Palpitations with AV Node Ablation

What it feels like

by AgentX86 - 2020-06-21 21:13:07

Are you in permanent Afib?  Do you know what sort of pacemaker they're going to implant?  Number of leads?  Lead locations?'

I'm in permanent atypcal Aflutter (caused by a Maze gone wrong).  I had an AV/His ablation about 2-1/2 year ago and have two leads, one in each ventricle.  I don't have any atrial leads because I'm paced in my ventricles only.  If everything is going right, I feel nothing, just like NSR.  I did have PVCs at first but they've all but been eliminated. 

I recommend an AV ablation only after everything else has been tried and failed. I had three ablations and I can't count the number of cardioversions over the years.  My EP was pushing the AV ablation but I wanted to make sure nothing else was going to work.  It didn't and in fact the drugs (Sotalol) damaged my SI node so I needed a pacemaker.  Going to PM dependency wasn't a huge stretch to get rid of that crap.

What it feels like

by SofieR - 2020-06-21 21:58:55

Thank you for your response.  I'm in constant aFib which can be relieved wit a cardio version.  Previously the CV would hold for several months, but since March I've had 3 CVs and I've just gone back into aFib yesterday, while I'm on amiodorone.

I will need to contact my cardiologist tomorrow and know he will insist on a  Pacemaker  as we have tried everything else.  I think he might try one more CV but I don't know.   
 

He is suggesting two leads for the ventricles only.  

BTDT

by AgentX86 - 2020-06-21 22:28:58

A DCCV is a stopgap.  My fist one was good for seven years but that's exceedingly rare.   The next DCCV (I had an amioderone one done between) I had didn't last until they got me back to my room (a couple od days after my GABG/Maze).  I had a DCCV at the end of a two of my three ablations, too (one while I was awake -  YEOUCH!) because the ablation didn't put me back into NSR.  Noneof the ablations lasted without drugs (Sotalol or Amio).   Within a week after I went off the drugs I was back in flutter.  I don't recommend another DCCV.  I think it's a waste of time at this point.

I know exactly what you mean about the fish flopping.  My flutter was the worst!  I didn't sleep for weeks on end.  Kinda made work (I'm an EE) impossible.

After the AV ablation, I've been good.  In fact, from the minute I had the PM, my life changed.  I was almost on a high for a couple of months after.  I've been alright since (other than a seizure last October, not related to the PM but perhaps because of long-term Afib'/lutter). 

Note that with only V-leads you will be in AV dyssynchrony.  Your atria will do nothing, really less than nothing. You may have some limitations because of this.  I don't, that I know of anyway.  It might take a little time to get the PM dialed in properly but that's pretty standard for all but couch potatoes.

For a couple of years I was walking 20mi/day but I've cut back to 10-12mi/day, now, with Covid closing everything.  I now walk 10mi (3 hours) around the neighborhood, first thing in the morning.  I don't run becase my knees/feet wouldn't take the abuse, so I'm not really pushing my cardiac output.

Bottom line is that it will take care of your Afib but at the cost of becoming pacemaker dependent.  It's not the best situation but there are a number of members here who are dependent.  We live a normal life but it's a little disconcerting, at first, realizing that you are dependent on that thing to keep working for you to keep working.

Decisions decisions

by Gemita - 2020-06-22 03:41:11

Hello Sofie,

AgentX86 has personal experience of the benefits of an AV node ablation, I do not, but I did consider an AV node ablation a few years ago.  I have paroxysmal AF with a rapid ventricular response rate and several other arrhythmias.  I note that you are not in permanent AF yet although it sounds as though it is heading that way?

As a matter of fact, I asked my EP the very same question “will I still feel my AF/palpitations after going through the finality of taking out my AV node?”.  His answer was:

"You ask a very good question about whether you would have symptoms following an AV node ablation.  An AV node ablation is not a perfect treatment as you would still get AF, you are clearly aware of this.  However, the main symptoms that I suspect you experience are probably due to a rapid heart rate and irregularity of your heart beat.  Both of these would be eliminated by the AV node ablation.  However, when you are out of rhythm, you might have some minor symptoms, although I suspect you would not have a major drop in blood pressure.  In summary I suspect you would be significantly better and almost certainly would never feel the need to attend hospital during attacks, although you would not perhaps be quite as well as you might be if we were able to eliminate the AF (at least in the short to medium term) with a pulmonary vein isolation ablation".

My understanding from his comments was that I might still feel or be aware of my AF following an AV node ablation but I would certainly not be so symptomatic or bothered by it any more.  This is because after an AV node ablation, an implanted pacemaker would pace me at a steady, fixed rate and I would be less affected by the chaotic arrhythmias in my atria getting through the AV node to affect my ventricles.  At the time I considered an AV node ablation, I was frequently going in and out of AF, sometimes multiple times a day.  I felt every sudden fall/surge in my heart rate as I went in and out of AF and I was very sensitive to the long pauses in my heart rate as I came out of AF and went back in to normal sinus rhythm and this was so destabilising.

My EP (electrophysiologist) did however warn me of the potential danger of developing heart failure symptoms from right ventricular pacing “alone” due to any dyssynchrony between the two ventricles.  If this were to occur he said he would upgrade my system to pace the left ventricle too to restore harmony between the two ventricles.  But I see you have been offered two ventricular leads from the outset which sounds even better.

My decision eventually was to go for a dual chamber pacemaker one lead in right atrium and one lead in right ventricle and leave my AV node intact.  I made the right decision “for me” since my present set up is proving very beneficial,  I can always revisit having either a regular pulmonary vein isolation ablation or AV node ablation in the future should my AF and other arrhythmias progress.

Cardioversion never worked for me.  They tried it three times in succession during an investigational study (EP Study) and each time I went back into AF almost immediately.  Only IV Flecainide proved successful in getting me back into normal sinus rhythm.  At best I believe cardioversion can only be a temporary fix with an arrhythmia like AF which as we know is not curable, although some folks have long long remission periods after a regular ablation.

By the way an AV node ablation is usually successful first time with need for repeat procedure very uncommon.  Procedure I was told would take around 20 mins, so seems less invasive than a regular ablation which can be lengthy.  Good luck with whatever you decide

Pulse

by SofieR - 2020-06-22 09:54:49

Thanks for the great responses. So, with a ventricles only PM with AV node ablation, when you take your pulse or feel your heartbeat at night, does it feel like NSR with a steady beat from the ventricles, or do you still feel irregular or floppy?

How it feels after an AV node ablation ?

by Gemita - 2020-06-22 11:08:44

Hi Sofie,

AgentX86 has described how it feels after an AV node ablation and it seems to have worked well for him, giving him relief from his symptomatic Atrial Flutter and feeling as though he is in normal sinus rhythm when everything goes well.  

After an AV node ablation providing you do not develop any ventricular arrhythmias in the future like, for example PVCs, you should feel a steady, even pulse produced by your pacemaker pacing your ventricles.   As I mentioned in my earlier post, you might still be aware of AFib in your atria because it will still be there after an AV node ablation, but your AFib should not cause any distressing symptoms or affect your heart rate/heart rhythm as before, since your pacemaker will be set to pace your ventricles at a nice steady rate set by your doctor.

Have you been in touch with your doctor, and what has he recommended?  Have you agreed to an AV node ablation?

As you will hear many say on this forum, an AV node ablation is really the option of last resort when you have tried everything else and it has failed. At one time, my symptoms were so bad I would have tried anything to get some relief.  Now I am glad I held back.  Only you will know how bad your symptoms are and what you are prepared to do to improve your quality of life.

There are several members of this Club who have had an AV node ablation and they have stated it was the best treatment they could have had.  It is such a big decision so take your time.  

Feels like

by AgentX86 - 2020-06-22 20:12:51

There shouldn't be any sensation of Afib at all after an AV ablation. What you feel when in Afib is the LV contraction pushing the blood out to the rest of the body. You don't feel the atria at all.

Some who have an AV ablation, those with proximal AF, can get a three-lead PM. The pacemaker will work like a normal PM when in NSR and shift gears into V-only pacing when AF raises its ugly head. You likely would feel this change and likely notice the loss of AV synchrony. That's why I asked the question about the lead placement. You'll be V-only paced, so this doesn't apply.

The other possible issue, that Crusty brought up in another thread today, is the possibility of the dyssynchrony causing a reverse pressure wave when the RA beats against a closed (because the RV is contracting at the same time) tricuspid valve. It's possible that this can be felt (and potentially seen) in the neck.

The biggest two problems we've already covered,  though, and they aren't insignificant. Dyssynchrony causing the loss of the atrial "kick". It's really more than the loss of the kick  because the atria will be beating against closed mitral/tricuspid valves some of the time. I don't notice this because, while I do a lot of exercise, it's not high intensity.

The other HUGE problem is the "unnecessary" choice to become pacemaker dependent.  You're trading a life threatening possibility, however small, for quality of life. You *have* to be fully on board with decision and make it with eyes wide open. I'm an example of someone who.made that choice and wouldn't do otherwise thirty months later (long time? - you decide). Gemita, OTOH, chose differently and is happy with that choice.

The questions that have to be answered,  and only you can answer them (don't let your EP or anyone else push you) are "have you tried EVERYTHING else", and "can you have a full life as you are". Since ablations and amioderone (it "always" works) didn't work, perhaps you've gone far enough down that road to answer the first question.  The second is firmly in your court. No one else can help you with this one. AV ablation is serious stuff and it is a one way street.

Thanks

by SofieR - 2020-06-22 23:47:05

Great information, thank you.  I am definitely better prepared for my discussions with my doctor.  I don't think I have any other treatment options, so am at making a choice between having an AV ablation or just managing the aFib and rapid heart rate.  A big decision indeed