8 Weeks Today!

Hi Everyone FG here. Well, it's been 8 weeks! Today! Went fast. The time, not the heart he he...

I'm at a rock solid 50 bpm at rest, with my natural rate response from AV node still good to about 140 during exercise. Dual chamber Medtronic MRI conditional PM. DDI is my setting. I am still in 100% persistant AF but complete heart block keeps all those extra little signals away from my ventricles. Taking Eliquis twice daily. Feeling fine but went back to exercise a little too vigorously and hurt my knee. Oh well it will heal.

So now they want to work on my AF. They can cardiovert and put me on medicine, or try to go ahead with ablation at the same time. I never get SVT or other tachycardia events because none of the atrial impulses reach the ventricles in 3rd degree block. So the idea is to restore NSR, then use the pacemaker as an artificial "jumper cable" across to the ventricles. Has anyone heard of that? Anyone have that? What would you do? Meds or ablation right away?

Thanks, FG 


8 Comments

"Has anyone heard of that? Anyone have that?"

by AgentX86 - 2023-05-18 17:11:58

Probably 75% of the people here have AV block and a two-leaded pacemaker so that part isn't just common, it's the norm. Add AF on top of that and you probably cut that by four but till a big number.

The drugs/ablation decision is complicated.  Drugs are certainly less invasive so the natural inclination is to climb the ladder with drugs untill none work anymore, then go to ablation.  The problem is that the longer one is in AF, the lower the probability that an ablation will successful.

Whatever you decide, an ablation really has to be done by a specialists specialist.  Not all EPs are equal.  There is a huge difference between an EP who does ablations and an EP who does little other than ablations. An ablationist should do at least 100 a year and have 1000 under his belt.

Ablations

by FG - 2023-05-18 17:47:03

Thanks Agent. On our visit 5/8 he encouraged ablation saying, " I do about 130 of these a year. But my more conservative patients may want to start with medications...". He also was the one who put in my LBB pacing lead. 

A Fib

by Rch - 2023-05-18 19:26:06

My suggestion to you is to ask your EP what he would advise after he reviews your history, echo, labs etc and follow his advice. If you do not feel the fibrillations and if it doesn't impact QOL, then you could consider the medications for a while. However, as per my EP, A.Fib begets A.Fib and longer you are in A.Fib, harder to revert to NSR! 

8 weeks old today. Many congratulations!

by Gemita - 2023-05-18 19:29:15

FG you say that you are in persistent AF and that your fast atrial rates do not reach the ventricles because of your 3rd degree block.  That tells me that you are not particularly symptomatic and that you have time to decide what needs to be done.  In your shoes I would take that time and perhaps allow yourself a bit longer to heal from your pacemaker and get used to pacing before taking the next step.  An ablation is certainly more effective  than cardio version and medication but the healing period following a pulmonary vein isolation ablation for example can be a long one and some patients report their symptoms may intially worsen until healing is complete - 3 to 6 months.

Cardio version never really held my AFib for more than a few beats, but medication did work well for a couple of years before it stopped working and became pro arrhythmic.  I have been able to hold off an ablation and today I am in a much better place than I could ever have hoped for.  My AFib continues to be intermittent but completely under control with minimum meds, no ablation in my history and just a low dose beta blocker to control my heart rate.  I am getting some amazing success from pacing alone FG.

What is your gut instinct telling you, you should do?   I would proceed quickly to an ablation if you are so symptomatic that your quality of life is affected.  If you are feeling generally better following your pacemaker and I believe you are from your comments, I would be inclined to wait a little longer.   Certainly NSR would be wonderful if you could achieve this with say only one ablation, but you may need more than one ablation to achieve this with persistent AF, but these are questions to ask your doctors.

I see you have a dual chamber pacemaker so certainly if you can get back into NSR, your pacing experience should be a smoother and more effective one, without the complications of having fibrillating upper chambers.  With AFib it is the "irregularity" of rhythm that causes me the most distress and since with third degree block you do not feel these irregular heart beats or have any fast signals getting through your AV Node to drive your ventricles too fast, your symptoms will naturally be well controlled.

But I am delighted you are feeling so much better.  

AF

by FG - 2023-05-18 19:58:00

Hi Gemita! Yes AF now for over a year. I hope it's still reasonable to try to treat it. I was cardioverted last June and it lasted to Sept but they did not use meds because I was at 32-35 bpm in 3rd degree block. I hesitated on the PM as ya'll know...

I am not now symptomatic, I never really was except for what I can now see was a degree of "mental dullness". I was able to exercise so I was not symptomatic that way but I was forgetful and a lot better now. At least that's what my wife says! So the PM was the right move. 

When he said stroke was possible during an ablation I kinda freaked out...that's the main reason I would probably try cardioversion and meds first, but then we are getting along at about 1 year... What do you think?

Yes of course Persistent AF is still treatable

by Gemita - 2023-05-18 20:12:39

Persistent AFib is certainly not Permanent AFib although I have known patients who have successfully had an ablation even with Permanent AFib and are now back in NSR, so with an experienced EP you should do well.  

You are on anticoagulation so you should be safe from the stroke risk.  They have to give us a percentage risk figure.  I wouldn't let that stop me from trying to get a permanent fix for Persistent AFib, especially if your EP has confidence he can succeed in stopping it.  But you have time with a pacemaker now to experiment a little first, without rushing into an ablation.  It is a nice position to be in and frankly, I would take your time.  That doesn't mean sitting on the fence forever, but just allowing yourself more time to get used to pacing and other less invasive treatments first to see how well they work.  

Thanks Again

by FG - 2023-05-19 13:17:11

Thanks to all of you Gemita, Agent, Lavender, and all the rest who keep this Club alive.

What a great resource for all of us. I agree for now I see no reason not to try medication first. A friend who has highly symptomatic (rate to 180) fast AF was put on "Tikosyn" after his 2nd ablation and he says he can feel no side affect from that medication and is cureently doing fine.  But he says they probably won't use that med at first on me.

Meds

by Lavender - 2023-05-23 21:57:13

Do what they advise but if you are given options-maybe try meds first. You would still have plan B. 

Two months in already!! Time flies when you're having fun!😜

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