Flutter and Pacemaker

Been managing afib/flutter  for 10 years now. I can tell when I am in aflutter and can not function. I have been cardio converted over 30 times. I am being told that a pacemaker with a sinus node ablation would stop the flutter/fib. They tell me my heart would still be in flutter. If I am still in flutter and the pacemaker is controlling heart rate only, will I still feel terrible like I do now when in flutter/fib? I have asked the EP and cardiac Doctors and they seem to dance all around the question. Sinus Node ablation is non-reversable so don't want to do anything that is not reversable. Is there anyone that have had this done and left the heart to flutter constantly? How do you feel?



"Sinus node ablation"

by AgentX86 - 2021-12-29 22:08:35

You're describing an "A/V node ablation", rather than  a "sinus Node Ablation". The A/V node connects the right atrium to the right ventricle and synchronizes the atria and ventricles. After this is done, the heart won't beat normally on its own so you'll need the pacemaker to survive. You'll become "pacemaker dependent".

No, this is not reversable. In for a penny, in for a pound.  Think about it very seriously. Only continue if you have done everything else to relieve your symptoms, if not fix the fib/flutter. The only reason to go down this path is if your quality of life is so poor that you'll do anything to get it back.

I had an A/V node ablation February 2018. I had a Cox Maze in 2014 to try to fix my Afib and I ended up trading a symptomatic Afib for a highly symptomatic Aflutter.  After three years trying everything, there wasn't an alternative.  One  of the drugs damaged my thyroid and another my sinus node.  Because of the sinus node damage, I needed a pacemaker so had an A/V node ablation at the same time (unusual that they be done toghether).  I felt better and had more energy by the time I got to the recovery room.  I felt almost what could be called a "high" for a couple of weeks.  It solved my problem completely but you absolutey must be sure that you can't live your life without this exceptional step.

Yes, I'm still in permanent flutter but I don't feel any of it.  Becasue the atria no longer do anything, and really less than nothing, I don't have the atrial performance 'kick" so I'll not be competing in any olympics (I was so looking forward to Beijing). Of course, being in permanent flutter, my atria weren't doing anything anyway.

Know what you're doing and only go down that path with open eyes.

AV Node ablation

by Gemita - 2021-12-30 06:50:38

Yes as AgentX86 states, I believe you are referring to an AV Node ablation from your description Steve?   Can I assume that you have tried a catheter ablation for both atrial fibrillation and atrial flutter?  I note you have had 30 cardioversions and no doubt have tried medication.

You say you “don’t want to do anything that is non reversible”, so we have a problem since an AV Node ablation to prevent Atrial Flutter or your Atrial Fibrillation from passing through the AV Node to affect your ventricles is sadly not reversible.  My question is, would you still want to go ahead knowing this?  

You ask “How would I feel after an AV Node ablation”?  No one really knows but I asked this question too when I was considering this ablation for my atrial tachy arrhythmias, including Atrial Flutter and Fibrillation.  My doctor kindly attempted to answer and he said the following and I quote from his letter:- 

“An AV Node ablation is not a perfect treatment as you would still have Atrial Fibrillation.  However your main symptoms I suspect are due to a rapid heart rate and irregularity of your heart beat.  Both of these would be eliminated with an AV node ablation because your atrial tachy arrhythmias would be prevented from passing through your AV Node to affect the ventricles so you should feel much better.

Of course you would feel even better if we were able to stop your Flutter/AF in the first place and leave your AV Node intact, but in your case trying to stop your many atrial tachy arrhythmias would likely require several complex ablations because of the multiple sites from where they originate.  Multiple ablations would increase procedural risks whereas an AV Node ablation would be a short, simple, final procedure, usually successful on first attempt, taking no longer than approx 20 mins”. 

Of course you would become pacemaker dependent Steve but pacemakers are very reliable today and rarely fail.  In the event of failure, a good percentage of us develop “escape rhythms” so we could hopefully stay safe until help arrived.  Have a read of the following link if you are concerned about pacemaker dependency although many members here, young and old are completely reliant on their devices and have lived comfortably, safely for many years.  In the unlikely event of developing heart failure from Right Ventricular pacing following an AV Node ablation, an upgrade to a CRT pacemaker to restore synchronisation between the left and right ventricle should hopefully correct the problem.  In any event leaving rapid Atrial Fibrillation/Atrial Flutter to push your ventricles too hard will quickly lead to heart failure symptoms, so something needs to be done Steve.  I do hope things improve for you quickly.


AV node ablation to control atrial arrhythmias this

by Selwyn - 2021-12-30 07:26:43

Steve, it would be a help to know your age ( personal profile information).

As we get older, cardiac output declines (as do a lot of other physical parameters!).  The atria help the overall cardiac output. If you require maximum cardiac output, you are never going to get this with atrial fibrillation and atrial flutter. This does not matter if you are not planning to exercise to your maximum capacity.

In general, in younger people with atrial arrhythmias, it is important to achieve proper control of the atria, so that cardiac output is maintained. The most distressing symptom is the conduction of the fast atrial arrhythmia to the ventricles via the AV node and conducting L+R bundles. The result is a fast heart beat, which in its own right  may reduce cardiac output.  Rate limiting is therefore important.

A lot of people do not notice their atrial fibrillation- they are not excerting themselves.  If you want to achieve decent exercise capacity, you need functioning atria. You can achieve functioning atria without arrhythmias by:

1. Drug therapy

2. Cardioversion ( electrical or drugs)

3. Ablation 

All of the above will also return the heart rate to a decent level. An A-V node ablation will do the same for the heart rate, though leaves the atria to do their own thing ( with a reduction in cardiac output).

Personally for my various atrial arrhythmias , I have had drug therapy ( and bad side effects),  electrical cardioversion ( works for a short while), and various ablations. I have been offered an A-V node ablation- there is no way I would want a A-V node ablation as I am very active and need my atrial help in cardiac output ( having a pacemaker is bad enough).

The best solution to exercise ,  is always to try to get the atria to function normally. If this cannot be done, then a A_V ablation will stop the fast heart beat distress, though make you totally reliant on your pacemaker for heart rate. 

So, a lot depends on life style, and with this age expectation. Most younger people are very unhappy to be in atrial fibrillation/flutter even with the heart rate controlled. Having said this, "you cut the cloth to suit your means", and eventually people have to adapt. Even Clint Eastwood says, " A man must know his limitations!"  There is harm risk in having flutter ablations and atrial fibrillation ablations. An A-V node ablation is relatively straight forward - it will leave you with permanent atrial dysfunction. If you drive your  motorcar at 30 mph all the time you are a happy motorist, until you want to go down the motorway at 70mph. 

I have seen  some very unhappy people with AF/A flutter in spite of having their heart rate controlled. They yearn to be back to 'normal'. They have exercise limitation and some 'heaviness' around their chest. With time they may adapt to their new norm.


Lots to consider

by TLee - 2021-12-30 10:57:18

I learn more every time I come here! I appreciate the details about this ultimate treatment for afib/flutter, as I have been dealing with afib for several years & have experienced just about everything but.

You say that you feel terrible with your arrhythmia, and I have certainly been there--dizziness, shortness of breath, fatigue, ugghhh. I had cardioversion (only once, not 30x!), cryo-ablation (again, once), and increasingly strong medications that could slow my heart rate too much, so now a pacemaker. My last interrogation showed 0% afib, which must make my doctor happy--me, not so much. I actually felt better with less medication (less side-effects) & a low-ish percentage of afib. 

I say all this because I am still in a position to try lower doses of the meds, or a switch to something different. I can also still tell my doctor that I am willing to live with SOME arrhythmia to feel better most of the time. This could be a route for you to investigate before jumping into a permanent situation.


by AgentX86 - 2021-12-30 14:14:04

I've probably said all of this above but TLee has good advice, "Lots to consider" and "investigate before jumping into a permanent situation".  I've said it but can't stress this enough. Ablate and Pace is irreversable and does make you dependent on your pacemaker.  Think of it as a complete heart block on top of a pacemaker with a completely severed right atrial lead. Your pacemaker will be limited to VVIRV.

I don't think I would have done it without having to have a pacemaker anyway, because drugs bit me twice. Of the high-power antiarrythmics the only one I hadn't tried was tikosyn and it would have been tempting strike-three. My EP had been discussing it as an option for six months, since ablation #2 failed, so it wasn't out of the blue but at that point I didn't see another option.  That's where you head has to be. No doubts allowed!

I wouldn't worry about the atrial kick.  It amounts to about 20% of peak performance.  Unless you're into competetive sports you won't get to where that 20% matters. The atria's function is to help refilling the ventricles at high heart rates, which is only needed during extreme sports (more like a 200mph race car limited to 160). If you're in AF/AFL your atria aren't doing anything anyway.

A CRT pacemaker is the standard after ablate and pace, which will help of there is a broken lead down the line.  It's exceptionally rare but a failed pacemaker can be life-threatening.  As Gemita notes, most have a ventricular escape rhythm, normally with a rate of 20-40bpm.  If it's there, it would be enough to keep you alive but perhaps not consious. This is what people see with a complete heart block. Your pacemaker tech will test for this during pacemaker interrogations but is only allowed to test down to 30bpm so may not to see it, even if it is there.

I hope I didn't repeat myself too much but it is important stuff.  It is your  life!

Sinus node ablation

by TAC - 2021-12-31 16:23:40

After a sinus node ablation, you become 100% dependent on your PM. That means that your heart will beat only by the electrical impulses sent by you PM. That's it. 

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