Perspective on next steps - potential total A/V block with PM

Hi Group,

Yes another newbie here with a general perspective question.  I would greatly appreciate any responses that help with the decision.

Male 58, 6', 185 lbs.  I developed AFIB and Artial Flutter starting 2-3 years ago which became progressively more debilatating: a flight of stairs fully winded me.  I had a number of nuclear stress tests showing no underlying heart disease. I tried several anti-rhythmic drugs that did not help and made me extremely sleepy and foggy minded.

Finally moved to an EP Cardilogist here in the Houston (teaching physican in the med center).  He performed a cathather ablation in September.  Great news it completely addressed the AFIB and Flutter.  The bad news is that I immediately developed pretty much continual PVC's.  The net effect was that I was still tired and had limited ouput capability.  

We waited three months and tried the anti-rhythmic drugs again.  No success or change.  So a couple weeks ago (Merry Christmas) I went in for a second catherther ablation (which I had to be awake for!).  Sadly they quickly found a single point causing the PVCs but it was next to the main conductive node for the heart ( I believe the A/V node?).   So it was not possible to do the ablation without being prepared for a PM (read insurance approvals).

So here comes the question.  Could I live with the current condition and limitations?  Yes probably although it is a real drag being tired not interested in exercise all of the time.  I only occassionally feel the PVCs, so there isn't much significant pain.   The obvious other option is a total A/V block (I believe thats the channel the EP doc said, but I may have it wrong), and install a PM for full pacing.  Obviously that brings on all the long term implications.  

So most of the people on this board have PMs.  And I suspect a number faced a similar choice path.  Would you say "don't sweat it go ahead with the block/PM" or would the myriad of potential risks/problems tell you to advise waiting as long as possible?

I tend to be proactive tend on medical issues, but like to get a sense if I should go slow or go for it.

Thanks for all responses!



Perspective on next step

by TAC - 2022-01-01 11:54:50

To begin with, AF is the most difficult arrhythmia to be treated with ablation. Several attempts are needed, but no success is promised. Complication like the one you had is quite common. It's called PAFAT (Post Atrial Fib Ablation Tachycardia). Sometimes, it feels worse than the original AF and it's very difficult to treat. It may cause intense fatigue and syncope because it interferes with the heart's pumping function. If a PM becomes necessary to overcome this PAFAT, it won't be the end of the world. I do carry a PM after I suffered an almost complete A/V block. I feel fine and hardly think I have a PM. A second opinion won't hurt.

Planned AV Block ?

by Gemita - 2022-01-01 12:43:51

Hello James, welcome and happy New Year.  From your post, if I have understood correctly, it seems that to stop your PVCs you would need a catheter ablation procedure performed close to your AV Node that could potentially cause permanent damage to the AV node, preventing your own natural heart signals from your sinus node passing through your AV Node down to your ventricles.  You would then be in partial or total AV block and would likely need the support of a pacemaker.

You then go on to talk about the other option being a total AV Block at the outset.  I don’t see how this is going to stop the PVCs which originate in the ventricles (either right or left ventricle), unless your ectopics are coming from above the AV Node and you mean you have developed PACs (premature atrial contractions) not PVCs following your ablation for your AF and Flutter?

I would be inclined to get a few opinions from several EPs before going ahead and taking out the AV Node which seems so final.  Also, an ablation is not a guarantee of stopping an arrhythmia, whereas damaging the AV Node is a sure way of ensuring that you will have some degree of AV block for the rest of your life and it might be too high a price to pay, especially since you say you do not feel your PVCs.  Clearly though you have symptoms from your PVCs otherwise you wouldn’t be looking at risking such a procedure.  

The other point I would like to make is that it is early days following your first and second ?aborted ablation procedures and the heart is still healing and may need longer to do so. For that reason alone I wouldn’t go rushing into any decision.  I too have arrhythmias, including AF, Flutter and ventricular arrhythmias. I have a dual chamber pacemaker but an intact AV Node and that is the way I want to try to keep it for as long as possible. 

The other point is whether your insurance will cover for an elective procedure + pacemaker for a potentially benign arrhythmia especially in the absence of any structural heart disease?  There is a lot to think about and a lot to be discussed with your doctors, so take your time.

Can you live with your current condition?  Only time will tell.  I certainly found it difficult to cope with frequent ectopics and other arrhythmias and my pacemaker has been immensely helpful. If as TAC suggests, you have developed bradycardia as a result of your ablation for AF/Flutter, then certainly a pacemaker may help by giving you a higher heart rate, but I am unsure that taking out the AV Node is the answer?

Comlete A/V block

by AgentX86 - 2022-01-01 16:05:04

If I understand you, the choice, is a "simple" one.   The worst case scenareo (other than that of any procedure on the heart) is that they get rid of the PVCs but kill the A/V node.  You're then basically in a complete heart block situation.  There are many here in a similar situation, through more natural means but here just the same.  Since there is no atrial arrhythmia a simple two-lead pacemake fixes everything. If this will sove your constant PVCs, it's a small risk.

OTOH, if your atrial arrhythmia were still there it would get telegraphed to your ventticles and your pacemaker has done nothing. In this case, they'd have to disconnect the atria and ventricles permanently.  The decision would become a lot more complicated.

IMO (if I understand you) it's a no-brainer.  A simple heart block it's one of the easiest thing for a pacemaker to fix. IMO a trading constant PVCs for a pacemaker isn't even a choice.  PVCs suck the big one. You'll still have a functional sinus node so the pacemaker will make your completly whole.

My situation is more complicated because I had to make that choice but my atrial arrhythmia was permanent and unfixable.  The A/V node ablation meant that I was in complete, and un-fixable, heart block.  My ventricals have to beat with the atria competely disconnected.  The pacemaker paces the ventricles only.  The difference is huge and must be taken seriously.  Your choice is far more simple.

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But I think it will make me feel a lot better. My stamina to walk is already better, even right after surgery. They had me walk all around the floor before they would release me. I did so without being exhausted and winded the way I had been.