confused about PM

Hello. I am new to this board and new to the pacemaker world so please bare with me. I am a 30 year old who just had a PM implanted last week. I have atrial tachycardia. I have had 3 failed ablations and can no longer get my tachycardia controlled with medications. They placed a Kappa dual lead PM. In 5 weeks I am going back in for them to totally ablate the AV node. I am very confused about this. I dont understand why they dont ablate my SA node instead of the AV node. He told me that after the ablation that I may still feel my atria beat rapidly but that we could treat this with meds. I dont want medications. I am done with them. What I dont understand is so there is a range, like mine is 60-130, at which the ventricle will pace. So what prevents the ventricles for just responding to the atria (since the pacemaker is going to sense what the atria is doing and respond if appropriate)? For example, I get a lot of tachycardia when I first step out of bed in the morning. If my atria beats at 130 what is going to prevent the pacemaker from responding to that? Is it going to sense that this is inappropriate and not pace the ventricle? I am really frustrated and want this to be over with, My heart rate will always be 100-150 when I do something like walk up a flight of stairs. But I dont need that high of a heart rate, so will the PM still respond up until 130? Any thoughts and education would be GREATLY appreciated.

7 Comments

AV vs SA ablation

by ElectricFrank - 2009-06-27 01:06:12

The idea behind an AV node ablation with your condition is to cut the pathway between the artium and ventricles. Then the path is re-established by the pacemaker. Since the AV conduction is through the pacemaker it can set limits on the maximum rate. In fact if your atrial tach prevents the pacer from using the atrium as a pacing source, then they will likely use Rate Response to time the V Pace. This is a motion sensor that uses your body movement to determine an appropriate HR.

One question about the Atach and med you may want to discuss in advance with the cardio. If the artrium is left in Afib or Atach, they tend to be concerned about clots forming and traveling to bad places. In this case they would still want to treat it with blood thinners.

If I was in that situation I would want to see some actual risk statistics of both Atach and of blood thinners. I would want the stats to be presented in the same mode (absolute or relative). From my limited observations of the stats I have some real questions about using the thinners. I don't have the problem so I haven't tracked it down in detail.

hope this helps

frank

rate response

by sam78 - 2009-06-27 01:06:58

I do believe that they will be using rate response with me. I have heard it mentioned many times and that is what my pacemaker card says. So will the rate response essentially overdrive my atrial rate if is not appropriate yet still within the set range? Like if the rate response on detects my heart rate needs to be 60 and my atria is at 90 or 100 will it still only pace at 60 even though the atria is faster and it is still within the parameters??

ITS OK

by pete - 2009-06-27 03:06:10

You will be 100% dependant on your pacemaker. Like me. You will get an AV node ablation. Like me. The results are usually very good. The ventricular pacing leads will not sense your atrium pacing as they are not placed in the area of the atriums. My pacemaker leads sensed and recorded episodes of ventricular tachycardia during the period between fitting the pacemaker and the AV node ablation. After the AV node ablation the ventricles behaved themselves being 100% controlled and dependant on the pacemaker. So many patients have gone down your route. You are about to get the treatment they should have given you long ago. If they were to totaly ablate the sa node you would need a 4 lead pacemaker with 4 leads.( I dont think they make them anyway) This would be a risky proposition. More to go wrong, and the heart would struggle at the first hurdle. At least your heart should have a residual pace to the ventricles if you get some kind of problem in the future so the doctors will have time to keep you in the land of the living. Chances of a problem are slim so dont worry. You should be able to cut out most drugs. I think you will only need an ace inhibitor, digoxin and warfarin. Get your platelet count checked before taking warfarin or any anticoagulant. The doctors dont always pick up on a low patelet count and it can be fatal if you also take an anticoagulant. Let us know how the ablation goes. Its a quick and straigtforward one. Cheers Peter

AVN ablation

by heartdoc - 2009-06-28 02:06:59

Your SA node is not the problem. Apparently some other place(s) in your atria are generating impulses at much faster rates. The AV node is the connection between the aria and the ventricles. Destroying it means that your ventricles will be dependent on the pacemaker to tell them when to contract.
The pacemaker monitors your atria as well, and when it's functioning normally it will simply synchronize your ventricles with them. When the atrial tach develops, the pacer will ignore it and use its rate adaptive programming to determine your heart rate. There will probably be overlap between your normal sinus rates and the atrial tach (eg, when you are exercising your sinus rate may well get up into the atrial tach range), so your pacemaker will probably need to be reprogrammed several times to "get it right," and it may never be perfect. If your atrial tach is on the slow side, it can be a real problem for your pacemaker to distinguish between them. This would be dealt with by having your pacemaker switch to its rate adaptive mode at a lower rate; this is usually well tolerated.
Note that ventricular contractions from a pacemaker are not normal, and after many years can result in a cardiomyopathy--something to consider at your age. On the other hand, there are ways to ameliorate this problem, and also pacemaker technology advances every year, so this may never be an issue for you.
Regardless, you should be sure that your atrial tach truly cannot be ablated before you go ahead with the AVN ablation. Have you had a second opinon?
BTW, at your age, unless you have other heart problems, anticoagulation would not be needed, regardless of your atrial rhythms. As you get older (>60 or so), however, this may become necessary. (But who knows what we will be able to do in 2040.)

Hi

by Hot Heart - 2009-06-28 03:06:59

Hi there sorry dont know much about this stuff, but just wanted to say welcome to the site

HH

worried

by sam78 - 2009-06-28 11:06:49

Thank you for your response. What you talked about is what concerns me. Because I have a cross between atria tach as well as inappropriate sinus tach, and I just so afraid that the pacemaker is not going to be able to decide when what the atria is doing is appropriate. In the end I guess this will be a good result for me because I may be able to get back into to doing at least some form of exercise. At this point, I am not allowed to do anything because I get into SVT (or atrial tach). I just dont want to have to continue to live with this fast rhythm (like 120's when I am walking around the house). I am not doing any anticoag and do not expect to have to either. I just want to have energy again and be able to exercise and not race when I am not doing anything. I have not had a second opinion because I have the best EP on my side of the state. He did offer to send me to the big center across state but we have done 3 studies and I figure if in 3 studies he cant find it, they arent going to be able to in 1 study. I have 100% trust in my EP doctor, thankfully I know I have the best in town.

Heartdoc

by ElectricFrank - 2009-07-02 10:07:37

Welcome to the site (or my discovery of your presence!). Glad to have your expertise here.

frank

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