HELP

I have/had Afib. I started having chest pain, SOB, and palpitations in May of 2010. It had been 3 years since my last AFib episode. My docs headed straight to an ablation in June 2010. Since then, I cannot get my heart rate to increase appropriately with exercise. My max heart rate in March 2010 was 171 and in December 2010 it was 115. One doc says I have sick sinus syndrome and another one says I don’t. I have been home for work for 4 months now and I am going crazy. My resting pulse before all of this was in the 30s with no symptoms. I am an avid runner/cyclist so my resting HR was also attributed to my exercise. After 6 months of no exercise my resting HR is in the mid 40s. I have also been diagnosed with MVP/MVR. I have been told it is not bad enough to cause all of my symptoms.

How high of a HR can a pacemaker provide? One doc told me it will only go up to about 130 for me since my resting is so low. I just don’t understand how last week one doc was ready to schedule the procedure in 2 days and yesterday the doctor said it will not help me.

I am 40 years old and just want to get back to normal.

12 Comments

SickSinusSyndrome

by biker72 - 2011-01-06 01:01:00

Sounds like Sick Sinus Syndrome to me. You need to see your EP about this.

As a 72 year old cyclist, I feel your frustration. You get conflicting opinions and wind up not knowing what to do. The biggest problem is finding a PM tech that has had experience with prople that exercise.

My PM can be set as high as 185bpm. It's currently set at 140 and resting is 60bpm.

I have been diagnosed with SSS and A-Fib. I'm in A-Fib about 95% of the time. My PM corrects both of these problems.

answers to questions

by Firefoy - 2011-01-06 08:01:19

I have been off of work for almost 4 months. I am a firefighter and need to be at 100% to return to work.

I had a segmental ablation using RF. I had a CT angio done before and after to r/o PVS. It was negative. I had a barium swallow test to rule out an esphogeal fistula. It was also negative. I have had every test possible to see if my current situation is a byproduct of the ablation. It appears that the ablation was a sucess with no side effects and no more AFib. My EP has performed hundreds of ablations.

Thanks for all the repsonses. I appreciate knowing that I am not the only one dealing with this.

Ablation (different types)

by agelbert - 2011-01-06 08:01:53

The term "ablation" covers a lot of territory. It is important for you to learn all about ablations. After you find out EXACTLY what was involved in your ablation (what precisely was burned away), you should be better armed with the information you need to weigh the side effects and possible remedies to them. Good luck to you.

ABOUT ABLATIONS:
MedHelp Member's Question

1. What is the most accepted form of ablation these days: focal point (I hear that's an older method?), circumferential (more problems with stenosis?), and segmental (involves more mapping?)? What are the main differences/advantages/disadvantes?

2. What is the most common method used in ablation also...RF, microwave, cyrotheramy? Differences/advantages/disadvantages? Should a cool tip catheter always be used in RF ablation?

3. Should a TEE always be down prior to the procedure to check for clots in the heart? What's the difference between a TEE and a regular echo?

4. How can stenosis be prevented and monitored for? How common is that?

5. How long have ablations been performed as a procedure in hospitals?

6. What is a good rule of thumb for how many ablations an electrophysiologist should have performed already to be considered "experienced"?

Doctor's Answer
by CCF-M.D.-MJM, Aug 30, 2004 12:00AM
Hello,

These are very complicated question and without knowing the very specifics of the case, near impossible to answer. For example, the approach ablation is dependent on the mechanism of her AF (i.e. is it from a focal point based on mapping, if it is, than focal ablation is the right approach). Many doctors are experienced in one technique and may be biased to there approach. At the clinic, we use radio frequency and segmental mapping with ablation.

2. Some RF catheters use a cool tip. There is no standard of practice yet.

3. TEE is done for anyone in atrial fibrillation
at the time of procedure. If they are in normal sinus rhythm, it is up to the doctor on whether they think it is necessary.

TEE looks at the heart through the esophagus and is better at seeing clots in the atrium. transthoracic is better less invasive. TTE views the heart through the thoracic wall.

4. Stenosis is a known complication of PVIs. Even a perfectly done procedure can lead to PS. Typically a TEE follows the procedure at 3-6 months to assess for PS. Some hospitals do CT instead of TEE. It is not standardized. The incidence of PS is 1-3%.

5. I actually don't know the answer to this one. It is a relatively new procedure.

6. There is not standard yet. The procedure is too new. I think 50 is a good number, but there is no data to back that up. We do about 5 per day here. As always, high volume centers with high volume operators usually have better outcomes.

You might be amazed at how far and how often people travel to Cleveland to have their procedures.

I hope this helps and good luck!

Why the slow pulse?

by agelbert - 2011-01-06 10:01:08

You stated that after the ablation, you can't get your pulse above 115 in exercise when previously you could get it to 171. And the doctor says the ablation didn't cause it? I would get a second opinion.
Think about it. You've got the same cardiovascular system you had before the ablation. You have probably gained a little weight being idle for several months. Your resting pulse has gone up ten. It stands to reason that your oxygen demands haven't changed when you exercise. It's a complicated bio-chemical-electrical dance in there, but when those muscles of yours are using up oxygen faster, the heart is supposed to 'get the message' and respond with a faster pulse.

Since you are obviously very fit, you may not be experiencing dizziness when you are exercising and can't get the pulse above 115. But nevertheless, that rate, when you used to do 171, doesn't sound right to me.

Don't be shy. Consult another doctor if you start gettting symptoms like dizzy spells when exercising.

A-fib

by mike thurston - 2011-01-06 10:01:10

I am totally ablated and my high setting on the PM is 140bpm. It can be higher than that for sure. My EP says that is high enough for me :) Anyway I would at the very least consult with a GOOD EP and you could check with the Cleveland Clinic. There should not be that much controversey about what the PM will provide in terms of settings etc. Best wishes.
Mike T

firefoy

by sugar - 2011-01-06 10:01:30

question - you have been working from home for 4 months or you have not been working for 4 months? Sometimes when doing an ablation, your natural pacemaker gets interrupted permanently. Afib after 3 yrs.? Some people are in Afib all the time - I spend alot of time in Afib and I do have medication when it isn't slowing down. Take your info to another dr. and do research online. There are people in here that have a great deal of experience so I hope others respond. My longest time in Afib since the pacemaker was placed 13 months ago has been 33 minutes which isn't bad. I have many, many per day and I keep on exercising to help prevent clots etc. I have had a heart deform since birth and Afib since I was 24 yrs. old as fast as 230-240 caught on the machines and the hospitals couldn't stop it - ablation at 46 and a pacemaker at 60 yrs. old. Others will hopefully help more than I can.
Be well, Sugar

Heart rate issues

by ElectricFrank - 2011-01-07 12:01:00

First off either your docs are incompetent or not telling you the whole story.

The question is where in your cardiac system is the problem occurring.

It starts with the atrium (sinus rhythm). The sinus pacemaker is where your natural HR is determined based on a bunch of things. If this isn't working then they call it SSS. A normal ECG will show atrial beats on one or more of the traces. All that is needed is to have an ECG taken during rest and again during exercise. (the official way is have you do a treadmill test). If your atrial rate increases normally then it rules out SSS.

Then looking at the same ECG check to see if the ventricular rate follows the atrial rate. This tells whether the AV nerve bundle is conducting the atrial pace to the ventricles. If not then you have AV block (or I hate the term Heart Block).

By the way the test can be confounded by meds so I would be off them if possible

If either of these are having problems then a pacemaker is in order and can usually do a good job of correcting either problem.

You may be suffering from MDS (Multiple Doctor Syndrome). If docs disagree there is a pecking order which makes any type of intelligent diagnosis impossible.

I experienced this early on with my AV Block where the pacemaker rep and the cardiologist disagreed. I got them both together and let them know I wouldn't tolerate medical politics. Actually, the cardiologist is an excellent surgeon, the rep understands pacing, and I am an electronic engineer so we make a good team.

Hope this helps. Feel free to ask if you have any questions.

frank

Frank

by Firefoy - 2011-01-07 12:01:32

Thanks for the response Frank. I completely understand the electrical conduction system of the heart. My ekg shows sinus brady at rest with LVH by voltage criteria. There is no evidence of any type of heart block. My heart rate does increase with exercise but not like it used to. In March of this year at work, I had a treadmill test using the Gerkin protocol and was able to complete 16 min and achieve a heart rate of 171. My last stress test was a full cardiopulmonary test measuring my expired gases on a bike. I barely made 8 min with a respiratory rate of 60, a max heart rate of 115 and a max BP of 192/110. I was at my max and the doc stopped the test due to my BP at the same time.

Sure sounds like something has changed

by ElectricFrank - 2011-01-08 01:01:17

The high BP can cause reduced max HR in some people. I'm only guessing, but I wonder if the natural sinus pacer uses this to limit max BP.

Something else that jumped out at me is the respiratory rate of 60. It would mean that you were completing an inhale/exhale cycle in one second. There's no way that this can fill the lungs.This is more representative of a anxiety or panic condition. The high BP fits the model also.

It's hard to pin down actual numbers, but several references refer to 25 as being the upper end of normal for adults during exercise.

frank

respiratory numbers

by Firefoy - 2011-01-08 09:01:37

frank,
the pulmonologist did state that the increase in respiratory rate without the increase in volume was unusual. a new EP i saw this week took x rays to rule out phrenic nerve injury. of course i was hoping to hear from him before the weekend and i didnt so it just continues my waiting time. the pulmonologist wants to send me to pulmonary rehab. i dont see the connection between my ablation and a change in respiratory function. i was averaging 6 miles a day running around an 8 min/mile pace 1/1/10-4/30/10 until the problems started.

goof

by ElectricFrank - 2011-01-08 10:01:16

I meant we aren't well understood.

Interesting

by ElectricFrank - 2011-01-08 11:01:12

One thing I should say on all this: I have little direct knowledge of the physiology involved in very high output dynamics. As with a lot of this stuff my comments are based more on an engineering approach.

If you consider that the lungs lie between a ventricle as a source and atrium as a receiving stage for blood, it would seem like any change in either chamber could upset that great balance we have inherited. An ablation can affect the nature of the contraction of one or both chambers by changing the spread of the depolarization wave. While this isn't likely significant in us normal mortals, it could have a major effect under very high O2 requirements. Like many meds and procedures, ablation has both intended and unintended results.

Again all this semi-medical terminology doesn't indicate a direct knowledge on my part. Just thinking out loud. LOL

Do any of the docs your are seeing have experience in sports medicine? Anytime we lie outside the middle of the bell curve we are well understood by the average docs.

frank

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A pacemaker suddenly quitting is no more likely to happen than you are to be struck by lightening.