AV node ablation and type of pacemakers used for it.

AV node ablation and type of pacemakers used for it

by IPGENG12 - 2020-02-17 20:38:35

I ended up having to get an AV Node ablation and a pacemaker to deal with intractable atrial arrhythmias (medicines and 4 attempts at ablating the atrial arrhythmias failed).  I was implanted with a CRT-P system (one lead in atria, one lead in right ventricle and one lead to pace the left ventricle, called a coronary sinus lead).  The left ventricle lead had to be turned off two days after the implant after it moved and caused phrenic nerve stimulation (e.g. spasms).  I felt OK at first.  After two years, though, I had gone into permanent atrial fibrillation + I was paced 100% of the time from my right ventricle.  It sounds like you are in the same situation- 100% paced from the right ventricle.  In my case, this led to ventricular dissynchrony (left and right ventricles not beating in synch) and put me into early stage of heart failure,  diagnosed with a low ejection fraction (30%) with an echocardiogram.  As a result, I had to get a new left ventricular lead placed (after removing the old one).  This got both my ventricles beating in synchrony again and my heart function restored (EF is now almost 55%).  In your situation,  I would recommend that you talk to your EP or Cardiologist about only being paced in the right ventricle.  With 100% pacing, this can have poor outcomes like it did with me.  I'm now feeling fine with my system- no atrial pacing, 100% paced on both left and right ventricles.  Hope this helps and that you will feel better soon!

AV Node ablation

by Gemita - 2020-02-17 21:28:28

Hello and welcome. Not a nice subject to discuss but it may be in my future too. I do understand how you feel about your AF and Flutter and how they adversely impact on your quality of life.  I am very symptomatic when I am out of normal sinus rhythm too and I can really struggle sometimes to carry on with my normal activities.  At the moment my ablation is on hold since I have managed to get my arrhythmias firmly under control which is providing some welcome relief at last.  I have a dual chamber pacemaker and pacing has proved immensely helpful.

I know several people who have had an AV node ablation and they seem to be doing really well and are no longer affected by their troublesome arrhythmias.  Most have been able to stop their anti arrhythmic medication and/or heart rate control meds because the arrhythmia(s) is no longer able to get through the AV node to affect their ventricles, the main pumping chambers of the heart.  The pacemaker is then set to pace the ventricles at a nice steady rate.  The arrhythmias (in your case AF and Flutter) would still remain in the atria, but you shouldn't feel them any more.

I note you have a single lead pacemaker. My EP did caution me that after an AV node ablation, 100% pacing of the right ventricle alone could lead in a small number of patients, to heart failure symptoms, due to a loss of synchrony between the two ventricles. This could be addressed with a pacemaker upgrade (additional lead to left ventricle) so this is something that needs to be discussed with your EP.  Are you in permanent AF/Flutter? I note your heart rates are well controlled.

Hopefully others on this forum will tell you about their experience with an AV node ablation.  It is final and last resort but it may be a good option for you.  Have you had a second opinion or spoken to another doctor about this?  It might be wise before you go ahead.  Gather as much information as you can.  I expect you have had all necessary checks and a recent echocardiogram.  Have you tried an ablation and anti arrhythmic meds ?
I wish for the very best

The LAST option

by AgentX86 - 2020-02-17 22:59:57

An AV ablation should be the absolute last ditch effort to solve a QOL issue.  I got there two years ago after a full Cox Maze swapped my Afib for atypical (left) Aflutter (not a good trade), then several drugs including Ameoderone damaged my thyroid and SI node.  I needed a PM for the latter (drug induced SSS) and then had an AV ablation a month after my third failed ablation. I'd gotten to the point where I couldn't sleep, so couldn't concentrate (rather a necessity for an engineer).

I won't say that the AV node ablation solved all my problems but the difference was amazing.  Overnight, I felt a lot better.  I could sleep again and in a few days I felt much better than I had in years. I no longer feel the Aflutter but my atrial rate is still 240-300bpm.  The problem is still there but I don't feel it.

The downside of an AV node ablation is that the heart is no longer synchronized.  The atria beat completely independent from the ventricles, which means that the ventricals will pump against closed valves.  The heart then loses the atrial "kick" plus some performance.  An otherwise healty heart has more than enough reserve to supply the body.  That performance isn't missed, except for high-level athletes. 

Your cardiologist is right.  A typical two-lead pacemaker (RA+RV) doesn't do any good because its purpose is to replace a nonfunctoinal AV node and you're trying to intentionally creat a block. Generally, a two-lead CRT pacemaker (RV + LV) is used.  CRT is preferred to make sure the ventricles beat together, at least. A His lead doesn't work because the Bundle of His is usually destroyed along with the AV node.

You really should be talking to an electrophysiologist about this.  This is out of the perview of cardiologists.  They can give you a lot more information.

Again, an AV node ablation should be the option of last resort.  You've tried everything and your QOL is still poor.  Your symptoms are so bad that you can't function and you've tried everything else.

me too

by Violet West - 2020-02-18 14:20:33

I have had an AV nodal ablation and implanted CRT for permanent AFIB/aflutter  It was a last resort for me after years of misery, drugs, cardioversion and cardiac ablations.  I had been treated by my cardiologist and my electrophysiologist throughout this period, but I got a second opinion for my peace of mind.  It's been amazing! I feel "normal."  

Are you not consulting with an EP? 

Not sure why you say that AV nodal ablation has "fallen out of favor" but it's not too common for treatment of AFIB.  However, it was mentioned to me by both docs from the beginning, so it wasn't too much of a suprise. Mentally, it was a bit tough, but, again, I'm very happy with my result. 

Thanks

by slbailey - 2020-02-18 18:31:11

Thanks for the feedback. This is exactly the kind of response I was looking for. To answer some of the questions: I am in permenant a-fib flutter. I had an ablation for a rapid heartbeat years ago which solved that probem. This time when I saw the electrophyiologist he said that since my beats are not rapid an ablation would not work. I haven't been able to tolerate any of the anti-arrhythmia meds. Whenever I have read about AV-nodal ablations, the article always states that it is a last resort measure although I understand that some years ago it was performed regularly. I feel I am willing to undergo a "last resort" measue if there is any hope of improving my quality of life. I liked your comment violet that you feel "normal. I would love that!.

Option of last resort

by AgentX86 - 2020-02-18 21:01:53

SLB, it sounds like you're ready to take the step. You folks are right, it seems that AV node ablations have fallen out of favor recently but I know what worked. It certainly didn't take any years off the body and it's highly unlikely to extend it any but it is making those years bearable and in fact, enjoyable. That's all I asked for. I hope you find the same.