Tikosyn vs. Pacemaker

Greetings!  I am a 68 year old male with a thirty year, complicated history of afib, flutter and tachycardia.  I had Robotic Maze surgery in 2008 and was med free for four years.  I have had two ablations in the past year.  September '17 and April '18. Two weeks ago I was admitted to the ER with a heart rate of 170. I was had a cardio version and currently I'm in bradycardia with a pulse below 60 and am on Sotalol 120.  I have been prescribed many heart medicines with differing doses and have break throughs (episodes) with all of them.  Sotalol, Multaq, Propafenone and others years ago.

While in the hospital the on duty cardiologist, a nurse and the hospital doctor all mentioned to me during my four day stay Tikosyn.  I had never heard of it.  During a follow up with my cardiologist's assistant I was told my cardiologist was not considering putting me on Tikosyn.  Figures it would be unsuccessful.  He wants to iinstall a dual chamber pacemaker and keep me on 120mg Sotalol.  (The PM would control the Bradycardia, and hopefully, the Sotalol would controll the afib.)  I h ave been with my cariologist for a number of years and have faith in him.  However, I am wondering if I should leave his practice and try to Tikosyn with a new cardiologist.

Thoughts??


6 Comments

Tikosyn

by AgentX86 - 2018-08-27 21:59:54

Tikosyn is a fairly powerful antiarrhythmic but it comes with problems.  It tends to lengthen the QRS complex, which is dangerous.  Dangerous enough that they'll keep you in the hospital for 72 hours to see how you react to it.  Like all antiarythmics, it tends to work for a while then requires increasing doses until it doesn't work anymore.  Drugs aren't a permanent solution for AFib symptoms. 

Since they're putting you through this, I assume that you're symptomatic (otherwise they'd just put  you on a rate control drug, an anticoagulant, and call it a day).

The dual chamber pacemaker with Sotalol is a reasonable alternative.  That was one of my choices but I wanted to try an ablation (or three) first.  The other alternative was an AV ablation and a biventricular pacemaker.  I ended up with the AV ablation.

Back to your question:  It's perfectly reasonable to ask for a second opinion ("you're ugly too!") but if you get a different answer, who breaks the tie? IMO, if you have as good of a relationship with your cardiologist as I do, and it sounds like you do, you'd take his opinon over the new guy.  OTOH, you really need to be seeing an electrophysiologist with this problem.  A normal cardiologist isn't equipped to deal with the heart's electrical system. You should seek the opinion of an EP. Keep your plumber, too.g

Tikosyn

by lmhause - 2018-08-27 22:03:56

Hi, not knowing your history in its totality I believe regardless of the medication you are taking you will need to pacemaker.  My suspicion is that you have devloped sick sinus syndrome along with the a-fib.  The pacemaker will prevent significant bradycardia and can also keep your ventricular rate from going as high as you experienced.  

Let me know your thoughts...

 

Tikosyn vs. PM

by Bluedogg - 2018-08-27 23:34:17

Thanks, Agent and LMH for your quick responses. By cardiologist I meant electrophysiologist. I realize a pm is in my future, and, if episodes continue, I would have an AV ablation and be 100% dependent on the pm. My doctor seems to think Sotalol 120 will help the afib, flutter, etc, and the pm will eliminate the current low pulse rate. I have had episodes while on Sotalol before my last two ablations.

The more I read about Tikosyn the less eager I am to try it with new cardiologist. Was hoping in a miracle drug and curious why my doctor never mentioned it. Doesn’t believe Tikosyn would work , but Sotalol will?

Tikosyn

by AgentX86 - 2018-08-27 23:48:19

Yes, the Sotalol + PM was the first plan my EP advised, before my first ablation.  "If this doesn't work, here are the alternatives." The thought process is exactly what you're told, above.  However, the Sotalol was already doing its job on my SI node and it was getting worse (8-second pauses).

An AV node ablation is a last ditch option but it's one that will work.  If you're symptoms are bad enough for your EP to even be discussing this stuff, it's not a bad option.  Sotalol likely won't work forever and you'll need more and more to do anything.

Yes, Tikosyn has a lot of problems.  Perhaps your EP knows something that he's not saying (like your QRS complex is already enlongated?).  It shouldn't cause any problems if you ask. He should have a good answer.

Whatever you do, stay away from ameoderone.  It's nasty stuff and you're too young to deal with that. My cardiologist had me on it for a short time, a couple of  times.  It did the job, or should I say it put off the problem, at least while I was on it.

 

Tikosyn

by Bluedogg - 2018-08-28 00:03:06

Thanks. You sound like you’re a veteran of these battles.

I am aware of ameoderone and it’s nasty side effects. It was mentioned in the past and is not being considered. I’m meeting with my EP tomorrow. I’ve only heard his thoughts through his two assistants. Suddenly a pm appointment became available for this Friday.... or wait until October. I feel a bit under the gun to decide. Not sure if Tikosyn, which new EP might prescribe, is worth delaying the inevitable.

Tikosyn

by AgentX86 - 2018-08-28 11:16:24

If you believe a PM is inevitable,  forget the tikosyn. It has risk an significant cost. If you're going to have to go the PM route anyway, get on with it. You won't be in the hospital as long with the PM,  either.  ;-)

Whether you go with sotalol + pacemaker or AV ablation +pacemaker is a choice. The AV ablation route has a higher probability of success but as you note, it will leave you dependent (rarely a problem). It will also cause AV dyssynchrony,  which might also be a problem.

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My pacemaker is the best thing that every happened to me, had I not got it I would not be here today.