Complications

 

HISTORY:

Non ischemic cardiomyopathy. Heart rate 30-52. BP  varies, not sky high. Near fainting. Remarkable lightheadedness one occasion. Left ventricle some subendocardia damage, same ventricle has septal dyskinesia, that is, instead of squeezing, it moves in other direction, (hopes this yields to electrical correction).

LBBB, Bradycardia, muscle damage moderate, but ventricles are electrically, mavericks 

EF about 35%, 40% some tests. frequent PVC’s.

 

TREATMENT

BI-ventricular Pacemaker May 2019 — not effective, LV pacing below 80% due to PVCs.

Ablation December 2019 did not succeed in quenching the PVCs that were making pacemaker ineffective, as PVCs were sourced in summit of lvot — danger of doing harm. 

I'm a little better than before pacemaker as pm does address bradycardia -- was 30-50 bpm, now about 100 bpm. But EF is still about 35%. 

I'm watching fluids and sodium.

Amio and Mexiletine (antiarrhythmias) which we used to quench PVCs have been discontinued -- not working.

Isosorbide mn, lisinopril, spironolactone. Lasix Eliquis and Metoprolol added over time. Metoprolol leaves me very tired  

My EP is great; and now is considering second ablation -- this time under general anesthesia, and by an out-of-state cardiologist, who would have some other trick up his sleeve if ablation fails -- I understand.

Any observations?


 


4 Comments

Some thoughts

by Gemita - 2020-10-22 05:54:18

I like the description that your ventricles are electrically, mavericks.  Can we tame them, I wonder with another more targeted ablation?  Why not, if the cardiologist/EP has experience in dealing with difficult cases.  

A couple of thoughts.  Have they ruled out all other causes for your PVCs?   I see you do not have ischaemic heart disease as a cause, although you do have cardiomyopathy.  Have they ruled out valve disease or an obstruction (narrowing) somewhere?  You mention the finding of source of PVCs in the LVOT (left ventricular outflow tract), so this presumably is the area where they will focus a second ablation and have a good look around as well.  I attach a link which might be of interest.

https://onlinelibrary.wiley.com/doi/pdf/10.1016/S1880-4276%2806%2980009-8

Looking at your meds, I am glad you have stopped Amiodarone which can cause many unwanted symptoms.  It may take a while (up to a couple of months I believe) for this drug to fully leave your system.

I was told beta blockers may not always be the best choice of med for PVCs.  I see you are on Metoprolol.  My EP felt a calcium channel blocker (CCB) like Diltiazem or Verapamil might be a better med for my PVCs than a beta blocker, but I am unclear whether a CCB would be a safe option for you?  It may though be worth asking your doctors if you could try an alternative safe medication if Metoprolol is making you so tired and not helping?  

I note you are running on a heart rate of 100 bpm (seems quite high) although I have found that a higher heart rate can actually help to suppress my PVCs, since they were often triggered by falling heart rates.

Finally, have you had a recent check of your electrolytes?  Spironolactone may cause high potassium levels so you may need to watch your diet that you aren't eating too many high potassium foods as well.   When electrolytes are out of balance, we can develop worsening arrhythmias, so hopefully your doctors are checking your levels ?  

I see you are watching fluids, but try not to get dehydrated (which you could easily do on a diuretic like Spironolactone) since dehydration will play havoc with electrolytes too and may cause faintness.  A careful balancing act with medication, lifestyle, fluids, foods may be just as important as getting another ablation.

I hope for the very best for you

Complications

by Jereems - 2020-10-22 13:11:26

Thanks, Gemita.

According as EP quenched them, the pvcs re-ignited, as they were being triggered from summit of lvot.

So 2nd ablation plans to target summit, which EP avoided 1st time, because of conscious sedation, danger of collateral damage and of puncturing septum. 2nd time will be by cryoablation, I think, with general anesthesia. 
Reports said nothing recently about septal dyskensia, (as one "flap" of LV squeezes, the other -- septum -- used to loosen) and that may suggest that pacemaker has addressed that feature as well as bradycardia. But 78% LV pacing is very low, should be 92-100%. Pvc burden about 38 going from memory. EF about 35%. 
I don't question EP's choice of meds nor his having excluded other causes -- he has been painstakingly thorough and methodical in his analyses all along. And sure-footed when he makes a decision. The word is probably differential diagnosis?
He cautions me that stopping pvcs might not be the cure-all; I think he means, may not necessarily revitalize sluggish systems, though avoids saying heart muscle may have deteriorated since diagnosis 2 years ago. 
We are starting Cardiac Rehab. 
But one is aware that, prior to PM, and prior to 1st ablation, the forecast was good, but outcome was suboptimal. 
I am unsure what, if anything, the out-of-state EP may have up his sleeve if 2nd ablation does not seem to be working. 
My EP, I still say, is the greatest!

Complications

by Jereems - 2020-10-22 13:15:56

And GP is scheduling lots of blood work shortly, thyroid etc. 

I am hopeful for a good outcome

by Gemita - 2020-10-22 14:03:03

Jereems, sounds as though you are in very good hands and that you have complete confidence in your EP and doctors treating you.  What a difference that can make.  I am glad they are going to carry out lots of blood work to look for other treatable causes for your symptoms before progressing further.  I can see they are leaving no stone unturned which must be so reassuring.

I agree stopping the PVCs or reducing their frequency might not be the "cure all" but it would certainly help ease your symptoms, improve blood flow and make you feel better.   It might also help prevent more dangerous ventricular  arrhythmias from occurring in the future.  I know when I get prolonged PVCs, I find it very hard to function (or sleep) and frequent PVCs can certainly weaken the heart muscle over time leading to cardiomyopathy.

I would be very interested to hear of your progress in the future.  If the forecast was good before your pacemaker and your first ablation, perhaps with a successful second ablation your condition will slowly improve in all areas.  Enjoy and benefit from cardiac rehab to build strength prior to any further treatment 

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I wouldn't be alive if it wasn't for pacemakers. I've had mine for 35+ years. I was fainting all of the time and had flat-lined also. I feel very blessed to live in this time of technology.