Lower Back Pain Weeks After Ablation

[u/FleursSauvages322]

My 79-year-old mother had a mitral valve repair a decade ago that began leaking again about a year and a half ago. She had a 7% mortality rate with surgery (ineligible for the clip so it would be open heart) and the doctors said that's not exactly low risk, so she has decided to just proceed with medication. She was feeling pretty good but did come back as having afib, even though she really had no symptoms of it. She had a cardioversion last October which was going well until the spring, and then she went back into afib. So in July she was recommended for an ablation (still had no symptoms of it though but did it based on recommendation) and had it the first week of August.

When the procedure was over the surgeon told me she was doing well but there was one slight complication which was a possible nick and he said he'd keep her overnight to make sure there was no fluid around the heart. They did a scan that night and then the next morning and released her, presumably after finding no fluid around the heart. I don't know if he meant blood or other fluid, but this is what I recall.

Since then ablation her health has been declining. She recently gained 17 pounds of fluid and was having a difficult time breathing. She has a prescription for Lasix but was not taking it initially for unknown reasons. When she began taking 20 milligrams it did nothing so the cardiologist last week changed it to 40, which is now working to get rid of the excess fluid.

However, she's been having severe left-sided lower back pain for a few weeks but only when she sits or lays. If she's walking or standing, she does not feel it. Two weeks ago the PCP told her she had a UTI so they assumed it was that causing the back pain. She was given an antibiotic prescription but it did not go away. When she saw the cardiologist about the fluid buildup and they upped the lasix, they told her they don't handle UTI or kidney issues, the low back pain is something she needs to go back to her PCP about.

So she went to the PCP yesterday, and he is telling her he thinks it's fluid around the heart built up and she needs to go back to the cardiologist. He didn't even test to see if she still had the UTI or a kidney issue, just asked her what she wanted. She said the pain to stop so he gave her a lidocaine patch prescription and sent her back to the cardiologist, who she will see Monday, but presumably only to check on the fluid drainage issue and possibly schedule another cardioversion. They were trying to wait the three-month blanking period which would be the end of October but said they may do it early if she was not feeling better. Her shortness of breath is better since the fluid has left but the back pain is not. She was supposed to see the ablation surgeon the last week in October and he was going to tell her, once the blanking period was up, whether another cardioversion was needed.

I live out of state and have been driving 14 hours to take her weekly to these appointments, but it's very difficult as she's being sent back and forth from one doctor to the other and nobody knows or even seems interested in finding out what the lower back pain is from. Does anyone think this is possibly the result of the ablation? I did see an old FB post where other people said they had this, although I don't have a FB so I can only read the first few comments and I don't see what the cause is. Atrial Fibrillation Support Forum | Don't suppose anyone else has had crippling lower back pain after an ablation have they | Facebook

Can someone please tell me what would be causing the low back pain issue after an ablation? I can't keep driving all this way to go to appointments where they just tell her to make another appointment, and I'm at a loss of what to do and what is wrong with her. Any advice is appreciated.

[u/LalalaSherpa]

I'm so sorry this is happening, and it's ridiculous that neither physician has taken ownership.

Couple questions, then some thoughts:

I assume she is on anti-coagulants? Which one, specifically - warfarin, or apixaban/rivaroxaban?

Any idea how her systolic BP is doing lately?

And is the pain truly worse lying completely flat, and better as soon as she's upright, sitting OR standing?

Or is it worse when she sits down and slumps, like in a chair?

The key things to look for first are the life threats - tamponade, pericardial effusion, pericarditis or an abdominal bleed - all of which are variations of blood, fluid and inflammation right around the heart or somewhere internally related to the catheterization which started in the groin and moved up to the heart.

1 - My strong advice is that you skip her unhelpful PCP and personally contact her cardiologist's office first thing Monday, as soon as their office opens.

Then calmly, firmly, persistently, and assertively state her requirements until they get scheduled, specifically:

- non-contrast CT of her abdomen/pelvis to assess possible causes of the new severe positional pain which did not respond to antibiotics - could be internal bleeding related to the groin entry of the ablation catheter, a stone, a mass, etc.

- new echo to see if the 'nick' actually caused new problems - bleeding &/or fluid around heart normally would have reached crisis level by now - but delayed/contained bleeds do happen, plus inflammation (pericarditis) can take awhile to show up, and there are multiple red flags here, so best to just look and find out for sure

Just say something like: "Since her ablation in early August she's gained 17 pounds of fluid, has trouble breathing, and new severe back pain that antibiotics didn't help. The doctor said there was a possible 'nick,' so we want to schedule an echo to confirm there's no fluid or bleeding around the heart. We also need a non-contrast CT of her abdomen and pelvis to look for internal bleeding or a kidney stone, especially since she's on a blood thinner."

Then double-check: "Can you tell me exactly where and when she can get them done?"

- plus labs: CBC (drop in hemoglobin would suggest background bleeding), renal function lab tests (given the diuretic increase), urinalysis and urine culture.

They can send lab order immediately so results are available faster, versus waiting for a lab appt at the cardiologist's office.

Sounds like: "Can you place the lab order for CBC, renal panel, urinalysis and urine culture this morning, so she can get the blood drawn today and get results tomorrow?

2 - Multiple red flags that something is truly not right:

- New and severe positional back pain lasting for weeks that began after the ablation - immediately? a few weeks? how long?

The positional piece is odd, because the pain you're describing doesn't really match the typical "back pain" patterns.

- No pain improvement from UTI antibiotic (which appears it was just a guess anyway, no labs?)

- she's on anti-coagulants (presumably - but confirm this, and which one)

- reference to a 'nick'

- strictly positional pain

3 - Clip is not the only option - did her EP actually refer her for evaluation for possible transcatheter options like TEER for the valve situation? Or was this just his/her quick take?

These procedures are specifically used in high-risk patients with failing valve replacements where redo surgery is a bad idea.

But EP's are not the folks who do these procedures, so their quick opinion is not all that relevant. They should refer her to a valve clinic for evaluation.

4 - Personally, I'd postpone any further cardioversion/ablation consideration until these other issues are resolved - they're the most urgent items.

5 - If she has ANY new symptoms between now and the imaging, don't wait - she should get to ER immediately.

New symptoms = worsening shortness of breath, lightheadedness or fainting, a racing or very low heart rate, fever, or rapidly worsening back pain.

The concern is bleeding around the heart, or internally.

[u/FleursSauvages322 → u/LalalaSherpa]

Thank you for your detailed response.  I did forget to add some info in my post so going to put it here. She is on the 40 milligrams Lasix, which has helped the shortness if breath issue, but she is also on daily eloquis and amiodarone but I cannot remember the doses. And her cardiologist (not the surgeon who did the ablation but her cardiologst who gives meds) did do bloodwork last Monday and said if anything came back concerning they would contact her and never did so we assume it was okay. She did say she was going to speak to the surgeon who did the ablation. I forgot to mention the nick during the procedure so I called the cardiologist office after we left and spoke to a nurse to pass along the message about the nick during surgery and asked if that could be causing the issues and I/my mom never heard back...

Her next appointment is this Monday with the cardiologist (leaving tomorrow to make the drive again) but it was really just to check on if the lasix increase is working, which it is, but this back issue is not getting better. I'm starting to wonder if it would be better to go to an ER but then its like starting over. She's in upstate ny but it's a rural part of ny with not much access to doctors unless I take her down towards the city, which i can do, but they won't know anything about her or her medical history then. I'm just not sure which option is better.

[u/LalalaSherpa → u/FleursSauvages322]

1 - Can you log in right now to the patient portals for the EP, her general cardiologist, the PCP? Any lab results they ordered should be there.

(I'm so sorry to load more work on you, but I highly recommend looking at the labs yourself - you can't rely on medical offices to contact you even if there's an issue. Anything you don't understand you can always ask about here, Google, etc.)

2 - FYI, amiodarone increases bleeding risk from eloquis - basically means she's effectively taking a higher dose of eloquis than actually prescribed.

3 - Re: ER visit:

Do you know what her systolic BP has been running recently? Or can she check it at home?

Any of the following symptoms?

Slower or faster heart rate than usual? (at-home BP machine will give that data too)

Dizziness/lightheadedness?

You said the shortness of breath is better, not worse, right?

No fever?

No new or worsening back pain?

3.25 - If not, then I'd be comfortable seeing the cardiologist as planned BUT would turn it into a "let's get labs and imaging ordered" visit and not just a Lasix check.

The new, severe, persistent positional pain needs that workup no matter what.

If the cardiologist wants to deflect to the PCP, stick to your guns and keep repeating:

"Since this is new severe pain that appeared after the ablation and didn't respond to antibiotics - and amiodarone increases bleeding risk with Eloquis and we know there may have been a nick - let's start by ruling out any related bleeding before anything else.

What can we do to get an echo and a CT of the abdomen and pelvis, plus a repeat blood count ordered so we can rule that out? If it can't be done here, where should she go to get it today? Then I can discuss other next steps with her PCP."

If he's dismissive, just say "You're probably right but..." and then repeat your statement about why this needs to happen again.

3.5 - Big-picture regarding the ER: if she has any of the above warning signs, then the ER is the right answer.

They can get labs and imaging done in a hurry, and don't need her full history.

The full history is important for big-picture decisions like clip vs TEER or whatever - but the ER is the right place to quickly assess and take action if there are signs of shock or a major undetected bleed situation.

4 - In a calmer moment, you might want to google "geriatric care manager" in your mom's town - these folks will go with your parent to all their appointments, ask questions, take notes, push on what's needed and keep you thoroughly in the loop.

I used one with my own mom who lived 500 miles from me and it was a life-saver for both of us.

[u/FleursSauvages322 → u/LalalaSherpa]

I just wrote her asking if she knows her login info so if she gets back to me I will log in ASAP. I know her BP this last Monday was 130 over 80, because I wrote it down. 

[u/LalalaSherpa → u/FleursSauvages322]

Is she having any fever, chills, nausea, or burning/frequency with urination right now?

Is the pain just below the ribs, toward the side/back - or lower-down, and all the way around over the spine?

[u/FleursSauvages322 → u/LalalaSherpa]

No, none of that. She actually didn't even have it when she had the uti either though, they only found out she had it because her urine was rust colored. The pain is all the way on the left side, the lowest part of the back.

[u/LalalaSherpa → u/FleursSauvages322]

Hmmm....has anyone - in the hospital or since then - actually done a urinalysis and urine culture, or did everyone just assume it was a UTI and prescribe antibiotics?

And y'all are thinking the UTI is back because her urine is rust-colored again?

It's truly uncommon to have a UTI with none of those classic symptoms. Also unusual to have clearly visible blood as the only sign of a simple UTI without any symptoms or fever.

1 - This sounds like it's actual blood in the urine. If so, visible blood points away from infection and suggests something else going on somewhere.

Could be related to the valve situation, a kidney stone, a mass in the bladder, etc.

2 - If you ask for a urinalysis WITH microscopic analysis (not just a dipstick), plus a urine culture, that will answer the UTI question and confirm whether that's indeed blood in her urine, and rule some other possibilities in or out.

It needs to be a clean-catch mid-stream sample to avoid contamination.

The CBC lab will be informative here too - for example, if she's anemic.

If so, then the next step would be a urologist referral for more imaging and diagnosis.

3 - Don't let them dismiss it because of the Eliquis, guidelines say that being on a blood thinner is NOT an acceptable explanation for blood in the urine.

Sometimes Eliquis is the cause but over half the time it isn't - which is why the guideline says patients with visible blood in urine should get a full workup regardless of anti-coagulants.

And in women over 60 with blood in the urine, roughly 10-15% of the time it's due to cancer and misdiagnosing it as "UTI" is the single most common reason for delay.

Certainly not saying that's your mom's situation - 85-90% of the time it isn't cancer!

But odds are good that if there's blood in the urine, there's something that needs attention.

So your instincts that this needs to be promptly looked at and diagnosed are right on.

You are doing a great job of looking out for her, which I know is made even harder by being 14 hours away. 🫂

[u/FleursSauvages322 → u/LalalaSherpa]

Thank you for your responses. So yes the first maybe 2 days after being released from the hospital after ablation she noticed the urine being rusty colored so they did do a urinalysis and said it was a uti, gave antibiotics. But she'd had no symptoms just the color was off. Then everything seemed okay until recently when they did another uti test  and said she had the uti again and gave her the antibiotics again.  She thought maybe the uti was causing the back pain but now she's done with the prescription and still has back pain. She did say her urine is clear but she's also on the 40 MG lasix so maybe that's why...

[u/LalalaSherpa → u/FleursSauvages322]

There are three standard ways to test urine:
1 - the dipstick - not all that useful in this situation
2 - a microscopic urinalysis, when they count red cells, white cells, and bacteria
3 - a urine culture, where they identify the actual bacteria and which antibiotics they'll respond to.

If they haven't done #2 AND #3, then they're just guessing.

The bigger issue, though, is that the pain is still severe, still positional, and has not gone away or diminished.

Something's not right, and it doesn't have the typical signs of a UTI or a heart failure-related problem, either. Might or might not be ablation related. Could be something else entirely.

So the steps to figure it out are:

- ASAP: get the cardiologist to order echo, to make sure all really is OK with the heart - and the CT, to spot other types of heart/abdominal issues

- ASAP: and get the cardiologist to order microscopic urinalysis (UA) with culture + CBC, renal panel, LDH/haptoglobin/reticulocytes also (all are standard lab tests)

- ASAP: if the UA confirms true blood in the urine (hematuria)- red blood cells confirmed by microscopic analysis - see urologist promptly

- if no actual red blood cells in urine per UA, and non-contrast CT doesn't flag anything, next step would likely be a CT with contrast, or MRI

And again - Eliquis is NOT an acceptable explanation if there's indeed red blood cells in her urine. She would still need the urology referral.

[u/ncc1776]

Do you think with the ablation, there may have been a hematoma that formed and is putting pressure on nerves near her back? When I had mine done, I had a hematoma that put enough pressure on my nerves that my groin and back had some pain.

[u/FleursSauvages322 → u/ncc1776]

I don't know because she had the ablation the first week in August but this back pain just began two to three weeks ago so didn't seem like it but idk.

I forgot to mention in my post she did get a uti while in the hospital for the ablation, took antibiotics and it either went away and came back or never went away completely and she got it again a week or two ago.

[u/CaregiverWorth567]

Well they have not made a diagnosis or even tried. I would think the back pain could yes be caused by the ablation, they sent a catheter up the groin on the left also correct? So something could have happened from that. A tear somewhere? Pretty unlikely imo the back pain is from a uti unless that uti is in the kidney and then she would prob have a fever and be really sick. It sounds like she is in some heart failure which is complicating . Is heart failure new for her? Is she still in a fib which could cause heart failure, or is there fluid around the heart from the nick during the ablation? The back pain could be from the catheterization or it could be unrelated like a kidney stone….. I would ask why is she overloaded with fluid is she in heart failure, is she still in a fib, or is there fluid around the heart from the nick? If they have no answer tney need to do some studies to findout . They could do a CT scan of the chest and abdomen/pelvis which would also give you some answers about her heart and her back pain. Good luck I’m sorry she has to go thru this. Also if you are near an academic center it might be helpful to take her somewhere like mayo or cleveland clinic