Bi ventricular pacemaker

AV Node Ablation?

by Gemita - 2021-07-20 06:58:25

Haz, if I understand correctly, you have been offered an AV node ablation where they ablate your AV Node permanently to prevent the electrical signals from your natural pacemaker, the sinus node, located in the right atrium, from getting through your AV Node to reach your ventricles.  This is because very high heart rates from AF driving your ventricles would be dangerous causing a number of symptoms and if not controlled, could lead to heart failure.  

Many members have had an AV Node ablation with great success and great relief from their atrial tachy arrhythmias.  It doesn’t stop them and they would still continue in the atria, but you would no longer feel them or get symptoms since an AV Node ablation would prevent the arrhythmias/high heart rates from passing through the AV Node to affect your ventricles.  You would then be able to come off some of your medication.  Of course an AV Node ablation would be final and permanent and you will then become 100% pacemaker dependent.  I think this is your main fear?  It is a big step to take and this is why it is very important to be sure that this is the only solution on the table.  Have you exhausted all other possibilities?

A biventricular pacemaker would take over the pacing in the right and left ventricles, and because both ventricles would be paced, this would give balance between them and the potential problems associated with right ventricular pacing alone, possibly triggering dysynchrony between the two ventricles would be addressed.  We have often discussed right ventricular pacing alone and the concern about this leading to heart failure.  My EP/Cardiologist recommends a biventricular pacing system also if I decide to go ahead with an AV Node ablation.  I see you are in the UK too.

Are you worried about the pacemaker stopping and being left with no pacing support?  This is often the fear.  When I was considering an AV Node ablation, I was told that pacemakers are extremely reliable and rarely fail and in any event most of us have some form of escape rhythm or develop them which will protect us for long enough until we receive help in the event of a rare pacemaker failure.  All I can say is that there are so many here with heart block and who are and have been 100% pacemaker dependent for years, if not for a life time, so please try not to worry needlessly about something which is unlikely to happen.

Is the AV Node ablation safe?  It is a simple, short procedure, lasting no longer than 20 mins or so I was told, with potentially fewer risks than from a regular ablation for AF (atrial fibrillation).  Will it shorten your life?  Well uncontrolled AF, especially at fast heart rates, I believe will shorten life, so an AV Node ablation is one very effective tool to use when a regular ablation like a pulmonary vein isolation ablation or medication has failed to help.

I hope for the very best for you.

Av node ablation

by Haz - 2021-07-20 11:02:54

Gemita 

Thankyou so much for your response that has totally eased my mind it's a big step to take and I have already been through so much having a new valve and Cox maize 4 and a standard ablation and in between all this I had four strokes               (TIA) so this is the way to go 

Thankyou so much 

BiV pacer

by Julros - 2021-07-20 12:03:38

Hi Haz, I think Gemita has answered most of your questions, I just have a couple of things to add from my personal experience. I have not had an AV node ablation, but I do have a BiV pacer to prevent dyschrony and pacemaker induced heart failure. 

1) the device is quite a bit bigger so on a thin or petit person it will be quite noticable if it is placed subcutaneously (under the skin). It can be placed under the muscle, but this more painful, at least initially. 

2) The LV lead is notorious for stimulating your diaphragm, causing muscle twitches, hiccoughs or possible GERD. This can be adjusted, but can take some time and skill. 

Biventriculer pacing

by Haz - 2021-07-20 12:27:45

Hi julros 

thanks for the info that's good to know and do you find the muscle twitches a problem strange how it causes hiccups and gerd but I suppose you will get used to them, at the moment my af is permanent and racing so I get no rest it would be a small price to pay 

thanks julros 

AV Node Ablation

by Gemita - 2021-07-20 14:52:11

Haz, yes an AV Node ablation is not something that we consider lightly.  It is a giant step to take but I can see you have explored several different options and still your AF rages.  Time for a fix I think.  The more I think about it, the more I feel it might be right for me too should my arrhythmias worsen.  Four TIAs may well be a warning sign, so please take good care.  I presume you are on anticoagulation?

Av node ablation

by Haz - 2021-07-20 15:36:03

Hi gemita 

yes I am on warfrin my af has been more of a problem than my heart valve everything else is ok now but the af is a real problem my last ablation took three and a half hours and I was only in sinus rythem for 23 seconds this has been going on now for four years and absolutely node ablation is my last hope I've got no other option but I feel a bit easier about it now 

Steve 

Last hope

by AgentX86 - 2021-07-20 23:32:47

I have had an AV node ablation. It has to be the last step considered. As others have noted you will be pacemaker dependent but more, you won't have a junctional escape rhythm.

You will also lose A/V synchrony so your atria will no longer function.  They'll reall be a load on the heart. The heart has plenty of reserve capacity for most of us but any competetive sports will probably not be possible.

I see that you've gone down a similat path as I have. I had a Cox maze during CABG surgery, wich got rid of my Afib but replaced it with permanent atypical Aflutter (left atrium).  I had a slow AV node so instead of a high heart rate, it was only marginally higher but pounding and in random groups of 3, 4, or 5. I could only get a few hours sleep a night (after I finally passed out, really). I had three ablations to try to fix it but no luck.  I ended up needing a pacemaker anyway, so went with the AV node ablation.

Having an AV node ablation doesn't fix anything. This is important to remember.  You'll still need to be on anticoagulants for life and other drugs, particularly beta blockers, will probably be needed.

A biventricular pacemaker is used so that at least left-right synchrony is maintained because A/V synchrony won't be. The LV lead also acts as a backup.  A broken lead is very serious.

Note: If I'm not around much, we got in a car crash last Friday night and I broke my right wrist in three or four places. Aside fron some amout of pain, typing on-handed is bad. Left-handed only is next to impossible. After a day of tying  to figure out how to use a mouse (right-hand ergonomic) backwards with <shift> and <cntl> modifiers, more probably isn't going to happen much. I though I could add something here.

AV Node ablation

by Gemita - 2021-07-21 02:13:24

AgentX86

Thank you for struggling to type.  That sounded like a nasty accident and I hope you both recover well.  I am sure your injury will affect your daily activities for quite a while, so please take care and be extra patient with yourself as you heal.   

One of your comments about an AV Node ablation surprised me.  You said:   “Having an AV Node ablation doesn’t fix anything”.    This statement is incorrect.  We know it doesn't stop the AF, but the main aim of the procedure is to stop any fast atrial arrhythmia from reaching the ventricles and driving them at dangerously high speeds.  An AV Node ablation will effectively do this and will help us to reduce, and even come off many of our anti arrhythmic and rate control meds since the irregularity of rhythm and any high heart rates from AF will be prevented from getting through the AV Node to affect the ventricles, the main pumping chambers of the heart.  It was explained to me that I would still feel slight rhythm disturbances in the atria following an AV Node ablation, but these would no longer cause troublesome symptoms for me personally, requiring no anti arrhythmic or rate control meds.  Yes anticoagulants need to be taken for life because AF would still continue in the atria and therefore the risk of forming clots would still be there.  

As to loss of A/V synchrony, I suggest with uncontrolled AF, A/V synchrony has already been impaired and being able to come off strong doses of medication would enable most of us to exercise better and feel less tired in any event to perhaps make up for any loss of atrial kick, but this is only my opinion.

You clearly have the experience of an AV Node ablation AgentX86, I do not, but I think you might agree you are in a much better place now (well before your car accident) than you were before your AV Node ablation.

Steve, there are many members of the Pacemaker Club who have had an AV Node ablation, many of them are enjoying a quality of life now and even tell me that they wish they had got the procedure done earlier rather than struggling with medication and failed ablations for so long.  Of course the opposite is also true, many members have had successful ablations and that is obviously the most favourable outcome, but when medication and ablations fail and AF cannot be controlled, an AV Node ablation can give immediate symptomatic relief and be the only effective treatment remaining.  I am still hopeful for a good outcome

About node ablation

by Haz - 2021-07-21 09:43:46

Agentx86 

Thankyou for taking the time to respond I know this must have been very difficult and I hope you both make a full recovery 

I really do appreciate your honesty because this is my last hope and quite scary but having said what you have said did you actually feel any better after having it done and has it improved your life ie sleeping and afib also all the doctors told me I would have an escape rythem just a very slow heart rate . I was also told beta blockers could stop and this broken lead is this common.

Gemita

Thankyou again for your help maybe somethings are different on different people and to be honest I've struggled with this for so long now I'm sure it could not be any worse 

Words?

by AgentX86 - 2021-07-21 20:36:41

An A/V ablation doesn't "fix" anything. It avoids some of the side effects of AF, or in my case AFL, but it didn't "fix" anything. I still need all of the drugs that I did before, except the antiarrhythmics. Who cares, they're used to treat symptoms and I'm now permanently asymptomatic. ...but not fixed. ;-)

OTOH, a successful Afib ablation does "fix" the AF ("successful" being the operative word). Any symptoms stop and drugs are no longer needed.

Sure, if I sound negative towards A/V ablations it's just because it is (usually) "just" a QOL descision. Because of the implications one had be pretty sure there are no other alternatives and that the benefit truely outweighs the cost.

Yes, it's essentially given me my life back.  I've been working three years that I couldn't have (retiring in September). I liked my job and the people I work with so wanted to continue.  It's time to play now.

It sounds like HAZ has his head screwed on straight an has been given good choices. He (maybe a bad assumption;-) has to make the final decision and needs both sides. I'd never go back but everything worked out perfectly, too. 

Words?

by Gemita - 2021-07-22 00:24:58

AgentX86

Yes I think we can only resolve this by putting it down to “words” and our own interpretation of them.  Why would an AV Node ablation exist or be done if it didn’t help “fix something”.  It does more than treat our symptoms.  It clearly takes out the AV Node preventing conduction of the atrial tachy arrhythmia from the atria to the ventricles, thereby preventing the chaos in the upper chambers from getting through the AV Node to affect the ventricles, so in that sense it does fix something.  A non ablated AV node could not prevent the arrhythmia from being conducted from the upper chambers to the lower chambers, even with medication, which could only slow conduction, not stop it.  But let us not argue over words.  We have both made good comments for Haz and hopefully accepted each other’s point of view.  And by the way, I have always maintained that AF will still continue in the atria after a successful AV Node ablation.  I have never hidden this fact, and I believe I have always given both sides of the story too and have never knowingly painted a false picture of what an AV Node ablation procedure can and cannot do.  But yes I can be accused of trying to raise Haz's spirits and expectations for a successful outcome, I admit that.

Yes I think Haz knows what he is doing and is not going into this blindly.  He has got all the facts now, so hopefully the procedure will go well for him and he will slowly become less symptomatic which is the primary goal of any treatment.

Steve, on the subject of a broken lead as per AgentX86's comment “The LV lead also acts as a backup.  A broken lead is very serious”, no fortunately this doesn’t happen too often but like everything in life “it could happen”.  Some of us are just plain unlucky to have it happen, or it can depend on the skill of EP at time of the procedure, on manufacturing components of leads and so on.  It is rarely caused by anything you might have done like pulling on a lead, especially if you observe the initial restrictions given to you at the start of your implant journey.  Once the lead tips are well embedded into heart tissue, they usually stay put.  They always leave sufficient lead ‘slack’ so that the patient can stretch and exercise without dislodging the leads.  

The other question you raised was about an escape rhythm.  I was also told by my EP that an escape rhythm would occur.   I can see you are still worrying about the underlying possibility of a lead or complete pacemaker failure.  Well with two ventricular leads, at least you are protected if one lead fails.  As to the device itself, pacemakers are incredibly reliable and rarely fail.  Most of the time, problems occur when the pacemaker is working properly, but it may just need to be reprogrammed. Other times, there might be a true problem with the battery, a lead, or an electrode. These problems can sometimes be fixed with reprogramming of the pacemaker. Other times, they may require a procedure to fix the problem. This is often called a lead revision.  So unless you had a catastrophic failure of everything all at once, unlikely in my opinion, no harm will come to you.  

Fix?

by AgentX86 - 2021-07-22 14:01:38

All it does is bury the symptoms, it doesn't "fix" anything. It's rather like aspirin. It doesn't fix anything but will reduce/eliminate the symptoms. You still have the damage but don't feel it (so much). Or, it reduces fever but you still have the virus. The original problem is still there.

Re: Escape rhythm: Pretty much any nerve cell in the heart can act as a pacer. This escape rhythm come in a hirarchy of locations an the fastest wins. 

1) First is the SI node at about 60bpm, we all know about this.  Then there are some abnormal trial rhythms that will overtake the SI node.  We all know them as Afib, Aflutter, and PACs. There are probably other less common ones.

2) After the SI node in the hierarchy comes the AV node at about 30-40bpm.  This is known as the "junctional rhythm". If nothing is coming from the atria, the AV node will take over.

3) At the bottom, we get ventricular rhythms that may be 10-20bpm (or not). Abnormal ventricular rhythms can overtake any of the above and we get PVCs or ventricular tacycardia (very bad). At 20bpm, it's like a constant 3sec pause between beats. At 10bpm, the pauses are 6sec. It's hurtin' pup time.

After an A/V ablation, which includes ablating the bundle of His (at least in my case), only the third option is left.  It's not much to go on. My EP told me that the couldn't find #3, either. I did  have PVCs with a 70bpm paced rate in the months post surgery but none since (though at 80bpm). After implant they are only allowed to test down to 30bpm and I fail that test every time (the elevator ride test).  So, yes there should be one more escape but nothing is guaranteed in this life and even if there isn't something you ever want to test.

That's why this stuff is so serious and why I am tough on those considering it. It's been great for me but I also understand the possible consequences. Education before decision.

Fix

by Haz - 2021-07-23 15:50:13

Thanks agent x86

i really do appreciate your honesty, I just wanted to speak to someone who has had the av ablation done and yes I understand what you are saying there are no guarantees about the escape rythem .I do feel now that I will have it done because trying to live with perminant af at speeds of 220 bpm is impossible it has taken over my life , I have been carpenter for 37 years since all this happened I've been told I can no longer do that job ,I've had to take early retirement from my local government job and now they saying with the new pacemaker I can't even use a drill because it will interfere with the pm im devastated but I still have a 14 year old at home and it stops me doing things with her ie swimming etc I want to be as healthy as I can be for her and my wife and maybe I could go teaching carpentry 🙏 also a big thanks to gemita for explaining the technical side of things I can't thank you enough        
                   Thanks Haz 

Drill

by AgentX86 - 2021-07-23 19:19:32

Use that sucker on whomever fed you the linr of BS that you can't use tools.  Any and all hand-held power tools that you're ever likely to come across are perfectly save. Even stationary woodworking and any light metalworking tools are just fine.

Welding is iffy. Check with your EP. There is a list of welding types and their safety on PM manufacturers sties. My EP banned me from riding lawn tractors because the operator essentially sits on the alternator.  I was also warned to be extremely careful working under the hood of a running car, for the same reason.

The bottom line is; be extra cautious because you will be dependent. And always follow the instructions from your EP. He knows you and your situation far better than we can.

By ventricular pacemaker

by Haz - 2021-07-28 17:12:23

Thanks agent x86 

that's really good to know 

do you know if having a av node ablation improves blood pressure my bp has been in the 80s and I have been told it's because my heart is out of rhythm apparently when it beats in time ,BP increases is this possible 

Hi agentx86

by Haz - 2021-09-16 16:30:40

The time has come for my bv pacemaker to be fitted on the 24th then the ablation node ablation one month after thanks for all your help and comments fingers crossed 

Av node ablation

by Haz - 2021-09-16 16:32:15

Thanks gemita for all your help 

Just saw your update

by Gemita - 2021-09-17 06:16:11

Haz, I send my very best wishes and AgentX86's too in case he doesn't see this update, for a very successful outcome.  Keep your spirits up and never stop believing that your symptoms will get better.  I will be thinking about you on the 24th and in the weeks following.  Please do let us know how you are when this is all behind you.  Good luck and stay safe

Gemita

AV node ablation

by Haz - 2021-10-31 16:18:30

Hi gemita and agentx86

i have had my Medtronic CRT.P pacemaker fitted now and after a bit of recovery time and swelling to go down,it's fine, I'm still getting fast heart rates and terrible AF but now I have my date for the av node ablation operation it's the 9th November just want to get it done now . I am getting muscle twitches with this new pacemaker but I will discuss them with my doc.

haz