AV node ablation and cycling

Great to find this web site and forum.  Quick background:  I am a 68 year old male who is an avid cyclist (about 150 miles/week).  I have had A-fib for approximately 20 years.  My second ablation in 2014 gave me 6 years of relief and joy with an Afib burden of <5% and using a simple PIP approach to convert after brief episodes.  Otherwise, no medication.  Unfortunately since Feb. 2021 I have been in afib almost constantly with no help from drugs and 2 cardioversions that were short lived.  I had my 3rd ablation this past week.  All past ablation sites were found to be still durable, so the current site was mapped and ablated along with some additional "preventive" lines.  Came out of the procedure in sinus rhythm but reverted to afib in 48 hours.  Since then I have converted back briefly but then back into afib.  On follow up with my EP, the possiblity was raised of an AV node ablation and of course, PM.  Which has sent me here.

The EP has suggested a leadless PM which has many positive attractions to it.  But the more research I have done, the less appropriate this PM approach seems to be for an active cyclist.  As many on this forum have pointed out - cycling is not really facilitated by an accelerometer sensor, you need a "respiration" sensor as well.  To my understanding, leadless PM's have only the accelerometer sensor.  I would be very interested in hearing from other active cyclists and their experiences with PMs.  Also, any who have also had AV node ablations.  I know that even after the AV node ablation, my atria will still be fibrillating, but my ventricular contractions will be "normal" and regulated.  But I still have concerns as to how the ventricles will be appropiately filled if still in afib.

Look forward to hearing from anyone with similar situation.



AV node ablation

by AgentX86 - 2021-05-29 14:07:51

Yes, I've had an AV node/His bundle ablation, a little over three years  ago. I'd had AF for about eight years, fortunately a DCCV set me right for about seven of that. In 2014 the picnic was over. My new cardiologist (hadn't had one in years) did their usual testing, he found four blockages (one 90% and two 100%), none stentable. I was then sent for a CABG. As long as they were playing with my heart, my cardiologist had the thoracic surgeon do a Cox maze and clip my LAA.

All that stopped a symptomatic persistent Afib, replacing it with an extremely symptomatic permanent fluttet. In they hospital they tried another DCCV which didn't last as long as it took them to wheel them back to my room.

Like you, I then had three ablations,and several antiarrhythmics, which suppressed the AFL but also my heart rate  dangerously. I'd already had Bradycardia and they couldn't manage both the AFL and Bradycardia. The drugs (specifically sotalol) damaged my SI node so needed a PM. It wasn't a big step to a AV node ablation.

Since I was so symptomatic (couldn't sleep at all), the relief from the AV node ablation was one of the best decisions I've made. As you said, it's still there but I don't notice it at all.

Since you're athletic, one thing to note is that an AV ablation will automatically put you into AV dyssynchrony. You'll lose about 20% of your peak performance. Maybe even a little more because the atria and ventricles are working against each other much of the time. The heart has more than enough reserve capacity for most people but high-end athletes need everything they can get. You'll lose that 20+ percent.

As you've rightly figured out, an avid cyclists probably won't do well with an accelerometer based PM. A minute respiration sensor will probably work better but is more complicated and may require more tuning. You will anyway because you're active.

My thing is walking (10mi. a day - just got back) and my accelerometer based PM works well enough for that. Hills can be problematic thougg none I walk are too challenging. A few flights of stairs. You'd think that if a $100 FitBit can count stairs that a $10,000 PM could, with the same technology, already on board. The thing that really hurts is moving heavy stuff up stairs or a hill. The steps are tsame same as walking but the energy expended is quite different.

I don't think I'd want a leadless PM. It's bad enough to have AV dyssynchrony but you sure don't want RV/LV dyssynchrony on top. I have a CRT PM  (His is out of the question) to avoid that. I really don't know if a leadless PM can avoid RV/LV dyssynchrony but it's something to ask, pointedly.

That's enough to type on my phone and probably more than anyone wants to know. If you have more questions please feel free to send a PM.

Vent filling with disordered atria

by crustyg - 2021-05-29 18:13:39

"I still have concerns as to how the ventricles will be appropiately (sic) filled if still in afib." Less well than with A=>V synchrony but well enough.

I was in AFlut for about 6months second time, with my vent rate controlled by variable block at the AV node (5:1, 4:1, down to 1:1 - not smart) and can attest that my cardiac output was fine.  My swim coach actually commented that I was using my legs properly in freestyle (normally I use my legs like a long-distance swimmer - hardly at all), and there is no proper atrial contraction to fill the ventricles in AFlut.  As muscle exercise increases the skeletal muscles squeeze blood into their veins and the non-return valves in the veins assist in moving blood back to the RA.  This is why soldiers standing to attention on parade are told to do toe lifts if they feel faint, it makes the calf muscles pump blood back to the heart.

I agree with you - a leadless PM is inappropriate for you.  I'd be blunt and ask any EP-doc who suggested one how much they are being paid to push such a poor choice - and then change EP-doc.

AV node ablation and cycling

by Rob F. - 2021-05-29 19:43:38

Thank you AgentX86 and CrustyG, your comments and insights are both very helpful.

AV node ablation (no cycling)

by AgentX86 - 2021-05-30 19:39:59

One thing I should mention is that an AV ablation is nothing to take lightly.  You will be in dyssyncrony (as mentioned above) but you'll also be pacemaker dependent, with the added complication that you'll have no junctional rhythm.   You'd be quickly running out of backup pacemakers (escape rhythms).

Pacemakers rarely fail but I may be in a world of hurt if it did (I have no escape rhythm).  That may be an advatage of a leadless PM (leads are the weak point) but a CRT PM should take care of that emergency, at least in an emergency.  Again, I don't see how it's a good solution though.

Make sure you understand everything before you go into this.  You need to make sure your doctors understand your lifestyle, that you understand what the pacemaker will and won't do for you, how likely it is that this will "fix" your problem, and what the potential down-sides are.  IOW, to give informed consent to this extreme measure, you need to be informed.

AV Node ablation and control of AF

by Gemita - 2021-05-31 07:33:29

Hello Rob,

I am so sorry to hear of your difficulties and failure of several ablations. I note that PIP (pill in the pocket) approach no longer works for you.  Of course you are still in the blanking period having just had another ablation, let us not forget that, and even though your AF seems to be lingering, throwing a final tantrum, it could just be the storm before the calm.  I have heard from many AF sufferers who were in permanent AF for several months following an ablation and then reverted and stayed in sinus rhythm for years, so perhaps have faith and wait for a few months Rob would be my best advice.  Cardioversions didn’t work for me either, lasting less time than yours. 

A pacemaker/AV Node ablation?  You would need your pacemaker in place in any event prior to an AV node ablation and this would give you a bit more time to consider all your options and to try out a few settings to see what might suit your lifestyle before the next stage - AV Node ablation.  You might be pleasantly surprised and find that some of your symptoms ease with a pacemaker alone.

I considered an AV Node ablation some years ago and may still go down that route if my AF worsens although for now low dose beta blocker Bisoprolol, anticoagulation and dual lead pacing are all I need at the moment to feel less symptomatic when in AF.  I have not had a "regular pulmonary vein isolation ablation" since I have been told it will not address my several tachy arrhythmias in one procedure and I would be apprehensive of having perhaps two or more ablations since this would increase my risks.   In many ways an AV node ablation makes a lot of sense for me as well.  We can stop many of our rate control/anti arrhythmic meds in the knowledge that the fast atrial rates will be prevented from passing through the AV Node to reach our ventricles, the main pumping chambers of the heart.  The AFib will still be fibrillating in our atria following an AV Node ablation but we shouldn’t any longer feel it.  But of course AV Node ablation is a very final step and should only be considered when nothing else works since there is no going back and we would be totally pacemaker dependent.  However having said this, a fast, uncontrolled arrhythmia is dangerous too and may quickly lead to many health problems, possibly including heart failure and dementia in the future, so we really need to control the arrhythmia.  In any event, pacemakers are very reliable today and rarely fail.  

A leadless pacemaker?  Sounds good for the future but a lot more work needs to be done particularly on retrieving the device at end of battery life.  For the moment, even with the additional procedural risks of inserting leads, I would still go with a pacing system with leads.  For an athlete this type of pacing system would I believe provide a better chance of adjusting/optimising the settings to suit your particular needs. 

Good luck with your decision Rob.  Take your time in coming to a decision is my best advice.

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