Atrial tachycardia with sudden termination

Atrial Tachyarrhythmias

by Gemita - 2023-03-21 04:46:05

Mae, hello, I am so sorry to hear you are still fighting this.  Any sudden substantial heart rate drop or heart rate increase can affect cardiac output and therefore could well cause pre-syncope or even syncope.  I know this from personal experience and some of us, depending on our heart condition/other health conditions and of course age, will be affected more than others.  I am extremely sensitive to any sudden heart rhythm/rate change.  Depending on the cause, I hope it can be treated effectively for you.  

You ask “Would that go along with my original diagnosis of Tachy Brady and SSS?”  Yes the symptom of a sudden heart rate drop could most definitely be part of the Tachy/Brady/Sick Sinus Syndrome condition if you find yourself still questioning whether a pacemaker was really needed?  Finding the arrhythmia responsible and its exact location will be needed now to effectively treat it.  I see they are looking at Inappropriate Sinus Tachycardia (IST) - see link attached, Atrial Tachycardia as well as a vasovagal cause.  Long term monitoring will be the key here to successful arrhythmia identification and treatment.  

My arrhythmias were picked up by the Reveal Linq implant monitor as you may know from our previous correspondence, the findings of which were then confirmed by an EP Study.  Between these two tests and a lot of effort on my part to keep diary notes/dates when my symptoms occurred, helped confirm the arrhythmias present.  

Depending on how symptomatic you are, you could then proceed to an ablation.  My feeling though is unless your symptoms are occurring frequently and your quality of life is truly affected, I would try to avoid an ablation for as long as possible Mae.  I know the sooner an arrhythmia is stopped the better in most cases, but sometimes going in too heavily, too quickly before you or your doctors have all the facts, can be just as risky and lead to worsening symptoms.  Going down the ablation route might either give you a long respite from your sudden arrhythmias, or trigger even worsening symptoms, at least during any healing period.  Even in the best, most experienced hands, a patient suffering from a vasovagal condition may not always be completely helped by an ablation, and this would be my main concern as a vasovagal sufferer myself.

When you say AT with sudden termination, I wonder whether your doctors actually saw this happen due to sudden ‘natural’ termination of the arrhythmia, or whether the termination occurred 'forcibly' due to a pacing/mode change to try to control your atrial tachy arrhythmia?  There are a number of settings which could potentially cause a sudden rate drop response and I would ask your doctors whether your sudden heavy fall in heart rate was caused (1) by your tachy arrhythmia suddenly ‘naturally’ terminating or (2)  by an automatic pacing adjustment happening (like mode switch kicking in for example) to try to prevent the tracking of your fast atrial arrhythmia?  There is even a setting called Rate Drop Response, at least on my Medtronic PM, so there may be a setting they can adjust more sensitively to help with your symptoms during a rapid, sudden heart rate fall?

I see you have the closed loop system and a Biotronik PM.  I believe this is a very good PM to help with your 'complex' condition.  I also see that your doctor wants to try Ivabradine for the IST which is also used experimentally for the treatment of postural orthostatic tachycardia syndrome.  I hope it helps.  Good luck Mae whatever path you decide to follow and please let us know how you progress since we learn so much from each other.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5872261/

Gemita

by Mae11 - 2023-03-21 10:57:19

Thank you Gemita for sharing your extensive knowledge with me. I read the attached article and wonder if one of the first lines addresses my issue. I honestly believe the IST relates to one of my prior posts about low stroke volume. I have also been told that I am hypovolemic, which we started fludrocortisone for, but I developed chest pain and told to stop. (( My EP now suspects that my RV lead may be out of place because I am getting stimulation under my left breast from that lead, as well as a recent pleural effusion))

I'm hopeful there will be some relief from the ivabradine once I am able to try it. I agree about the ablation, and that article and your comments make me even more hesitant. I have already has 3 surgeries in under 2 years. I certainly don't want to go that route and not have a substantial, long term relief. 

As soon as he watched the drop he asked me if I had done something to cause it. I said no but I think I need to lie down, I may pass out. So its my understanding it was not the pacemaker that stopped it.

My quality of life honestly isn't great. But I feel that it's a combination of these issues, not just one. I'm hopeful though that we are on the right path.

I am not surprised you are having rhythm disturbances

by Gemita - 2023-03-21 14:15:01

Mae, the RV lead potentially being out of place and your recent pleural effusion would concern me.  I hope they have treated the pleural effusion and confirmed the cause.  My husband had a pleural effusion due to pacemaker lead trauma which had to be drained several times.  He was treated for a bacterial chest infection with antibiotics and a short course of an anti inflammatory since he had pleuritic type pain (sharp in nature).

The Ivabradine I see is used to treat heart failure (my sister is taking it 2 x 5mg per day) and she tolerates it well, although I see it is also used for IST.  However after a pleural effusion and with a potentially poorly positioned RV lead, I am not surprised that you are getting episodes of tachycardia.  Once both these potential causes are addressed, you may find your symptoms will naturally ease without any further treatment.  Wouldn't that be wonderful.

The low stroke volume and hypovolemia need to be addressed too.  Have you had a recent echocardiogram to check your ejection fraction and have you had any other tests for these conditions?  

Try to rest, keep well hydrated and take good care of yourself.  A pleural effusion, depending on the cause may take a few months to completely resolve.  Try not to get anxious over the IST.  As long as your heart rate is well controlled now and in the future on Ivabradine, it will give you more time to address all of your current difficulties xx

RV lead

by Mae11 - 2023-03-21 16:12:26

I'm sorry to hear of your husband's issues and I hope they have cleared and he is well now. 

I have had a strange, full/almost squeezing type feeling in my chest since around September or October. Not necessarily painful, but uncomfortable. He was aware of it and told me to stop taking the fludrocortisone, since it started shortly after starting it. It started getting a bit worse at the beginning of February so I requested to be seen. I had also had a recent bout with Influenza A, so he was worried I had pericarditis. I was given colchicine to be on the safe side. He ordered a limited echo to check for that and the pleural effusion was found incidentally and was small. It didn't give a number as far as ejection fraction, just said within normal range.

He was then worried that the RV lead had perforated my lung because of the stimulation I was getting along with the effusion. He ordered a CT that showed that the effusion had resolved and there was no perforation, but it is placed poorly.

I go back May 4th to go over the results of the monitor and all of this. 

Near syncope with HR drop

by Gotrhythm - 2023-03-21 17:34:06

I can't claim any knowledge or experience with atrial tachycardia. However, from recent experience I can say that sudden HR drops, 136 to 95, 113 to 80) even though the upper rate wasn't techically tachycardia, can cause near-syncope.

I suspect that because I have mild VVS, I'm perhaps more sensitive to drops in BP.

In my case the cause of the jumps in HR turned out to be a rare kind of PMT.  I'm loathe to compare symptoms because when it comes to the heart, the same symptoms can have so many different causes. Correct diagnosis depends on a lot more data than you'll get in a Pacemaker Club post. But if you wish to know more about what was going on with me, see my post last week about my experience with RNRVAS.

Hope you can figure it out soon.

Interesting

by Mae11 - 2023-03-21 21:44:44

I read your post and a little bit online about RNRVAS. I find it quite interesting. I was found to be in PMT live while being seen at Cleveland Clinic. He said it was atypical because I was not at my max rate but indeed PMT. They pushed out my PVARP and my AV delay "longer than the norm". I want to say it was maybe 350. In the notes it says that "VA conduction is 309ms". Would this be retrograde conduction? And if so is that just because I was in PMT? I try my best to understand, but like you I have to reread about 40 times to try and take it in and make sense of it. 

I'm sorry you were struggling but so happy that you were knowledgeable enough to make them see your issue! 

The PMT saga

by Gotrhythm - 2023-03-22 14:55:20

I don't begin to know enough about VA conduciton settings to tell someone else what their settings might mean. 

All I know it that the tech widened the PVARP as much as other settings would allow, but the RNRVAS still showed up when I walked around.

Fotunately for me, AV function is fine, so switching the mode to AAIR didn't so much correct the problem of RNRVAS as offer a detour around it. I think of it as, instead of trying to widen the road where I was getting to close to the cliff edge, we just found different road.

Like you, this isn't the first time I've encountered a super rare PMT. I know how frustrating it is to feel something happening but get mostly blank looks when you try to explain it. 

The crucial point to understand about RNRVAS is that there are no "pacemaker check-up programs" that will reveal RNRVAS. It's something that the tech has to observe as it is happening, in order to diagnose it.

For me that means, forget trying to impress anyone with your knowledge. Instead, whip out your people skills to get manimum cooperation from the tech. I reminded the tech that we had met before and told him (with truth!) that he was my hero for a catch he made in a previous session.

Again, good luck with getting this problem handled soon. Findint yourself near-syncope when all you are trying to do is chop the onions take all the fun out of it.