attach further files after attaching one, by clicking on "attach further reports/pictures”.
Or
You can mail me your reports at YYYY@YYYY and with Subject as ATTN: Dr. XXXXXXX Ahmad


Sorry for inconvenience but instead of just answering a query I am trying to give to the best possible advice and it will be great if I could go through your reports.

Waiting for your response

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Brief Answer:
I have seen your reports and will explain in detail.

Detailed Answer:
Hi,

Thanks for taking time to upload your reports in such fine resolution and detail. I apologize for being late in replying but didn't want to reply before i had

reviewed the reports closely, I actually had to log in through a personal computer to view PDF files and it took time to get my hands on one. Then i discussed it with

a XXXXXXX cardiologist of my department to get a second ,more experienced opinion.


Here in my answer i will try to explain your reports to you , then I will tell you the latest guidelines and then i will show you both sides of the coin without any

bias for the doctor who did procedure on you. I will give my opinion as well in the end and will leave it upon you to decide what was the best choice and what could

and what should have been done.


So we start with your reports.

1- ECG:

All ECG's before ablation are more or less normal except in one in which it shows atrial flutter. Yes you were right in saying that atrial flutter is cousin of

fibrillation , but being elder it is more organized compared to flutter, faster, a bit more dangerous if it causes ventricular tachycardia and can hurt you if allowed

to hit you for a longer period.

ECG's after ablation:

ECG after ablation show changes consistent with ablation and in your case ablation seems to have gone quite well..yes there was a big complication, a really scary

ordeal you had to go through but as far as heart is concerned it seems that ablation is working fine so far.

ECHO:

Your echo shows that your heart is in a very fine condition working really well.. probably better than about 90% of people in your age group, well age is nothing but a

number i believe :). Your heart is good to go for decades.


NEW GUIDELINES FOR ABLATION:


The main indications for catheter ablation are:

1-Symptomatic supra-ventricular tachycardia (SVT) due to atrioventricular nodal re-entrant tachycardia (AVNRT), Wolff-Parkinson-White syndrome, unifocal atrial

tachycardia, and atrial flutter (especially common right atrial forms).

2-Atrial fibrillation with lifestyle-impairing symptoms, after inefficacy or intolerance of at least one anti-arrhythmic agent.
Symptomatic ventricular tachycardia (VT), especially idiopathic VT.

Other indications for catheter ablation include:

Symptomatic drug-refractory idiopathic sinus tachycardia.
Lifestyle-impairing ectopic beats.
Symptomatic junctional ectopic tachycardia.

REFERENCES:


1-Greenberg ML et al, Catheter Ablation. Medscape, Mar 2011
2-Tung R, XXXXXXX NG, Shivkumar K; Catheter ablation of ventricular tachycardia. Circulation. 2011 May 24;123(20):2284-8.

I told you indications in the last discussion we had few days back, and i told you criteria if ablation, that was what we follow clinically. Here i have quoted what

test books say about indications, here ,i want to further say that

1-Ablation should be considered in case of SYMPTOMATIC flutter or fibrillation:
by symptomatic we mean chest pain, severe palpitation, syncope, hypo-tension , altered mentation, Hypo-tension ,heart failure, shock.

2- As you must have read, it says fibrillation which is refractory to meds, in your case you actually responded well to meds.

3- Fibrillation which impairs life, that again wasn't your case.



Catheter ablation:

It is no doubt the BEST treatment for ablation but there is always a criteria we follow ..guidelines tell us possibilities and probabilities of future risks and then

according to doctor's experience and guidelines he chooses what looks like best option for his patient.

What two possible decisions doctors can make and why:

1- To Monitor, observe, and follow up regularly:

Most of the doctors would chose this option, including me and the XXXXXXX i discussed your case with, he said he won't go for ablation until it was really indicated ,

e-g you had CHRONIC A-fib or flutter, VT, symptoms, very frequent episodes or episodes which didn't get controlled by meds.


2- To go for ablation:

Not many doctors would go for it in your circumstances but there are some reasons which make doctor go for such procedure, here they are:

a- When doctor considers it a life threatening danger to leave it without ablation.

b- When doctor is one of those doctors who hold the opinion that going straight to ablation is safer for longer benefit and safety.

c- When Doctors experience tells him that it should be ablated there might be no suggestive lab evidence.


d- There was a reason which you mentioned in our previous discussion, doctor ablating a private patient :).



MY OPINION:


I personally think that i would not have gone for an intervention
in your case and i would have waited to see how things progressed and if frequency of episodes and

severity was increasing or not and when i would be sure that benefits overshadow the risks then i would have gone for intervention.

I would also like to say that the ordeal you went through was huge and painful, your doctor would never have intended this to happen but this happens rarely, after-all

intervention is intervention, it has it,s risks but thing is, you are healthy now and you heart is doing great , ablation has cured the focus of arrhythmia and you are

safer now , it's a chapter worth closing now.

It is always such a pleasure to hear from you, indeed kids these days teach elders but to touch a higher level you need somebody to lift you and that'r our elders who

give us shoulder and make us reach higher ... we can never know more than our elders their experience can never be compared with out knowledge of few gadgets.

I also want to congratulate you and thank you for spreading light of knowledge, my mother is a teacher too and i can feel the impact you have on a society, one day every one has to leave this world but this knowledge, this light which has enlightened many hearts isn't gonna die, it will keep passing on, into generations. Thank you so much for your service :)

I can say with much confidence that you must have been among the most favourite teachers of your students . Stay blessed and healthy. Don't think much about the past , your ordeal is over you are alive and healthy ablation worked and there is no more danger of flutter ,fibrillation etc. You have many years ahead why ruin them with thoughts of past.

I wish you a real healthy and happy life stay blessed, if you have any other query or input i am more than happy to discuss. Thanks for your confidence and bearing with me.

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Brief Answer:
It's always a pleasure to discuss with you.

Detailed Answer:
Hi,

Thanks for writing back,

It's always a pleasure discussing your condition with you, i always enjoy if patients wants to know about their condition instead of just wanting a prescription and a prompt cure, a treatment list is available on internet any body can find it but a doctor patient relationship should be holistic. Instead of just curing the patient physically.

I will try to explain why ablation is not 100% , actually arrhythmias are caused by two reasons most of the times:

1- Re-entrant currents:

You must be knowing that heart contracts because of current circuit, the current is generated in atria and goes to venticles so atria contract 1st and then when current reaches the ventricles they contract afterwards. It is very important that this current keep going in one direction and never turns back to atria... atria will generate a new pulse any ways but if extra current comes bach to atria from ventricles (called re-entrant) current , then rhythm disturbances occur, atria produce their current and current comes from ventricles too so a cycle starts developing and atria who were getting one current surge per unit time now get 3-4 surges of current so they suffer 3-4 times quicker contractions.

What we don in ablation therapy is that, we freeze or block the path of re-entering current and arrhythmia doesn't occur again, but sometimes a new path is formed and arrhythmia again start occurring , ablation fails very seldom, most often it is a new ectopic focus of current production or a new pathway of re-entering current which causes recurrence of arrhythmia.

This specially occurs in patient with history if ischemic heart disease like heart attack etc. As you don't have this risk factor or any others so i believe you have very little chance of recurrence.

And option of medical management when this happens god forbid, or re-ablation is always there as a LAST RESORT.

It's my pleasure that you wrote back to me and you are always welcome to discuss this or any other health issues any time to need to or feel like. Stay blessed always :) Wish you the best of health.

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Brief Answer:
Its always a pleasure discussing with you

Detailed Answer:
Hi,

Thanks for writing back and appreciation i indeed work hard to come up with authentic ino with refrences and i try to explain things in simple words without using complex terminology, so that you understand things better.


I didn't mention it but now as you had the same problem so i will like to tell you that i lost my written answet twise while replying to you , when i got your reports i took time to discuss it with a XXXXXXX cardiologist, then 1st i wrote a detailed answer as usual and faced a power breakdown my laptop got turned off itsled and lost the answer.

Then i mustered up courage to write again and wrote an answer again ...took me some time and effort to write and i hit some key and it was no where to be found... this time i was really close to an end and losing the whole answer was really disappointing .

But till then i actually had learnt by hearrlt, every thing i had wrote twise, so for the third time i wrotr in writing software and kept saving the written answer after every 5 minutes... this was when i was able to write a full answer.


I am pleased that my hardwork pays off and you are geting educated about the arrhythmia issue with time.

Your appreciation is always my reward.

And yes you are always wellcome to share any thing you want. May it be Koala.... I love the animal though it's not found in my region. I am all ears and eyes:)

Stay blessed and healthy :)

And yes you can share any

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