need informed advice

G'day, everyone, I had a 2 lead Biotronic pacemaker with 2 leads implanted in Oct 2013, I had to have my yearly check up with my 2 cardiologist 2 weeks ago, the one who fitted my pacemaker and the other one who put a stent in. Part of the check up was a stress test, which showed up some problems in the heart and the pacemaker read out also showed that I have been having some Atrial Fibrillation events in the last 10 months. that cardiologist put me on Xarelto (a blood thinner) for that problem So I had to have an Angiogram a couple of days ago to see what is happening in the heart, end result was that I now have to have a triple bypass, I asked the cardiologist if that would fix the Fibrillation problem , however he said it will make it worse. I spoke to the surgeon who is going to do the bypass and he said that he can do a procedure whilst he is in the heart that can fix the fibrillation problem, which is far more successful than trying to do it later , however I am receiving conflicting advise from the cardiologist who did the stent and angiogram he does not think it would be a good idea to have that procedure done, he also wants me to stop taking another drug that I am on called Plavix, which he put me on after I had the stent procedure in Oct 2013, even though my other Cardiologist said I should continue taking it because it does a different job than the Xarelto , the cardiologist said it is my decision if I go ahead with the Fibrillation procedure and which drug I should stop taking, I have no medical background so I am looking for some good informed advise ???

4 Comments

Maze procedure

by golden_snitch - 2015-02-09 02:02:29

Hi Rick!

So, the pacemaker is showing that you have had some Afib events, but you did not feel anything or had these episodes confirmed via holter monitor or some other kind of ECG? How many episodes did you have and how long did they last? At this point I would say that it's important to figure out how much the Afib actually bothers you, and to evaluate how bad the episodes are (many episodes lasting long vs. just a few episodes lasting a few minutes or so). If you don't do anything about Afib, it definitely has the tendency to worsen over time. BUT if you are not symptomatic that is actually not that much of a problem - as long as you take a blood thinner to prevent strokes. If Afib doesn't bother you, it does not need to be treated, you need no rhythm or rate control. But you need the blood thinning drug.

The procedure the surgeon is referring to is probably the so called "Maze" procedure. See: http://www.cts.usc.edu/mazeprocedure.html
In my opinion it makes sense to do it during an open heart surgery in patients who are highly symptomatic with Afib and in whom other Afib therapies have probably already failed or have not been tolerated well. Not sure, if one would do this in someone who isn't symptomatic. I do understand that, if the surgeon needs to go in anyways to do the bypass, he could do the Maze as well, it probably won't hurt. But it's kind of an additional procedure, carrying its own risks, and if there is no real need for it, then why do it? You should discuss this with an EP (heart rhythm specialist) and the surgeon.

If you have stents and Afib, you need to be on two different drugs for anticoagulation: Aspirin or Plavix for the stent plus Xarelto (or Pradaxa, Eliquis, Warfarin, Coumadin) to prevent clots caused by Afib. Aspirin and Plavix do not prevent blood clots caused by Afib. There are also Afib patients who receive a triple-therapy with Aspirin, Plaxiv and, for instance, Xarelto for the first couple of months after stent placement.

Hope this helps a bit.

Inga

good information

by pace-man - 2015-02-09 04:02:03

Hi Inga.
I have readings from my pacemaker since Oct 2013 , however the Atrial Fibrillation only started in April 2014 and the last one occurred 1st Dec 2014 ,I don't think I have had any since, they all occurred at night and most of the time I was asleep, however thinking back I do recall waking up being very breathless, so I surmise that was when I was having one of episodes, The first one 22/4/14 only went for 4 seconds and my bpm was 186.
The second & third one occurred on the 8/5/14 it went for 7 and a half hours (137bpm) then stopped for one minute and then went for another 3 hours (158bpm), the 4th one was on the 12/8/14 and went for 4 hours (87bpm) ,then the 5th one on the 18/8/14 (184bpm) and only lasted for 6 seconds, the 6th & 7th ones were on the 1/12/14 the first one went for 3 hours(100bpm) then stopped for 1 minute then restarted for another 3 and a half hours (95bpm) I am still waiting to hear back from the surgeon as I spoke to him this afternoon and told him of my concerns , he was going to speak to the cardiologist who did the pacemaker and come back to me, my pacemaker paces for 33% of the time at the moment and I have no problems with it , so I asked him if he was to do the Maze part of the procedure would that alter how often my pacemaker would pace and he said it is possible it could end up pacing 100 % of the time. I am currently taking 100mg of asprin, Plavix and Xarelto. the cardiologist wants me to stop the Plavix and continue with asprin and Xarelto, however the cardiologist also said that after the bypass the Atrial Fibrillation problem will become worse. my pacemaker is set for 60bpm for night and 70bpm for the day. the surgeon said that I should stop taking one of these drugs because I would have a high risk of internal bleeding, so what are your thoughts on all of this. Rick

Helpfull

by pace-man - 2015-02-09 05:02:40

Hi Inga, you have been very helpful with all of the information that you have provided, I feel more comfortable in making a decision in regards to my future well being and health, in regards to the 100% pacing , what the surgeon was saying is that when he does the Maze procedure sometimes it can disrupt the electrics to a point that the heart will need to be 100% paced, by a pacemaker, he was explaining all of the possible risks associated with that procedure. I shall have a good read of those links that you have provided, I think I received more helpful and informed information from you than I have from 2 cardiologist and heart surgeon. Thanks again. Rick

Triple therapy

by golden_snitch - 2015-02-09 08:02:10

Hi Rick!

There are guidelines on "triple therapy" in patients with Afib and stents. I know that a friend of my parents' who has Afib had to take this after drug-eluting stent placement. But after three or six months he was allowed to discontinue the Plavix, and stay on Asprin + Pradaxa only. You can get the guidelines from this site:

http://eurheartj.oxfordjournals.org/content/early/2014/08/21/eurheartj.ehu298.extract

About bypass surgery making Afib worse or leading to complete heart block (100% pacing) - never heard that before. Aortic valve replacement sometimes leads to heart block due to the surgery site being very close to the AV-node. Bypasses are usually not placed somewhere close to the electrical conduction system of the heart, as far as I know. But I might be wrong about that. Your surgeon should be able to explain that to you.

Inga

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