ATRIAL FLUTTER AND ABLATION

I believe my history of a rather unusual type of heart disease and its subsequent course presents an interesting picture of how medicine has evolved in recent years, certainly a far cry from when I first started practicing medicine in 1956.

In 2004 I was diagnosed with a genetic form of heart disease, Myxomatous Degeneration of the Mitral Valve. The event leading to the diagnosis was the sudden onset of shortness of breath while on a snow shoeing trip. An echocardiogram at that time showed an enlarged heart caused by severe Mitral regurgitation related to Myxomatous degeneration of the posterior leaflet of the Mitral valve and the rupture of a chordae tendonae, a tendon connecting the leaflet to the heart muscle which helps open the valve on filling of the left ventricle. Actually, it was the tendon rupture which accentuated the Mitral regurgitation that precipitated the acute episode

Open heart surgery followed shortly thereafter at the Texas Heart Institute in Houston where they repaired the Mitral Valve and inserted rings into both the Mitral and Tricuspid valve orifices to accommodate the smaller leaflet on the left side.

Post surgery, Dick was left with an abnormal rhythm, atrial flutter, for which he had a cardioversion several months later in Durango, CO. Then followed a quiescent period of two years but with a reduced capacity for exercise and with a normal heart rhythm but with frequent extra-systoles (extra heart beats) which were treated with medication.

In 2006 atrial flutter recurred after a short stint of running (my last attempt to return to running). One cardiologist actually thought I was in ventricular tachycardia (I didn’t think so as I felt pretty good) so she called for an ambulance and I was rushed to the OHSU hospital ER. There one of my cardiologists thought it was atrial flutter and he massaged my carotid sinus and the flutter stopped for a short time (but confirmed that it was a. flutter) but it recurred. At this time they decided to put in an ICD (intracardiac device, pacemaker/defibrillator) and they did a right heart catheterization to ablate the source of the a. flutter in the right artrium which was successful.

Now to the present time some two years later in the fall of 2008. The atrial flutter recurred two weeks ago for unknown reasons. My primary cardiologist, who is a well known electrophysiologist, Dr. Jack Kron, recommended that I have another ablation to stop the flutter. He warned me ahead of time that he thought the flutter might be originating from the left atrium but they were going in on the right, safer side anyway. On doing the procedure they were able to map out the electrical pathway that occurs in the heart that instigates the contraction of the several chambers of the heart. He was correct in that the mapping showed the locus for the a. flutter originated in the left atrium. A point of interest that I didn’t know before, and related by another cardiologist later, is that a. flutter originates in the atria of the heart while atrial fibrillation originates from the area of the pulmonary vein which empties blood from the lung into the left atrium.

During the procedure, they could have penetrated the septum between the two atria from the right side to enter the left heart with the catheter but decided not to do so because of the danger involved. So they did the next best thing. The a. flutter begins in the left atrium and then follows a circuitous path over to the right side. They ablated or cauterized (burned) several areas in the right atrium to break the circuit and then they cardioverted my heart to break the rhythm. So, now I am back in a normal sinus rhythm; however, they are not sure how long it will hold. When, and if, the a. flutter recurs, we will then decide whether or not to ablate the locus of the rhythm by catheterization from the left side. In any case, I am now feeling better.

Unfortunately, they had another bit of news from the procedure. They indicated that I had a lot of scarring of the electrical pathways on the right side of the heart. Dr. Kron left on vacation right after the procedure so I haven’t had a chance to talk to him yet but got the above information from one of his partners. They don’t know the source of the scarring but thought it might have been from my prior open heart surgery in 2004. I think that is unlikely as all they did on the right side of my heart at that time was to put in a Duran ring around the Tricuspid valve, as they had placed one around the Mitral valve, too, making both openings smaller to accomodate the smaller posterior leaflet after removing the middle degenerated portion. In any case, they should have seen this scarring when they did the ablation on the right side back in 2006. I await the return of Dr. Kron to get a better explanation of the source of this scarring.

So, what is turning out to be a saga, continues, so stay tuned for the next episode.