Ablation part of pace and ablate

You ask a good question

by Gemita - 2022-05-17 06:07:47

Toni,  I note you are high risk for pulmonary vein isolation ablations and don't fit the criteria.  You have tried powerful meds, not well tolerated because of being asthmatic, hence you have been placed on Amiodarone.  You have been advised to have an AV Node ablation and have already received your CRT pacemaker in readiness.  I know, last resort, but it is a reasonable one for control of AF at high heart rates which could quickly lead to worsening symptoms, including heart failure. 

If this helps, I asked the same question you seem to be asking when I was considering an AV Node ablation and this was my EP's response:

"You ask a very good question about whether you would still have symptoms following an AV Node ablation.  An AV Node ablation is not a perfect treatment as you would still get AF;  you are clearly aware of this.  However the main symptoms that I suspect you experience are probably due to a rapid heart rate and irregularity of your heart beat.  Both of these would be eliminated by the AV Node ablation.  However, when you are out of normal sinus rhythm, you might have some minor symptoms, although I suspect you would not have a major drop in blood pressure.  In summary, I suspect you would be significantly better and almost certainly would never feel the need to attend hospital during attacks, although you would not perhaps be quite as well as you would be if we were able to eliminate your AF completely. 

The other benefit from an AV Node ablation is that it is successful first time in the vast majority of patients (95% or more).  We do very occasionally have to repeat the procedure but this is very uncommon. The procedure itself only takes about 15 to 20 minutes.  With a successful AV Node ablation you will be able to stop many of your anti arrhythmic/rate control meds".

Toni all I can say is that it is so normal to have doubts at this late stage.  My advice is perhaps to ask for a little more time if you are undecided?  You have to be sure it is the right decision for you.  I know many members here who have had an AV Node ablation and are now doing well without being pounded by atrial tachyarrhythmias pushing their ventricles too fast.  I hope it will be the same for you too.

Pace and ablate

by toniorr11 - 2022-05-17 07:29:01

Hi Gemita. Thanks for your reply. I guess the problem for me is what can I expect in terms of what my heart will feel like after the AV node ablation. Currently I am in NSR most of the time. I've been extremely well controlled for the 6years on flecainide but I'm now getting breakthrough fast AF and the amiodarone I'm currently on is keeping my heart stable but it can't continue and they say there's no other way of controlling the fast ventricular response. I accept that. I'm just wondering if it feels different after the AV node ablation. It sounds like it will be different but how? Specifically? 

Gosh, this is hard!! Lol. 

Yes it is a difficult decision

by Gemita - 2022-05-17 07:47:56

Toni, yes this is hard, especially as you are in NSR for most of the time at the moment, so you will not know how it will feel with a loss of AV synchrony after the AV Node ablation, although you must have been affected by both Flecainide and now Amiodarone, so it will be good to get off some of your meds.

No one can know how an AV Node ablation will personally affect now or in the future, although you will lose the atrial kick which accounts for some 25% I believe of your cardiac output.  However being in AF with a rapid ventricular response rate and taking meds like Amiodarone for extended periods would probably take a heavier toll in the end.

It sounds to me as though you would benefit from having more time to consider this, even though you have already gone down the AV Node ablation route with your CRT pacemaker implant already in place.  The fact that you are still in NSR is a very good sign though and I personally would be slightly reluctant to sever the AV Node just now, without perhaps having further discussions, especially in view of your new concerns.  I would take my time and get used to pacing first and get all the questions out of the way 

AV ablation

by AgentX86 - 2022-05-17 12:54:59

I had an AV ablation and pacemaker implant (same time) four years ago. I'd been through every possible alternative and was still miserable. I had permanent AFL after a less than unsuccessful Cox maze procedure. I went through several drugs, damaging my thyroid and sinus node, and three failed ablation attempts. Because my SI node was damaged, I needed a PM so the jump to an AV ablation wasn't a  huge one for me.

All this to say that you HAVE to try everything else first. Any of these procedures assume that you're so symptomatic that you have a poor quality of life. A poor QoL is the ONLY reason to do any of this. The arrhythmia won't be fixed, just the symptoms relieved. An AV ablation is the last step and has to be taken very seriously.  Seriously!

After an AV ablation the atria are useless, if not a net negative impact on the heart's output. If the heart is in flutter, as mine is, the atria aren't doing anything anyway so that's not a big deal for me. You can live a perfectly normal life with no atrial function. Their purpose is to help fill the ventricles and amount to about a 20% increase in heart output at maximum heart rate. They're not needed at normal heart rates. Unless you're a competitive athlete this probably won't matter much.

While antiarrhythmics are no longer needed (these have already been found to be ineffective or dangerous, right?) anticoagulation will still be needed for life. The arrhythmia doesn't go away, it just can't be felt.

After the ablation, you will be dependent and there is a good chance that you will no longer have any escape rhythm, meaning that the only thing keeping you alive is your pacemaker.

The point of all of this is that you really have to make sure that you've done everything else possible and your quality of life is to the point that you'll try anything. If you're not to that point, don't.

I wouldn't look back. It worked for me. I am still in permanent flutter but I feel great. I felt 100% better before my feet hit the floor. It was almost a high, for a couple of weeks. OTOH, I am dependent with no escape rhythm so it's not all roses.

BTW, I'd never take Amiodarone for more than a few months. That stuff is poison, literally. It amazed my thyroid. Fortunately I recovered but I was only on it for six months.

Coping

by toniorr11 - 2022-05-18 11:49:05

Thanks for the replies. I think I have to be guided by my cardiologist. He says that I'm only in NSR because of the amiodarone which MUST stop soon. There is no other drug regime that works for me now so I really don't have anything else to do. I've been to A&E 4 times this year ( before the amiodarone) and had 2episodes at home which reverted quickly. The thought of living my life with fast AF hanging over me is intolerable and really my heart must be being affected already by so many episodes. I've got 6weeks until clinic. See what happens there. I'm not an athlete but it would be good to be able to go for a walk without feeling like I'm going to push my heart too much! 

Coping

by AgentX86 - 2022-05-18 12:20:29

Are you on rate control? If not, that's the first step. Now that you have a pacemaker, thy should make more choices to keep your heart rate down. If your symptoms are because of the irregular heartbeat itself, and is _completely_ intollerable an AV node ablation will almost surely solve this problem.

An AF ablation by one of the top ablationist EP has a decent chance to work, as well.  Not just any EP has these skills. A top EP will have done a thousand ablation, or more, and  will do well more than a hundred per year.

An AV ablation is positively the last step. It's serious stuff (many professionals believe it's never necessary) and is irreversible.

As far as exercise goes, atria are really only involved at maximum heart rate. Their evolutionary purpose was a a hunter chasing down prey. I walk ten miles a day with absolutely no problem from my heart. My heart rate maxes out at somewhere between 110 and 120. It depends on how I measure it. It's really difficult to get a good number.